Fracture Management Guidelines Fracture Management

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Clyde Emergency DepartmentsFracture Management GuidelinesFracture ManagementGeneral AdviceThis guide gives brief advice about the management of common fractures presenting toED. Where there is uncertainty, discuss cases with senior medical staff or consult thevariety of orthopaedic and emergency medicine textbooks available in ED.There is afracture clinic held Monday-Friday at RAH and IRHEmergency referral of all orthopaedic cases should be made to the orthopaedic FY2 atRAH and the on call orthopaedic registrar at IRH.Paediatric fractures requiring emergency orthopaedic discussion and assessmentshould be discussed with senior doctors. Sometimes it is appropriate to refer directly tothe ortho registrar at RHC if requiring manipulation / operative treatment. Generally wedo not sedate children for fracture manipulation in ED. Non-operative cases can bereferred to the local orthopaedic receiving team.In general terms, fractures can be categorised in four ways:Fracture TypeDISCHARGABLEVFC REFERRALEMERGENCYREFERRALSOCIAL REFERRALFeaturesSome fractures can be dischargedfrom ED with appropriate advice.Advice leaflets are available on CEMwebsite for these casesFractures requiring POP cast orspecific orthopaedic review. Patientsshould be given follow-up advice forthe VIRTUAL FRACTURE CLINICFractures requiring discussion withand advice from the receivingorthopaedic service to determine ongoing managementFractures which result in significantfunctional impairment for the patientsufficient to preclude them frommanaging at homeExamplesLittle metacarpal #5th Metatarsal #Radial head #Colles #Lateral maeollus #Fibula neck #Neck of femur #Ankle # with talar shiftTibial plateau #Pubic ramus #Neck of humerus #Virtual Fracture Clinic (VFC)Patients requiring referral to the virtual fracture clinic should be provided with a VFCadvice leaflet and they should then make an appointment at reception prior to leaving.Virtual fracture clinic discharge checklist1. Patient has adequate analgesia prescribed2. Appropriate initial treatment (splintage/cast/sling) has been given3. Patient has telephone contact details4. Patient provided with VFC leaflet (on CEM)5. Patient makes a VFC appointment at reception6. Patient understands that they will be contacted the following working day1

Clyde Emergency DepartmentsFracture Management GuidelinesExamination TipsThere are some key points to remember during the clinical examination of all patientspresenting with a fracture.LOOK Comment on obvious deformityAssess for adequate local skin perfusion/discolourationFEEL Assess distal circulationAssess for distal sensory functionFeel for local crepitusMOVE Move the joint above and below the injuryComment on both active and passive movementADDITIONAL Upper Limb Injures- Ask about HAND DOMINANCE and occupationLower Limb Injuries- Document weight bearing abilityX-rays NEVER request an x-ray prior to examining the patientRequest the CORRECT x-rays- it is unfair to assume the radiographer will knowwhich x-rays are required- they have not examined the patientCertain injuries require SPECIFIC VEIWS- these are discussed during thedescription of the relevant injury- in the event of uncertainty- ask before sendingthe patient to x-rayIn most cases- TWO views are required. Where a single view is acceptable- thisis described in the context of the relevant injury.As a guide:TWO VIEWS- AP and LateralTWO JOINTS- Above and below the injury in long bone fracturesOpen FracturesManagement of open fractures is as follows: Irrigate wound with saline Saline soak dressing IV Antibiotics- 1.5g IV Cefuroxime Assess tetanus status Appropriate fracture management (POP/Splint) Refer to on-call orthopaedics2

Clyde Emergency DepartmentsFracture Management GuidelinesUpper Limb InjuriesSterno-Clavicular Joint DislocationDiagnosis made on CHEST X-RAY. Assess for joint asymmetery.Clinical examination used to differentiate type of dislocation.Anterior DislocationClavicle is more prominent on palpation over the anterior chest wallManage with a broad arm sling and fracture clinic follow-upPosterior DislocationThere is a palpable depression on the anterior chest wallPerform ECGRefer to on-call orthopaedics.Clavicle FractureIn suspected clavicle fractures, request a CLAVICLE X-RAY. One view is adequateTypically, the fracture is found in the middle thirdDISCHARGE CHECKLISTü Assess for skin tenting (if present refer to orthopaedics)ü Assess upper limb neurovascular statusü Broad arm slingü Ensure appropriate analgesiaü Ensure safety for dischargeü VFCAcromio-Clavicular (AC) JointIf AC joint injury is suspected, X-rays of BOTH AC joints are required for comparison.GRADEFEATURESINo asymmetry on xray.Clinical diagnosisIISubluxation on x-rayJoint capsule remainsintactIIIAC andcoracoclavicularligaments tornJoint capsule disruptedMANAGEMENTBroad-Arm sling for 2-3daysAdequate analgesiaEARLYMOBILISATIONDischarge to GPBroad-Arm sling for 2-3daysAdequate analgesiaEARLYMOBILISATIONDischarge to GPMay require weightbearing viewsBroad-arm slingRefer to fracture clinic3

