The fracture clinic

Chapter 16 The fracture clinic



The Fracture Consultation 428

Patient’s notes 431

The organisation and running of fracture clinics varies from hospital to hospital. These differences are often dictated by the layout of the departments involved – records, appointments, secretarial, clinical, treatment, plaster, theatre and X-ray – and and also by an established line of practice. A system which has worked for a number of years is difficult to change, as an apparently obvious improvement in one area may upset the smooth running of others – to the overall detriment; and change of any kind in an established system is unusual if it attracts universal acceptance. Those who work in fracture clinics have usually to do so within a framework imposed upon them, and it would be invidious to suggest a ‘best way’ of doing things. Nevertheless it might be helpful for the beginner who is confronted for the first time with a fracture clinic to offer a few guidelines on the handling of the actual consultation.


The newcomer to a fracture clinic is usually impressed by the number of cases dealt with in a short space of time. This speed often conceals the number of rather important decisions that are made about the patients’ care. These decisions are, of course, determined by the basic principles of fracture treatment, but to ensure the smooth running of the clinic, the most professional and kindliest contact with the patient, and the avoidance of any error in management, the use of a simple system, at least at the beginning, may be of some help.


Assuming that the usual courtesies of greeting have been made, each consultation should start with asking the two questions – ‘what?’ and ‘when?’ and end with asking ‘when?’ and ‘what?’. In the middle there are a number of things to go through which can be conveniently dealt with under three headings, each starting with the letter A – ‘the three As’.



THE FRACTURE CONSULTATION



‘WHAT?’


Every decision that is made, and everything that is done, is directly dependent on the diagnosis. This must be clearly stated at the beginning of the notes on the first fracture clinic attendance, where they will serve as a guide to everyone who sees the patient subsequently. It is a never-ending source of astonishment as to how difficult it may be to find this information, the time taken often varying directly in proportion to the size of the records. If there is a problem, a glance at the initial radiographs (they alone are helpful to label) may give the answer. Time spent establishing the diagnosis is essential. Recording it will prevent the effort having to be repeated at the patient’s next attendance.



‘WHEN?’


The point here is to establish the time that has passed since the patient’s injury. While this can obviously be calculated on every occasion from the entries made on the day of injury and on the clinic visit, it is of greater practical value to give the elapsed time.


It is more professional to establish these primary facts before confronting the patient, rather than searching through the notes in his presence. When making the appropriate notes, where brevity should not compromise accuracy, the addition of a qualifier in the case of the diagnosis may be helpful: e.g.:


Undisplaced L Colles 2/52 ago.


or


7/52: # mid-shaft R femur, I-M locked nailing.


On the solid basis of the knowledge of what you are dealing with, you can proceed to Assessment, Action, and Advice.



ASSESSMENT



1 The first step is to establish if the fracture to date has been treated appropriately and adequately, e.g. if a fracture has been manipulated, then it is necessary to consider whether this was the best method of treatment in the circumstances; the desirability of internal fixation or other methods of dealing with the condition should be reviewed. Then the check radiographs should be studied to assess the quality of the reduction, and an overall assessment made.

2 If a plaster cast has been applied, it should be seen to be appropriate to the injury. It should be checked for tightness, slackness or other inadequacy, and if it is only a backslab, a decision should be made as to whether it needs completion. The presence of swelling, the quality of the circulation, and any impairment of nerve supply in the limb should be noted.

3 If the fracture has been treated surgically, the need for inspection of the wound or removal of sutures should be assessed. If the fracture has been internally fixed, the quality of the fixation should be reviewed so that a decision may be made regarding the degree of mobilisation that may be permitted without the fracture coming adrift.

4 If some time has elapsed since the injury, an assessment should be made as to whether a greater degree of freedom may be permitted, e.g. whether a supporting sling may be discarded or whether a cast may be removed to allow joint mobilisation, or whether a walking heel may be applied to a leg plaster.

5 A decision when to remove all external splintage is not usually required until an appropriate length of time has elapsed since the injury, and in making the decision, radiographs may be required to check the state of union, and/or the cast may be removed so that a clinical assessment of the fracture may be made.


ACTION


Having assessed the fracture, the appropriate action should be taken. What should be done generally follows in a clear cut fashion from the assessment: e.g. if a plaster is too tight it should be split, or if there is complaint of local pressure the plaster should be windowed or trimmed.


The only difficulties that are likely to arise are those associated with the assessment of the treatment that has been carried out. This tends to present less of a problem as experience grows, although with the variety and vagaries of chance and changing opinion the need for the critical analysis of every case is one of the continuing delights of fracture clinics and one which prevents them ever becoming dull. The point which is imperative to note is that if there is any doubt regarding the treatment or progress of a fracture, a more senior opinion should be sought without delay. Procrastination narrows the available treatment options, and will attract the criticism of why an earlier opinion was not sought. It is generally easy and a pleasure for a senior colleague to give timely advice on the treatment of a case, and gives him confidence in the reliability and common sense of his junior. Delay or failure in seeking advice may lead to an undesirable or even tragic outcome.



ADVICE


The patient should be given clear and appropriate advice. Some of the areas which might be considered include the following:


1 They should be told, or preferably shown, what exercises they should do to encourage or preserve movements in the joints related to their fracture.

2 If they have been given an arm sling they should be advised when and if they may discard it, and how the limb may be exercised with and without it. If they have a leg in plaster they should be given clear advice on how much weight, if any, they should be allowed to transmit through the limb.

Related posts:

Factors affecting healing; complications; pathological fractures Open fractures: internal fixation Foot injuries Injuries about the ankle The shoulder girdle and humerus The pelvis, hip and femoral neck

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Mar 20, 2017 | Posted by in ORTHOPEDIC | Comments Off on The fracture clinic

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