Management of Limb Injuries in Adults and Children Over 2 Years

Management of limb injuries in adults and children over 2 years
Last Review Date: March 2010

Version: 1 Page 1 of 17
Clinical Protocol
Title: Management of limb simple fractures and soft tissue Injuries in adults and
Children over 2 years
Document Author: Carol Gilmour Date March 2010
Ratified by: Care and clinical Policies
Group
Date: 17
th
March 2010
Review date: March 2012
Links to policies: TCT History taking and clinical documentation protocol, TCT
Consent Policy , TCT Child protection policy, TCT Safeguarding adults for abuse
policy, TCT Entonox PGD and TCT entonox protocol

1. Purpose of this document

1.1. To ensure registered nurses employed by Torbay Care Trust within MIU have clear
guidance on the assessment, treatment and management of limb simple fractures
and soft tissue injuries in adults and children over 2 years.

NOTE FOR CHILDREN AGED 2-5 YEARS CAUSING ANY CONCERN REFER TO A+E
FOR FURTHER ASSESSMENT

2. Presenting Symptoms
2.1. All or some of the following symptoms may be present in a patient presenting to the
MIU:
Pain, swelling, bruising/redness, wounds, inability/difficulty to weight bear,
reduced/loss of function and heat.
3. Specific recordings:
3.1 Additional history taking requirements include:
Record the mechanism
When, where and how the injury occurred and any resulting disability
Immediate /graduation of swelling
First aid treatment received including e.g. analgesics, ice, relocation of injury.
Record the pain score
Record any previous injury to the limb and relevant medical history, allergies ,tetanus
status and current medication ,especially warfarin or other anticoagulants and steroid
treatment. REFER ALL PATIENTS ON ANTICOAGULANT THERAPY TO A+E
Look for medical or non accidental causes of injury
Dominant hand


3. Clinical examination:
LOOK
Compare the limb on either side
Briefly examine the entire limb to exclude other injuries
Inspect limb for swelling, bruising or deformity or wounds

FEEL
Palpate for bony tenderness ( which usually indicates x-ray is required)
When palpating note crepitus

MOVE
Range of movement i.e. flexion and extension, abduction and adduction, supination
and pronation, internal and external rotation, thumb opposition, able to form tight
grip.

SPECIAL TESTS
Check for rotational deformity of fingers in finer/hand injuries
Always examine the neck in shoulder injuries and the pelvis in femur injuries
Examine for adequate skin perfusion, pulses, sensation and movement distal to the
injury
Check and record capillary refill
Examine for neurovascular compromise and transfer urgently to A+E if identified
For general approach to wounds see TCT wound management protocol


Radiography: Where nurses have undertaken specific training they can request x-
rays
Give a brief description of the trauma sustained and state where the suspected injury is
Request the correct views
With long bone shaft injuries always include views of the proximal and distal joints
Do not rely on poorly centred views of the suspected area, e.g. elbow in forearm views,
hip or knee in femur view
Always take views in at least two planes, at 90 where possible (not usually necessary
for the clavicle)

Where appropriately trained/experienced x-ray can be viewed and interpreted by MIU
nurse and/or advice sought from Torbay A+E medical practitioner .Clearly documenting
the name of clinician and advice given

Describing A Fracture
Closed or open
Name of the bone, left or right, and part of the bone fractured e.g. distal, midshaft,
proximal.
Type of fracture (transverse, oblique, spiral, compression, comminuted, impacted,
avulsion, greenstick)
Any intra-articular involvement
Describe any deformity in terms of displacement, tilt or rotation of the distal fragment
from the anatomical position, and state the direction of displacement (e.g. dorsal, volar,
radial, ulnar, lateral, medial, valgus, varus)
State the Grade or Classification of the fracture where common practice
Immediate Management of Any Limb Injury
Analgesia until pain score ideally below 4/10
Immobilise to minimise pain, blood loss and neurovascular damage
Elevate to minimise pain and swelling
Follow Up
Refer all fractures to the Fracture Clinic or orthopaedic team /A+E dependent on
presentation and finding as detailed below
Arrange follow-up of other injuries as appropriate by appropriate health care
professionals
GP or Practice Nurse
MIU
Physiotherapy


Management of Specific Fractures
Patients with specific upper limb fractures should be managed as below:

