Senior Manager MIU Services/Nurse Consultant Emergency care

Transcription

1 Title: MIU Forearm and wrist injuries - management of Ref No: 1955 Version 2 Document Author: Ratified by: Senior Manager MIU Services/Nurse Consultant Emergency care Care & Clinical Polices Group Meeting Clinical Director of Pharmacy Date 18 October 2017 Date: 18 October December 2017 Review date: 12 January 2021 Links to policies: 1. Purpose of this document - This clinical protocol provides a clear framework for nurse/paramedic practitioners employed by Torbay & South Devon NHS Foundation Trust when providing care to patients over 2 years of age presenting at Minor injury Units with forearm and wrist injuries. 2. Scope of the Policy: This protocol is for the use by Minor Injury and Emergency Department practitioners employed by Torbay & South Devon NHS Foundation Trust who has achieved the agreed Trust clinical competencies to work under this protocol. 2.1 Red Flag: Ensure all patients on anticoagulants i.e. Warfarin, Dabigatran etexilate (Pradaxa ), Apixaban (eliquis ) and Rivaroxaban (Xarelto ) have appropriate medical follow up/review blood tests INR review where risk of bleeding. 3. Assessment 3.1. Presenting signs and symptoms; may include some of the following; Pain, swelling, bruising/redness, wounds, inflammation/heat, reduced or loss of function, deformity, subluxation/dislocation, Numbness/altered sensation. 3.2 History: refer to protocol for History taking and Clinical Documentation and the protocol for the management of soft tissue injuries. Specific History; Traumatic (direct/indirect), non traumatic Establish mechanism of injury e.g. fall onto outstretched hand, direct blow/impact, twisting injury, Hand dominance Previous injury Occupation. 4. Clinical Examination: 4.1. Look Symmetry (compare right with left) Swelling Version 2 (January 2018) Page 1 of 8

2 Bruising/discolouration Wounds/grazing Deformity Dislocation/subluxation 4.2. Feel (palpate) include upper arm and elbow examinations. Note any bony tenderness, crepitus, step/deformity over; Proximal/mid-shaft/distal radius and ulna bones Radial/Ulnar styloid processes Radial head Carpal bones including scaphoid Metacarpals/ phalanges Ulna including olecranon Radius including radial head 4.3. Move Flexion/Extension Supination and pronation of forearm Ulnar and radial deviation at wrist. Grip Abduction adduction of fingers/thumb, thumb opposition Special Tests Sensation/circulation (neurovascular status) distal to and over injured site. Thumb compression test/telescoping of thumb (scaphoid) Radial and ulnar collateral ligament laxity of joints. Rotational deformity/alignment 4.5. Investigations 5. Treatment X-ray where there is clinical indication of fracture or dislocation requesting appropriate views. If suspicious of a scaphoid fracture ensure scaphoid views are taken. 5.1 Colles Fracture A distal radius fracture within 2 5 cm of the wrist with dorsal tilt of the distal fragment if displaced The commonest of all fractures, usually resulting from a fall on the outstretched hand. Seen mainly in middle-aged and elderly women, where osteoporosis is a factor. Complications include wrist stiffness, persistent deformity, carpal tunnel syndrome, delayed rupture of extensor pollicis tendon and Sudeck s atrophy Fractures may be the result of a collapse or giddy turn rather than an accidental fall, especially in the elderly. Always ascertain the cause of the fall and investigate and manage appropriately Specific Examination Pain, swelling and often the characteristic dinner-fork deformity of the wrist. Version 2 (January 2018) Page 2 of 8

