Fracture assessment and management

Fracture assessment and management

Jun 13, 2018 0
emergency,onthepods,Orthopaedics,radiology,rheumatology

Musculoskeletal injuries represent a significant proportion of presentations to the Emergency Department. In this podcast, James talks with Dr Nicholas Maluga about the initial fracture assessment and management priorities for patients with trauma and fractures.

Summary Writer:  Dennis Neuen

Script Writer: Dan Heitman

Editor:  Nicholas Maluga

Interviewee: Nicholas Maluga

About Dr Nicholas Maluga

Dr Nicholas Maluga graduated from the University of Tasmania in 2009 with a double degree of Bachelor of Medical Science and Bachelor of Surgery. He completed his internship and resident years at the Monash Medical Centre in Melbourne and relocated to Sydney to complete his Masters of Surgery from University of Sydney in 2013. Since then, Nick has been working as an Orthopaedic Registrar at St Vincents Hospital, John Hunter Hospital and is currently at Nepean Hospital.

Nick is currently working to complete his second Masters of Clinical Epidemiology from University of Newcastle. His early research interests were in Paediatric Orthopaedics and he completed and presented at the Australian Orthopaedic Association meeting a large research project which looked into physiotherapist led screening for Developmental Dysplasia of the Hip in newborns. Nick’s current research interest lies in utilising technologies to deliver and streamline healthcare and physiotherapy access to remote areas.

Fracture assessment and management

With Dr Nick Maluga, Orthopaedic Registrar, Nepean Hospital, Sydney, Australia

Introduction

Up to 70% of all Emergency Department (ED) presentations are musculoskeletally related. All junior doctors will have significant exposure to fractures, whether in ED or on an Orthopaedic rotation. It is essential to have a basic understanding of initial assessment and the management priorities in patients with trauma and fractures.

Case 1

You are working in the ED as a junior doctor and you’re told about the next patient, a “29-year-old male, high-speed trauma, obvious deformity to left leg, splint administered by paramedics.” What is your approach?

  • Based on Early Management of Severe Trauma (EMST) principles: ABCDEFG
    • Airway maintenance with cervical spine stablisation
    • Breathing and ventilation
    • Circulation and haemorrhage control
    • Disability
    • Glucose – DEFG ‘don’t ever forget glucose’
  • Remember to expose patient
  • Quickest way to assess the ABCs is to talk to the patient
    • If they are responsive and verbalising; then airway, breathing and circulation likely intact
  • History – AMPLE
    • Allergy and tetanus (ADT vaccine) status
    • Medications – potential interactions, cause for presentation
    • Past medical history – underlying cause for presentation
    • Last meal/drink – fasting status important for potential surgery
    • Events leading up to presentation
  • Examination
    • Closed or open injury?
    • Neurovascular examination
      • Distal to injury
        • Target major nerve distributions
        • Pulses
        • Temperature and capillary refill
        • Ultrasound – useful to assess circulation
  • Identify film – right patient and location
  • Type of fracture
    • Incomplete
      • Greenstick
      • Bowing – typically paediatric populations
    • Complete
      • Transverse
      • Oblique
      • Spiral
      • Comminuted
  • Location
    • Which bone (e.g. femur) and specific part (shaft, head vs. epiphysis, diaphysis)
  • Displacement
    • Angulation – distal fragment comparatively to proximal fragment
    • Translation – translation along proximal fragment
    • Rotation
    • Distraction (lengthened)
    • Impaction (shortened)
  • Immobilisation/splinting is key in management, especially for analgesia (quick and easy)
  • Prevent further damage to structures surrounding fracture – reduce inflammation, fat embolism, oedema
  • Splinting should be above and below the joint
  • Partial splint (backslab) is preferred to complete splint (circumferential casting)
    • Gustilo open fracture classification system
      • Scores I to IIIC
      • Increasing scores represents worse outcomes
  • Clean wound – keeps wound moist, reduce infection
  • Irrigation is controversial
    • Can be done to reduce bacterial load
    • But if wound appears clean, may not need to be done (as can cause damage)
  • Photography of wound useful as can both monitor progress and also minimse need for re-dressing and stress to patient, provided consent obtained
  • Pain out of keeping with injury is highly suspicious for compartment syndrome
    • E.g. 10/10 pain persisting after opioid administration
  • Risk in both open and closed fractures
  • Devastating clinical damage if not picked up – surgical emergency, clinical diagnosis
  • Monitoring compartment pressures
    • More indicated when patient is intubated or in ICU and clinical examination with “5Ps” not possible
  • “5Ps”
    • Pain (to passive stretch)
    • Paralysis
    • Paraesthesia
    • Palpable swelling (wood hard swelling)
    • Pulses (absent – normally too late)
  • Management: emergency surgery for fasciotomy
  • Complication: gangrene, necrosis, rhabdomyolysis, acute kidney injury, amputation, sepsis, death
  • Immediate: swelling, loss of function, hypovolaemic shock, pain
  • Early: neurovascular, visceral, soft tissue injuries, haemothorax, compartment syndrome, wound infection, joint injury, emboli
  • Long term: Malunion, non-union, osteomyelitis, ischaemic contractures from missed compartment syndrome, avascular necrosis (non-long bones – scaphoid and femoral head)
  • Systematic approach will ensure you do not miss anything
  • Know your anatomy, understand what structures can be damaged
  • Show initiative – ask for help early

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Tags: #compartment syndrome,#emergency departement,#fracture assessment,#fracture management,#Fractures,#musculoskeletal,#orthopaedic,#Orthopaedics,#physiotherapy,#radiology,#radiopaedia,#surgery,#trauma,#trauma management,#X-ray

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