Orla Callender. Talk ortho like a pro, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.30463
Clear and structured communication between the emergency and orthopaedic team is paramount to ensuring a smooth transfer of care for children with fractures and traumatic injuries. Use this checklist to structure your referrals to ortho like a pro, and test your x-ray interpretation skills with the quiz below.
History
Injury is force meets child; child is damaged. Force causes an easy-to-remember event – shock, pain, ‘crack’, blood, fear – so there will always be a history of an injury. When taking a history, remember the six honest men: when, how, where, what, who and why.
In addition to a full history of presenting complaint and past medical, vaccination and developmental history, a trauma history should include:
- Date and time of injury
- Exact mechanism of injury when possible, preferably in parent’s or child’s own words
- Environment in which the injury occurred
- Symptoms at time of injury and subsequently
- Hand dominance for upper limb injury
- Analgesia administered
- Fasting status
- Relevant past medical history such as bleeding disorders
Sadly, we must always remain vigilant for signs of non-accidental injury (NAI). The presenting injury needs to reasonably fit with the account as to the mechanism of injury.
Examination
Whilst the majority of the examination of a traumatic injury is centred on the affected site, the examination must always include:
The examination should be broken down into:
- Inspection
- Palpation
- Movements and gait
- Neurovascular status
- Special tests
Imaging
Fractures can generally be identified on an AP and lateral radiograph. Use a systematic approach and apply the rule of two’s.
Apply rule of two’s:
- Two views as standard; occasionally other views may be required
- Two joints viewed
- Two sides where comparison of normal is necessary
- Two occasions before and after procedures or in specific instances (such as when a scaphoid fracture is suspected)
A fracture may appear as a lucency (black line) where a fracture results in separation of bone fragments or as a dense (white) line where fragments overlap. If bone fragments are impacted, then increased density occurs which may be the only radiological evidence that a fracture exists.
Sometimes, there is no direct evidence of a fracture and instead, we need to rely on indirect evidence. Looking for radiological soft tissue signs can provide clues to fractures. These include displacement of the elbow fat pads or the presence of a fluid level.
The AABCS approach, described by Touquet in 1995, can be used to carry out a structured interpretation of a limb x-ray.
Key points:
• Examine the entire radiograph in detail before concentrating on the area of concern – Look at the whole x-ray and the x-ray as a whole
• Remind yourself of mechanism of injury – Are the radiographic findings relevant to patient history? How do the findings correlate with clinical findings? Do you need to re-examine the patient?
• Take an x-ray before and after procedures
• Get help – If the x-ray doesn’t look right ask someone else, and ensure there is a backup reporting system in place
• Document both what you see and what you don’t see on the x-ray
Describing fractures
Fractures are described systematically. Start with the site (name and part/portion of bone), then extent (fracture type/line, open/closed, articular involvement), then describe the distal fragment (displacement and angulation). Describe any involvement of the skin and damage to related tendons and structures such as nerves or blood vessels.
Describing the site
Long bones are often described based on thirds: proximal, middle (diaphyseal) and distal segment. Including nearby anatomical landmarks (head, neck, body /shaft, base, condyle, epicondyle, trochanter, tuberosity etc.) helps describe the area of interest.
In paediatrics, fractures are described including the anatomical divisions of the bone segments: the epiphysis, the epiphyseal plate, the metaphysis and the diaphysis.
- The diaphysis is the shaft of the bone
- The physis is the growth plate. Also known as the epiphyseal plate, the physis occurs only in skeletally immature patients and is a hyaline cartilage plate in the metaphysis, at the end of a long bone.
- The metaphysis lies between the diaphysis and the physis. An easy way to remember this is to think of the word metamorphosis – a change; the metaphysis is the area of change between the physis – the growth plate – and the diaphysis – the shaft. The metaphysis is only used to describe a bone before it matures – it is the growing end of the long bone. Metaphyseal fractures are almost pathognomonic of NAI. They are also known as corner fractures, bucket handle fractures or metaphyseal lesions
- The epiphysis sits above the growth plate – epi (Greek for over or upon – like the epidermis) – physis – upon the physis
Describing the extent
For revision of specific terms to use to describe the type of fracture, see the fracture terminology glossary below. Key characteristics to add include whether the fracture is open or closed, and whether the fracture is intra-articular (inside the joint capsule) or extra-articular. Extra-articular fractures are usually less complicated.
Describing the distal fragment
There is a convention to ensure that the same injury is described in the same way: angulation, displacement, and dislocation are described by where the distal fracture fragment is in relation to the proximal fragment, or in the direction of the fracture apex.