3 Maximal tenderness is over the distal radius If maximal tenderness is in the anatomical snuffbox without obvious deformity document this, obtain scaphoid views, and ensure the patient is followed up Check the distal sensation and pulses Examine the elbow for associated injury (e.g. radial head fracture) and obtain elbow views if there is pain or tenderness. Examine the shoulder Investigations /Radiographs Distinguish from a Smith s fracture by the volar position of the thumb in the lateral view Anterior/posterior and lateral show a fracture through the distal radius with characteristic deformities: Dorsal and radial displacement of the distal fragment Dorsal tilt of the distal fragment on the lateral view the articular surface normally has a 5º volar tilt Radial tilt of the distal fragment on Anterior/posterior view the articular surface normally has a 22º ulnar tilt Impaction, with shortening of the radius in relation to the ulna Rotational deformity towards supination, not obvious on radiography There is frequently a fracture of the ulnar styloid, which if displaced indicates disruption of the inferior radioulnar joint Check for any intra-articular component, which usually mandates Orthopaedic referral (see below) Check for associated injuries such as scaphoid, triquetral or base of thumb fracture, carpal dislocation or diastasis Check for subtle fractures such as undisplaced dorsal cortex or radial styloid fracture, longitudinal fracture extending to the joint surface, or undisplaced impacted fracture, which may appear only as a slight increased density in the metaphysic Treatment If undisplaced or not for manipulation Analgesia as per Patient Group Direction or advise over the counter analgesia. Treat as per orthopaedic ED/MIU fracture and Trauma triage guidelines Apply below elbow dorsal plaster slab and provide plaster advice, High arm sling and trauma Triage follow up. If displaced and/or impacted refer to appropriate skilled ED or orthopaedic practitioner for manipulation and reduction. Where MIU practitioner has been deemed competent in performing haematoma blocks these may be carried out in the MIUs where medically appropriate. NB appropriate number of skilled staff require to support management plan/manipulation and reduction including plastering. 5.2 Isolated Radial styloid fractures An intra-articular fracture caused by similar mechanisms to scaphoid fracture, i.e. a fall on the outstretched hand or kick-back injury Check on anterior/posterior view for scapholunate diastasis Treatment; Analgesia, as per Patient Group Direction (PGD) or advise over the counter analgesia. Treat as per orthopaedic ED/MIU fracture and Trauma triage guidelines Apply below elbow POP and provide plaster advice, High arm sling and trauma Triage follow Encourage simple hand, elbow exercises/movement Displaced fractures Treat as per orthopaedic ED/MIU fracture and Trauma triage guidelines refer to orthopaedics. Version 2 (January 2018) Page 3 of 8

4 POP backslab and sling 5.3 Isolated radius/ulnar fractures Fall onto outstretched hand or direct blow Treatment Undisplaced fracture distal forearm plaster of Paris backslab below elbow, high arm sling, analgesia as per PGD. Trauma Triage Undisplaced fracture midshaft forearm POP backslab above elbow, broad arm sling, analgesia and trauma Triage. Displaced fracture refer to Orthopaedics for further advice management 5.4 Scaphoid fracture Caused by a fall on to the outstretched hand or kickback injuries Fractures across the waist or proximal pole of the bone jeopardise the blood supply to the proximal fragment. If the patient is managed incorrectly then disabling non-union, delayed union or avascular necrosis may result Some hairline fractures are not detectable until 5 to 10 days after the injury, when bone resorption makes most fractures more obvious Diagnosis Suspect when there is pain or swelling on the radial aspect of the wrist following any injury Look for filling of the anatomical snuffbox (ASB) and tenderness in the ASB. Compare both sides and press gently at first. Beware that tenderness here may also be a sign of Bennett s or radial styloid fracture Over the volar aspect of the scaphoid (scaphoid tubercle) Over the dorsum of the scaphoid Look for scaphoid pain on gentle flexion with ulnar deviation, resisted pronation and longitudinal compression (telescoping) of the thumb Radiographs Request scaphoid (4 views) and not wrist (Anterior/posterior + lateral) views. Check all four views carefully for subtle hairline fracture, linear lucency or cortical discontinuity, which may only appear on one view TREATMENT Fracture clinically suspected fracture Low index of suspicion (X-ray apparently normal, Unlikely mechanism, poor signs or under 12 years) Treat symptomatically with Elastic support (futura splint) as required and high arm sling. Encourage simple hand, wrist, elbow and shoulder exercises. Provide analgesia as per Patient Group Direction or over the counter analgesia. Emergency Department Consultant review or Fracture clinic follow up as per local Acute hospital guidelines 7 10 day post injury. High index of suspicion (Mechanism, symptoms, signs and limited movement) Treat: Plaster of Paris neutral back slab or future splint with thumb extension, High arm sling. Encourage simple hand, elbow and shoulder exercises. Provide analgesia as per Patient Group Direction or advise over the counter analgesia. Emergency Department Consultant review or Fracture clinic follow up as per local Acute hospital guidelines 7 10 day post injury. Definitive scaphoid fracture (Fracture on x-ray) Treat: Undisplaced: Scaphoid Plaster, high arm sling, analgesia as per Patient Group direction, and refer to Trauma Triage. Displaced fracture: refer to orthopaedics. Version 2 (January 2018) Page 4 of 8