Clyde Emergency DepartmentsFracture Management GuidelinesScapula FracturesRequest SCAPULA X-RAYCommon injury in frail elderly patientsAn isolated fracture of the scapula is uncommon and is often associated with chest wallinjury and underlying pulmonary traumaAssess and document WINGING of the scapula- This is caused by an injury to serratusanterior and requires out-patient orthopaedic follow-upDISCHARGE CHECKLISTü Satisfactory respiratory observations and examinationü Broad arm slingü Ensure adequate analgesiaü VFCAnterior Shoulder DislocationOne view (AP) is satisfactory to diagnose anterior shoulder dislocationManagement of suspected shoulder dislocation:IV Access IV Morphine Assess and Document Axillary Nerve Function (badge patch)Request x-rayDislocation?YESNOTransfer to ResusAdequate monitoringTwo doctors presentSedateAttempt reductionAlternative diagnosisBroad arm slingAdequate analgesiaDischargePost-attempt x-rayAssess and document post attempt axillary nerve functionYESPolyslingAxillary PadEnsure adequate analgesiaEnsure safe for dischargePost sedation adviceVFC follow-upReduced ?NOEnsure adequate analgesiaPolylsing for comfortRefer on-call orthopaedics4

Clyde Emergency DepartmentsFracture Management GuidelinesAnterior Shoulder Dislocation with associated fractureAnterior shoulder dislocation often associated with a fracture of the greater tuberosity ofthe humerusFracture SiteUndisplaced greater tuberosityfractureGreater tuberosity fracture displaced 1cmFracture neck of humerusAction RequiredAttempt reductionRefer to on-call orthopaedicsDo not attempt reductionRefer to on-call orthopaedicsDo not attempt reductionPosterior Shoulder DislocationUncommon diagnosis- 1:20 of shoulder dislocationsAssociated with seizure and electrocutionClinical features Arm held in internal rotation Reduced active external rotation Assess and document axillary nerve functionX-ray findings AP View is often normal Assess for “light-bulb” sign on AP view Easier to diagnose on “Y”-ViewManagement Attempt reduction in ED If successfully reduced- give polysling and ensure adequate analgesia. VFCIf reduction unsuccessful- refer to on-call orthopaedicsNeck of Humerus FractureCommon injury in elderly patients with underlying degenerative bone diseaseRequest a HUMERUS X-RAYDISCHARGE CHECKLISTü Assess and document upper limb neurovascular statusü Ensure adequate analgesiaü Ensure suitable for dischargeü Collar and cuffü VFCShaft of Humerus FractureUsually associated with a rotational injury (such as arm-wrestling)Common in metastatic bone diseaseRequest a HUMERUS x-rayExaminationSignificant deformityAssess and document radial nerve function (active wrist extension and sensation in theweb-space between thumb and index finger)5

Clyde Emergency DepartmentsFracture Management GuidelinesManagementType of FractureTwo-PartThree or More PartsManagementHumeral bracePost application x-rayAdequate analgesiaFracture clinic- next clinicHumeral bracePost application x-rayAdequate analgesiaRefer to on-call orthopaedicsElbow and Forearm InjuriesElbow DislocationClinical Features Gross deformity Loss of characteristic “triangular” appearance over posterior aspect of elbow Assess and document distal neurological function (Beware MEDIAN nerve)NERVEMOTOR FUNCTIONSENSORYFUNCTIONMEDIANThenar Eminence ofthumbAdduction on MCPJFlexion of MPCJOppositionActive wristextensionRadial border ofindex fingerRADIALULNAR Intrinsic handmuscles- abductionand adduction ofMCPJWeb-space betweenthumb and indexfingerUlnar border of littlefingerAssess and document distal vascular functionIV Access and IV morphine prior to x-rayImmobilise in broad-arm slingX-Ray Findings Request ELBOW X-RAY Usually olecranon dislocates posteriorly Assess for associated fracture- especially radial head/neck and coronoidprocessIn case of fracture-dislocation- refer to orthopaedics, DO NOT attempt reduction in ED.There is a significant danger of ingress of fracture fragments into the joint.6

