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3 General Surgery & Trauma

3.5 Specific Injuries - Regional Orthopaedics

3.5.1 Spinal Injury, Cervical Spine

Reviewed by TB Hassan.

Date : July 2005

Background

The Problem:

The Solution:   

Trauma patients where the cervical spine is of concern can be divided into 2 groups as follows:

Where cervical spine X-rays are always indicated consistent with the clinical picture:

 

Examples:

References:

1) Stiell I G, Wells G A et al. The Canadian C-spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA 2001; 286: 1841-8

2) Hoffman JR, Mower WR, et al. Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma. NEJM 200; 343: 94-9

3) Maurice S, Brown S et al. The Effect of Introducing Guidelines for C-spine Radiographs in the A&E Department. J Accid Emerg Med 1996; 38-40

Whiplash

 

These injuries are common.  Better referred to as "Acute Cervical Sprains". Most "whiplash" symptoms come on several hours after the accident, and in these cases bony injury is rare.  Treat with analgesics, and advise gentle mobilisation and heat.  Soft collars are now discouraged. Refer back to the G.P.  Immediate neck pain and stiffness at the time of the accident is more worrying.  See above for guidance.

Management of Acute Non Traumatic Back Pain
Reviewed by TB Hassan
Date : July 2005

Approximately 5% of all medical consultations in the U.K are for back or neck pain. There are a multitude of causes of back pain that can be categorised as mechanical, inflammatory, referred and sinister (table 1).
In the majority of patients no definite anatomical diagnosis is made (non-specific back pain). This can be easily managed in A&E, with advice, analgesia and referral back the GP.
It important not to miss the sinister causes (eg. malignancy and infection), but this rare and can only be diagnosed with further investigations.

Mechanical back pain

  • Spondylolisthesis
  • Spondylosis
  • Intervertebral disc prolapse
  • Including cauda equina
  • Spinal stenosis
  • (claudication type pain)
  • Apophyseal joint disease
  • (exacerbated by lumbar extension,
  • cervical or thoracic rotation)
  • Non-specific back pain

Sinister Causes

  • Infection
  • Discitis
  • Epidural abscess
  • Malignancy
  • Myeloma
  • Osteoporotic crush fracture
  • Paget’s disease

Referred Pain

  • Aortic aneurysm
  • Pyelonephritis, renal calculus
  • Pancreatitis

Inflammatory back pain

  • Rheumatoid arthritis
  • Seronegative spondyloarthritides
  • Psoriatic
  • Ankylosing spondylitis
  • Reiter’s
  • Enteropathic
  • Behçet’s

The first stage in managing the patient who presents to the Accident and Emergency Department with back pain should be a history that focuses initially on attempting to categorise the pain into one of the four groups mentioned above (table 2).

Table 2: Features in the history
Other features that must be elicited in the history are the presence of sensory or motor symptoms, and any bowel or bladder dysfunction.

The examination of the patient with back pain should comprise four parts:
1. General;
2. Spine examination;
3. Neurological;
4. PR & perianal sensation.


The general examination should in particular look for any evidence of malignancy. The examination of the spine should include assessment of: tenderness and muscle spasm; cervical spine flexion, extension, rotation and lat flexion; thoracic spine rotation; lumbar spine flexion, extension, lat flexion; and the SI joints. The neurological examination should focus on eliciting upper motor neurone signs and signs of intervertebral disc prolapse. The PR & perianal sensation must be documented.

There are two related conditions that warrant particular attention: intervertebral disc prolapse and cauda equina lesions. The intervertebral discs are living structures, which flatten during day & re-expand at night. They are comprised of a firm nucleus pulposus surrounded by an annulus fibrosus. The disc is a symphysis between each pair of vertebrae and, with the two posterior facet joints, allows movement between the vertebrae. Tension in disc maintained by fluid imbibition at a cellular level. If imbibition fails: the disc collapses; there is increased movement between vertebrae; the annulus fibrosus is exposed to increased stress and the patient may experience low back pain. As degeneration proceeds the annulus fibrosus softens; and the degenerate disc bulges the annular ligament backwards, usually just lateral to the midline. If disc bulge occurs in a tight spinal canal opposite a nerve root, the function of the root is affected. 90% of lumbar disc protrusions involve the lowest 2 spaces, L4-5 or L5-S1. Occasionally, the L3-4 disc protrudes.

A protruding L4-5 disc will irritate the L5 nerve root, etc. Regarding terminology, the terms ‘radiculopathy’ or ‘radicular pain’ should be used to indicate nerve root problems and pain; ‘sciatica’ is a misleading term and should be avoided.

In the history of the patient with suspected intervertebral disc prolapse, the following features are typical: recent, well-defined onset; back pain initially progressing to unilateral leg pain, which is present below the knee; numbness in same distribution; coughing or sneezing reproduced the pain. The examination should be focussed on confirming the diagnosis and ascertaining which the offending disc is. Straight leg raising will reproduce the leg pain and therefore be reduced on that side. The process of ascertaining which disc has prolapsed will be aided by table 3.

