I have been provided with information to answer your request by Ms Lyn McDonald, Site Director, Royal Infirmary of Edinburgh.

Transcription

1 Lothian NHS Board = Waverley Gate 2-4 Waterloo Place Edinburgh EH1 3EG = Telephone: Date: 15/06/2015 Our Ref: 5229 Enquiries to : Bryony Pillath Extension: Direct Line: bryony.pillath@nhslothian.scot.nhs.uk Dear FREEDOM OF INFORMATION WRIST INJURY I write in response to your request for information in relation to guidance for examination and treatment of wrist injuries available to NHS Lothian staff. I have been provided with information to answer your request by Ms Lyn McDonald, Site Director, Royal Infirmary of Edinburgh. Question: We should be grateful if you would provide us with any documents / policies / protocols from 26 March 2013 onwards which provide guidance to doctors working in A&E departments on how to examine, document and treat wrist injuries including suspected scaphoid fractures. Please provide information on the standard procedures used in investigating and treating wrist injuries including information on any induction programs in place for training medical staff in how to deal with such injuries, all from 26 March 2013 onwards. Answer: All doctors working in the Emergency Department are supervised and supported by a senior team of staff which is consultant lead. The junior doctor induction includes a session on minor injuries. I have enclosed the orthopaedic referral pathway, the patient information leaflet, and an example of the teaching materials. Orthopaedic services provide the follow up for patients with suspected scaphoid fractures. I hope the information provided helps with your request. If you are unhappy with our response to your request, you do have the right to request us to review it. Your request should be made within 40 working days of receipt of this letter, and we will reply within 20 working days of receipt. If our decision is unchanged following a review and you remain

2 5229 Wrist Injury June 2015 dissatisfied with this, you then have the right to make a formal complaint to the Scottish Information Commissioner. If you require a review of our decision to be carried out, please write to the FOI Reviewer at the address at the head of this letter. The review will be undertaken by a Reviewer who was not involved in the original decision-making process. FOI responses (subject to redaction of personal information) may appear on NHS Lothian s Freedom of Information website at: Yours sincerely ALAN BOYTER Director of Human Resources and Organisational Development Cc: Chief Executive Page 2 of 2

3 Emergency Department Referrals to Orthopaedic and Trauma Surgery General principles Polytrauma ED Senior as soon as arrival predicted or confirmed, then early Orth referral. Open fractures ED Senior then early Orth referral. Displaced intra-articular injuries ED Senior +/- Orth. Neurovascular impairment ED Senior +/- Orth. Dislocations of native joints or grossly displaced fractures reduce on recognition, then Orth. Failed reduction of displacement or dislocation (native/prosthetic) Orth before reversal of sedation. Red flag symptoms suggestive of infection or malignancy Orth. Skin / soft tissue injuries ED Senior, should NOT be sent to # clinic. If uncertain, or pts do not fulfil following criteria ED Senior. Shoulder / Arm Acute traumatic shoulder dislocations reduce, TTC ACJ sprains, minimally displaced GP/Physio ACJ dislocations (grade III VI) TTC Osteoporotic fractures of proximal humerus TTC Displaced # in under 55 yrs or # dislocations Orth Humeral shaft TTC Scapular fractures Orth Clavicle fractures TTC Rotator cuff impingement / subacromial bursitis Physio Suspected rotator cuff tears TTC Key TTC Refer to Trauma Triage Clinic GP.Discharge to care of GP Orth...Refer directly to orthopaedics on call ED Senior.Discuss with ED cons/reg Physio Arrange physiotherapy from ED Axial Skeleton Trauma Cranium / intracranial neurosurgery C/spine fracture neurosurgery Fractures of thoracic / lumbar / sacral spine ED senior Back pain without trauma 1. Mechanical. Discharge to GP with analgesia. No orth. review or follow up. 2. Radiculopathy with acute motor defect Orth 3. Cauda equina (central disk) suspected. Monday to Friday 9am-5pm urgent MRI. If positive or out of hours direct to neurosurgery. If negative GP/ Orth 4. Systemic Red flag symptoms Orth. Pelvis / acetabulum Fracture Orth Hip and pubic rami Fracture Orth. See hip fracture protocol. Femur Fracture shaft Orth (in skin traction and splint with femoral nerve blockade) Tibia Fracture shaft/tibial plateau Orth (reduced in above-knee backslab with check XRs Knee Atraumatic: Acute pain and swelling? septic arthritis ED senior Traumatic Acute knee injury TTC Patella dislocation ED senior/ physio. No immobilisation. Patella fractures / extensor mechanism disruptions Orth. Ankle Isolated lateral malleolus with no talar shift TTC Bimalleolar fracture or any fracture with talar shift Orth Pilon fracture Orth Achilles tendon rupture, equinus backslab TTC Foot Tarsal fracture, (incl. calcaneum) or LisFranc injury Orth Metatarsal # shoe or Moonboot, TTC + leaflet Displaced intra-articular fractures hallux TTC Lesser phalangeal fractures (closed) d/c + leaflet Elbow Olecranon fractures Orth Radial head/neck fractures, undisplaced TTC, leaflet Radial head/neck fractures, displaced TTC Distal humeral fractures Orth Elbow dislocation, reduce, backslab then TTC Elbow fracture dislocation Orth Forearm / wrist. Midshaft forearm fractures Orth Colles type fractures TTC after Bier s block reduction (Failed MUA by senior ED Orth whilst block still effective) Volar displaced (Smith s type) Orth High energy wrist / forearm Orth Hand Scaphoid or other carpal bone fracture fracture TTC Carpal dislocations or # dislocations, eg trans-scaphoid Orth Metacarpal undisplaced TTC, displaced Orth Phalangeal fractures TTC Finger dislocations DIPJ, with no #, Mallet splint 3/52 Finger dislocations PIPJ, with no #, buddy strap + Physio Mallet fingers soft tissue mallet splint + leaflet Mallet fingers with bony fragment or subluxation mallet splint + leaflet + TTC Closed distal phalanx tuft fractures ED Protocol / Mallet splint Other distal phalanx fractures or nail bed injuries ED senior Bennett s fracture undisplaced TTC, displaced Orth UCL injuries unstable TTC + splintage Revised Oct TO White & A M Grant

