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BSUH VFC Initial Management Guidelines Dec 2014

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BSUH VFC Initial Management Guidelines Dec 2014 BSUH VFC initial management guidelines Dec 2014 Contents Page Elbow injuries: Radial head / Radial neck fractures 3 Elbow dislocations 3 Shoulder Injuries: Shoulder dislocation 4 ACJ dislocation 4 Proximal Humerus fractures 5 Greater Tuberosity fractures 5 Midshaft Humerus 6 Mid-shaft clavicle fractures 7 Lateral 1/3 Clavicle fractures 8 Medial 1/3 clavicle fractures 9 Soft tissue injury shoulder 11 Calcific tendinitis 11 Common lower limb injuries Foot injuries: 5th Metatarsal fracture 12 Stress fractures 12 5th Midshaft fractures 12 Single Metatarsal fractures 12 Single phalanx fractures 12 Multiple Metatarsal fractures 13 Mid-foot fractures 13 Calcaneal fractures 14 Ankle injuries: Page 1 of 18 Weber A ankle fractures 15 Weber B 15 Weber C 15 Medial malleolus / and Posterior malleolus fractures 15 Bi-tri malleolus fractures 16 Soft tissue ankle injury / Avulsion lateral malleolus 16 TA ruptures 16 Knee injuries Locked Knee 17 Soft tissue knee injury 17 Patella Dislocation 17 Patella fractures 17 Possible Tumours 18 Page 2 of 18 Upper Limb Injuries Elbow injuries Radial head / neck fractures Mason 1 head / borderline Mason 1-2 protocol BAS for comfort only 2/52 and early gentle ROM DC VFC. Patient to contact VFC at 3/52 post injury if struggling to regain ROM Mason 2 >2mm articular step off discuss case with consultant on hot week likely conservative management if unsure d/w upper limb consultants opinion for 2/52 repeat x-ray and review in VFC Mason 3 head # or >30degrees neck angulation = Urgent Ref to UL clinic (LL or LT) for discussion with regards to surgical management. Elbow Dislocations No fractures => immobilisation in backslab from A&E and urgent UL clinic (7-10days) for removal of cast and Ax stability of elbow (LL/LT/CH/EG) Fractures o Un-displaced . Immobilisation in backslab from A&E and urgent UL clinic (7-10 days) as above. o Displaced . ? TCI for fixation put on Bluspeir for discussion in morning meeting and inform patient possible CT required pre surgery. Page 3 of 18 Shoulder injuries GHJ dislocation Primary: Young dislocations < 55: Conservative management with sling for 3/52 and initial exercises as per protocol and DC VFC to self-management Older dislocations 55+ (cuff tear unless proven otherwise) No fracture o Polysling for comfort + pendulum scapula setting o UL clinic at 3/52 post injury for Ax RC physio to be arranged from this clinic as required GT fractures (post reduction film) . Un-displaced Polysling for comfort + elbow wrist and hand and scapula setting UL clinic at 3/52 post injury Ax RC and if x-ray unchanged physio to be arranged from this clinic as required. >5mm displaced ? TCI for fixation put on Bluspeir for discussion in morning meeting and inform patient possible CT required pre surgery. Recurrent: Disuses with patient if under a UL consultant or wishes to consider surgical management or repeat conservative management. If surgical ref to UL clinic Cameron Hatrick or Physio as requested. ACJ dislocation Rockwood Grade 1 and 2: Conservative protocol with BAS for comfort up to 3/52 with early pendulum and scapula setting and DC VFC Rockwood Grade 3: Conservative protocol and refer to UL clinic for 3/52 post injury physio to be arranged from clinic as appropriate Rockwood Grade 4-6 : Discuss with UL consultants if Mon/Tuesday/ alternative Thursdays or put on Bluespeir for discussion on trauma ward round? TCI or further imaging if required. Page 4 of 18 Proximal humerus fractures Most likely for conservative management but to consider patient factors and clinical factors on x-ray, sometimes a CT can be used to further examine the extent of the injury: Patient factors: Consider patient Age, Occupation, Handedness, Other PMHx Predictors or poor outcome and relative indications for surgery: <7mm medial metaphyseal hinge (increased risk AVN) 3 or 4 part fractures (Neer ) Varus displacement >40 degs posterior angulation (apex anterior) If considering surgical management: Try to get imaged reviewed by Enis Guryel or Cameron Hatrick or if unable put patient on bluespeir for surgical consideration. Conservative management: Collar and cuff / Polysling depending on comfort Proximal Humerus protocol: hand, elbow and pendulum UL clinic at 3/52 post injury Greater Tuberosity fractures Un-displaced Conservative management: Collar and cuff / Polysling depending on comfort Un-displaced GT protocol: hand, elbow and pendulum (avoid active abduction 6/52) Referral to physiotherapy for 3/52 post injury No routine FU unless physio or patient contacts with difficulties Minimally displaced (<5mm displacement with no superior translation) Conservative management: Collar and cuff / Polysling depending on comfort Un-displaced GT protocol: hand, elbow and pendulum (avoid active abduction 6/52) UL clinic at 3/52 with repeat AP and axially views on arrival ensure no shift Referral to Physio from clinic as appropriate Displaced ( >5mm displacement with translation of GT) For consideration of surgical management: Try to get imaged reviewed by Enis Guryel or Cameron Hatrick or if unable put patient on bluespeir for surgical consideration. Consider patient factors and clinical factors on x-ray, sometimes a CT can be used to further examine the extent of the injury: Patient factors: Consider patient Age, Occupation, Handedness, Other PMHx Predictors or poor outcome and relative indications for surgery: Superior translation of the GT Page 5 of 18 Posterior translation of the GT Midshaft Humerus Conservative management indicated in vast majority: criteria for acceptable alignment include: < 20° anterior angulation < 30° varus/valgus angulation < 3 cm shortening Conservative Mx: Collar and cuff 3/52 + Humeral Brace if correct position Clavicle fracture protocol: hand, elbow and pendulum UL clinic at 3/52 with repeat AP and incline views Referral to Physio from clinic as appropriate Considerations for surgical management IM Nail or ORIF Patient age Angulation as above Sever soft tissue injury or bone loss Vascular injury requiring repair BPL or PN injury Pathological fracture If considering surgical management: Try to get imaged reviewed by Enis Guryel or Cameron Hatrick or if unable put patient on bluespeir for surgical consideration. Page 6 of 18 Clavicle injuries Mid shaft clavicle fractures (80-85% prevalence) Conservatively managed if: No neurovascular compromise No tenting of the skin and subsequent skin threat <2cm displacement measured from inferior cortex to inferior cortex# Low demand patient Conservative Treatment: Collar and cuff / Polysling depending on comfort for 2/52 Clavicle fracture protocol: hand, elbow and pendulum UL clinic at 3/52 with repeat AP and incline views Referral to Physio from clinic as appropriate Considerations for surgical management Absolute indication for ORIF = neurovascular compromise Strong relative indication: Skin threat High demand patient >2cm displacement measured from inferior cortex to inferior cortex, For consideration of surgical management: Try to get imaged reviewed by Enis Guryel or Cameron Hatrick or if unable put patient on bluespeir for surgical consideration. Page 7 of 18 Lateral 1/3 clavicle fractures (10-15% prevalence) Type I Fracture occurs lateral to coracoclavicular ligaments (trapezoid, conoid) or interligamentous Usually minimally displaced Nonoperative Stable because conoid and trapezoid ligaments remain intact Type Fracture occurs medial to IIA intact conoid and trapezoid ligament Medial clavicle unstable Operative Up to 56% nonunion rate with nonoperative management Type Fracture occurs either IIB between ruptured conoid and intact trapezoid ligament or lateral to both ligaments torn Medial clavicle unstable Operative Up to 30-45% nonunion rate with nonoperative management Type Intraarticular fracture III extending into AC joint Conoid and trapezoid intact therefore stable injury Nonoperative Patients may develop posttraumatic AC arthritis Type A physeal fracture that occurs IV in the skeletally immature Displacement of lateral clavicle occurs superiorly through a tear in the thick periosteum Clavicle pulls out of periosteal Nonoperative sleeve Conoid and trapezoid ligaments remain attached to periosteum and overall the fracture pattern is stable Page 8 of 18 Type Comminuted fracture V Conoid and trapezoid ligaments remain attached to Operative comminuted fragment Medial clavicle unstable Conservative Treatment: Collar and cuff / Polysling depending on comfort for 2/52 Clavicle fracture protocol: hand, elbow and pendulum UL clinic at 3/52 with repeat AP and incline views Referral to Physio from clinic as appropriate Considerations for surgical management Strong relative indication: Skin threat High demand patient >2cm displacement measured from inferior cortex to inferior cortex, For consideration of surgical management: Try to get imaged reviewed by Enis Guryel or Cameron Hatrick or if unable put patient on bluespeir for surgical consideration. Medial 1/3 clavicle fractures (5-8% prevalence) Anterior Most often non-operative displacement Rarely symptomatic Nonoperative Posterior Rare injury (2-3%) displacement Often physeal fracture-dislocation (age < 25) Stability dependent on costoclavicular ligaments Must assess airway and great vessel Operative compromise CT scan to evaluate Surgical management with thoracic surgeon on standby Conservative Treatment (Anterior displacement): Collar and cuff / Polysling depending on comfort for 2/52 Clavicle fracture protocol:
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