Table 3: Neurological Examination in Intervertebral Disc Prolapse (Which nerve root is affected?)

Nerve root          Sensory               Motor

L4                     medial calf          knee jerk

L5                     lateral calf &        EHL
                        medial foot

S1                    lateral foot &        ankle jerk
                       back of calf

The most important condition to exclude early in the consultation is a cauda equina lesion,

This warrants an emergency neurosurgical or orthopaedic referral. The spinal cord is shorter than the vertebral column, finishing at L1/2. Below this level nerve roots travel in the lumbar cistern (subarachnoid space) to exit the vertebral canal at the appropriate level. The bundle of nerve roots in the lumbar cistern resembles a horse’s tail- hence the name ‘cauda equina’. A very small proportion of intervertebral discs rupture in the midline of the annulus fibrosus & compress the cauda equina.

Cauda equina lesions classically present with: painless retention of urine; perianal anaesthesia; and bilateral radicular pain. …BUT the things also to look for are:
• Severe exacerbation of back pain on a background of worsening chronic back pain.
• Ask and DOCUMENT that the patients does not have abnormal sensation when they wipe themselves with loo paper or have difficulty passing urine.
• Have persisting sensory and/or motor deficit from symptoms or signs.

MAKE SURE TO DOCUMENT ALL RELEVANT SYMPTOMS AND SIGNS IN THE NOTES.
The – if you are still unsure…yes you guessed it – ask a SENIOR! We have a low threshold for urgent investigation

The investigation of back pain obviously depends on the probable cause. Non-specific back pain requires no further investigation. If however, a sinister or inflammatory cause is suspected then investigations are warranted under the care of the appropriate specialty (table 4).

Table 4: Investigation to be considered in the investigation of back pain (see protocol below).

Management obviously depends on cause. General measures are analgesics, bed rest, physiotherapy, and appropriate referral to a specialist. Regarding referrals, table 5 indicates when and to whom specialist referral is indicated.

Table 5: Specialist referral

1.Radiculopathy
No improvement in symptoms and signs after 6 weeks rest
An increase in neurological deficit
CAUDA EQUINA (emergency)
Intractable pain
2.Neoplasia or serious mechanical lesion suspected (urgent)
3.Rheumatology
Inflammatory cause (urgent)
Radiculopathy refractory

References

1. van Tulder MW, Scholten RJ, Koes BW, Deyo RA. Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000 Oct 25: 2501-13.
2. Malmivaara et al. The treatment of acute low back pain- bed rest, exercises, or ordinary activity? N Engl J Med 1995 Feb 332:351-5.
3. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low back pain and sciatica. Cochrane Database Syst Rev 2000.
4. Van Tulder MW, Malmivaara A, Esmail R, Koes BW. Physiotherapy and Exercise Therapy for acute low back pain. Cochrane Database Syst Rev 2000.

 

3.5.2 Hand Injuries

 

These are very common and often very disabling. It is essential to manage these well from the outset, as it can be an unforgiving area.

 

Hands Service at LGI

The 'Hands Service' at the LGI is run jointly by the Plastic Surgical Hands Team & the Orthopaedic Hands Team and is DISTINCT from the Fracture Clinic Team. The Hands Team are responsible for injuries from the mid-carpal line distally and the Orthopaedic team from the Mid carpal line proximally. see diagram below.(PAC 24/07/07)

 

Hands Clinic

Please ensure that when you refer a patient to the Hands Clinic you document 'Hands Clinic' on the ED card and ensure that all relevant x-rays are available in HARD COPY for the hands secretarial team to collect from ED reception. The Hands team will arrange for the date and time of F/U and send out appointments to the patients.

IF you get asked to put a patient into 'Plastics Dressing Clinic' make sure you take the name of the doctor who asks you to do this and document this and their precise advice in the ED card. This will lead to fewer difficulties later should patients be deemed by the hand team to be in an inappropraite clinic.

PAC 02/07

 

 

Thumb

 

SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

Ulnar collateral ligament MCP jt

Instability (ie no end-point on stressing), Steiner bony fragment

High arm sling

Refer Hand Surgery

Radial collateral ligament MCP jt

Instability (ie no end-point on stressing), Steiner bony fragment

FWS with thumb extension

Refer Hand Surgery

Prox phal # not involving joint

Deformity

Neighbour strapping or Zimmer splint.

If deformity cannot be corrected then immediate Hand Surgery referral. If corrected ED RC 5-7 days

First MC # involving C-MC joint (Bennetts #)

Displacement

 Analgesia and high arm sling.

Refer Hand Surgery

 

Finger-tip injuries

Nail injuries

Fish-hook injury

If the hook is still present, anaesthetise the injured area, clip the hook with cutters, and put it through in its original direction of travel. Cover for tetanus. Clean and dress the wound, give prophylactic antibiotics and discharge.

