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:

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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

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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.

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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.

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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

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 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.

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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.

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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

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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: hand, elbow and pendulum  UL clinic FU required

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Surgical management

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. May need CT scan to evaluate direction of clavicle translation.

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Soft tissue shoulder

Possible significant soft tissue / Rotator Cuff injury

Attendance in A&E with history of trauma x-rays taken to exclude a fracture consider possible significant soft tissue injury / RC injury.

Management:

If concerned about possible massive RC tear over phone

 If Brighton and Hove resident can do urgent referral to BICS under the? massive RC pathway  If anywhere else needs ref to UL clinic at about 2 weeks for US cuff and possibly ref fro USS as required

If no concerned about possible massive RC tear over the phone

 Either DC if patient happy  Or place on SOS for 3/53 self-directed management with option for patient to contact us if continuing to have weakness and effected function.

Calcific tendinitis

Attendance in A&E with pain ++ and no history of trauma and x-rays taken show calcium deposits in tendon.

 If Brighton and Hove resident can do urgent referral to BICS for consideration of USS guided injection.  If anywhere else needs urgent ref to UL clinic for consideration of USS guided injection.

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Common Lower limb Injuries

Foot injuries:

Base 5th MT fractures

Conservative management:

 Black boot 3/52 and base 5th protocol  DC VFC

A true Jones fracture:

 Black boot 6/52 and Jones base 5th protocol  Foot and Ankle clinic at 6 weeks for clinical examination and XOA. If not healed review in another 6 weeks with XROA  If not healed then possible ORIF of non-union

Stress fractures

 Black boot for 6/52 if caught initially  If delayed presentation or evidence of healing back boot for comfort and avoid stress riser e.g. running / sports  F&A clinic at 6/52 post injury

5th Midshaft fractures

Conservative management:

 Black boot 6/52 and midshaft protocol  If significant shortening or rotation the F&A clinic at 6/52 if not DC VFC

Single Metatarsal fractures

Conservative management:

 Black boot 3/52 and generic foot fracture protocol  DC VFC

Single phalanx fractures

Conservative management:

 Black boot if supplied / required or buddy strapping as appropriate 3/52 and generic foot fracture protocol  DC VFC

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Multiple Metatarsal fractures

Conservative management:

 Black boot 6/52 and generic foot fracture protocol  Consider Foot and ankle clinic if significant angulation or displacement

Any fracture to base 1st/2nd MT’s or concerns for Lis franc injury

Follow suspected Lis Franc protocol:

Mid-foot fractures:

Un-displaced: Conservative management

 Black boot 3/52 and generic foot fracture protocol  DC VFC

Avulsion fracture: Conservative management

 Black boot 3/52 and soft tissue foot protocol  DC VFC

Displaced or multiple: Get food and ankle specialist review

Soft tissue foot injuries:

 If excluded all possible fractures and Lis franc injury  Black boot if provided for up to 3/52 and soft tissue foot protocol  Dc VFC

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Calcaneal Fractures

Most os calcis fractures should be discussed via inpatients and the F&A team or Steve Nicol but if they come through to the virtual fracture clinic

Indication for ORIF:

 Intra-articular  Loss in Bohlers angle  Or increase Gissane’s angle (indicating collapse of the posterior facet).  Communited fractures

If conservatively managed –

 Black boot for 6/52 can either be NWB if so consider need for DVT prophylaxis or TTWB/PWB  Advise to remove the boot for ankle ROM exercises  F&A / Steve Nicol clinic at 4/52 post injury with XROA

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Ankle injuries:

Weber A ankle fractures

Conservative management:

 Black boot for 4/52 and weber A protocol  DC VFC

Ankle fractures

Stable determined by:

 Talus is congruent in the mortise  Trans- or infra-syndesmotic fibular fracture  No medial injury  No clinical evidence of higher-energy injury

Weber B

Stable: Conservative management

 Black boot for 6/52 and weber B protocol  ESP clinic RV with weight-baring mortise and true lateral XROA 2/52 & 6/52  If no clinical or radiological evidence of fracture healing at 6/52 arrange 3/52 RV in ESP or F&A clinic as appropriate