Clyde Emergency DepartmentsFracture Management GuidelinesManagement Transfer to resus Adequate monitoring Consent for procedural sedation Two doctors present Sedate Reduce- usually with longitudinal traction and slight flexion Assess and document distal neurological function post-reduction Long-arm backslab (apply BEFORE post reduction x-ray as reduced joint isoften unstable) Post-reduction x-ray Refer to on-call orthopaedics.Even if reduced- patients are often admitted for elevation and circulation, sensation andmovement check as there is a significant incidence of neurological deficit associatedwith swelling.Distal Humerus FractureClinical Features Not generally associated with gross deformity Reduction in active elbow movement- especially reduced flexion Assess and document distal neurological function Assess and document distal vascular functionFractures may be SUPRACONDYLAR or INTRA-ARTICULARX-ray findingsFractures can be subtle.Supracondylar fractures are seen on the lateral elbow viewANTERIOR HUMERAL LINEDraw a straight line down the anterior aspect of the distalthird on the humerusAt least ONE-THIRD of the capitellum must lie IN FRONT ofthis lineAn abnormal anterior humeral line indicates posteriorangulation of a supra-condylar fractureManagement Ensure adequate analgesia Long-arm backslab Check neurological and vascular status post backslab application Refer to on-call orthopaedics7

Clyde Emergency DepartmentsFracture Management GuidelinesBEWARESupra-condylar fractures are associated with BRACHIALARTERY injuryArterial Occlusion results in VOLKMANN’s CONTRACTUREresulting in necrosis of forearm tissueAssess and documentBRACHIAL PULSERADIAL PULSEULNAR PULSEOlecranon FractureClinical Features Gross deformity Palpable “gap” over the olecranon Loss of triceps function- unable to actively extend elbow Assess and document distal neurological function Assess and document distal vascular functionX-ray Findings Request ELBOW X-ray Obvious gap in olecranon best seen on LATERAL viewManagement Ensure adequate analgesia Long arm back-slab and broad arm sling Refer to on-call orthopaedicsOlecranon fractures are generally operatively repaired using a tension band wire asthere is a significant association with functional impairment and non-unionRadial Head/Neck FracturesOften result from a fall onto an out-stretched handClinical Features Not commonly associated with deformity Flexion and extension and usually preserved Reduced pronaiton and supination of the hand Assess and document distal neurological function Assess and document distal vascular functionX-Ray Findings Radial neck fractures are best seen on LATERAL view Radial head fractures are best seen on AP view8

Clyde Emergency DepartmentsFracture Management GuidelinesRADIAL-CAPITELLAR LINEOn the lateral x-ray a line drawn through the middleof the shaft of the radius must pass through thecapitellumDisruption of this line indicates dislocation of theproximal radio-ulnar joint.ManagementType of FractureInitialManagementRadial head- 33% ofarticular surfaceBroad arm slingAdequate analgesiaRadial head- greaterthan 33% of articularsurfaceRadial neck- less than15 angulationBroad arm slingAdequate analgesiaRadial neck- greaterthan 15 angulationBroad Arm SlingAdequate analgesiaBroad arm slingAdequate analgesiaFollow-UpDischargeAdvice leaflet form CEM websiteEARLY MOBILISAITONVirtual Fracture Clinic follow-upDischargeAdvice leaflet form CEM websiteEARLY MOBILISAITONVirtual Fracture Clinic follow-upJoint EffusionPatients with clinical findings consistent with a radial head fracture who do not have anobvious fracture on x-ray but have evidence of joint effusion (“fat-pads”) on their x-rayshould be managed with: Adequate analgesia Broad Arm Sling Advice leaflet from CEM websiteFAT PADS“Fat-Pads” are seen on lateral elbow x-ray.An anterior fat pad can be a normal variant but if elevated(“sail-sign”) this is more suggestive of an intra-articularfracturePosterior fat pads are always pathological9