FINGER FRACTURES

Fingers 8D

SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

# prox phalanx

Rotation, AP or lateral deformity, oblique fractures

MUA if displaced, neighbour strap, consider Zimmer splint

If cannot be corrected then immediate Hand Surgery referral  otherwise  A&E RC 5-7 days

PIP dislocation

avulsion #, instability

MUA, post reduction xray, neighbour strap

ED RC 7 -10 days    but if complex refer to hands

volar plate injury PIP

avulsion #, instability

Neighbour strap

ED RC 7-10 days     but if complex refer to hands

avulsion # middle phalanx

instability

Neighbour strap

ED RC 7-10 days     but if complex refer to hands

mallet with avulsion #

Subluxation.  >1/3 of articular surface fractured

mallet splint (with written insuctuions)

ED RC 1 week. 

If >1/3 articular surface fractured the refer to hands

mallet - no #

 

mallet splint (with instructions)

ED RC 1 week

Flexor tendon injury

Any significant wound over a hand/finger flexor surface may have injured the underlying tendons.  Therefore examine them specifically and note your findings.  If there is a definite tendon injurythen refer to Hands, if you are uinsure discuss with an ED Senior.

Trigger finger

Painful clicking of the finger on flexion.  The cause is a nodule on the flexor tendon, which catches on the sheath.  Best treated with a steroid injection, refer tthe Hands service

 

Extensor tendon injury

Supected or definite tendon injuires should be referred to the Hands Service. A tendon inury of less than 30% of the tendon does not require repair, but will need splintage. Discuss this with asenior before discharging the patient to Hands clinic.

Mallet finger

This is a dropped distal inter-phalangeal joint, often following fairly minor injury.  Flexion is possible but not extension.  Check the X-ray for a fracture.  If fragment is less than 1/3 of joint surface, treat in a mallet splint which must not be removed for 4 weeks.  If fragment is greater than 1/3 joint surface, ask A&E senior or refer Hands .  If no fracture, Mallet splint for 6 weeks. 

 

Metacarpal fractures

See Hand 8H

Shaft: Check for angulation (>30degrees) or rotation of digit.  If present, manipulation required.  If unstable at manipulation, refer to Hands for internal fixation.  If stable, volar slab for index or middle metacarpal, ulnar border slab or ring or little finger metacarpal with fingers in extension. 

Neck: Much more deformity acceptable.  Operative treatment or manipulation rarely required.  Neighbour strap and futura splint and review in RC 7-10 days.


SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

carpo-metacarpal dislocation

Associated #

MUA, NS & HAS

ED RC 7-10 days

# thumb metacarpal

Subluxation of thumb carpo-mc jt

If simple fracture of Metacarpal then MUA and Scaphoid cast

ED RC 7-10 days.

# dislocation thumb carpo-mc jt (Bennett's)

Don't try manipulation

Analgesia and high arm sling

Immediate referral to the Hand

# base 5th mc ("baby Bennett's")

Subluxation of carpo-mc jt

Analgesia HAS

Referral to the Hand Surgeons

# mc neck

Gross angulation

MUA only if grossly displaced, neighbour strap, high arm sling

A&E RC 7-10 days

# mc shaft

Gross angulation, shortening, rotation of finger

MUA if clinically displaced, POP volar slab to fingertips in slight flexion & high sling

Hands referral or A&E RC 3-5 days

 

Summary of Hand Presentations (note 2 pages)

PLEASE NOTE THAT THERE HAVE BEEN SOME MINOR CHANGES TO THIS LIST (in red)

ALL HAND OPD SLOTS NEED TO BE APPROVED BY THE ON CALL TEAM & THEIR NAME DOCUMENTED IN THE NOTES

3.53 Management of traumatic wrist pain

Authors:   David Elson, John Sloan & Mukarram Naim

Written January 2002 review 7/05 DWH

             

OBJECTIVE

To describe a process for the safe and efficient management of traumatic wrist pain, which rapidly discriminates between simple sprain and more serious pathology?

CLINICAL CONDITION

Trauma sustained to the wrist is a common cause of presentation to the Accident and Emergency department.  The most common mechanism of injury is a fall on the out stretched (or less commonly flexed) hand.  Other less common mechanisms are crush, knocks or punches, RTA, and hyperextension injuries1. The most common significant injury after trauma to the wrist is a fracture of the scaphoid bone but many other differentials exist.

TARGET PATIENT GROUP

Trauma patients who subsequently complain of wrist pain.

SEQUENCE OF INVESTIGATIONS and DIAGNOSIS

There is no substitute for taking a careful history of the mechanism of injury.  This does not need to be lengthy, but does need to be precise.  A fracture will usually be preceded by significant injury, and if the patient has no history of injury, this will usually mean no fracture.  In the same way, high impact trauma will often result in a significant injury. This guideline does not attempt to cover non-traumatic conditions.

