Title: Protocol for the Management of Lower Leg, Ankle and Foot 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 lower leg, ankle and foot 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 have achieved the agreed Trust clinical competencies to work under this protocol. 2.1 Exclusions All patients presented with a lower limb 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 on anticoagulation such as warfarin, Dabigatran (Pradaxa ), Rivaroxaban (Xarelto ) and Heparin for further medical review/follow up including INR testing. NB Be aware of limb threatening conditions such as ankle fracture dislocations and refer via 999 ambulance immediately 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. inversion or eversion. Was there a fall from a height? 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. Version 1.1 Page 1 of 11
The amount of swelling may depend on whether ice and elevation have been applied The amount of pain on examination may depend on whether analgesia has been taken Past medical history including previous injuries to effected limb Refer all patients on anticoagulation for medical urgent follow up/review. Where concerns e.g. significant swelling refer to orthopaedics or Emergency department for review. 4. Clinical Examination Observe where possible patients gait, balance, mobility, ability to weight bear Look Symmetry Deformity/dislocations Swelling, particularly below the medial and lateral malleoli Bruising/discoloration, Wounds/grazing Feel: (palpate from knee down) Note any tenderness over: Proximal fibula Tibia and fibular shaft Lateral malleolus and ligaments, including the anterior talofibular ligament Medial malleolus and deltoid ligament Calcaneum Talus, navicular, cuboid, cuneiforms Metatarsal bones including the base of 5 th metatarsal Phalanges Move Inversion/eversion Dorsi/planter flexion Internal/external rotation Flexion/extension of toes. Ability to weight bear Special tests Sensation/circulation Anterior draw test (Gently pull the foot forward on the tibia to test for Anterior/posterior laxity Of the anterior talofibular ligament) Achilles tendon: Simmons/Thomson test Talar tilt test (Gently invert the ankle, if tolerable, to test for laxity of the whole lateral ligament complex). Assess for foot drop (peroneal nerve) Version 1.1 Page 2 of 11
Interpreting Radiographs: Request ankle or foot views using the Ottawa ankle rule below Fractures are usually obvious, but may only be seen on one view If one fracture is seen, look carefully for another fracture or joint space widening Accessory ossicles adjacent to the tips of the medial and lateral malleoli are common as are fracture fragments. A larger accessory ossicle, the os trigonum, is sometimes seen at the back of the talus on Lateral view. Clinical correlation is important. In addition, and accessory ossicle has a well defined (I.e. sclerotic) outline; a fracture fragment is usually ill defined on one of its sides Ankle Anterior/posterior mortice view: The joint space should be uniform all the way around. Widening of the medial joint space indicates damage to the medial ligament Look for a small bone fragment within the joint or a defect in the cortex of the talus, which indicates an osteochondral fracture Inspect the lateral and medial malleoli Lateral view: Inspect the lateral and medial malleoli, and the posterior aspect of the tibia Inspect the calcaneum, as well as the navicular and base of 5 th metacarpal if shown The Ottawa Ankle Rule The rule avoids unnecessary X-rays by identifying patients likely to have significant ankle fractures It has almost 100% specificity for clinically significant fractures, and can save up to 40% of X-rays It is based on assessment of the ability to bear weight (four steps), and the areas of bony tenderness It applies to children and adults presenting with acute (within 10 days) ankle injuries The Ottawa Ankle Rule Version 1.1 Page 3 of 11
1. A 2-view ankle series (Anterior/posterior (AP) and lateral) is required only if there is any pain in the malleolar zone and any of the following: Bone tenderness at A, the posterior edge or tip of the lateral malleolus Bone tenderness at B, the posterior edge or tip of the medial malleolus Inability to bear weight both immediately and in the Emergency Department 2. A 3-view foot series (Anterior/posterior (AP), oblique and lateral) is required only if there is pain in the midfoot zone and any of the following: Bone tenderness at D, the navicular Inability to bear weight both immediately and in the Emergency Department 3. A 2-view foot series (Anterior/posterior (AP) and oblique) is required only if there is any pain in the midfoot zone and: Bone tenderness