FRACTURE CLINIC SERVICES
3 components:
Setup
Services
Communication
Team:
Consultant led clinics. All new patients to be reviewed by senior surgeon or any
juniors/ACP directly supervised by senior surgeon
Facilities:
Plaster rooms available
Imaging facilities available and reports should not delay treatment
Services:
Core services – All new appointments should be seen in fracture clinic within
72hrs of presentation to ED/GP. All new appointments should have a
management plan and any surgical treatment must have planned admission. Also,
a system in place for rapid access to fracture clinics if any problem with the
clinical injury
Integrated services –
Falls prevention and fracture liaison services for fragility fractures
Physiotherapy and OT direct access
CRPS should have access to pain referral team for adequate analgesia
Communication:
All outcomes of the appointments must be available to GP and patients in writing
If patient needs to be transferred to another clinic, then direct referral pathways
and transfer of images and X rays available
All common presentations should have patient information booklets. And written
information when casts, slings applied
MANAGEMENT OF TRAUMATIC SPINAL CORD INJURY
ASIA impairment scale
Grade A to E
A – Both sensory and motor loss below the level of injury
B – Sensation preserved. Motor sensation is not preserved
C – More than half of the key muscles have power less than 3
D – Atleast half of the key muscles have power greater than 3 or more
E – No deficit
Imaging –
24-hour access to CT scan and MRI
Management –
Protocols for managing bowel, bladder, gastric, skin and neuroprotection
must be agreed with the Spinal cord injury centre and available in all ED
managing spinal cord injuries
If patient is fit for transfer to spinal centre, then this must be done within
24 hours
If patient not transferred, then atleast spinal outreach services from the
spinal centre must be arranged within 5 days of referral and then follow-up
contact atleast weekly till the patient is transferred
Management of spine must follow written agreed protocols of spinal centre
if not then it needs to be discussed with the spine surgeon within 4 hours of
presentation.
An early, joint management plan must be recorded within 12 hours in the
medical notes
Centres treating these injuries must be capable of performing the surgery
within 4 hours of injury
Aftercare –
Psychological support for all patients available
Monitoring –
All patients with spinal cord injuries must have referral data submitted to a
national SCI database
FRACTURE LIAISON SERVICES
Role of fracture liaison services is to identify those patients in secondary/
primary care, who are at risk of future falls, thus proving that these services
are cost effective
Setup
Led by Consultant physician or General practitioner
FLS must have linked metabolic bone service to provide timely access to
patients regarding bone health
Must have multifactorial bone assessment including DEXA scan within
12 weeks of fall
FLS must have system in place to review patient compliance for
treatment
Communication
Patients must be provided with written info on bone health, lifestyle,
nutrition and bone protection treatment
GP must be informed of test results and recommendations
FLS must undertake routine audit and submit data to National FLS database
SPINAL CLEARANCE IN TRAUMA PATIENTS
Spinal cord precautions is not recommended for more than 48 hours
A protocol for spinal cord precautions must be in place in all hospitals and this
precautions must be maintained till the spinal examination is completed or the
radiological investigation done
If patient is expected to be unconscious, unassessable or unreliable for more than
48hrs, then radiological spine clearance must be carried out
ASIA examination and documentation of examination findings must be carried
out; any sign of injury mandates urgent scanning
For cervical spine, appropriate standard is thin slice (2-3mm) CT spine from the
base of occiput to the T1 with both saggital and coronal sections.
If patient has head injury, CT spine along with CT brain is a must
For thoracic and lumbar spines, along with CT CAP, CT thoracic and lumbar spines
must be carried out, as part of trauma series
A senior radiologist must confirm the radiological spine clearance before
removing all spinal precautions
MRI is the urgent investigation of choice for SCI
PELVIC FRACTURES
Posterior pelvic ligaments are stronger, and any disruption of the posterior
ligaments is indicative of high energy trauma
Vertical ligaments are the strongest any vertical shear fractures are indicative of
highest trauma
Young Burgess classification of Pelvic fractures
AP compression – Type 1 ,2,3
Lateral compression – Type 1,2 ,3
Vertical shear
Management of bleeding and HD instability
Pre-hospital – Pelvic binder pre-hospital. Pelvic fractures with hemodynamic
instability must be transferred to MTC with pelvic consultant or if sent to trauma
unit, then they need to be transferred to MTC, after the patient is made HD stable
In hospital – IV Tranexamic acid, within 1 hour of injury. In presence of HD
instability, then active hemorrhage protocol
If no control of bleeding, then surgical packing or selective embolization of pelvic
vessels
Imaging
CT Trauma series
If patient undergoes damage control laparotomy, they must have CT pelvis ruling
out pelvic fracture prior to laparotomy. Pelvic binder must not be removed for
post binder pelvic X-ray until the patient is haemodynamically stable.
All polytraumatised patients require a post-binder X-ray after resuscitation, even
in the presence of a ‘negative’ CT scan because a well applied pelvic binder can
mask a catastrophic pelvic ring injury.