Clyde Emergency DepartmentsFracture Management GuidelinesForearm FracturesTwo eponymous fractures of the forearm exist.The forearm is a ring structure so will often disrupt in more than one place.Clinical Findings Deformity of forearm Reduction in active range of elbow and/or wrist movement Assess and document distal neurological function Assess and document distal vascular functionX-Ray Findings Request RADIUS and ULNA x-ray If suspicious on MONTEGGIA fracture/dislocation (see below) may needdedicated LATERAL elbow viewFACTURENAMEX-RAY e of ulnar shaftand dislocation ofproximal radial-ulnar joint(Abnormal radialcapitellar line)Fracture of radius withdislocation of distal radialulnar jointAdequateanalgesiaLongarm backslabBroad Arm SlingRefer to on-callorthopaedicsAdequateanalgesiaLongarm backslabBroad Arm SlingRefer to on-callorthopaedicsGALEAZZIShaft of Ulna FractureTypically affects the middle third of the ulna“Night-stick” fracture- resulting from a direct blow on the forearm when the patientraises their arm to protect their faceClinical Features Forearm deformity Palpable step and/or crepitus over ulnar aspect of forearm Assess and document distal neurovascular function- especially ULNAR NERVEX-Ray Findings Request RADIUS and ULNA x-ray Pay particular attention to the LATERAL elbow x-ray and the RADIALCAPITELLAR line. Fracture of the ulna is often associated with a MONTEGGIAfractureManagement Ensure adequate analgesia Long-arm back-slab Broad arm sling VFC10

Clyde Emergency DepartmentsFracture Management GuidelinesWrist InjuresColles FractureTypically follows a fall on an out-stretched handCommon in elderly patients with associated degenerative bone diseaseClinical FeaturesDeformity- typically described as “dinner-fork” with swelling to the dorsal surface of thewristAssess for distal neurological function- especially MEDIAN NERVENERVEMOTOR FUNCTIONSENSORYFUNCTIONMEDIANThenar Eminence ofthumbAdduction on MCPJFlexion of MPCJOppositionActive wristextensionRadial border ofindex fingerRADIALULNARIntrinsic handmuscles- abductionand adduction ofMCPJWeb-space betweenthumb and indexfingerUlnar border of littlefingerAssess for distal vascular functionX-Ray FindingsFracture of the distal radius with dorsal angulation of the distal fragment.When assessing the x-ray comment on:Fracture FeatureX-ray to ReviewClinical featuresIMPACTIONAP ViewANGULAITONLateral ViewRadial styloid shouldbe 1cm distal to ulnarstyloidIn the NORMAL x-raythe joint line tipsforward by 5 .11

Clyde Emergency DepartmentsFracture Management GuidelinesAssessing AngulationStep 1- Draw a line through the middle of the distal radiusDORSALDISTALPROXIMALNEUTRALPOSITION (0 )VOLARStep 2- Draw a line across the articular surface of the distal radius- this line willnormally tip “forward” by five degreesDORSALNORMAL WRISTTILTS “FORWARD” BY5 DISTALPROXIMALNEUTRALPOSITION (0 )VOLARStep Three- If the fracture angulated by more than 15 degrees (so tilts “backwards” by10 degrees it will require manipulationDORSALIF FRACUTRE TILTTSBY MORE THAN 10DEGREES- REFERNORMAL WRISTTILTS “FORWARD” BY5 PROXIMALDISTALNEUTRALPOSITION (0 )VOLAR12

