Title: MIU Upper leg and knee injuries- management of Ref No: 1971 Version 3 Document Author: Ratified by: Senior Manager MIU Services Nurse Consultant Emergency Care Care & Clinical Policies Group Meeting Clinical Director of Pharmacy Date 18 October 2017 Date: 18 October 2017 21 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 including ED with upper leg and knee injuries 2. Scope of the Policy: This protocol is for the use by Minor Injury and Emergency department nurse/paramedic practitioners employed by Torbay & South Devon NHS Foundation Trust who has achieved the agreed Trust clinical competencies to work under this protocol. 2.1 Exclusions/Red flags All patients presented with upper leg and knee injury will be triaged/assessed. Those patients outside clinical protocols including x-ray protocol will be referred to the appropriated clinical setting. Refer all patients (prior to discharge) on anticoagulants i.e. Warfarin Dabigatran etexilate (Pradaxa ), Apixaban (eliquis ) and Rivaroxaban (Xarelto ) for further medical review, bloods/inr testing. NB Be aware of serious limb conditions such as mid shaft Femur fracture and refer to Emergency department via (9)999 ambulance immediately where presenting to MIU. 3. Assessment 3.1. Presenting signs and symptoms; may include some of the following; Pain, swelling, bruising/redness, wounds, inflammation/heat, inability or difficulty to weight bear, reduced or loss of function, deformity/dislocation 3.2. History; refer to protocol for History taking and Clinical Documentation and the Protocol for the Management of soft tissue limb injuries; Specific: Establish when, where and how the injury occurred. Establish the exact mechanism e.g. Valgus stress of knee may result in Medial collateral ligament injury Varus stress of knee may result in Lateral collateral ligament injury Twisting to flexed knee may result in Meniscus injury Forced flexion or hyperextension may result in Anterior cruciate ligament injury (isolated or with medial collateral or medial meniscus) Dashboard impact - may result in Posterior cruciate ligament injury (often with medial or collateral ligament) Version 3 (January 2018) Page 1 of 8
Did the patient fall from a height. What type of surface did they fall onto? Ask whether the patient could weight bear immediately after the injury A crack felt or heard does not necessarily indicate a fracture Was there immediate swelling to the injured limb. Pain score at time of injury and on presentation First aid treatment received. The amount of swelling may depend on whether ice and elevation have been applied Swelling of immediate onset indicates an acute haemarthrosis. Swelling developing over several hours indicates a reactive effusion Ask about any history of clicking, locking (inability to fully extend), and giving way including previous knee problems and surgery Past medical history including previous injuries to effected limb Medications - red flags e.g. anticoagulants 4. Clinical Examination Observe where possible patients gait, balance, mobility, ability to weight bear prior to examination. During examination always examine both legs, exposed to the upper thighs, while the patient is lying supine Look Symmetry Suspicion of a hip fracture observe for shortening and rotation of lower leg Swelling, Bruising/discoloration, Wounds/grazing Deformity/dislocations Feel: (palpate from hip down) Note any tenderness over: Pelvis, hip Proximal midshaft and distal Femur Femur condyles and joint line Patella, patellar tendon Distal tibia, tibial plateau, tibial tuberosity Fibula head Feel for warmth and crepitation. Test for effusion of the knee by inspection, the patellar tap test and, for small effusions, the fluid displacement test Assess muscle tone and bulk. Confirm wasting by comparing measurement with the other limb. Palpate collateral ligaments of knee. Palpate joint line of knee for meniscal injury. Move hip (Passive. Active & resistance) Flexion/extension Abduction/adduction Internal/external rotation Move knee (Passive Active & resistance) Extension (normal = 0 ). Try to obtain full extension if not obviously present. Pain may be the cause, but a springy block to full extension suggests a meniscus tear Flexion (normal = over 135 ) Version 3 (January 2018) Page 2 of 8
