3.1. Presenting signs and symptoms; may include some of the following;

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1 Title: Clinical Protocol for the management of Forearm and Wrist injuries. Document Owner: Deirdre Molloy Document Author: Deirdre Molloy Presented to: Care & Clinical Policies Date: August 2015 Ratified by: Care & Clinical Policies Date: August 2015 Review date: August 2017 Links to other policies: 1. Purpose of this document - This clinical protocol provides a clear framework for nurses employed by Torbay & Southern Devon Health & Care 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 Unit staff employed by Torbay and Southern Devon Health Care 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, Dabigatram etexilate (Pradaxa ), Apixiban (eliquis ) and Rivaroxaban (Xarelto ) have appropriate medical follow up/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 Bruising/discolouration Version 1.1 Page 1 of 8

2 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 Version 1.1 Page 2 of 8

3 Pain, swelling and often the characteristic dinner-fork deformity of the wrist. 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. Apply below elbow dorsal plaster slab and provide plaster advice High arm sling. Fracture clinic follow up. If displaced fracture refer to Emergency Department for manipulation 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. Below elbow Plaster of Paris backslab, High arm sling, Encourage simple hand, elbow exercises/movement Version 1.1 Page 3 of 8

4 Fracture clinic follow up Displaced fractures seek Emergency Department advice. 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. Fracture clinic follow up. Undisplaced fracture midshaft forearm POP backslab above elbow, broad arm sling, analgesia and fracture clinic follow up. 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. Version 1.1 Page 4 of 8

5 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, next available fracture clinic. Displaced fracture: refer to orthopaedics. 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 antiinflammatory 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. Version 1.1 Page 5 of 8

6 Give analgesia as per Patient Group Direction or advise over the counter analgesia 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 Fracture Clinic follow up. Refer displaced or overlapping factures to the Orthopaedic team Tenderness of distal radius over growth plate with no apparent seen on x-ray Treatment Treat as growth plate injury Analgesia as per Patient Group Direction or advise over the counter analgesia, Plaster of Paris back slab below elbow neutral position. High arm sling Fracture Clinic as above 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. Fracture clinic follow up Slipped distal radial epiphysis Usually a Salter-Harris type 2 injury of adolescence. Growth disturbance is rare. Refer to Emergency Department, 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, Fracture Clinic follow up Carpal body fractures, Scapho-lunate diastasis, carpal dislocation including lunate dislocations. Version 1.1 Page 6 of 8

7 Refer to Emergency department or orthopaedics for advice re treatment and follow up/referral. Give analgesia as per patient group directions. 6. Documentation 6.1. Clinical records must be written in accordance with Torbay and Southern Devon Health & Care Trust History Taking and Clinical Documentation protocol and the Nursing & Midwifery Council guidelines of records and record management (2009) A summary letter of the MIU 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. Version 1.1 Page 7 of 8

8 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 2015 British National Formulary for Children 2015 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 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S NHS Devon Protocol for Wrist & Hand injuries Minor Emergencies Splinters to fractures. Butteovolli P, Stair T Distribution Minor Injuries, A Clinical guide. Purcell D. 2 nd edition 2010 Torbay Care Trust Protocol for limb simple fractures and soft tissue injuries South & west Devon Formulary and referral Amendment History Issue Status Date Reason for Change Authorised V 1 Created February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for forearm and wrist injuries V 1.1 Reviewed August 2015 Reviewed no clinical changes Documentation amendments to reflect new Symphony IT system D Molloy D Molloy Version 1.1 Page 8 of 8