5 5.5 Extensor Tenosynovitis Commonest in the age groups, a painful swelling develops over the distal radius following unaccustomed repetitive activity. There is pain and crepitus on movement Treatment :Rest Support double tubigrib or future splint (without thumb extension) Advise or provide Ibuprofen Non-steroidal anti-inflammatory as per Patient Group Direction. For follow up with General Practitioner 5.6 De Quervain s Tenosynovitis Inflammation of the tendon sheaths of abductor pollicis longus and extensor pollicis brevis, usually in the middle-aged. There is pain, swelling and crepitus over the radial styloid Symptoms can be reproduced by thumb or wrist movements, and Finklestein s test is positive Treatment; Rest, Support double tubigrib or future splint Advise or provide Ibuprofen Non-steroidal anti-inflammatory as per patient Group direction. For follow up with General Practitioner Severe Cases seek Emergency department senior advice. 5.7 Wrist sprain Only consider this diagnosis after excluding scaphoid injury or other fracture or dislocation Can occur following hyperextension or flexion of the wrist, causing swelling and tenderness around the wrist joint Treatment: Advise or provide Ibuprofen Non- steroidal anti- inflammatory as per patient group direction. Support bandage (tubigrib) and high arm sling Encourage simple wrist/hand exercises. Review where appropriate with GP in 5 7 days, or local unit, to ensure full mobility has been regained 5.8 Children s Fractures Greenstick fractures Treatment: Minimally or undisplaced greenstick and torus (buckle) fractures. Give analgesia as per Patient Group Direction or advise over the counter analgesia MIUs Plaster of Paris back slab (above elbow in children under 2 years or it will fall off) otherwise below elbow neutral position. Plaster advice. High arm sling and advise simple hand exercises Trauma Triage Clinic follow up. Refer displaced or overlapping factures to the Orthopaedic team. Emergency Department Treat as per orthopaedic ED/MIU fracture and Trauma Triage guidance soft cast plaster and orthopaedic discharge advice leaflet. Version 2 (January 2018) Page 5 of 8

6 5.8.2 Tenderness of distal radius over growth plate with no apparent Fracture seen on x-ray Treatment ; If painful treat as growth plate injury until x-ray report confirmation. Analgesia as per Patient Group Direction or advise over the counter analgesia, Plaster of Paris back slab below elbow neutral position. High arm sling X-ray confirmation to growth plate injury refer to trauma Triage no growth plate/fracture identified review in MIU/ED in 3-5 days and reassess. Refer to trauma triage if remains acutely painful otherwise remove POP and advice gentle return to active mobilisation Salter Harris Type fracture Treatment minimally or undisplaced. Plaster of Paris backslab below elbow neutral position, high arm sling, Analgesia over the counter or as per Patient Group Direction. Trauma triage follow up or as per orthopaedic ED/MIU fracture guidance Slipped distal radial epiphysis Usually a Salter-Harris type 2 injury of adolescence. Growth disturbance is rare. Refer to orthopaedics as may need manipulation NB Swelling and reduced range of movement is more subtle in children immediately post injury but becomes more obvious over a few days. Rely on clinical examination skills and specific bony tenderness. 5.9 Smith s fracture & Barton s fracture Refer to orthopaedics: apply Volar back slab below elbow. Give Analgesia as per PGD according to patients pain score 5.10 Carpal chip Fractures Minor avulsion of a carpal bone at a ligamentous insertion may occur with wrist hyperflexion or hyperextension. The triquetral is the commonest site. Request oblique or special views to exclude carpal body fracture Look carefully for carpal subluxation, dislocation or diastasis and refer if in doubt Treatment: Give Analgesia as per Patient Group Direction, Plaster of Paris back slab (or support bandage if symptoms minimal). High arm sling Simple hand exercises, Trauma Traige 5.11 Carpal body fractures, Scapho-lunate diastasis, carpal dislocation including lunate dislocations. Refer to orthopaedics for advice re treatment and follow up/referral. Give analgesia as per patient group directions. Version 2 (January 2018) Page 6 of 8

7 6. Documentation 6.1. Clinical records must be written in accordance with Torbay & South Devon NHS Foundation Trust History Taking and Clinical Documentation protocol, Nursing & Midwifery Council guideline standards including record keeping or relevant registering body e.g. Health & care professional Council (HCPC) standards including record keeping guidance A summary letter of the MIU/ED attendance and the care delivered must also be sent to the General practitioner and also the health visitor if less than 5yrs or school nurse if aged between 5yrs and 16yrs to ensure the central medical record of the patient is accurate For patients being transferred to the Emergency department, ensure records are completed in a timely manner on shared symphony IT system. A summary letter will be sent to the General practitioner in the normal manner For patients seeing the General practitioner or specialist within the next 24 hours ensure the patient has a copy of the attendance record to take with them. A summary copy will be sent to the General practitioner in the normal manner. 7. Discharge information 7.1 Ensure those patients who have been referred for further acute intervention has appropriate transport to meet their needs, all relevant treatment has been prescribed and/or administered and correct information & documentation is given to the patient. 7.2 The patient /carer understand that if the condition deteriorates or they have any further concerns to seek medical advice. 7.3 The patient and /or carer demonstrate understanding of advice given during consultation. 7.4 The patient/carer has been provided with written advice leaflet to reinforce advice given during consultation 7.5 The patient/carer demonstrates and understanding of how to manage 8. Training and implementation: MIU Network meeting Cascade. All staff adhering to protocols must have agreed training and proven competence to work within protocol. Each protocol must be agreed and signed by line manager. 9. Monitoring tool _ Regular review of clinical practice to ensure individuals are adhering to clinical protocol. 10. References Accident & Emergency, theory into practice. Dolan B, Holt L Acute Medical Emergencies, a nursing guide. Harrison R, Daly L British National Formulary 2017 Clinical orthopaedic Examination. McRae R. 5 th edition 2004 Differential Diagnosis. Rafley, A. Lim, E. 2 nd edition 2005 Guide to physical examination and History Taking. Bickley 2003 Version 2 (January 2018) Page 7 of 8