Surgical stabilization
Transferred to specialist centre within 24 hrs
Definitive surgery within 72 hrs
If definitive not possible, then temporary external fixator
In displaced vertical shear fractures, traction is essential as early definitive surgery
not possible
Urological and bowel trauma
Open pelvic fractures must be assessed by General surgeon to rule out bowel,
anus, rectum injuries
If any bowel/rectal injuries, then defunctioning stoma is essential
The site of stoma should not interfere with pelvic fixation
Monitoring and aftercare
Data should be uploaded to the TARN (Trauma Audit and Research Network)
Aftercare
Thromboprophylaxis instructions
Sexual instructions
Follow-up in specialist pelvic trauma unit or rehab centre
Pelvic fractures with Urological Trauma
Even if there is CT evidence of Urological trauma, it is recommended to try a
gentle single attempt at catheterization and also immediately inform Urological
surgeons
If the catheter passes and there is blood in urine, then do retrograde cystogram
If catheter does not pass or if it drains frank blood, then retrograde urethrogram.
Also Suprapubic catheterization needed. This has to be done by Urologist.
The placement of a suprapubic catheter may alter the timing of pelvic fracture
surgery and so the pelvic fracture service should be involved at an early stage
If there is urine leak from either bladder or urethra along with pelvic fracture,
then the fracture is considered as OPEN FRACTURE and needs IV antibiotics cover
for 72 hrs and early fixation of fracture
Surgical management
1. Bladder injury
Intraperitoneal vs extra-peritoneal
Intra-peritoneal rupture should be treated with urgent laparotomy and direct
repair
Extra-peritoneal rupture should be treated with catheter alone
2. Urethral injury
Recommended treatment is delayed repair at 3 months of urethral rupture in
males
But if there is anorectal injuries, bladder neck injury, massive bladder
displacement, penetrating trauma, then primary repair within 48hrs
OPEN FRACTURES
Gustilo-Anderson classification
Type 1 – Clean wound <1cm size
Type 2 – Clean wound 1-10cm size without significant soft tissue damage
Type 3a - >10cm wound with significant soft tissue damage, but there is adequate
periosteal coverage
Type 3b – Periosteal stripping, with massive contamination of soft tissues
Type 3c – Open fracture with associated vascular compromise
Documentation of NV status before and after splintage/reduction
IV antibiotics within 1 hour of presentation
CT Trauma series should be clinically co-related to direct limb specific sequences
If there are any extremity injuries, then CT angio is mandated
Surgical management
Immediate debridement for contamination with sewage, aquatic or when there is
associated vascular compromise (arterial/compartment)
Within 12hrs, in cases of high energy solitary injuries
Within 24 hrs in cases of low energy open fractures
After debridement, all surgeries are considered clean. For example, definitive
fixation in the same setting as debridement, must proceed only after re-drape, re-
prep, fresh instruments etc
Definitive soft tissue cover must be carried out within 72hrs, if not done during
debridement
If planned for amputation, then it must be MDT decision involving Ortho, plastics,
rehab, patient and carers and can be carried out within 72hrs of injury
SUPRACONDYLAR FRACTURES
Gartland classification:
Type 1 – Minimally displaced, no medial comminution
Type 2 – Displaced only in one plane, intact posterior cortex
Type 3 – Displaced in 2 or 3 planes
Type 4 – Complete periosteal disruption with instability in flexion and extension
If there is medial comminution which means that loss of Baumann angle, leading
to varus malunion (Gunstock deformity), then CRPP is recommended
What is Baumann angle?
Baumann angle is the angle between the middle line parallel to the humeral long
axis and the line along the lateral condylar physis as viewed on AP image
How to examine?
Rock, paper, scissors and OK sign
Rock – Median nerve
Paper – Radial nerve
Scissors – Ulnar nerve
OK – AIN
Most affected nerves in SC#?
AIN>Radial nerve>Ulnar nerve, usually damaged in flexion type deformities
When to take patient to theatre?
a. Non operative – Type 1 and type 2 without any NV deficits, given that
anterior humeral line joins middle 1/3rd of capitellum, minimal swelling
Non operative is long arm casting with less than 90 degree flexion. Repeat X
ray at 1 week to assess positioning and long arm casting maintained for 3
weeks
b. Operative is CRPP
Non urgent – Type 2,3 with no NV deficits
Can be managed overnight with above elbow backslab with 30-
40degree flexion and continuous observation
Urgent – For any fracture with pink pulseless hand, poor peripheral
perfusion
Excessive swelling, brachialis sign is positive, open injury/threatening
to skin
Method of surgical stabilization
Atleast two K wires engage in the cortex proximal to the fracture
Use 2mm K wires
K wires in cross fashion minimizes loss of fracture reduction whereas wires in
divergent fashion reduces risk to ulnar nerve
Documentation in OP notes regarding the clinical stability post fixation and clinical
alignment
Documentation in OP notes if any medial wire placed and how they managed to
avoid damage to ulnar nerve
How to do surgery CRPP?