Clyde Emergency DepartmentsFracture Management GuidelinesManagement Ensure adequate analgesia Apply wrist splint Broad arm sling Patients NOT requiring manipulation should be referred to the virtual fractureclinicIndications for manipulation1. Displacement of ulnar styloid2. Impaction resulting in radial styloid being less than 1cm distal to ulnarstyloid3. Angulation where joint line tips backwards by greater than 10 (15 fromnormal position)4. Distal neurological deficit on examinationColles fractures are manipulated to preserve function. The threshold for manipulation ispatient dependent. Patients who are unfit for GA can have their fracture manipulatedunder procedural sedation. All patients requiring manipulation should be referred to theon-call orthopaedic service.Smith’s FractureSometimes called a “Reverse” CollesFracture of distal radius with volar angulation of the distal fragmentClinical FeaturesFall onto a flexed wrist, clinical deformityAssess distal neurological function especially MEDIAN nerveX-ray FindingsLateral x-ray shows a fracture with VOLAR angulation of the distal fragment.ManagementThese are inherently unstable injuries and require referral to the on-call orthopaedicserviceElevate and apply a Colles backslabBarton’s FractureIntra-articular fracture of the distal radiusVolar angulation of the distal fragmentClinically unstableRefer to on-call orthopaedicsScaphoid InjuryThe scaphoid is one of the carpal bones, situated on the proximal of the two rows of thecarpal bones and found on the radial aspect of the wrist.The scaphoid id palpated in the “Anatomical Snuff Box”- ASB- An area found at thebase of the thumb metacarpal and bordered by the tendons of: Extensor Pollicus Longus Abductor Pollicus Longus/Extensor Pollicus BrevisScaphoid fractures are associated with avascular necrosis owing to the nutrient bloodsupply entering the bone distally.The scaphoid comprises:13

Clyde Emergency DepartmentsFracture Management Guidelines Proximal Pole (site of avascular necrosis) Waist (commonest site of fracture) Distal PoleThe distal pole of the scaphoid forms part of the articular surface of the wrist.Avascular necrosis of the proximal pole predisposes the patient to chronic wrist pain,stiffness and limitation of functionClinical Features Fall onto an outstretched hand Tender over anatomical snuff box Tender at base of thumb when thumb is “telescoped” (pulled out to length) Tender to palpate scaphoid- especially on volar aspect of wrist Assess for distal neurological and vascular functionX-Ray Findings Request SCAPHOID views Fractures are most commonly seen on thewaist of the scaphoid It is comparatively to see scaphoid fractures on initial x-raysBEWAREScaphoid views should ONLYbe requested where there is aclinical suspicion of a scaphoidinjury.Negative x-rays require thepatient to have their wristimmobilised and follow-upManagement of Scaphoid InjuriesX-RAY FINDINGSSCAPHOIDFRACUTRENO FRACTURESEENINITIAL MANAGEMENTFOLLOW-UPSplint- NO thumb extensionBroad Arm SlingAdequate analgesiaRefer to virtual fractureclinicAdequate analgesiaWrist splintBroad Arm SlingRefer to virtual fractureclinicPerilunate DislocationOften missed on lateral x-ray- suspect in high energy injuries with a normal x-rayClinical Features Deformity of dorsal surface of wrist Absent extension Assess for neurological and vascular statusX-Ray FindingsEasiest seen on LATERAL x-ray. A straight line drawn on the lateral x-ray should passthrough all three structuresLook for alignment of:DISTAL RADIUS ARTICUALAR t Colles backslab Refer to on-call ortho for MUA 14

Clyde Emergency DepartmentsFracture Management GuidelinesHand Fractures Hand fractures are managed symptomatically with the priority being on themaintenance and early restoration of function.Comprehensive assessment is necessary to ensure that functional status ispreserved and injuries where function may be compromised are identified andappropriately treatedIn general terms, hands should be immobilised for the least duration possible asprolonged splintage encourages stiffness and limits functionIt is of paramount importance that hand injuries are ELEVATED. This will reduceswelling and encourage early mobilisation thereby facilitating early restoration offunctionDocumentation DOMINANCE must be documented (which hand the patient writes with) OCCUPTION should be documentedHand ExaminationHand surfaces are described as PALMAR and DORSALThe borders of the hand are RADIAL and ULNARDigits have names: THUMB, INDEX, MIDDLE, RING, LITTLENeurological ExaminationNERVEMEDIANRADIALULNARMOTOR FUNCTIONSENSORY FUNCTIONThenar Eminence of thumb Radial border of index fingerAdduction on MCPJFlexion of MPCJOppositionActive wrist extensionWeb-space between thumband index fingerIntrinsic hand musclesUlnar border of little fingerabduction and adduction ofMCPJDigital nerves are examined by assessing sensation of the RADIAL and ULNAR borderof each finger.Hand X-RaysIf the palmar surface of the hand is injured then HAND X-RAY should be requested.For finger injuries a dedicated FINGER X-RAY of each affected digit is necessary (evenif this means 5 separate films)For metacarpal injuries a LATERAL HAND X-RAY is required15