at C, the base of the fifth metatarsal Note: Allow a lower threshold for radiography in the very young, the elderly, those who are difficult to assess (e.g. intoxication, learning difficulties, stroke, presence of other injuries), and after injury from violent mechanism, (e.g. fall from a height, road traffic collision). The rule does not apply to heel injuries e.g. fall from a height. These must be assessed independently with calcaneal views if relevant history and local tenderness 5. Treatment: 5.1 Management of Ankle Sprains All patients who are unable to weight bear when seen must be followed up. This may be by physiotherapy, GP, Minor injury unit (MIU), Emergency department (ED)Clinic or even Fracture Clinic depending on your concerns and the patient s circumstances Most avulsion or flake fractures can be treated the same as sprains. If in doubt get senior advice The threshold for referral to physiotherapy should take into account the patient s expectations, including work, sport, hobbies etc, as well as the severity 5.1.2 Moderate Sprain, able to weight bear Rest, elevate above hip level Apply ice for periods of 20 minutes over the first 48 hours Strapping. Stick if necessary Give analgesia as per Patient Group Direction or advice on over the counter analgesia e.g. Non-steroidal anti-inflammatory drugs (if tolerated), paracetomol Exercise sheet. Begin weight bearing as soon as symptoms allow Consider physiotherapy if recurrent Version 1.1 Page 4 of 11
5.1.3 Moderate to severe sprain, unable to weight bear As above, crutches Refer to physiotherapy Follow up in 5 to 7 days by GP or MIU. Refer to Fracture clinic if further problems Exceptionally, consider a lightweight walking cast for 7 to 10 days - for very severe symptoms or difficult social circumstances, e.g. the elderly or difficulty with crutches 5.1.4. Severe sprain, ankle unstable Give analgesia as per patient group direction. Refer to the Orthopaedic team. 5.1.5. Minor avulsion or flake fracture Treat symptomatically as above 5.2 Ankle fractures 5.2.1 Isolated lateral malleolus fracture (no deltoid ligament tenderness) Assess pain score and give analgesia as per patient group direction(pgd) or advise on over the counter analgesia e.g. Non-steroidal anti-inflammatory drugs and/or paracetomol Apply below knee Plaster of Paris backslab in neutral, using entonox if necessary as per patient group direction Take check radiographs in Plaster of Paris where manipulation required. Elevation, crutches, analgesia as per PGD or advice over the counter analgesia, Fracture Clinic follow up. 5.2.2 Lateral malleolus fracture with talar shift Assess pain score and give analgesia as per patient group direction. Apply temporary below knee POP backslab, Refer to the Orthopaedic team on call. 5.2.3 Undisplaced isolated medial or posterior malleolus fracture Assess pain score and give analgesia as per patient group direction or advise over the counter analgesia e.g. Non-steroidal anti-inflammatory drugs and/or paracetomol. Apply below knee plaster of Paris backslab in neutral, using entonox if necessary Take check radiographs in Plaster Elevation, crutches, analgesia as per PGD or advice over the counter analgesia, Fracture Clinic 5.2.4 Displaced medial or posterior malleolus fracture, bimalleolar or trimalleolar fracture Assess pain score and give analgesia as per Patient Group Direction. Apply temporary below knee Plaster of paris backslab, Refer to the Orthopaedic team Version 1.1 Page 5 of 11
5.3 Tibia and Fibula fractures 5.3.1 Isolated fractures of proximal and upper midshaft of Fibula NB examine popliteal nerve (include observation for foot drop, if present refer to orthopaedics) Give analgesia as per patient group direction. Apply tubigrib or temporary below knee POP backslab according to patients pain score. Provide crutches. Refer to fracture clinic 5.3.2 Undisplaced fractures of Tibia and Fibula Assess pain score and give analgesia as per patient group direction. Apply temporary full leg POP backslab and provide crutches. Refer to the Orthopaedic team on call for further advice re immediate or fracture clinic referral. NB Assess for Compartment syndrome and risk of thrombosis 5.3.3 Displaced fracture of tibia and Fibula Assess pain score and give analgesia as per patient group direction. Consider entonox as per PGD Apply temporary full leg POP backslab or await ambulance support with relevant splintage. Refer to the Orthopaedic team on call for further treatment and transfer by ambulance to local emergency department. NB Assess for Compartment syndrome and risk of thrombosis 5.4 Lower leg injuries 5.4.1 Significant Lower leg swelling with no Fracture seen on X-ray: Assess pain