1
ST
MC
Significant angulation, dislocation and /or
fracture involving the joint
Refer to acute hospital
#not involving the joint Bennetts POP and check x-ray
Refer to #clinic

5
TH
MC
5th MC Neck-displaced/severely angulated,
any rotation ( lateral x-ray to measure)
Discuss x-ray with A+E team at SDHfT
Un- displaced or minor angulation DTG/crepe/neighbour strapping
Finger exercise
MIU follow up or #clinic
5
th
MC shaft-> 30 degrees angulation Discuss x-ray with A+E team at SDHfT
5
th
MC base Refer to orthopaedic team? plastics
involvement

Other MC
Displaced/multiple/angulated >30 Refer to A+E orthopaedic team? Plastics
input required

Base of MC Futura splint & refer to Plastics

Un-displaced or minor angulation

buddy strapping and refer to fracture clinic at
SDHfT
Finger exercise


All Phalanx # to Index, Middle, Ring, Little Digits
Check for rotation deformity and overlap

Angulated transverse fractures of the Proximal Phalanx may be very disabling,
if in doubt refer to A+E for medical practitioner assessment
Check base of little finger Proximal Phalanx carefully, may be difficult to see
angulation

Displaced/angulated,
comminuted (mulitfragmentary)
Refer to A+E orthopaedic team SDHfT

Un-displaced

Digit Phalanx -Buddy strapping
Thumb Phalanx Elastoplast thumb spica.
If laxity at 1st MCPJ - Refer to A+E
orthopaedic team at SDHfT
Finger exercise
MIU follow up

Mallet Finger

Always x-ray
Mallet splint and instructions. (Inform
patient splint
will be insitu for at least 6 weeks
Refer to SDHfT fracture clinic

Dislocations of Proximal and Distal Interpharangeal Joints
Check the history of injury fits with a dislocation

Check circulation of the digit, if in doubt refer to A+E for medical practitioner assessment
Check the nerves distal to the dislocation.
Uncomplicated dislocations

Buddy Strapping
Refer to A+E for medical practitioner
assessment
Signs of a fracture with dislocation

Refer to A+E orthopaedic team


Wrist
No bony injury Treat according to severity of pain or
swelling
Supportive bandage with or without sling
Un-displaced fracture P.O.P. backslab, sling,
Fracture clinic,
Instruction sheet regarding care of plaster

Displaced fracture Splint/sling, backslab.
Liaise with hospital re: transfer with
documentation
and
X-ray number documented clearly on notes,
nil by mouth

Scaphoid
Fracture may not show on first x-ray.
History may be of a fall onto outstretched hand or a starting handle type injury.
If the mechanism of injury or the clinical signs suggest a possible fracture of the
Scaphoid ALWAYS treat as for a fractured Scaphoid.
Clinical signs include:
Specific tenderness and/or swelling in the anatomical snuffbox
Specific tenderness over the Scaphoid tubercle
Pain on telescoping the thumb
Very poor grip
Reduced wrist movement

Management:
Scaphoid P.O.P for confirmed fracture, sling 24 hours
Confirmed fracture to Fracture clinic,
Instruction sheet regarding care of plaster
Suspected fracture rather than proven futura splint, sling for 24 hours - refer to GP


Radius and Ulna
No bony injury
.
Supportive bandage, with or without sling
Follow up at GPs surgery if necessary
Un-displaced fracture

Appropriate P.O.P ,sling
Fracture clinic appointment,
Instructions regarding care of plaster.

NB. An isolated mid-shaft fracture of one of forearm bones (except transverse mid
shaft Ulna) (Defence fracture) with other intact suggests Radio-ulnar joint
dislocation. It is essential that x-rays include the joints above and below the injury.

MONTEGGIA- Dislocation radial head with fracture ulna
GALEAZZI- Fracture radius with dislocation inferior radio-ulnar joint

Radial Head/Neck
Un-displaced

Collar & cuff
Fracture clinic
Severe/dislocated Refer to SDHfT Orthopaedics

NB effusion /inflammation in elbow joint suggest possible fracture and should be referred to
General Practitioner. If patient unwell or pyrexial consider infective arthritis or bursitis and
refer to A+E for further investigation.