Clyde Emergency DepartmentsFracture Management GuidelinesThumb Metacarpal FractureThese are generally unstable and associated with significant functional impairmentSuspected thumb metacarpal fractureAssess sensation to RADIAL and ULNAR border of thumbAnalgesia and high elevation slingRequest thumb x-rayFRACTURE?YESApply BENNETT’S castHigh Elevation SlingAdequate AnalgesiaVirtual fracture clinicNOWrist Splint withThumb ExtensionAdequate analgesiaEarly mobilisationEnsure no UCL injuryBEWAREBENETT’S FRACUTREIntra-articular thumb metacarpal fracture involvingthe carpo-metacarpal joint Apply Bennett’s CastHigh Elevation SlingREFER ON-CALL ORTHOPAEDICSMetacarpal Shaft Fracture- Index-Little fingersPatients with a metacarpal shaft fracture require a LATERAL HAND X-RAY to assessthe degree of angulationOften the radiographer will provide this view when they identify this injury on the AP oroblique x-ray but you must ensure that it has been taken prior to discharging patientIndex/Middle/Ring/ Little Metacarpal Shaft FractureEnsure True Lateral Hand X-rayAngulation greater than 20 YESVolar Slab and Buddy Strapaffected fingersHigh elevation slingAdequate AnalgesiaON-CALL ORTHONOBuddy Strap affected fingersHigh elevation slingAdequate AnalgesiaVFC16

Clyde Emergency DepartmentsFracture Management GuidelinesBoxer’s FractureThis is a fracture of the little metacarpal neck- often associated with a punch injuryIt is essential to examine for and document ROTATIONAL DEFORMITYASSESSING ROTATIONAL DEFORMITYAsk the patient to make a fistEnsure that none of the fingers overlap or turn under each otherDOCUMENT your findings asNO ROTATIONAL DEFORMITYROTATIONAL DEFORITY OF xxxx FINGERRotational deformity requires ORTHOPAEDIC REFERRALAngulation will often correct with remodelling- rotationaldeformity NEVER will correctLittle finger metacarpal neck fracture on x-rayRotational DeformityYESBuddy strap ring and littlefingersHigh elevation slingAdequate analgesiaREFER ON-CALL ORTHONOBuddy strap little and ringfingers- 2-4 WEEKSHigh elevation slingAdequate analgesiaEarly MobilisationDischarge advice leafletBEWAREBoxer’s fractures are often associated with a wound found on thedorsal surface of the hand over the little MCPJYou must ask explicitly if this injury was caused by punching athird party in the mouth (patients are sometimes reluctant to admitthis stating for example that they “punched a wall”)If this was sustained by punching a third party in the mouth- a“fight bite” injury1. Infiltrate would with local anaesthetic2. Scrub and irrigate wound3. Prophylactic antibiotics- CO-AMOXICAV 375mg tid4. BBV Screening- Often need accelerated Hepatitis BVaccine Course5. Ask about tetanus status17

Clyde Emergency DepartmentsFracture Management GuidelinesFractures of Index/Middle/Ring Metacarpal Neck/HeadLess common than little metacarpal head/neck fracturesStandard AP and OBLIQUE x-rays of the hand are adequateIf rotational deformity- REFER ON-CALL ORTHOPAEDICSNo rotational deformity present then:ü Buddy strap affected and adjacent fingerü High elevation slingü Adequate analgesiaü Virtual fracture clinicProximal and Middle Phalangeal FracturesSuspected proximal or middle phalangeal fractureAssess and document ROTATIONAL DEFORMITYRequest FINGER x-rayProximal or middle phalangeal fracture /- rotational deformityYESBuddy strap affected and adjacentfingersAdequate analgesiaHigh elevation slingVirtual Fracture ClinicNOBuddy strap affected andadjacent fingersAdequate analgesiaHigh elevation slingEarly mobilisationDischarge- No follow-upDistal Phalangeal FractureThese are often associated with a crush injury and nail-bed wound.These do not require antibiotics even if open. Irrigate, close wound, buddy strap.Dislocated fingerFingers typically dislocate in a dorsal/palmar plane. Deformed fingers with radial/ulnarangulation are usually fractured with associated collateral ligament injuryReducing a dislocated fingerGenerally the dislocation will be dorsal1. Ensure the finger is anaesthesised2. Palpate the dislocated articular surface on the dorsal aspect of the finger3. Whilst applying GENTLE traction to the finger- push the articular surface distally backinto joint4. It will be clinically apparent when the dislocation is reducedWhere the dislocation is associated with a fracture- reduction should still be attempted18