score and give analgesia as per patient group directions. Elevate limb and provide ice treatment. Refer to Emergency department for further assessment where there is a risk of compartment syndrome or suspicion of thrombosis 5.4.2 Calf Strain (gastrocnemius strain) Acute gastrocnemius tears usually occur during sport, (running, twisting etc) There is pain on weight bearing (may only be partially weight bearing on tiptoe) and tenderness and/ or swelling, usually over the medial belly. Patients may describe a feeling of been hit in the back of the leg/calf muscle. Carefully check the Achilles tendon for signs of rupture Differential diagnosis includes Deep Vein Thrombosis and ruptured Baker s cyst Treatment Minor strain Analgesia, ice application, elastic support and progressive weight bearing Treatment Severe sprain Version 1.1 Page 6 of 11
As above with crutches if necessary, physiotherapy referral and GP or minor injury unit follow up 5.4.3 Achilles Tendon Rupture Specific history May follow sudden muscle activity, especially in sports The patient feels a sudden sharp pain or blow behind the ankle, followed by difficulty walking and standing on the toes Examine the patient prone or kneeling on a chair with the feet hanging free over the edge There may be swelling, pain or bruising and even a palpable gap in the tendon Always perform and record the result of the calf-squeeze/simmons/thomson test: Gently squeeze the calf. If the foot moves as the ankle plantar flexes, the Achilles tendon is intact. If it fails to move, the Achilles tendon is ruptured. Compare both sides. Record the test as normal or abnormal, rather than positive or negative to avoid confusion Treatment of ruptured Achilles tendon Refer all cases to the Orthopaedic team Place in aquinous POP back slab and provide crutches Treatment may be conservative or surgical but requires orthopaedic review. 5.4.4 Achilles Tendonitis Symptoms may include a history of gradual onset of pain and stiffness over the tendon. Tenderness over the tendon on palpation. Crepitus and swelling. Pain on active movement. Treatment: Advise non -steroidal anti- inflammatory medication as per patient group directions, ice and rest. May require physiotherapy if recurrent problem or unresolving following rest. 5.5 Growth plate (epiphyseal plate); Salter Harris Type 2 fractures are common 5.5.1 Minimally or not displaced Assess pain score and give analgesia as per patient group direction, Apply below knee POP backslab and provide crutches, Advise elevation and arrange Fracture Clinic follow up. 5.5.2 Displaced: Refer to orthopaedics Analgesia (as per patient group direction), backslab, elevate, Refer to the Orthopaedic team for manipulation 5.5.3 Growth plate injury without fracture If no fracture is seen on radiographs but there is a lot of tenderness of the distal tibial or fibular epiphysis, treat as a growth plate injury, Version 1.1 Page 7 of 11
Analgesia as per patient group direction, below knee Plaster of paris backslab, crutches, elevation and Fracture Clinic Assess pain score and give analgesia as per patient group direction. Refer to orthopaedics on call for further advice. 5.6 Tarsal Bone fractures 5.6.1 Calcaneal Fractures Specific history; Usually follows a fall from a height but may be caused by a twisting injury. Examine the calcaneum in all ankle injuries Signs and symptoms include swelling, bruising and tenderness over the heel and sides of the calcaneum. In major fractures the heel appears flattened and tilted laterally Investigations to include specific calcaneal x-rays views. Check Bohler s angle for flattening (less than 30 degrees) indicating a crush fracture Treatment. Simple Undisplaced fracture. POP back slab below knee or wool and crepe depending on patient s pain score. Advise analgesia as per patient group direction. Provide patient with crutches. Arrange fracture clinic follow up. Treatment of all other calcaneal fractures, refer to Orthopaedics for further advice/review. NB Patients with calcaneum fractures may have further significant injury including spinal injuries. Refer for further assessment. 5.6.2 Minor avulsion fractures of Talus or Navicular. Assess pain score and give analgesia as per patient group direction. Apply below knee POP backslab and provide crutches. Fracture clinic follow up 5.6.3 All other Talus or navicular fractures Assess pain score and give analgesia as per patient group direction. Refer to Orthopaedics for further management 5.6.4 Simple Cuboid fractures with no Tarsometarsal joint involvement Assess pain score and give analgesia as per patient group direction. Apply below knee POP backslab and provide crutches. Fracture clinic follow up 5.6.4 Tarsometatarsal (lisfrancs) injuries/dislocations There is disruption of one or more of the joints, usually with associated fracture of the metatarsal, cuboid or cuneiform bones Prompt reduction is necessary because of the risks of swelling, circulatory impairment (especially dorsalis pedis) and compartment syndrome Assess pain score and give analgesia as per patient group direction. Refer to Orthopaedics for further management. Version 1.1 Page 8 of 11