Supracondylar
Displaced or dislocated

Check radial pulse if absent, gentle traction
may restore
Refer to SDHfT A+E

Un-displaced

Above Elbow backslab POP
Collar & cuff
Refer to Fracture clinic

Beware of compartment syndrome especially in children


Olecranon
Displaced

Refer to SDHfT A+E

Un-displaced

Long arm pop & sling
Next Fracture clinic

All Elbow Injuries are Treated in Collar
& Cuff not a Broad Arm Sling

Humerus
Shaft Un-displaced

Test radial nerve
Collar and cuff
Refer next Fracture clinic

Shaft displaced

Refer to Orthopaedic team via A+E

Neck Un-displaced

Collar and Cuff
Fracture clinic

Neck displaced
Comminuted

Refer to SDHfT Orthopaedic team via A+E

Clavicle
No bony injury

Broad arm sling if necessary, early
mobilisation

Fracture

Broad arm sling
Fracture clinic

Displaced

Check pulse/nerve function. If normal broad
arm sling
and Fracture clinic, if absent refer to SDHfT
orthopaedic team via A+E
hospital


Shoulder Injuries
No bony injury

Broad arm sling for a short time if necessary
Analgesia in accordance with analgesia
protocol
Refer to GP within 3 days consider self
referral to physiotherapy

Suspected acute soft tissue
injury

Broad arm sling
Refer to A+E
Fracture

Refer to A+E

Dislocation

Analgesia in accordance with entonox
protocol
Refer to A+E by ambulance

Dislocation/Subluxation AC Joint Broad arm sling
Refer Fracture clinic

Complete Disfruption AC Joint Broad arm sling
Refer Fracture clinic

Patient with specific Lower limb fractures should be managed as below:

Fracture Neck of Femur
Requires Orthopaedic admission

Analgesia & transfer to acute hospital via
999
Cannulate if nurse has cannulation
skills and Sodium Chloride 0.9%
injection as per PGD.
Obtain ECG, if time permits


Fracture Shaft of Femur
Requires Orthopaedic admission

Analgesia & transfer to acute hospital via
999
Cannulate if nurse has cannulation
skills and Sodium Chloride 0.9%
injection as per PGD.

Donway splint (Supplied by
Ambulance)

Significant Avulsion Fracture Tibial Spine
Requires Orthopaedic Admission

Refer to hospital
Analgesia in accordance with
analgesia protocol
Long Leg Backslab POP

Osteochondral Fractures
Requires Orthopaedic Admission if
severe

Discus with A+E
analgesia protocol

Fracture of Tibial Plateau

Discuss with orthopaedic team at SDHfT for
advice
analgesia protocol
Refer to fracture clinic


Isolated Fracture Upper Midshaft Fibula

Examine lateral popliteal nerve
Discuss with orthopaedic team at SDHfT
analgesia protocol
Treat with tubigrip or POP if severe
pain if POP assess for
Thromboprophlaxis.
Refer to Fracture Clinic

Fractured Tibia and Fibula
Undisplaced

Long Leg POP
Adults Assess for
Thromboprophlaxis and refer to
Orthopaedics for advice
Children non-weight bearing on
crutches. Refer to fracture clinic

Displaced

Immobilise in backslab assess for
Thromboprophylaxis
analgesia protocol
Refer to A+E Orthopaedics
Fractures with sever soft tissue injury

Orthopaedic referral via A+E

Epiphyseal Fracture Lower Tibia
Undisplaced

Discuss with orthopaedic team at SDHfT
Displaced
Refer to Orthopaedic team SDHfTvia A+E

Toddlers Fracture
A toddler who falls and who will not
weight bear must have the whole limb x-
rayed
unless clinical examination can
localise an injured area. Spiral fractures
of the tibia may not be visible on initial x-
rays.

Refer to SDHfT for assessment and
management


This clinical guideline provides guidance to MIU nurses .If any potential
bony injury attending the MIU is outside your scope of practice arrange
transfer of the patient to A+E for further assessment and investigations

The need to X-ray a knee injury should be assessed using the Ottawa knee rules as
below and the patient referred to A+E

Knee X-ray in acute injury are required only for patients with any of the following :
1. Age 55 years or older
2. Isolated tenderness of the patella (no bone tenderness of the knee other than the
patella)
3. Tenderness at the head of the fibula
4. Inability to flex the knee to 90 degrees
5. Inability to bear weight (four steps) both immediately and in the department (unable
to transfer weight twice onto each lower limb regardless of limping)

The need to X-ray an ankle injury should be assessed using the 'Ottawa ankle rules'
see below:

Ankle X-ray is required only if there is pain in the malleolar region and any of the
following:-
1. Tenderness upon palpation of distal 6cms of posterior edge and tip of lateral and/or
medial malleolus.
2. Inability to weight bear both immediately after injury and/or in the department
(4 steps)
3. Age over 55

Foot X-ray is required only if there is any pain in the midfoot area and any of the
following: -
1. Tenderness upon palpation at the base of 5th MT and/or medial aspect of navicular.
2. Inabilities to weight bear, both immediately after injury and in the department
(4 steps)
3. Age over 55


Knee Injuries
Suspected Cruciate or Meniscus injury:
Knee gives way or locks
Any instability on movements
Unable to walk or weight bear
Pop felt or heard clicking
Pain on rotational movements

Refer to A+E
Haemarthrosis/large effusion

Refer to A+E
Dislocate patella

Check pedal pulses and circulation refer to
A+E
Definite minor sprain without instability or
effusion

Double tubigrip
Crutches if applicable
Analgesia in accordance with protocol
Give advice about exercising joint
Follow up with GP within one week
Suggest self referral to physiotherapy
Diagnosis uncertain

Refer to A+E

Ankle Injuries
No bony injury

Double tubigrip or Crepe if required.
Advice RICE.
Follow up GP/Physio if required (unable to
weight bear
without crutches)


Below knee P.O.P,
Crutches (none weight bearing)
Fracture clinic
Advice Re: aftercare of P. O. P

Displaced fracture

Refer to Orthopaedic team via A+E
A Severely Displaced Fracture that Poses a Risk of Neurovascular Deficit or Skin
Damage Should Be transferred urgently via 999 ambulance


Achilles Tendon (Ruptured)
Very sudden pain in lower calf may occur
spontaneously,
and/or History of injury with sudden pain in
lower calf.

Refer these
patients to
Orthopaedic team via A+E

May be missed because of pain and swelling
at the time of
injury and foot can be plantar flexed by the
long toe flexors

Refer these
patients to
Signs of rupture include
Palpable gap in Tendon or
Inability to stand on tiptoe on the affected
foot or
Positive squeeze Test (Simmonds Test)

Refer these
patients to

Bilateral fractures Requires Orthopaedic admission refer to hospital

Calcaneum
# Calcaneum

Wool & crepe
Crutches
Advice/elevation
Discuss with A+E orthopaedic team at
SDHfT (May also require
admission for elevation)
Fracture clinic

If involves subtalar
joint/depressed fracture

Requires Orthopaedic admission-refer via
A+E

Fracture Base 5
th
Metatarsal
Symptomatic treatment, usually crepe/DTG
but if severe pain Below Knee POP &
crutches
Refer fracture clinic


Other Fractured Metatarsals
Displaced/multiple

Refer via A+E to orthopaedic team

Un-displaced

Symptomatic treatment as above
Discuss with fracture clinic or A+E

Fracture Talus/Subtalar/Midtarsal Refer A+E
All Phalanges # to Great, 2
nd
, 3
rd
, 4
th
and 5
th
Toes
No bony injury

Two toe strapping if required Advise
supportive
sensible footwear


Two toe strapping
Advise supportive sensible footwear
Refer GP

Displaced fracture

Liaise with A+E orthopaedic team

Dislocations to Proximal or Distal Interpharagel Joints-Toes
Check the history of injury fits with a dislocation

Check circulation of the digit, if in doubt refer to a doctor for assessment

Check the nerves distal to the dislocation.

Uncomplicated dislocations

X-ray to confirm diagnosis
Buddy Strapping
Check X-ray
Refer to A+E
Signs of a fracture with dislocation

Refer to A+E


3. References:
Adapted from Plymouth teaching Primary Care Trust Minor Injury Unit Handbook of
clinical Protocols (V2:1)

Amendment History

Issue Status Date Reason for Change Authorised


CLINICAL PROTOCOL FOR THE MANAGEMENT OF SOFT TISSUE AND BONY
INJURIES ATTENDING MIU

The registered health professionals named below, being employees of Torbay Care
Trust and based at . Have received training and are
competent to operate under this clinical guideline

NAME
( Please print)
PROFESSIONAL
TITLE
SIGNATURE AUTHORISING
MANAGER
( Please print)
DATE

Management of Limb Injuries in Adults and Children Over 2 Years

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Last Review Date: March 2010

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