Unstable: Refer to inpatients and put on Bluespeir for EUA +/- ORIF

Weber C

Stable: Conservative management

 Black boot for 6/52 and weber B protocol  ESP clinic RV with weight-baring mortise and true lateral XROA 2/52 & 6/52  If no clinical or radiological evidence of fracture healing at 6/52 arrange 3/52 RV in ESP or F&A clinic as appropriate

Unstable: Refer to inpatients and put on Bluespeir for EUA +/- ORIF

Medial malleolus / and Posterior malleolus fractures

Stable and un-displaced: Conservative management

 Black boot for 6/52 and medial malleolus protocol  ESP clinic RV with weight-baring mortise and true lateral XROA 2/52 & 6/52

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 If no clinical or radiological evidence of fracture healing at 6/52 arrange 3/52 RV in ESP or F&A clinic as appropriate

Unstable / displaced: Refer to inpatients and put on Bluespeir for EUA +/- ORIF

Bi-tri malleolus fractures

Unstable / displaced: Refer to inpatients and put on Bluespeir for EUA +/- ORIF

Soft tissue ankle injury / Avulsion lateral malleolus

Conservative management:

 Black boot if required / given in A&E up to 3/52 and soft tissue ankle protocol  DC VFC

TA ruptures

Confirmed on USS requested by A&E and chases to do within 72 hours (Patricia Shaddock can chase this for you)

Gap <1.5cm and closes on plantar flexion: Conservative  Black boot / aircast boot with 3 wedges and heal cup the TA protocol to remove a wedge ever 2 weeks after  NWB on EC for 4/52  Blood test: FBC and U&E’s to test platelets before commencing Tinz 4500units OD  F&A clinic / Steve Nicol clinic at 4/52  Automatic referral to physiotherapy for week 9-10

Gap >1.5 cm and/or does not close on plantar flexion and/or delayed presentation: consider surgical management  Put on Bluespeir for discussion RE surgical management  Black boot / aircast boot with 3 wedges and heal cup  NWB on EC  Blood test: FBC and U&E’s to test platelets before commencing Tinz 4500units OD

Consideration to add to Bluespeir to determine management outcome  Age  co-mobidities,  Smoking status  Skin condition  Site of rupture (tendenous and complete for surgery)  Patient preference following explanation of pros and cons conservative and operative methods

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Knee injuries:

Locked Knee

If clinically proper locked knee A&E should have referred to inpatient team, if at home and still locked either URGENT AKC that week or return to A&E for orthopaedic registrar review. Must have had an x-ray and report as a few osteosarcomas have been picked up this way.

Soft tissue knee injury

If no bony injury reported on X-ray and no significant effusion / lipohaemarthrosis

 Triage over the telephone to determine if appropriate for AKC / SOS or DC  Indicators for AKC: Significant swelling, Unable to WB, signs of instability, unable to SRL and/or significantly restricted ROM especially into extension.

If no bony injury reported on X-ray and significant effusion / lipohaemarthrosis

 Low threshold for pre-arranging MRI before AKC  Urgent AKC in under 2/52

N.B If history of trauma and no X-rays arrange for patient to attached for an X-rays and review in VFC again

Patella Dislocation

1st time dislocators  Cricket pad for 2 weeks FWB can do static quads as per dislocation protocol.  AKC at 2/52  Pre arrange Physio to start at 3 weeks

Recurrent dislocators  Depends on previous number of dislocations and presentation  Review Physio strategy over phone discuss if they would like and AKC or re-referral to physio

Patella fractures

Un-displaced  Cricket pad for 2 weeks FWB can do static quads as per dislocation protocol.  AKC at 2/52

Displaced or vulnerable to being displaced should have been referred to inpatients.

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Possible Tumours

Need local and systemic staging and follow up within 2 weeks from when you see them.

Soft tissue lesion  MRI, plain films + CXR , blood tests  Older patient and possibility that it may be soft tissue metastasis then add investigations as for bony lesion Bony lesion  As above + bone scan +/- CT, myeloma screen

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