Straight leg raise. Ask the patient to straight leg raise, which against resistance generally excludes rupture of the quadriceps or patellar tendon, a transverse patellar fracture or avulsion of the tibial tubercle Special tests With the knee at 90 (if possible): Assess the anterior cruciate ligament for anterior glide (anterior drawer test). Up to 5 mm movement is normal. Over 1.5 cm indicates anterior cruciate ligament rupture. Less displacement and asymmetrical movement of the tibial condyles may suggest isolated cruciate laxity or rotational instability. Always compare both legs. If unable to flex to 90, assess in about 15 flexion (Lachman test). Assess the collateral ligaments Medial collateral ligament Look for tenderness of the medial ligament at its femoral attachment and the joint line. With the leg straight, gently apply valgus stress and examine for pain and opening up of the joint line, suggesting injury of the medial collateral ligament. Severe laxity may indicate additional cruciate rupture. Compare the two sides. If no instability is demonstrated repeat the test with the knee flexed to 30 and the foot internally rotated. Some opening up of the joint in this position is normal. Abnormal opening suggests a partial medial ligament tear Lateral collateral ligament Similarly, look for lateral tenderness and apply varus stress in extension and 30. Laxity in both positions suggests additional posterior cruciate ligament rupture Assess the posterior cruciate ligament for posterior glide (posterior drawer test) Palpate the joint lines, the ligament insertions and bony landmarks for tenderness Check the peroneal nerve Examine for weakness of foot dorsiflexion and eversion, and loss of sensation over the lateral aspect of the fore foot) Assess the menisci : McMurray test Assess sensation and circulation distal to injury. 4.1 Investigations, X-ray and the Ottawa Knee rule : AP and lateral are the standard views: If a patella fracture is suspected clinically and the standard views are normal, request alternate views with Radiographer advice. In traumatic knee injury Less than a week old In patients over 17 years Without distracting injury or previous surgery A knee radiograph is only indicated if one or more of the following apply: Age 55 or over Inability to flex the knee to 90 Tenderness of the fibular head Inability to walk four steps both immediately and in the unit Isolated tenderness of the patella Skyline views may be required seek radiographer advice Version 3 (January 2018) Page 3 of 8
If a tibial plateau fracture is suspected clinically and the standard views are normal, request oblique views seek radiographer advice Sometimes a fat fluid level in the suprapatellar bursa (lipohaemarthrosis) is the only sign of an intra-articular fracture NB All patients with suspected Femur and hip fractures must be referred to the Emergency department for Investigations and further management where presented to a community MIU 5. Treatment 5.1 Suspected Hip Fractures Assess pain score and give analgesia as per patient group direction. Consider use of entonox as per protocol. Immobilise patient in supportive manner. Refer to emergency department for further review and management via ambulance where presenting at a community MIU If competent cannulate patient and where prescribed or as per Patient Group Direction give 1 litre of Normal saline. 5.2 Suspected Mid-shaft Femur Fractures Assess pain score and give analgesia as per patient group direction. Consider use of entonox as per protocol. Immobilise patient in either full length back slab or await ambulance support with trauma splintage Refer to emergency department for further review and management via 999 ambulance where presenting to a community MIU If competence cannulate patient and where prescribed or as per Patient Group Direction give 1 litre of Normal saline 5.3 Distal Femur or condylar fractures Assess pain score and give analgesia as per patient group direction. Consider use of entonox as per protocol. Immobilise patient in either full length back slab or await ambulance support with trauma splintage Refer to Orthopaedics for further review and management via ambulance. 5.4 Fractured Patella Signs and Symptoms; Usually from a direct blow. There is pain, swelling, difficulty in bending the knee and perhaps crepitus or haemoarthrosis Investigations: May be difficult to interpret. Beware the bipartite patella (upper, outer quadrant) mimicking a fracture. If a patellar fracture is suspected clinically and the standard views are normal, request a skyline view Treatment of undisplaced patellar Fractures Assess pain score and give analgesia as per patient group direction. Immobilise patient in full length back slab. Arrange Trauma triage appointment Treatment of displaced, transverse fractures and undisplaced patellar fractures with extensor mechanism involvement, refer to orthopaedics for further management. Fracture clinic follow up Version 3 (January 2018) Page 4 of 8
