the patient Flashcards
Fractures
‘A break or crack in the continuity of something’
Bone Fractures – Main Causes
Trauma
Disease (pathological)
Overuse
Bone Fractures – Signs & Symptoms
*Pain
*Swelling
*Deformity
History taking is important as it can be
difficult to tell in some circumstances
Bone Fractures – Diagnosis
*Clinical presentation/Examination
*X Ray
*CT Scan
*MRI
*Bone Scan (bone scintigraphy)
Bone Fractures - Triage
questions to ask
Questions to ask depends on the setting you are in
Consider the common presentations discussed:
Pain, Swelling & Deformity
- Questions to ask (Pharmacy):
When (relationship to presentation)
Symptoms
How did it happen (nature of the injury)
Range of motion
Nature of the pain
Other factors to consider – Age of the patient
Bone Fractures – Treatment (First Aid)
If a fracture is suspected - two aims:
Prevent movement at the site of injury
Signpost to next stage of care
Closed fracture:
Immobilise - ask the patient to remain still
Support - above and below the injured area with hands until a sling or
bandage available, padding for further support
Sign post – Arm injury may be transferred to a urgent care centre or A &
E by car, leg injury may require an ambulance
Advice and monitor – if in shock elevate only the uninjured limb, advise
do not eat or drink. If bandages used monitor. Remove any jewellery if
safe to do so. Use ice for up to 20 mins every few hours.
Open fracture:
Cover the wound with a dressing or clean pad. Apply pressure around
the injury to control bleeding. Do not press on a protruding bone use
pads to build up until possible to bandage. Secure the dressing.
Immobilise - ask the patient to remain still and immobilise as per closed
fracture.
Sign post – Will require transport to hospital
Advice and monitor – as per closed fracture
Bone Fractures – Treatment (Drugs)
Paracetamol is suitable as a central analgesic for mild pain
* Add a weak opioid if appropriate for moderate pain e.g.
codeine
* In a secondary care setting IV therapy may be needed
* NSAIDs can be used as a supplement but not in frail or
older adults
* Regional anaesthesia may be needed for reduction
* NSAIDs – role in bone healing to give or avoid
Bone Fractures – Treatment (Casts/splints)
Not always necessary, some bones can use
immobilisation and gravity only
* Splints may be used
* Back slab casts until swelling gone down
* Full cast later
Bone Fractures – Treatment (Surgery)
Usually necessary for hip fractures
*May be required for complex breaks, open
fractures, comminuted or extreme instability
*May require external fixations initially
*Decision can be delayed
Bone Fractures – Treatment (Rehabilitation)
- Keep the immobilised limb raised to reduce
swelling - Exercise to prevent stiffness, flexing fingers and
toes - Eat well, protein and vitamin C
- Physiotherapy may be needed once a cast is
removed to try to recover movement and tone - Recovery time is bone specific 6-8 weeks for a
simple arm or wrist break. Severe leg break may
take 3-6 months
Bone Fractures – Fragility Prevention
A number of factors increase your risk of fractures:
Age
Sex
Smoking
Alcohol consumption
Medicines
Co morbidities
Low BMI
Long immobilisation
Falls risk
Bone Fractures – Warning Signs
Affected limb is numb, tingling or has pins and
needles
* Open Fracture
* Involvement of spine, neck or head
* Heavy bleeding
* Clear deformity
* Severe pain
* Age (FRAX score)
* PMH
Sprain V’s Strain
Sprain: Overstretching or twisting ligaments
(abnormal movement)
Strain: Tearing of the muscle fibres/tendons
(overexertion)
Sprain & Strains – Main Causes
- Trauma (accidental)
- Overuse (Physical activity)
- Fatigue
Sprain & Strains – Signs & Symptoms
- Pain
- Swelling
- Bruising (sprain)
- Difficulty moving/limited weight bearing
- Muscle spasm*s and cramps (strain)
History taking is important as it can be difficult to tell
in some circumstances
Sprain & Strains – Diagnosis
- Clinical presentation/Examination
Movement, tenderness, weight bearing - X Ray Decision based on clinical factors above
and age (Ottawa rules for ankle and foot) - MRI
Sprain & Strains – Common (Ankle/Foot)
Presentations
- Ankle Sprain
Aversion (ankle forced outwards/foot forced inwards) lateral
ligament
Eversion - deltoid ligament - Achilles tendon injuries
Pain behind the heel, worsens over time. Activity related - Plantar Fasciitis
Pain and tenderness across the plantar surface of the foot
and heel. Worse in the mornings. Builds overtime
Sprain & Strains – Common (Elbow/Knee)
Presentations
- Runners Knee (chondromalacia)
Pain creeps up on you. Pain at the front of the knee or
behind the knee cap. Aggravated by long periods of sitting or
going up/downstairs - Tennis Elbow (Lateral epicondylitis)
History of gradually increasing pain and tenderness. Outside
of the elbow joint and radiating to the upper arm - Golfers Elbow (Medial epicondylitis)
Inner side of the elbow and radiating down the forearm
Sprain & Strains – Common Presentations
- Thigh Strain
Pain worse on using the muscle. Not always a clear history - Delayed onset muscle soreness
Follows unaccustomed strenuous activity (last 48 hours),
complain of muscle tightness and pain, palpation of the
muscle is painful. Resolves within a week.
Sprain & Strains– Treatment (Self Care)
PRICE
(Protect)
Rest
Ice
Compression
Elevate
tell me about PRICE
Protect – Prevent further injury (24-48 hours post injury) use
a sling/cushion or crutch if needed
Rest – Stay off the injury for 24-48 hours, avoid activity to
worsen the pain or discomfort otherwise continue normal
activities. Small movements of injured body part reduces
blood flow & promotes healing
Ice – Ice pack for 10mins against the injury (wrapped in a
towel) until it becomes numb. Continue while the injury
remains hot to touch. ?move to heat after 2 days
Compression – Bandage to offer support until swelling goes
down
Elevate – Support the injured part above the level of your
heart
Sprain & Strains– Treatment (Drugs)
- NSAIDs (oral/topical) 48hrs after injury to avoid
delaying healing - Paracetamol as a central analgesic
- Rubefacients
Sprain & Strains– Treatment (Rehabilitation)
- Feel better around 2 weeks
- Avoid strenuous exercise for 8 weeks
- Severe sprains and strains can take months to recover
- Start active mobilization and flexibility (range of motion)
exercises as soon as tolerated without excessive pain - Athletes may return to play when there is full, painless
range of movement and muscle strength is restored - Avoid returning immediately to the same exercise level if
activity was the cause
Sprain & Strains– Treatment (Prevention)
- Not always possible
- If activity related warm ups are important
- Avoid work outs on tired muscles
- Being ‘unfit’
- Improper equipment
- Environmental factors