The examination finding of non-focal tenderness implies either trivial injury, or (if the injury is high energy), an injury which may require follow up after simple rest (high sling & analgesia).  High impact injuries may result in lunate dislocation, or lesser variations (dorsal or volar intercalated segmental instability) and warrant senior medical involvement.  The range of other investigations that may be required is outside the scope of this guideline.

Focal bony tenderness should lead to x-ray.  Occasionally the tenderness is associated with a history of repetitive use, and there is soft tissue crepitus on tendon movement, in which case, consider paratendonitis crepitans.  Tenderness over the anatomical snuff box should result in specific scaphoid views. Pain should be elicited at the extremes of movement and with axial loading (thumb compression). Axial pressure, AP pressure, swelling and ASB pressure with the wrist in ulna deviation may all be helpful in determining the presence of a scaphoid fracture.  AP tenderness has a sensitivity of 91% and specificity of 83%, whereas ASB tenderness has a sensitivity of 86% and specificity of 72%2.  It has also been suggested that pain when percussing over the head of middle metacarpal is suggestive of scaphoid fracture3. 

Scaphoid films at day 0 have a sensitivity of 80% in detecting scaphoid fracture(2).

Audit has shown that of the index population sent for scaphoid x-rays, 12.7% are said to have a scaphoid fracture(1), although only 9.4% of these are proven to be so on senior review, 70% of which were seen on first x-ray.  Many are distal pole fractures and waist fractures only account for about 4% of the index population.

At ED review at 10-14 days a second set of X-rays are no longer required as the 'pick up ' rate is so low. If the patient is till symptomatic an Isotope Bone Scan should be arranged. If the injury is felt to be more complex then an MRI should be organised after discussion with a senior.  A normal bone scan excludes serious injury4,5, and can lead to safe discharge of the patient.  It can be carried out anytime from 72 hours6.

 

TREATMENT

Patients in whom scaphoid fracture is never suspected, and who have normal x-rays, and who do not have wrist joint tenderness may be safely discharged with advice and anlagesia. 

Those with non-ASB wrist joint tenderness may have other problems, such as fracture of another carpal bone, paratendonitis crepitans, exacerbation of OA, crystal arthropathy, scapho-lunate injury, dorsal or volar intercalated segmental instability, TFCC injury and median nerve compression - follow up is recommended. Further imaging and investigation will be required in some cases, and senior medical involvement is necessary.  The range of treatments that may be required is outside the scope of this guideline.

Patients in whom scaphoid fracture is a possibility, but who have normal x-rays should be reviewed at 10-14 days for a repeat examination.  Immobilization can be by any means that is appropriate to the level of pain, and, as yet, there is no clear evidence to support one method of immobilization over another10,11,12.  The standard that is recommended is a fabric wrist support (Futuro - FWS), with or without a thumb extension, together with a high arm sling and analgesia.  Those in more pain may require a Colles backslab, or occasionally a scaphoid cast.

Obvious fractures should be immobilised in a plaster or resin scaphoid cast, given a high arm sling and analgesia, and brought back to the trauma/fracture clinic the following day.

Displaced wrist fractures should be dealt with according to local policy

KEY MESSAGES

Exclude if no history of injury, obvious Colles, Smiths or G/S #

Text Box: ü The most effective clinical examination to detect scaphoid fracture is AP compression combined with ASB tenderness in an ulna deviated wrist ü Focally tender wrists need x-raying ü The first scaphoid x-ray is 80% sensitive for scaphoid fracture ü In x-ray negative patients with ASB tenderness, there is no evidence to support one method of immobilization over another; we recommend a semi-rigid fabric wrist support. ü In most cases follow up at 10-14 days should be arranged following a negative first scaphoid x-ray ü Bone scans can be carried out early (any time from 72 hours) though we recommend waiting until a 10-14 day second x-ray is negative. ü Non ASB wrist tenderness, or persisting ASB tenderness in the presence of a normal bone scan requires further investigation.

 

 

 

 

 

 

NB The following Document still contains advice to re-xray scaphoids at 14 days. This is no longer the policy a bone scan is indicted at this stage.

