VAQ 5 Answer

Hmmm, subtle diagnosis? Not really. But while the problem is obvious and the first year medical student could tell you “it’s a bad fracture”, you need to demonstrate Consultant level interpretation and management.

So, what are the important issues in this case?
1) This is a limb threatening injury. This fracture carries a very high risk of:
   a.    Nerve (in particular median, +/- ulnar nerve) injury
   b.    Arterial ischemia.
   c.    Compartment syndrome
   d.    More proximal bony injury around the elbow
2) Given the lack of displacement of the bone fragments, the other complications of forearm fractures such as malunion/non-union/complex regional pain syndrome/delayed tendon rupture are not really of concern to us in the ED (although stuffing up the management could increase the chance of these).
3) This is an acutely PAINFUL injury – demonstration of expert paediatric pain management is essential.
4) This is an unaccompanied minor who:
   a.    Has a limb threatening injury
   b.    Is going to need an anesthetic (either regional or general, both of which carry risks)
   c.    Is technically too young to consent to treatment.
   d.    You need to know how to manage

So how to tackle the answer?

Describe and interpret the Xray:
Now one of our bug bears here at ED Exam is use of non-radiologic and non-orthopaedic terminology when describing fractures. Some people say “pretend you’re describing it over the phone” but never say who you’re meant to be describing it to.

We say: “pretend you’re describing it to the head Orthopaedic Surgeon or Radiology Consultant over the phone at 4am”. Be accurate, concise, and use the correct terminology.

Still not sure what we mean? Then read some radiology reports on some of your recent patients. The good ones will have no extraneous words, no non-radiologic/orthopaedic words, and definitely no non-medical words. They will mention relevant negatives, with emphasis on relevant.

Have you ever seen phrases like:
“a really nasty fracture”, “badly bent”, “serious”, “quite”, “deformed” (this is NOT a radiologic term) …on a radiology report?

No. So what are the words that you use?

When talking about fractures you need to mention the following:
Comminution:
Is there more than 2 fragments? Comminuted fracures are those that are broken into more than 2 pieces.
This fracture is non-comminuted
Direction of fracture through bone:
Transverse, spiral, longitudinal, oblique
This is transverse fracture
Displacement:
This means the amount by which the 2 bits of bone are displaced relative to each other.
If there is displacement, you need to state which direction it is: volar, dorsal, superior, inferior, lateral, medial, proximal, distal, and which bit is displced in which direction, and by how much (eg “the distal fragment is displaced dorsally by 5mm”)
NB: This fracture has complete separation of the radial fragments, with some dorsal and proximal displacement of the distal fragment
Shortening:
This means if the bone ends are driven into each other, or are overlapping each other (which can only happen if there’s displacement) resulting in the length of the bone being shorter than normal. Often seen in Colle’s fractures.
This fracture has some shortening related to the dorsal displacement of the distal radial fragment.
Angulation (& direction):
Self explanatory. What is the angle created by the 2 fragments of bone, measured down the middle of the long axis of the bone, and which direction is the distal fragment going.
This fracture is angulated – approx. 90 degrees dorsally
Which bones are broken:
Obvious really, but don’t forget to mention it!
In this case: Radius & ulna
Location of fracture in bone:
You can state this in centimeters from another bony landmark (eg the wrist joint), or you can sound even slicker by describing which part of the bone is broken: epiphysis, metaphysis, diaphesis/shaft.
This fracture: approx 6cm proximal to wrist joint, or it’s a diaphyseal/shaft fracture, or you could say junction of middle & distal 1/3 of forearm
bone
Associated injuries (presence or absence)
Fractures/dislocations in structures that are often co-injured with the obviously injured part.
In this case you would look for Monteggia type dislocation of radial head
If unable to assess, state what you need to make the assessment (see below), ie further views/images
In this case, there is also no apparrent Galeazzi injury at the wrist
Complications:
As mentioned above
Need for other views:
Needs AP, and AP/Lat of whole forearm

So we would describe this fracture as:

LIMB THREATENING INJURY:
Transverse, grossly angulated (approx 90 degrees dorsally) diaphyseal/shaft fracture of radius & ulna, approximately 6cm proximal to wrist joint
Some dorsal and proximal displacement of distal radial fragment, resulting in some shortening
Non-comminuted
No obvious Galeazzi injury
Need AP view & AP/Lat elbow/whole forearm to exclude Monteggia dislocation/elbow injury

(can you see how the Radilogist/Orthopod at home in bed will be able to visualise exactly what you’re talking about if you use the correct terminology?)