5.7 Metatarsal Fractures 5.7.1 Avulsion fractures of the base of 5 th Metatarsal. Usually associated with an inversion injury of the foot or ankle. Treatment: Assess pain score and give analgesia as per patient group direction Treat with tubigrib/support bandage or below knee POP backslab (podlux shoe if available) depending on severity of pain. Weight bearing as pain allows (Provide crutches to support partial weight bearing or non- weight bearing as patient tolerates) For fracture clinic follow up. 5.7.2 5 th Metatarsal Jones fracture Tends to occur in athletes during training, it has some of the features of stress fracture Non-union is common and is often associated with early weight bearing This may happen if mistaken for a base of fifth metatarsal fracture Treatment: Assess pain score and give analgesia as per patient group direction Treat with POP backslab below knee. Non weight bearing with crutches. For fracture clinic follow up 5.7.3 Other Metatarsal fractures Can be caused from crush injuries or sporting injuries Treatment: Undisplaced Fractures. Assess pain score and give analgesia as per patient group direction Treat with POP backslab below knee. Non weight bearing with crutches. For fracture clinic follow up. Treatment for multiple or undisplaced fractures refer to orthopaedics for further management. 5.8 Phalangeal Fractures 5.8.1 Toe injuries Radiography Apart from the hallux, most isolated toe injuries do not require radiography X-ray only if there is obvious deformity, gross swelling, suspected dislocation, compound injury, or MTPJ tenderness Treatment Undisplaced Toe fractures: Advise simple analgesia as per Patient Group direction. Neighbour strap and advise elevation. Advise discomfort may last as bone heals over 4 6 weeks. GP follow up if pain persists. Treatment displaced fractures and dislocations: Following x-ray, where competent manipulate under local anaesthetic digital block, neighbour strap, check x-ray and treat as above. Refer to ED if unable to relocate displacement or dislocation. Follow up by GP or Minor Injury Unit. Version 1.1 Page 9 of 11
5.8.2 Hallux fractures (Big Toe Fractures) Usually from a heavy weight falling on an unprotected foot May involve the IP joint and may be open Treatment; Trephine nail as necessary if subungal haematoma present, or remove if virtually separated Irrigate well with Normal saline. Treat open fracture with co amoxiclav as per Patient Group direction. Consider need for Tetanus prophylaxis as per patient Group direction and risk of tetanus prone wound. Proximal phalanx fractures may require a walking plaster with toe platform for pain relief. Seek advice from Orthopaedics on call. Simple Undisplaced closed fractures may be treated with Toe spica and arrange fracture clinic follow up. 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). 6.2. 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. 6.3. For patients being transferred to the Emergency department, ensure clinical records are completed in a timely manner on the shared symphony 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 attendance record to take with them. A summary record 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 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 subsequent problems Version 1.1 Page 10 of 11
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. 2000 Acute Medical Emergencies, a nursing guide. Harrison R, Daly L. 2000 British National Formulary March 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. 1999 NHS Devon Protocol for the management of Ankle Injuries NHS Devon protocol for the management of foot injuries Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 Minor Injuries, A Clinical guide. Purcell D. 2 nd edition 2010 South& west Devon Formulary 2015 Torbay Care Trust protocol for limb simple fractures and soft tissue injuries. www.patient.co.uk 11. Distribution Amendment History Issue Status Date Reason for Change Authorised V 1 Created February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for lower leg, ankle & foot injuries V 1.1 Reviewed August 2015 Reviewed no clinical changes required Documentation amendments to reflect new symphony IT system D Molloy D Molloy Version 1.1 Page 11 of 11