 

Taylor, Tony. LGI Clinical Governance data, April 2001.
The wrist. Chapter 74 in King and Bewes. Primary surgery volume two. (trauma) Oxford Medical Publications.1987
Wilson AW, Kurer MH, Peggington JL, Grant DS, Kirk CC. Bone scintigraphy in the management of x-ray-negative potential scaphoid fractures. Archives of Emergency Medicine. 1986; 3(4):235-42.
Murphy DG, Eisenhauer MA, Powe J, Pavlofsky W. Can a Day 4 Bone Scan Accurately Determine the Presence or Absence of Scaphoid Fracture? Annals of Emergency Medicine. 1995; 26(4):434-8.
Stordahl A, Schjoth A, Woxhott G, Fjermeros H. Bone scanning of fractures of the scaphoid. Journal of Hand Surgery 1984;9B(2):189-190
Tiel-van Buul MM. Roolker W. Verbeeten BW. Broekhuizen AH. Magnetic resonance imaging versus bone scintigraphy in suspected scaphoid fracture. European Journal of Nuclear Medicine. 23(8):971-5, 1996 Aug.
Tiel-van Buul MM. Broekhuizen TH. van Beek EJ. Bossuyt PM. Choosing a strategy for the diagnostic management of suspected scaphoid fracture: a cost-effectiveness. Journal of Nuclear Medicine. 36(1):45-8, 1995 Jan.
Gaebler C. Kukla C. Breitenseher M. Trattnig S. Mittlboeck M. Vecsei V. Magnetic resonance imaging of occult scaphoid ractures. Journal of Trauma-Injury Infection & Critical Care. 41(1):73-6, 1996 Jul.Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. J Bone and Joint Surgery (Br). 1991; 73(5): 828-32.
Sjolin SU, Anderson JC. Clinical fracture of the carpal scaphoid – supportive bandage or plaster cast? J Hand Surgery (Br) 1988; 13: 75-6.
Jacobsen S, Hassani G, Hansen D, et al. Suspected scaphoid fractures. Can we avoid overkill? Acta Orthop Belg 1995; 61:74-8.

Specific Wrist Injuries


Colles fracture

Anatomical reduction should be the aim of treatment unless the patient is very elderly or disabled. Reduction can be achieved in most patients over the age of 50 using a haematoma block. This consists of the injection of up to 10mls of 1% lignocaine into the fracture site. Do not forget the ulna styloid. Adequate reduction is rarely achieved without significant traction. The procedure for reduction cannot adequately be described here, but it is well described in several books, for instance - Practical Fracture Treatment by McCrae. The manipulated fracture should be held in place with a dorsal back slab and the patient should leave with a high arm sling. They should be referred to Ortho fracture clinic the following day.

In terms of the best procedure for reduction, between Biers block and haematoma block, evidence shows outcomes are significantly better with the use of Biers block as opposed to haematoma block. However haematoma block seems to be the most popular method. The reasons for this appear to be lack of training, fear of complications and the fact that Bier block is more time consuming. These issues should be borne in mind when choosing the reduction anaesthetic technique.

Lunate injury
This injury is easily missed. Small chip dorsal fractures are common and not too important. Peri-lunate dislocation is a serious problem. Radiologically it is visible on the lateral as the absence of the series of "C"s which are usually seen. Needs immediate referral for senior A&E advice, or referral to Hands on call.

Ulna fracture
See also "Forearm 8F" "Radial fracture" and "Olecranon fracture". A small fracture of the ulna styloid usually accompanies a Colles fracture. Shaft fracture should be handled as radial shaft fractures. Watch for injury to joints above and below; therefore x-ray joints above and below.

3.5.4 Radial fracture


Common injury, either as a Colles fracture, or radial head fracture. Greenstick shaft fractures are common in children. In these instances, X-ray the joints above and below to check for other fracture or dislocation

SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

Colles #,

correct angles on XRay

If undisplaced, Colles POP.  If displaced, haematoma block or Biers block, manipulation, colles POP, check Xray.  If young adult may need GA.

Next # clinic

# separation of lower radial epiphysis ("juvenile colles")

correct angles on XRay

If undisplaced, Colles POP.  If diplaced, probably needs GA ref orhto.

Orthopaedic trauma clinic or 2C if displaced

# scaphoid

specific xrays

Scaphoid POP

Orthopaedic trauma clinic

? # scaphoid

specific xrays

Scaphoid POP

ED RC 10-14 days

lunate / perilunate dislocation

Commonly missed

Immediate hand surgery referral.  Needs GA

Hands

other carpal #'s (hamate, lunate, triquetral, pisiform)

Commonly missed

Colles POP

ED RC 2 weeks

3.5.5 Elbow                                       Search EMRbank for Elbow

• Most commonly injured after a fall on the outstretched hand
• Fractures are Sometimes difficult to see on x-ray, especially in children who have multiple epiphyseal growth plates
• Look for an effusion (see fat pad sign or sail sign).
• Always check and document radial pulse. Refer all children’s' elbow fractures to the next Ortho TC.

SITE OF INJ

LOOK OUT FOR

MANAGEMENT

DISPOSAL

"Pulled" elbow

 

Forced supination, C&C

If reduced no FU, if unsure next RC

Supracondylar #

displacement, arterial injury, nerve injury

C&C

Ortho 2C

Lateral condyle #

If in doubt, xray other elbow

displaced, Orthos 2C

undisplaced, C&C

Ortho #C

Medial epicondyle #

Inclusion in joint?

Ulnar nerve injury?

