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Procedural Skills (SLO6)
Question 26 of 141
You are giving a teaching session for junior colleagues based in the Emergency Department. You are discussing reduction of fracture and dislocations. Which of the following injuries typically requires x-ray before reduction?
Answer:
- Dislocations that may not require x-ray before reduction include:
- Dislocations associated with considerable neurovascular compromise requiring urgent intervention
- Uncomplicated patellar dislocations
- Uncomplicated mandibular dislocations
- Some patients with very recurrent shoulder dislocations
- Pulled elbow in young children
Reduction of Fracture and Dislocation
Procedural Skills (SLO6) / Trauma
Last Updated: 14th March 2021
Fractures
When describing/documenting fractures, the following system can be used:
- Age of patient and time and mechanism of injury
- Open or closed fracture
- Compound (open) fractures occur when a fracture is open to the air through a skin wound
- Name of bone
- Position of fracture
- Type of fracture
- Simple: Single transverse fracture with only two main fragments
- Oblique: Single oblique fracture with only two main fragments
- Spiral: Seen in long bones as a result of twisting injuries, only two main fragments
- Comminuted: Complex fracture with more than two fragments
- Crush: Loss of bone volume due to compression
- Wedge: Compression or one area of bone resulting in wedge shape
- Burst: Comminuted compression fracture with scattering of fragments
- Impacted: Bone ends driven into each other
- Avulsion: Bony attachment of ligament or muscle pulled off
- Hairline: Barely visible lucency with no discernable displacement
- Greenstick: Incomplete fracture of immature bone following angulatory force
- Buckle: Kinking of the metaphyseal cortex following axial compression
- Pathological: fracture due to underlying disease e.g. osteoporosis
- Stress: Due to repetitive minor injury
- Fracture-dislocation: fracture adjacent to or in combination with a dislocated joint
- Any intra-articular involvement
- Deformity of fracture
- Displacement: The relative position of the two bone ends to each other
- Angulation: The position of the point of the angle
- Rotation: The degree of rotation from the anatomical position
- Grade or classification of fracture
- Presence of any complications e.g. neurovascular compromise
- Other injuries/medical problems (note poor bone health and comorbidities that may impede healing)
Managing fractures:
- Obtain a minimum of 2 radiographs from different views, typically AP and lateral
- Ensure adequate analgesia
- Consider sedation or regional anaesthesia (e.g. Bier's block for distal radius fracture, fascia iliaca block for femoral fracture)
- If isolated fracture or dislocation proceed with reduction in the ED; involve orthopaedic specialists if a fracture dislocation is present
- There are various techniques for reduction depending on injury and site
- Ensure adequate ongoing analgesia post-reduction
- Use appropriate immobilisation e.g. sling/cast/splint
- Perform repeat radiograph to demonstrate satisfactory reduction and to ensure no associated injury
- Assess neurovascular status of limb, paying close attention to nerve injuries associated with specific fractures/dislocations e.g. axillary nerve in shoulder dislocation
- Consider ongoing complications e.g. compartment syndrome
- Give discharge advice and arrange appropriate orthopaedic follow up
- In open fractures, consider antibiotic and tetanus prophylaxis
Dislocations
A dislocation involves complete loss of congruity between articular surfaces whereas a subluxation implies movement of the bones of the joint but with some parts of the articular surface still in contact. Describe dislocations in terms of the displacement of the distal bone.
Managing dislocations:
- Aim to reduce dislocations as soon as possible in order to prevent neurovascular complications, decrease risk of recurrence and reduce pain
- Make note of time of injury - delayed presentations may not be amenable to ED reductions
- In general, aim to x-ray to identify the exact dislocation (+/- fracture) before attempting a reduction
- Dislocations that may not require x-ray before reduction include:
- Dislocations associated with considerable neurovascular compromise requiring urgent intervention
- Uncomplicated patellar dislocations
- Uncomplicated mandibular dislocations
- Some patients with very recurrent shoulder dislocations
- Pulled elbow in young children
- Use analgesia/sedation/anaesthesia appropriate to the dislocation and the individual circumstances: analgesia options include Entonox, light sedation, local anaesthetic block, simple analgesia or, if it is a relatively recent dislocation in a relaxed patient, it may be done without any
- X-ray after manipulation to confirm adequate reduction and to check for fractures which may not have been apparent on initial x-rays
- Confirm neurovascular status
- Use appropriate immobilisation e.g. sling/cast/splint
- Give discharge advice and arrange appropriate orthopaedic follow up; simple dislocations do not require specialist follow up if there is no further instability
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