Displacement is the loss of axial alignment: dorsal (posterior), volar (anterior) or lateral displacement of the distal fragment with respect to the proximal fragment. The degree of displacement can be roughly estimated from the percentage of the fracture surfaces in contact. Where none of the fracture surfaces are in contact, the fracture is described as having ‘no bony opposition’ or being ‘completely off-ended’, and are potentially unstable. Displacement is usually accompanied by some degree of angulation, rotation or change in bone length.
Angulation is the angle created between the distal fragment and the proximal fragment as a result of the fracture. The anatomical reference point is the long axis. Angulation is described using words like: dorsal / palmar; varus / valgus; radial /ulnar. It may be described either by reference to the direction in which the apex of the fracture points (apex volar or apex dorsal) or by indicating the direction of the tilt of the distal fragment. Medial angulation can be termed ‘varus’, and lateral angulation can be termed ‘valgus’. To measure angulation, one line is drawn through the midline of the shaft. A second line is then drawn through the midline of the fragment and the angle can now be measured.
Rotation is present when a fracture fragment has rotated on its long axis relative to the other. It may be with or without accompanying displacement or angulation. It is more readily diagnosed on clinical examination.
Finally, perfecting your referral
Referrals to the orthopaedic team, using a framework like the ISBAR tool, should start with the child’s name, hospital number and who is attending with the patient. Then proceed to give a history, including a full history of the presentation, hand dominance, fasting status and any relevant clinical risk factors such as bleeding disorders. Describe your clinical findings, including neurovascular examination, and then the radiological findings in the order of:
- the bone(s) involved
- part of bone
- type of fracture
- fracture line
- extent of deformity and angulation
- and any associated clinical findings
Describe any other investigations, management to date and on-going treatment. Summarise events that have occurred before referral – analgesia, backslab casts, splints, antibiotics, tetanus boosters, wound cleansing, dressings etc.
As with any good referral, be clear about why the child is being referred. It may be reasonable to transfer full care of a child. Or, the referral may simply be to gain a second opinion on the diagnosis followed by management. Be clear about the type of care expected. And finally, discuss whether you feel the referral is urgent or not. It should be stated how quickly you expect the patient to be seen. Do you feel they need to be seen urgently, soon or routinely?
At this stage, a management plan and expected outcome can be discussed and agreed. This information can then be reiterated to the child and family. Make sure everything is clearly and concisely documented.
Done!
Fracture terminology
Non-displaced fracture: A fracture where the pieces of the bone line-up.
Displaced fracture: The pieces of the bone are out of line.
Closed fracture: Either the skin is intact or, if there are wounds, these are superficial or unrelated to the fracture.
Open / compound fracture: A wound is in continuity with the fracture site.
Unstable fracture: A fracture with a tendency to displace after reduction.
Complete fracture: The fracture line extends across the bone from one cortex to the other separating the bone into two complete and separate fragments.
Greenstick fracture: Only one cortex is fractured.
Torus / buckle: Buckling of the cortex with no break.
Comminuted: There are more than two fragments.
Transverse fracture: A fracture across the bone.
Oblique fracture: A fracture at an angle to the length of the bone.
Spiral fracture: A fracture that curves around the bone diameter.
Depressed: A portion of bone is forced below the level of the surrounding bone.
Avulsion fracture: The muscle have torn off the portion of bone to which is attached.
Stress fracture: Tiny cracks in the bone caused by repetitive injuries. A cortical break is not always seen but there is greying of the cortex due to callus formation.
Pathological fracture: A fracture arising within abnormal bone weakened by benign or malignant cysts or tumours.
Impacted fractures: One fracture fragment is driven into the other.
Plastic deformation: Deformation of bone without fracture of the cortex.
Epiphyseal fractures: A fracture to the growing end of a juvenile bone that involves the growth plate. Use the Salter-Harris classification if the fracture involves the epiphyseal plate.
Fractures don’t always occur in isolation – a joint may be involved.
Fracture-dislocation: A dislocation is complicated by a fracture of one of the bony components of the joint, such as a Galeazzi or Monteggia fracture-dislocation.
Subluxation: The articulating surfaces of a joint are no longer congruous, but loss of contact is not complete.
Dislocation: Complete loss of contact between the articulating surface of a joint. Displacement of one or more bones at a joint.
References
Bickley S. & Szilagyi P. (2003) Bates’ Guide to Physical Examination and History Taking (8th edn.) Philadelphia. J.B. Lippincott, Philadelphia.