Displaced?

xray other elbow

displaced, Orthos 2C

undisplaced, C&C

Ortho #C

Capitellum #

 

C&C

Orthos 2C

Olecranon #

 

C&C

Orthos 2C

Coronoid fracture

 

Undisplaced - C&C

Displaced - Orthos 2C

Ortho #C

Radial head fracture

"Fat Pad" sign

Comminution

If comminuted or fragment greater than 1/3 joint surface, or fragment grossly displaced,  then Orthos 2C, otherwise C&C

Ortho #C

Radial neck fracture

Degree of tilt

If more than 20o,  MUA, C&C

Ortho #C

Radial epiphysis

displaced

C&C

Ortho #C

Elbow dislocation

Nerve injury

Associated fractures

Vascular injury

Etonox, midazolam, manipulation, POP back slab at 90o, Check xray

Ortho #C

Radial head dislocation

Fracture of ulna

MUA, C&C, check Xray

Ortho #C

Pulled elbow

• A clinical diagnosis, with no need for X-rays (which look normal).
• The child is 6 months to 4 years and has been lifted by the hand / wrist, with subsequent reluctance to use the arm.
• Hold the child's lower humerus in one hand, and hold the child's hand in the other. Push and 'screw' the hand back into the elbow (pronate or supinate, both work), and rotate as far as you can. You will feel a click and the child will object. (So will Mum unless you predict this!) Then allow the child to play, and usually the function returns within 10 minutes.
• No sling or follow up necessary. Not associated with abuse. Advise the parent of the need to avoid direct pulls to the hand and forearm.
• An X-ray is usually not required as it is normal. If the child is not using the arm normally after attempted manipulation then put the arm in a collar and cuff and review the child in next A&E RC.

Tennis elbow

See 'Golfers elbow'. Similar condition but more common and affecting the lateral epicondyle.

Golfer's elbow

This is medial epicondylitis of the lower humerus, characterised by extreme local tenderness. NSAID’s/rest and GP follow up for mild cases. More severe cases may require a steroid injection is appropriate, confined precisely to the tender point.

Olecranon bursitis

• Usually follows minor trauma, or mild repetitive knocks.
• Can appear very hot and very swollen. Don't aspirate or incise. Treat with flucloxacillin 500mg qds and any non-steroidal anti-inflammatory drug for a minimum of 5 days. Most GPs will happily continue follow up.
• If there is systemic upset with fever and tachycardia and appearances of local extensive infection admit for IV antibiotics on to CDU

3.5.6 Humerus and Shoulder

Most common fracture is the surgical neck in the osteoporotic patient usually after FOOSH. Always document distal neurovascular deficit particularly if shaft fracture or a dislocation of the shoulder

SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

# clavicle

associated chest injury

BAS

Ortho #C

# scapula

specific xrays to confirm

BAS

Ortho #C

AC joint strain / dislocation

stress views to confirm

BAS

Ortho #C

Sterno-clavicular jt dislocation

associated chest injury

 

Ortho 2C

Dislocation – no #

beware posterior dislocation.  lateral xray necessary.  circumflex nerve injury

reduce (Milch / Kocher / Hippocratic).  Polysling (under clothing)

Ortho #C

Dislocation with #

beware posterior dislocation.  lateral xray necessary.  circumflex nerve injury

 

Ortho 2C

# greater tuberosity

 

BAS

Ortho #C

Surgical neck humerus

associated dislocation

 

Ortho 2C

# shaft humerus

radial nerve injury

U slab, sling, body bandage

Ortho 2C

Slipped upper humeral epiphysis

 

BAS

Ortho TC

• Fractured clavicle is common in both adult and child. Treat with a broad arm sling.
• Look out for dislocation, which is usually very painful. You must obtain two views of the joint, otherwise dislocations may be missed. Reduce as soon as possible.
• Acromio-clavicular dislocation is not usually serious, though will require immobilizing initially (BAS).
• Be vigilant for acute calcific tendonitis, which can affect young fit people. It is characterised by severe, spontaneous shoulder pain, which prevents sleep. The X-ray shows a calcified area below the acromion. Give NSAID and refer to othropaedics for a steroid injection as soon as possible. More chronic shoulder pain is complex; generally such patients should go to their GPs for treatment, though an X-ray may help to reassure them that nothing serious is being missed. Physiotherapy does not usually help these patients.

Dislocation of the shoulder

• This common injury is usually due to a forced external rotation of a fall on to the shoulder. The humeral head usually comes to lie anterior and slightly inferior to the glenoid.
• Examination show a obvious asymmetry with a step off below the acromion . Neurovascular complications can occur with this injury and it is essential to document the distal function as soon as the patient is seen.
• Patients who have had previous dislocations often dislocate with minimal trauma or even turning over in bed! If this is the case an Xray may not be required. All other cases will need Xrays and all cases need Xrays once reduction has occurred.
• Beware the Fracture dislocation of the shoulder. If the neck of the humerus is fractured and there is a dislocation then reduction may leave the humeral head in the dislocated position and the shaft of the humerus in the glenoid! Refer to orthopedics
• Treatment involves reduction under analgesia/sedation. See conscious sedation guidelines.

