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Induction Book 2 – Ortho

Author: Abhinav Singh / Editor: Charlotte Davies / Codes: CAP33 / Published: 31/07/2018

With the advent of urgent care centres, your exposure to orthopaedics won’t be what it used to be. However, if you follow some of the basic tips here, your orthopaedic surgeons and patients will be happy!

Bones have been healing for longer than orthopods have been around. There are two types of fixation- with absolute and relative stability which affects the mechanism of bone healing. The general rule is that all displaced fractures should be “reduced” (either open or closed) and then held in position through plaster of paris casts or plates/screws/intra and extramedullary fixation devices until healed.

First up is “should I x-ray”? If you’re not sure, have a chat with your senior. There are some decision tools to help you look at the ankle, knee and c-spine. Generally, we don’t x-ray toes, as the management doesn’t alter, and we x-ray the pelvis of every frail patient who falls.

All fractures

Prior to referring always comment on neurovascular status, ensure that the joint above and below is examined and imaged.

Document when the patient last ate or drank.

Consult seniors in the emergency department and/or radiology reporting before speaking to orthopaedics to “review” an x-ray.

Not all fractures need to be admitted into the hospital as many of these patients will be managed via the fracture-clinic pathway. Operations can be arranged via the fracture clinic, but the majority of patients need conservative management.

Specific Fractures

We’ve not covered all the fractures you’ll see here. Just the common ones. For more details, look at your Trust’s guidelines, or some of the RCEM Learning reference guides.

Colles Fracture

This is a stable fracture of the wrist, with a traditional dinner fork deformity on x-ray. It needs reducing, normally with a haematoma block, and the patient put in a Colles (Below elbow) backslab with fracture clinic follow up. Smiths and Bartons fractures are managed similarly speak to your ED senior.

Proximal Humerus

Fractures in the elderly without associated joint dislocation and gross rotational deformity can be managed with collar & cuff and be seen in fracture-clinic. Midshaft humerus fractures require a U-slab and discussion with the ortho SHO. Some of these may be suitable for conservative management some need an operation.

Clavicle

Surgical management depends on the fracture location (medial, midshaft, lateral), pre injury function, neurovascular injury and the state of the overlying skin. If there is any neurovascular injury and/or open fractures surgical fixation is needed. If neither is present, place the affected side into a Polysling and refer for outpatient management.

Femur

You will see a lot of neck of femur fractures (NOFs), and most departments have a fractured neck of femur pathway. These patients require an ECG, chest xray, baseline bloods (including 2x group and save) and fascia iliaca block to be done in the emergency department, prior to referring to the T&O SHO.

Ankle

Extremely common. Fracture/dislocations are reduced swiftly in the emergency department if the ankle looks wobbly, let your senior know ASAP! Ankle fractures need immobilisation have a look at the Weber catagory to see if they need a boot, or a plaster of paris. Most trusts agree that tubigrip isn’t worth using.

Tarsal/Metatarsals

Undisplaced metatarsal head fractures are generally managed conservatively with protected weight-bearing. However, pay close attention to the clinical history. Lisfranc fractures can be easily missed, if not considered.

Other Diagnoses

Open fractures

Administer prophylactic antibiotics, consider tetanus, mini-washouts outside the operating theatre are not indicated, as per BOAST guideline.

Septic arthritis

Consider this diagnosis in any patient with an acute joint swelling in association with being clinically unwell and inability to weightbear. Joint aspirate may be indicated but a negative tap does not rule out a septic joint. Clinical history and correlation is paramount.

Necrotising fasciitis

These patients are generally extremely unwell. LRINEC criteria can be used to score these patients however, clinical judgement is most important. Escalate these patients urgently to your seniors with prompt involvement of intensive care is mandated but immediate surgical consultant for potential operative debridement is key.

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