5.5 Patellar Dislocations (with no correlating fractures) or self -reduced Patellar Dislocations. Signs and symptoms; usually dislocates laterally. May reduce spontaneously. May have reoccurring dislocations. Treatment of patellar dislocations: Reduce under entonox as per protocol by gently extending the knee. If this fails (with knee x-rayed ) where competent to do so repeat with pressure on the lateral margins of the patella using both thumbs. Check post reduction x-rays. Reassess pain score and give analgesia as per Patient Group Direction. Apply full leg cylinder plaster of Paris cast (bi-valved). Provide crutches. Follow up as per orthopaedic ED/MIU Fracture and Trauma triage guidelines. 5.6 Proximal Tibial fractures (including Oestocondral and Tibial Plateau fractures) Most common is the depressed lateral plateau fracture caused by impact collateral and/or cruciate ligament rupture. Look for swelling haemarthrosis and instability. Assess pain score and give analgesia as per Patient Group Direction. Immobilise patient in full length back slab. Follow up as per orthopaedic ED/MIU Fracture and Trauma triage guidelines 5.7 PROXIMAL FIBULAR FRACTURES Commonly associated with ligament rupture or another knee fracture May be part of a Maisonneuve fracture of the medial ankle Check the peroneal nerve, examine the ankle and X-ray the whole tibia, fibula and ankle. Treatment If isolated and without nerve injury: Assess pain score and give analgesia as per Patient Group Direction Provide support bandage e.g. wool & crepe or tubigrib. Provide crutches for partial weight bearing support Follow up as per orthopaedic ED/MIU Fracture and Trauma guidelines 5.8 Osgood-Schlatter s Disease Recurrent pain, tenderness and swelling over the tibial tubercle in children, especially boys aged 10 15 years. Radiographs may show an enlarged or fragmented tibial epiphysis Treat symptomatically with rest, Advise non- steroidal anti inflammatory medication as per Patient Group Direction. Refer to General practitioner for orthopaedic outpatient follow up. 5.9 Collateral Ligament Injuries Minor Sprains without laxity Assess pain score and give analgesia as per Patient Group Direction Support bandage. Crutches (depending on mobility) Quadriceps exercises. Written, verbal advice regarding knee exercises. Refer for physiotherapy For Moderate/severe sprains with laxity, haemarthrosis or avulsion refer to Orthopaedics for further management. Version 3 (January 2018) Page 5 of 8
5.10 Bursitis Prepatellar and infrapatellar bursitis result from inflammation, often associated with kneeling. Treatment; Rest/ elevation, avoid repetitive injury. Consider knee support Advise Over the Counter Non-steroidal ant inflammatory medication. Advise General Practitioner follow up. 5.10.1nfected Bursitis Sometimes associated with trivial skin lesions over the knee, occupations requiring kneeling; otherwise assumed to be blood borne. There may be increasing pain, cellulites, pyrexia and malaise. To commence on flucloxacillin (antibiotic if not allergic to penicillin treatment and arrange GP or Emergency Department follow updepending on severity. 5.11 Acute Haemarthrosis Rapid onset of a tense and painful swelling following knee injury, indicates a serious injury e.g. cruciate ligament rupture, meniscal tear, tibial avulsion or tibial plateau fractures. Treatment: Refer to orthopaedics 5.12 Cruciate Ligament Rupture Anterior Cruciate: Frequently associated with tears of the medial ligament and the medial meniscus The anterior drawer test is positive and there may be haemarthrosis and avulsion of the anterior tibial spine Posterior Cruciate. There is often associated damage to the collateral The posterior drawer test is positive. Beware a false anterior drawer test as the posteriorly displaced tibia is pulled forward into a normal position. There may be a haemarthrosis and avulsion of the posterior tibial n radiographs Refer to the Orthopaedic team for further management. Treatment: If presenting immediately after injury, refer to Orthopaedic team If delayed presentation, support bandage, crutches, quadriceps exercises and refer to Truama triage. 5.13 Meniscus Injuries Acute tears in the young adult, usually male, are generally from a sports incident of weight-bearing stress. In the middle-aged there may be no history of trauma There is immediate pain and inability to continue playing, with or without a haemarthrosis Joint line tenderness is non-specific, but a springy block to full extension is almost diagnostic of a displaced bucket-handle tear Treatment of isolated meniscus tears If the Knee is locked Refer to Orthopaedic team. Definite new meniscus tear Assess pain score and give analgesia as per Patient Group Direction, support bandage, crutches, refer to Emergency Department review clinic Version 3 (January 2018) Page 6 of 8