There are several methods used for the reduction of the shoulder:

Kochers
• This should not be used in the elderly osteoporotic patient as it may lead to a fracture of the humerus
• Lie the patient flat
• Provide adequate analgesia; sedation may not be necessary
• Flex the elbow to 90 deg and slowly externally rotate the smoulder. This has to be done slowly an das the patient relaxes more external rotation will be achieved. Never force this.
• Slowly adduct the upper arm with the shoulder still externally rotated
• Then internally rotate the shoulder
• Reduction may occur at any point.
• Check the neurovascular function and place in a broad arm sling.
• Re-x-ray.

Modified Milch method
• With adequate analgesia and sedation slowly abduct the arm to 110 deg
• Apply traction with an assistant provides counter traction
• A slight amount of external rotation may be necessary
• Reduction may occur at any point.
• Check the neurovascular function and place in a broad arm sling.
• Re-x-ray.

Spaso technique
• Apply vertical traction with some external rotation
• New technique with good results, 87.5% success rate in HK trail
• Requires less analgesia and is thought to be less traumatic

3.5.7 Chest


Rib fracture
• Commonly associated with multiple trauma, with underlying visceral injury. If the history is suggestive of this treat along ATLS guidelines
• Often relatively minor in the when only 1-2 ribs involved.
• Beware of #s over the spleen or liver however.
• Beware of #s of the 1st and 2nd ribs, which may be associated with brachial plexus or vessel injury, or injury to the upper thoracic contents.
• In pre existing chest disease or the elderly, any more than 2-3#s can be very serious, therefore, consider admission in such patients.
• When only a single uncomplicated # is suspected, make the diagnosis clinically and do not X-ray. The simple reason for this is that many single rib #s will not show on X-ray and will not alter traetment.
• Be aware of the rib fracture with underlying lung disease. They are likely to develop primary or secondary lung injury unless treated properly.
• Treatment involves pain control, diagnoses of underlying assonated lung injury and prevention of secondary lung infection by appropriate advice regarding breathing exercises.

Sternal fracture
• Commonly associated with seat belt injury.
• If anterior cortex only is damaged, treat symptomatically. If both are fractured, check the ECG, and d/w CT surg as they will often require an ECHO.
• Most can be managed on ward 1 with adequate analgesia. Gross displacement, or an associated other injury, is a contraindication to admission to Wd 1.

3.5.8 Pelvis

• The majority of pelvic fractures in the young result from severe trauma
• These patients must be treated along ATLS guidelines
• The elderly often fracture the pubic rami after minor falls
• If the elderly are involved in major trauma they are likely to have serious pelvic fractures with a high mortality
• Visceral injuries must be sought for in all patients with pelvic fractures.

SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

Avulsion # (athletes)

 

symptomatic

Next # Clinic

# blade ilium

intra-abdominal injury

analgesia

Ortho 2C

Unilateral # pubic ramus

urethral injury

analgesia, mobility test

Ortho 2C

Bilateral # pubic ramus

urethral injury, bladder injury

 

Ortho 2C

"open book" #

severe blood loss - may be >20units

emergency (resus room) external fixation by Orthos

Orthos 2c stat

Acetabular # incl central dislocation hip

associated distal #, severe retroperitoneal haemorrhage

observe for shock, X match + blood replacement

TCI Ortho

 

3.5.9 Hip

• This is a common injury in the elderly after minor falls.
• A protocol exists for theses patients to be fast tracked through the department to the ortho wards (see guideline in central area).
• It is essential that these patients are on this protocol and have analgesia, all relevant investigations and their co morbid conditions addressed before admission to the orthopaedic ward
• In the young fractures around the femur are always serious implying a great deal of force. These patients must be treated along ATLS guidelines

SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

Dislocation

other associated #, sciatic nerve injury

urgent MUA (entonox or GA).  If complicated Ortho 2C

TCI Ortho

Central dislocation

associated distal #, severe retroperitoneal haemorrhage

observe for shock, X match + blood replacement

TCI Ortho

Slipped upper femoral epiphysis

lateral Xray essential

 

Ortho 2C

# neck of femur (NOF)

lateral xray essential

 

TCI Ortho

Avulsion # greater trochanter

 

assess pain + mobility

Ortho 2C

Irritable hip

systemic illness, history of trauma, signs of infection

CRP, WCC, ultrasound of hip (see g/l in paeds)

A&E RC as per g/l. If abnormal, Ortho 2C

3.5.10 Femoral fractures

SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

# shaft femur

shock, associated hip injury, distal circulation & sensation

analgesia (entonox, femoral nerve block), splint

TCI Ortho

Supracondylar # femur

distal circulation

analgesia, splint

TCI Ortho

Contusion of thigh

myositis ossificans (qv)

Raymed splint, PWB on crutches

A&E RC 10-4 days

3.5.11 Management of Acute Knee Pain In A & E

Authors : DWH
Date : 7/05

Background

Knee pathology is a common presentation to Accident and Emergency. Over 3 million patients present with knee injuries each year in the U.S. and are the second most common occupational accidents. Correct management is important as misdiagnosis can lead to chronic knee instability, degenerative joint disease and loss of knee function.