Supine position with arm board, touniquet high up in the arm but not inflated
Image intensifier ready. A gown pack/roll below the patient’s arm
4 steps of reduction:
1. Gentle traction with my assistant providing counter-traction for 5 mins to
correct Coronal alignment
2. With Image intensifier, correct varus and valgus deformity
3. Flex the elbow to assess stability and see if the anterior humeral line joins
capitellum
4. Pronate for medial comminution/ supinate for lateral comminution
If medial K wire is inserted then it will be OPEN, as you need to isolate ulnar nerve
The crossing of K wires (If medial wire is inserted), must be above the level of
fracture site. In the above image the K-wires cross at the level of fracture in AP
image and we can see deformity in lateral view
PAEDIATRIC FOREARM FRACTURES
Torus/Buckle fracture – Buckling of the cortices due to compressive forces on
FOOSH. Inherently stable given the fact that the cortices are intact
Galaezzi fracture – Distal 1/3rd radius fracture with DRUJ dislocation
Monteggia fracture – Proximal ulnar head fracture with radial head dislocation
Examination:
Rock, paper, scissors and OK sign
Management:
Casting is the gold standard as children have high potential for healing and
remodelling
Early closed reduction by manipulation under procedural sedation must be
carried out in a safe setting having monitoring, effective manipulation and
recovery
Discharge:
Documentation of NV status prior to discharge
#Clinic follow-up within 7 days
Consultant Ortho surgeon to review the documentation of the case and images
within 48 hrs of injury
DISTAL RADIUS FRACTURES
Colle’s fracture: Extra-articular fracture of distal radius which is dorsally displaced
Smith’s fracture: Extra-articular fracture of distal radius which is volarly displaced
Barton’s fracture: Intra-articular fracture of distal radius with radiocarpal joint
dislocation
Chaffuer fracture: Intra-articular fracture involving radial styloid process
Imaging:
PA and lateral views
Radiographs at 1-2 weeks post injury to confirm the fracture positioning. This is
done usually for cases where the initial fracture pattern was unstable and further
displacement would have needed surgical fixation
No radiograph needed when removing the immobilization
Management:
Intra-articular fractures managed within 72hrs of injury
Extra-articular fractures managed surgically within 1 week of injury
If manipulation fails for extra-articular, then surgery needs to happen within
72hrs from decision to operate
Patients sent home with manipulation, to be seen in #clinic within 72 hours of
injury
If using cast, then employ 3-point fix technique to hold the reduction and keep
the wrist in neutral flexion. Also remove the cast at 4 weeks to allow mobilization
Dorsally displaced fractures
Age>65 yrs – TO be managed conservatively
Age<65 years – If surgery needed, offer K-wire fixation if closed reduction
possible, or offer ORIF.
PERIPHERAL NERVE INJURY
1. An examination must be carried out in the following:
a. Immediately on presentation
b. Prior to any reduction/procedure
c. Prior to surgery when nerve injury is suspected
d. Post surgery following any procedure when nerve injury is suspected
e. In accordance with any written management plan
2. The examination must be
a. Generalised to ascertain any nerve injury
b. Specific in detail to identify deficit likely with the nature of
injury/procedure
c. Be explained in greater detail if concern over nerve injury raised
d. Be recorded in sufficient detail to compare the preceding and
subsequent examinations
3. There should be a clear and accessible pathway for suspected peripheral
nerve injury
4. When a nerve injury is associated with dislocation, joint should be reduced
immediately.
5. Formal advice should be sought:
a. Immediately when there is penetrating injury
b. Immediately when there is any damage intra-operatively
c. Prior to surgery, when definitive surgery is planned for fracture with
suspected nerve injury
d. Within 24hrs if no operative surgery planned
e. Immediately after surgery, even if bandages, plaster of paris removal
does not help
6. When a nerve is exposed during surgery, this must be documented in the
Post-op notes and also its relation with the Internal fixation device
7. When a damaged nerve is found at surgery, and single point of contact is
unavailable, then operation must be completed and nature of injury clearly
documented
CERVICAL SPINE CLEARANCE
Spinal precautions is not recommended for >48hours as the patient is at risk of
bed sores and also not very convenient for log rolling
Cervical spine can be cleared in the following:
a. No radiological cord damage on CT/MRI in an unconscious patient
b. Normal spine examination in a conscious patient
If CT spine needs to be performed, then do thin slice CT from occiput to T4
Initial report of CT scan is enough to send the patient from ED, but definitive
report without 18hours of injury
Radiology report:
If the report says, low quality CT scan or confounding co-morbidities – Then
continue spinal precautions, until an MRI is performed
Indications of MRI
If any suspicion of cord injury
If CT cannot be performed, like in Pregnancy
Ankylosed spines with negative or indeterminate on CT
Ambiguous CT scan
