Lower Limb Injury

You are the orthopaedic CT1 on call. You have been called to A&E to see a 24-year-old man who sustained a right lower limb injury after a slide tackle whilst playing football. You are shown the picture below. How would you proceed?

Example answer introduction

This is a plane radiograph in the A-P view of a lower limb. The most obvious abnormality is a transverse fracture of the tibia and associated transverse fracture of the fibula. This is potentially surgical emergency and I would asses this patient immediately using the ATLS protocol, implement an initial management plan and discuss this patient with the Orthopaedic Registrar.

Initial Assessment and Simultaneous Resuscitation

On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.

  • Airway with C-spine control

    • Check that airway is patient

  • Breathing

    • oxygen saturations, examine chest, examine work of breathing, breathing depth

    • if concerns give high flow oxygen through a non-rebreathe mask

  • Circulation

    • pulse, blood pressure, capillary refill time, skin turgor, fluid input/output

    • ensure IV access- 2 large bore etc- bloods as above, consider catheter

    • Give fluid challenge 500ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. Avoid deep probing open any neck wounds

    • If hypovolaemic think “blood on the floor + four more” - intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh – areas of internal haemorrhage

  • Disability - GCS, pupils, blood sugar, temperature

  • Exposure-  systemic signs of shock, other injuries

Provide constant reassessment during this acute phase.

Focused history

  • Allergies

  • Medications 

  • Past medical history including previous surgery

  • Last meal

  • Events leading up to this point

 

Examination

Examination in a trauma scenario is often done in "E" of ABCDE (ATLS). Often proper examination of limb trauma is later, especially in none-trauma EDs. 

 

Expose patient completely and look for any other injuries.

 

Assesses lower limb specifically for:

  • Compound fracture

  • Neurovascular deficit

  • Examine the joint above and below - this is a key point not to be missed in an interview scenario (and of course in clinical practice)

Immediate management and further investigations

​​Management

  • Adequate fluid resuscitation

  • Analgesia according to WHO ladder

  • Antibiotics as per local protocol for open/compound fractures

  • If contaminated open wound, wash with normal saline and give tetanus booster

  • Reduce closed fractures and immobilise in cast. If open fracture, will need to go to theatre, cover with betadine-soaked dressing.

  • Escalate to Orthopaedic Registrar, Vascular Registrar if vascular injury.

  • Prep for theatre – Bloods, Anaesthetist, Emergency theatres, Consent patient if able

  • Keep patient and any relatives informed

  • Document, document, document!!!

Investigations

If there is evidence of vascular injury, you may want to arrange angiography to be performed prior to theatre. CT scan may be helpful in assessing the ankle joint if there is intraarticular extension. This is something you would discuss with your registrar. 

Remember to document your findings and management plan and inform the patient/parents.

 Escalation​

Consider discussion with:

  • Orthopaedic Registrar on call

  • Potentially consultant if Registrar is unavailable

Tibia/Fibular fractures can be managed non-operatively or operatively depending on the severity of the injury. Your role is to ensure the patient is stabilised and to recognise where there is a there is a need for emergent surgery. Ensure regular review of neurovascular status once you have clerked the patient if they are going to the ward as the clinical picture may change following cast immobilisation or the patient may develop a late compartment syndrome. 

Useful Resources

​E-Medicine Article

 
 
 
 
 
 
 
 
 
 
Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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