Possible meniscus tear Assess pain score and give analgesia as per patient group direction, support bandage, crutches, refer to Emergency Department review clinic 5.14 Ruptured Quadriceps Tendon Complete inability to straight-leg raise, often with a palpable defect the muscle insertion Assess pain score and give analgesia as per Patient Group Directions. Refer to orthopaedics for further management 5.15 Ruptured Achilles Tendon Complete Inability to straight leg raise, a palpable defect in the patellar tendon and high riding patella. There may be an avulsion of the tibial tuberosity. Assess pain score and give analgesia as per Patient Group Direction. Follow up as per orthopaedic ED/MIU Fracture and Trauma triage guidelines. 6. Documentation 6.1. Clinical records must be written in accordance with Torbay & South Devon NHS Foundation Trust History Taking and Clinical Documentation protocol, the Nursing & Midwifery Council guidelines of records and record management (2009) or relevant registering body e.g. Health & care professional Council (HCPC) record keeping guidance 6.2. A summary letter of the ED/MIU attendance and the care delivered must be sent to the General practitioner and also health visitor if under the age of 5yrs and school nurse if 5yrs to 16yrs of age to ensure the central medical record of the patient is accurate. 6.3. For patients being transferred to the Emergency department, ensure records are completed in a timely manner on shared IT system. A summary letter will be sent to the General practitioner in the normal manner. 6.4. For patients seeing the General Practitioner or specialist within the next 24 hours ensure the patient has a copy of the treatment record to take with them. A 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 have 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 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 advice given during consultation 7.5 The patient/carer demonstrates and understanding of how to manage subsequent problems 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. Version 3 (January 2018) Page 7 of 8
9. Monitoring tool _ Regular review of clinical practice to ensure individuals are adhering to clinical protocol. 10. References British National Formulary 2017 Clinical orthopaedic Examination. McRae R. 5 th edition 2004 Differential Diagnosis. Rafley, A. Lim, E. 2 nd edition 2005 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S. 1999 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 NG38 2016 NICE fractures (complex) Assessment and Management NG37 2016 South and West Devon Joint Formulary Patient.co.uk Amendment History Issue Status Date Reason for Change Authorised 1 Created February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for upper leg and knee injuries 2 Reviewed August 2015 Review of protocol. Documentation reflects IT changes references updated 3 Revised 12 January 2018 Trust name change Management of fractures linked to Orthopaedic ED/MIU fracture & Trauma Triage guidelines 3 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 Care and Clinical Policies Group Clinical Director of Pharmacy Version 3 (January 2018) Page 8 of 8
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 http://icare/operations/mental_capacity_act/pages/default.aspx 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 3 (January 2018) The Mental Capacity Act Page 1 of 1
Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Policy Author Version and Date 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 Version 3 (January 2018) Rapid (E)quality Impact Assessment Page 1 of 2
Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call 01803 652476 or email marisa.cockfield@nhs.net For Torbay and South Devon NHS Trusts, please call 01803 656676 or email pfd.sdhct@nhs.net 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 3 (January 2018) Rapid (E)quality Impact Assessment Page 2 of 2
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 management of New Data Protection Regulation (NDPR) Version 3 (January 2018) Page 1 of 1