Classification

Traumatic Bony injury
               Non bony injury
               extensor mechanism,
               meniscal,
               ligamentous

Non-traumatic Septic arthritis
                      Crystal athropathy
                      Cellulititis
                      Bursititis

Assessment of the Knee

Relevant History


If non-traumatic
Consider: How long
               Pre-existing condition
               Occupation
               Alcohol, diuretics, cytotoxics
If traumatic
Consider: Mechanism of injury
               Popping sensation
               Immediate effusion
               Immediate weight bearing

Examination

Expose, supine position, reassure fears
Neurovascular compromise

Look: Effusion, masses, patella, erythema, muscle mass

Feel: Warmth, tender joint line, MCL/LCL tenderness, patella apprehension test, bursae

Move: Range of movement, stress testing (Valgus, varus, anterior draw, pivot shift, McMurray)

Investigation

X-rays  AP and lateral
           Avulsion fractures, fluid in suprapatellar pouch, fat-fluid levels
           Follow Ottawa guidelines for traumatic injury

Ottawa Guidelines for traumatic knee injuries (JAMA 1997)

1) Patients >55 yrs of age (pathological # ?)
2) Tenderness at head of fibula
3) Isolated patella tenderness
4) Inability to flex to 90 degrees
5) Inability to weight bear for 4 steps

Pittsburgh Rules

Any blunt trauma or fall plus
1) Age <12 or >50
2) Inability to weight bear for 4 steps

Pathophysiology of knee injuries

Grade 1: Stretching but no tearing of ligament, local tenderness, minimal oedema, no gross instability.

Grade 2: Partial tears of ligaments, moderate local tenderness, and mild instability with stress testing, moderate incapacity.

Grade 3: Complete tear of ligaments, discomfort with manipulation, variable oedema, clear instability with testing.

Meniscal injury

Pre-patella bursitis

Don't aspirate.  Treat exactly as olecranon bursitis.

Osgood-Schlatter disease

Patella dislocation

Chondro-malacia patellae

Mr Calder's Knee Injury Clinic

Definition:

A dedicated clinic for the assessment and treatment of acute knee injuries.

Clinical presentation :

Suitable cases might include:-

Locked knees

Acute Haemarthrosis following injury

Injuries where there is clinical suspicion of intra articular fragments eg osteochondral fracture after patella dislocation.

Medial collateral ligament injuries grade 2 (partial) or 3 (complete)   

Inappropriate referrals might include:-

Other fractures about the knee, eg tibial plateau or distal femur fractures.

Acute exacerbations of osteo or rheumatoid arthritis.

Suspicion of septic arthritis.

Other knee conditions requiring urgent admission.

Recurrence of known problems for which patient is already under specialist care.

Booking:

The idea is to have direct access booking through A & E reception. This will be accessible to A & E medical staff, acute knee physiotherapists and orthopaedic surgeons.

Knee injuries may still be referred to the Trauma clinic in the usual fashion if preferred.

If you have any queries about booking, please contact Carol Kirby (details below) for more information.

Location and timing:

The KIC will be held at the LGI, main Orthopaedic Out-Patient Department, on Wednesday afternoons from 2 pm onwards.

The clinic will be cancelled if there is no one available to staff it.

Clinicians:

The Consultant lead for this clinic is Mr Stuart Calder.

The staffing of the KIC is still evolving but initially will be run by Mr Calder. Mr Venkatesh, Mr Lawton and Mr MacDonald may become involved to varying degrees and sometimes patients may be seen by a Senior Registrar or Knee Fellow

THE CLINIC WILL BE CANCELLED WHEN THERE IS NO ONE AVAILABLE TO STAFF IT.

Contact details:

Carol Kirby          ext. 24775 Fax 24585  

 

3.5.12 Lower Leg

SITE OF INJURY

LOOK OUT FOR

1e MANAGEMENT

DISPOSAL

# shaft tibia

skin injury, arterial injury, nerve injury, compartment syndrome

if grossly displaced, urgent MUA

TCI Ortho

# shaft fibula

other #

BK POP, or DTG

Next #C

# neck of fibula

nerve damage

PTB POP

Next #C

 

Pre-tibial lacerations.

These are common in the elderly and those on steroids

Calf pain

 

Achilles tendon injury

3.5.13 Ankle/Foot Injuries

X-ray according to Ottawa Guidelines, which specify definite bony tenderness of the