8 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 Minor Injuries, A Clinical guide. Purcell D. 2 nd edition 2010 NICE Fractures (non complex) Assessment and Management NG NICE fractures (complex) Assessment and Management NG South & west Devon Formulary Amendment History Issue Status Date Reason for Change Authorised 1 Created February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for forearm and wrist injuries 1.1 Reviewed August 2015 Reviewed no clinical changes Documentation amendments to reflect new Symphony IT system 2 Revised 12 January 2018 Trust name Emergency department practitioner inclusion Orthopaedic ED/MIU fracture and trauma triage guidance NICE CG37 & 38 referenced 2 12 February 2018 Review date extended from 2 years to 3 years Senior Manager MIU Services/Nurse Consultant Emergency care Senior Manager MIU Services/Nurse Consultant Emergency care Care and Clinical Policies Group Clinical Director of Pharmacy Version 2 (January 2018) Page 8 of 8

9 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. Version 2 (January 2018) The Mental Capacity Act Page 1 of 1

10 Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Version and Date Policy Author An (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users Staff Other, please state Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Age Yes No Gender Reassignment Yes No Sexual Orientation Yes No Race Yes No Disability Yes No Religion/Belief (non) Yes No Gender Yes No Pregnancy/Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy could affect particular Inclusion Health groups less favourably than Yes No the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Yes No NA Are the services outlined in the policy fully accessible 6? Yes No NA Does the policy encourage individualised and person-centred care? Yes No NA Could there be an adverse impact on an individual s independence or autonomy 7? Yes No NA EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Who was consulted when drafting this policy? Patients/ Service Users Trade Unions Protected Groups (including Trust Equality Groups) Staff General Public Other, please state What were the recommendations/suggestions? Does this document require a service redesign or substantial amendments to an existing Yes No process? PLEASE NOTE: Yes may trigger a full EIA, please refer to the equality leads below ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Signature Validated by (line manager) Signature Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call or marisa.cockfield@nhs.net Version 2 (January 2018) Rapid (E)quality Impact Assessment Page 1 of 2

11 For Torbay and South Devon NHS Trusts, please call or This form should be published with the policy and a signed copy sent to your relevant organisation. 1 Consider any additional needs of carers/ parents/ advocates etc, in addition to the service user 2 Travelers may not be registered with a GP - consider how they may access/ be aware of services available to them 3 Consider any provisions for those with no fixed abode, particularly relating to impact on discharge 4 Consider how someone will be aware of (or access) a service if socially or geographically isolated 5 Language must be relevant and appropriate, for example referring to partners, not husbands or wives 6 Consider both physical access to services and how information/ communication in available in an accessible format 7 Example: a telephone-based service may discriminate against people who are d/deaf. Whilst someone may be able to act on their behalf, this does not promote independence or autonomy Version 2 (January 2018) Rapid (E)quality Impact Assessment Page 2 of 2

12 Clinical and Non-Clinical Policies New Data Protection Regulation (NDPR) Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure that all policies and procedures developed act in accordance with all relevant data protection regulations and guidance. This policy has been designed with the EU New Data Protection Regulation (NDPR) in mind and therefore provides the reader with assurance of effective information governance practice. NDPR intends to strengthen and unify data protection for all persons; consequently, the rights of individuals have changed. It is assured that these rights have been considered throughout the development of this policy. Furthermore, NDPR requires that the Trust is open and transparent with its personal identifiable processing activities and this has a considerable effect on the way TSDFT holds, uses, and shares personal identifiable data. The most effective way of being open is through data mapping. Data mapping for NDPR was initially undertaken in November 2017 and must be completed on a triannual (every 3 years) basis to maintain compliance. This policy supports the data mapping requirement of the NDPR. For more information: Contact the Data Access and Disclosure Office on dataprotection.tsdft@nhs.net, See TSDFT s Data Protection & Access Policy, Visit our GDPR page on ICON. Version 2 (January 2018) New Data Protection Regulation Page 1 of 1