Fractures on the CCFP exam

Approach

• Start with the airway, holding the neck still. Then breathing, then circulation, then a quick check of how awake the patient is.
• Stop outside bleeding with firm, direct pressure. Start fluids or blood by vein if the patient is in shock.
• Think of the pelvis and the thigh as places to lose a lot of blood. Bind an unstable pelvis.
• Splint a limb during this first check only to ease pain and slow bleeding. Full care of the limb comes later.
• Call for transfer early if your site cannot manage the injuries.

Approach

• Feel the pulses past the injury. Check colour, warmth, and how fast colour returns after you press a nail.
• Test feeling and movement for the nerves that cross the injury. At the ankle: the top of the foot, the first web space and the sole.
• Press along the bone up to the joint above and the joint below. A twisted ankle can break the fibula up near the knee.
• If the joints above and below are not tender, they need no films.
• Look at the skin over the break for a wound, or skin stretched pale over bone.
• Leave stress tests, strength and range of motion until imaging rules out a fracture.
• Write down what you found, and check again after any splint or reduction.

Approach

• Scaphoid: tenderness at the base of the thumb after a fall on the hand needs a thumb splint and a review visit, even with normal films.
• Elbow: an elbow that will not fully straighten after a fall can hide a fracture. So can a dark patch of fat pushed up by blood on the film.
• Child: a growth plate break can look normal on film. Splint for comfort and review.
• Child's outer ankle with normal films: most are sprains. Use a short-term brace or walking boot, and wean it over 1 to 2 weeks.
• Do not leave that child in a cast for weeks. Long immobilization brings stiffness and a limp.
• Stress fracture: pinpoint bone pain that builds with training can show nothing on early films. Stop the activity and image further if it changes care.
• Book repeat imaging or a review visit, and tell the patient why.

Approach

• Take a new inability to walk after a fall as a hip or pelvic fracture until proven otherwise.
• A short, outward-turned leg fits a hip fracture. A hidden break may show neither.
• Order more imaging before you rule out a fracture. Plain films alone are not enough.
• Look at the whole pelvis too. The thin bones at the front of the pelvis break after falls as well.
• Keep her off the leg and treat her pain while you wait.
• Ask why she fell: fainting, a new medicine or an infection.

Approach

• Reduce now when a break or dislocation leaves the limb pale, cold or without a pulse.
• Reduce now when skin is stretched white over a bone end. The skin can die and the fracture open.
• Do it in your department, under sedation. A recent meal is not a reason to delay an emergency reduction.
• Check pulses and nerves again after reduction. Then splint and X-ray.
• Still no pulse after reduction: image the artery and call surgery at once.
• Keep a limb with poor blood flow at heart level, not raised.
• Reduce and splint before transfer when it is within your scope.

Approach

• Score pain on arrival. Treat it before the patient goes to X-ray.
• Splint the limb. Support and stillness ease pain on their own.
• Mild to moderate pain: start a simple pain reliever by mouth.
• Severe pain or a deformed limb: give a strong pain reliever fast, by vein or by nose. Repeat it until the pain is controlled.
• Check pain again after each dose, and before and after any reduction.
• Pain relief makes the exam easier. It does not hide a fracture.

Approach

• Treat any wound over or near a fracture as linked to it. Blood with fat droplets comes from the marrow.
• Open fracture: cover with a sterile dressing, splint, and call orthopaedics at once.
• Compartment syndrome is swelling that chokes the muscle inside its sheath. Look for pain out of proportion and pain when you stretch the fingers or toes.
• Pulses are often still there in compartment syndrome. Do not wait for them to go.
• If you suspect it, split any cast or tight dressing, keep the limb at heart level and call surgery at once.
• After a fall from a height or a blow to the head, hold the neck still until it is cleared.

Approach

• Ankle or foot injury: apply the Ottawa ankle rules. They suit alert, cooperative patients who can feel the limb and are not distracted by other injuries, after blunt injury in the last 10 days.
• The ankle rules work in adults and in children older than 2.
• Rule negative: no X-ray. Imaging then adds radiation and delay, not better outcomes.
• Neck after trauma: in an alert, stable patient, use the Canadian C-spine rule. Image only if the rule says to.
• Minor head injury: use the Canadian CT (computed tomography) head rule in adults. In children, use the PECARN (Pediatric Emergency Care Applied Research Network) or CATCH (Canadian Assessment of Tomography for Childhood Head injury) rules.