4 Wrist X-rays Department of Accident and Emergency Medicine The Royal Infirmary of Edinburgh

5 Overview Anatomy of wrist Approach to x-rays Some x-ray abnormalities

6 A-P Wrist

7 A-P Wrist 1st Metacarpal Trapezium Trapezoid Capitate Hook of Hamate Pisiform Scaphoid Tubercle Triquetral Radial Styloid Lunate Radius Ulna Ulnar Styloid

8 A-P Wrist

9 A-P Wrist Flexor Retinaculum Flexor Digitorum Profundus Abductor Pollicis Longus Flexor Pollicis Longus

10 A-P Wrist Abductor Pollicis Brevis Hypothenar Eminence Flexor Retinaculum

11 A-P Wrist Median Nerve Flexor Carpi Radialis Radial Artery Ulnar Nerve Ulnar Artery Flexor Carpi Ulnaris

12 Lateral Wrist

13 Lateral Wrist 1st Metacarpal Trapezium Pisiform Scaphoid Tubercle Lunate Radius

14 Lateral Wrist

15 Lateral Wrist Extensor Pollicis Longus Extensor Pollicis Brevis Extensor Digitorum Abductor Pollicis Longus

16 Lateral Wrist Extensor Carpi radialis Longus Flexor Carpi Radialis Extensor Carpi Radialis Brevis Extensor Retinaculum

17 Lateral Wrist Radial Artery Radial Nerve

18 Normal A-P X-ray

19 Normal A-P X-ray

20 Normal A-P X-ray

21 Normal A-P X-ray

22 Normal Lateral X-ray

23 Normal Lateral X-ray 10-15

24 Normal Lateral X-ray

25 Normal axis

26 Fall on the outstretched hand C/o pain in wrist No obvious deformity Tender of distal radius

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28 Fall on the outstretched hand Patient carrying shopping C/o pain in wrist Obvious deformity Tingling in index and middle fingers

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31 Fall on outstretched hand C/o pain in wrist Swollen around the wrist - radial aspect Tender ASB

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34 13 year old fell onto hand C/o pain in wrist Obvious deformity NV intact Tender distal radius

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37 Fall onto hand C/o severe pain in wrist Tingling in middle and index finger Grossly swollen

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40 Royal Infirmary of Edinburgh Emergency Department and Orthopaedic Trauma Service Royal Infirmary of Edinburgh Emergency Department and Orthopaedic Trauma Service Advice for patients with fractures or dislocations Advice for patients with fractures or dislocations You have had an injury and the Emergency Department doctor or nurse has referred your case to the Orthopaedic Trauma Service. Your x-rays and records will be reviewed by a Consultant Trauma Surgeon in the next four days. If they decide that you need further assessment or treatment we will contact you (either by telephone or post) with an appointment to come back to the hospital for a clinic appointment. If no further treatment is required, a nurse will call you to check that you are improving and discharge you. We may also call you later on to check on your progress. Please make sure that the Emergency Department reception staff have recorded all the telephone numbers we may need to contact you. You have had an injury and the Emergency Department doctor or nurse has referred your case to the Orthopaedic Trauma Service. Your x-rays and records will be reviewed by a Consultant Trauma Surgeon in the next four days. If they decide that you need further assessment or treatment we will contact you (either by telephone or post) with an appointment to come back to the hospital for a clinic appointment. If no further treatment is required, a nurse will call you to check that you are improving and discharge you. We may also call you later on to check on your progress. Please make sure that the Emergency Department reception staff have recorded all the telephone numbers we may need to contact you. If you have a query regarding your appointment you can contact the appointments office on , Mon Fri from 9.30am to 3.30pm. Please allow five days before telephoning. In an emergency, contact the Emergency Department If you have a query regarding your appointment you can contact the appointments office on , Mon Fri from 9.30am to 3.30pm. Please allow five days before telephoning. In an emergency, contact the Emergency Department