Davis, F.C.W., 2003. Minor Trauma in Children. A pocket guide. London: Arnold.
Duderstadt, K. 2006. Pediatric Physical Examination. Mosby. Elsevier.
Purcell, D. 2003. Minor Injuries. A Clinical Guide. Edinburgh: Churchill Livingstone.
Larsen, D. & Morris, P. 2006. Limb X-ray Interpretation. Whurr Publishers Limited.
McRae, R. 2003. Pocketbook of Orthopaedics and Fractures. 3rd ed. Edinburgh: Churchill Livingstone.
Raby, N., Berman, L. & De Lacey, G., 2001. Accident & Emergency Radiology. A Survival Guide. Edinburgh: W.B. Saunders.
Touquet et al, 1995. The 10 Commandments of Accident and Emergency Radiology. BMJ 1995; 311: 571.
Image source for final quiz case: https://radiopaedia.org/cases/2c1840c5145638e56f599031f23dd0c8?lang=us
Year End 2020
Damian Roland. Year End 2020, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31631
How do you remember the major milestones of your life? Do you divide them into significant life events such the start of secondary school or use specific decades related to your age? Perhaps you may base it on geography – where your ‘home’ was at any given time?
There is a significant chance that the COVID19 pandemic may create a new form of reference point, that of everything pre- and then post-pandemic.
It’s actually quite difficult to go back to January 2020 and imagine what you thought 2020 might be like. So much has happened in the last 12 months that expectations have perhaps been irrevocably altered; leaving the retrospectoscope even more biased than it always has been.
I can objectively demonstrate that at the beginning of the year I had some funded research I would like to publish, that I was looking forward to a number of international conferences and was already wondering how winter 2020 would pan out (feeling that we’d got lucky in 2019 which hadn’t been quite as bad as 2018). I can’t quite remember what I was expecting in relation to new interventions and developments in paediatric emergency medicine but I think, even with hindsight bias, it’s reasonable to assume that I suspected many things were likely to remain in status quo.
At the beginning of 2020 there was no reliable biomarker for identifying serious bacterial illness in sepsis (and still isn’t) and by the end of 2020 management of asthma and wheeze still remains essentially unchanged (although we know magnesium sulphate nebulisers probably don’t add much). A systemic review of the management of asthma essentially said (with all respect to the authors who are just interpreting available evidence), “more research is needed”. There have been no major practice-changing studies in the management of gastroenteritis, seizures or bronchiolitis. In fact, in many countries of the world, the less is more approach to bronchiolitis was easy to implement as the public health response to #COVID19 appeared to completely remove it as a disease entity.
What about personal plans. Did you think about what you wanted to achieve at the beginning of this year?
Do you ever?
And if not why not? Should we not have a semblance of some goals, however small and sparse of detail? Or do you argue a random calendar month, which happens to be the one Julius Caesar determined a new year should start, is a poor method with which to do this?
Pushing philosophical questions aside it’s likely that COVID19 revised, or ripped up, many individuals, departments and organisations strategies. The consequences of this aren’t clear and it may never be possible to determine overall positive or negative impact. There is a delicate balance between what has been gained that wouldn’t have normally occurred versus those critical investments and interventions which haven’t. As the DFTB review has clearly highlighted the pathophysiological consequence of COVID19 on children is limited but the wider impact is potentially extreme. Regardless of which way the overall outcomes swing appropriately responding to many enforced changes is vital. The cancellation of DFTB20 was a great sadness but at the close of DFTB: Live + Connected it was clear it is possible to generate an atmosphere of collaboration and solidarity even when participants are distanced by thousands of miles. Future DFTB conferences, whether digital OR in-person, will utilise this learning for the benefit of either medium.
Without wishing to overlook the immense emotional trauma and financial hardship #COVID19 has had on society it is important that we all use 2020 to examine its impact on us as individuals. This will be through both our personal and professional lives. For the former, lockdown may have brought your immediate family and friends together, or it may have pushed them apart. In the latter, the utter transformation of healthcare services, both adult and children, will have altered your role in your department. This may have placed you in positions of leadership or responsibility that you have thrived in, or perhaps opened your eyes to a stale status quo, which had been implicitly tolerating without really enjoying. Every year brings the chance to reflect and grow but this year has given everyone a different lens with which to view their lives.
#COVID19 will have changed the world around you but I’d argue it is possible you may have changed more. 2020 may well be the milestone with which many new life journeys begin.