High risk for complications:
    Median/ulnar nerve injury
    Distal ischemia

Outline your management:
This case raises several issues as mentioned at the start.
Remember: Management = Treatment, Supportive Care, Disposition

Treatment:
People have mixed feelings about how much you should mention A/B/C in “isolated” injuries. Clearly there’s been significant force to the arm, which may have resulted from a big fall, and there may be other injuries, that may require resuscitation. But where there is no other information given directing you to this (eg a set of abnormal vital signs), and where there’s plenty to write about the obvious injury, I wouldn’t harp on about it. Also don’t get side-tracked into talking about what else you would “examine”, the question isn’t about this, it’s about management.

Also the glaring issue here is consent.
Can an unaccompanied 12 year old in pain consent to treatment?
Technically no. However if he is able to understand what you propose to do, is a “mature or emancipated minor” he may be able to. Also if it’s an “emergency” he may not need to (see below)

Do you need consent to proceed?
Technically yes.
BUT this is clearly an EMERGENCY, the failure or delay of treatment of which may result in serious damage to his health, significant pain or distress.

In Victoria the general principle is that if there is an Emergency, you can proceed with treatment, defined as:
Emergency treatment is urgent treatment required to save the life of a person; prevent serious damage to the person’s health; or to prevent the person suffering or continuing to suffer significant pain or distress. A practitioner does not require consent to proceed with emergency treatment (for a person who lacks capacity).
Personally I consider potential loss of function of one hand as “serious damage to a person’s health”, this is also clearly a very painful injury, and I would get treatment underway.  (The main problem in this case would be if he REFUSED treatment… but that’s for another question on another day!)
Remember treatment can be done in stages while attempts are made to locate his parents or person responsible, before any formal procedure is performed. Initial treatment such as analgesia, further X-rays, splinting, and referral, will take a little while and allow you time to track the parents down.

The “wrong” (or controversial) answer would be “urgent reduction under GA, parental consent not required due to emergency”. If you did that to my kid without taking reasonable steps to contact me (unless they had a seriously ischemic hand), I’d be quite displeased…

So, perhaps a good opener would be:
NB Unaccompanied minor with Limb threatening injury.
Commence initial treatment under Emergency doctrine while locating parents/person responsible
Ideally obtain parental consent prior to reduction/anaesthetic.
Possible exception – critical ischemia of hand
All avenues to contact parents/other relative/person responsible should be exhausted first

Initial Rx:
   Assess & treat A/B/C’s
   Seek & treat other injuries
Arm Injury:
   Analgesia:
    Intranasal fentanyl 1.5mcg/kg
    Can repeat once
   IV Access
   Morphine 0.1mg/kg prn
   POP volar slab
Urgent Orthopaedic consult

Definitive treatment = reduction, best done emergently
Indication for urgent reduction:
    Vascular compromise/ischemia
Options: – with parental consent
    Bier’s block (in ED)
    Sedation in ED (eg ketamine)
    GA/Ortopaedics
Depending on:
   Deprtment load
   Availability of staff/resusc cubicle
   Orthopaedic opinion/availability
   Theatre availability
   Fasting status

Supportive Care:
Ensure adequate analgesia
Ensure parents attend ED
Child friendly environment
Keep fasted if theatre planned +/- IV fluid prn

If you have time, you could mention NAI.  While this child is a bit older than you may expect for NAI, if you have time you could jot down…

NB Consider NAI if red flags present
    Incongruous history
    Unexplained other injuries
    Pattern bruises, multiple bruises, burns

Disposition:
Likely admission under orthopaedics.

So there you have it, a simple diagnosis, but you can really make your answer shine by using correct radilogic terminology, recognising the consent issue (& dealing with it in a consultant level manner), and recognising that this question lends itself to point form answers.

If you want more information about consent, check out this document from the VMIA (they are the people who provide isnurance to the public hospitals in Victoria, so they know a bit about it).

Also, here’s a flowchart from the Office of The Public Advocate (the guardianship administrators in Victoria) which really clearly explains consent in an Emergency.

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