Clyde Emergency DepartmentsFracture Management GuidelinesSuspected dislocated fingerAssess and document sensation on radial and ulnar border of fingerInsert digital nerve “ring” blockHigh elevation slingRequest FINGER x-rayDISLOCATION?YESReduceRepeat x-rayConfirm reductionBuddy strapHigh elevation slingAdequate analgesiaVIRTUAL FRACTURE CLINICNOBuddy strap affectedand adjacent fingersHigh elevation slingAdequate analgesiaEarly mobilisationDischarge-no follow upDislocated Meta-Carpal phalangeal jointThese injuries are generally difficult to reduce owing to the difficulty in achievingadequate local regional anaesthesia.They are also associated with moderate to severe functional impairment.ü Diagnosed on AP and oblique and x-raysü High elevation sling and adequate analgesiaü Refer to on-call orthopaedics.Hand InjuriesUlnar Collateral Ligament RuptureThis is sometimes called Gamekeeper’s or Skier’s thumbThe ulnar collateral ligament is part of the stabilisation mechanism of the thumbmetacarpal phalangeal joint.It is of vital functional importance in providing stability of the pincer grip between thumband index fingersAssociated with hyper-abduction injury of the thumb metacarpal phalangeal jointUlnar collateral ligament rupture is a functional disasterAdopt a low threshold of suspicion for this injury in any patient with a painful thumb andan associated relevant mechanism of injury19

Clyde Emergency DepartmentsFracture Management GuidelinesExamining UCL1.2.3.4.Examine the unaffected side firstStabilise the thumb metacarpal head on the radial borderMove the proximal phalanx into full ABDUCTIONAssess for demonstrable laxityIf the ligament is intact, resistance will be felt at full abductionExamination FindingsDEMONSTRABLE LAXITYUNABLE TO ASSESS DUE TO PAINAND/OR SWELLINGNO LAXITYManagement PlanX-ray ThumbRhizo Forte SplintAdequate analgesia and high elevation slingREFER ORTHOPAEDICSX-ray thumbRhizo Forte SplintAdeqaute analgesia and high elevation slingED Review in 5 daysX-Ray thumbWrist splint with thumb extensionAdequate analgesiaEarly mobilisation and DISCHARGEMallet InjuryMallet injury involves injury to the distal phalanx associated with disruption of the distalextensor mechanism thereby preventing active extension of the DIPJSee mallet finger guideline on CEM.20

Clyde Emergency DepartmentsFracture Management GuidelinesPelvic InjuriesPelvic injures are associated with significant trauma and high velocity injuries. In thiscontext, they will often be diagnosed and evaluated on trauma CT scan series of CTHead/Neck/Chest/Abdomen/PelvisInitial management of pelvic injuries in ED includes ABDCE assessment, adequateanalgesia and SAM splintage to minimise associated blood lossUrethral catherisation should be avoided until CT has excluded urethral injury.Symptoms include: Pelvic pain External evidence of bruising either anterior or posterior Clinical evidence of hypovolaemiaSignificant mechanism of injuryClinical suspicion of pelvic fractureManage in ResusABCDE Assessment including C-SpineIV AccessBloods including FBC and Group and SaveIV AnalgesiaApplication of SAM SplintDiscussion with radiology regarding imagingLow threshold for full body CT in context of significantmechanism of injuryRefer to Orthopaedics on CallBEWAREPelvic fractures can be associated with significant blood lossThis may be occult and in otherwise well patients may be physiologicallycompensatedPubic Ramus FractureCareful monitoring of patients cardiovascular status is necessaryFractures of the superior and/or inferior rami are comparatively common, especiallyEnsure that blood has been requested and is available for transfusionamongst elderly patients.21

Clyde Emergency DepartmentsFracture Management GuidelinesIn general terms, these fractures are managed conservativelyClinical Features Simple fall Impaired or significantly compromised mobility Anterior pelvic tenderness Reduced hip flexion and hip abductio

fracture clinic held Monday-Friday at RAH and IRH Emergency referral of all orthopaedic cases should be made to the orthopaedic FY2 at RAH and the on call orthopaedic registrar at IRH. Paediatric fractures requiring emergency orthopaedic discussion and assessment should be discussed with senior doctors. .

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