Chapter 17 Trauma Orthopaedics
In-patients
• Trauma orthopaedics covers a multitude of injuries that are admitted to hospital in varying ways.
• It can range from those patients who walk in via Accident and Emergency (A&E) or fracture clinic with minor injuries, to those that are brought in by ambulance with life-threatening multi-trauma injuries.
• No matter how they arrive their assessment starts as soon as they enter the doors of the hospital.
• A doctor will always admit the patient and collect a lot of useful information that you as a physiotherapist will need to know prior to assessing a patient.
• This will not be an exhaustive list, therefore it is essential that a thorough subjective assessment is carried out.
• Due to the high-energy nature of many of the injuries encountered on a trauma orthopaedic ward, it is likely that your patient will present with multiple injuries.
• A common mistake in assessment of trauma orthopaedic patients is to concentrate on their obvious injury.
• Because fractures are extremely painful, it is quite common for a soft tissue injury to be missed initially and only to be discovered at a later date, e.g. a patient may present with a tibial shaft fracture; however, the less obvious rupture of the posterior cruciate ligament may be missed.
• It is often a physiotherapist that discovers these secondary injuries.
• Because of this it is essential to complete a thorough subjective and objective examination of all limbs, in addition to the patient’s ‘obvious’ injury.
• Many patients who are admitted to a trauma ward will have associated wound and plastics issues from open fractures or fasciotomies.
• This is covered in Chapter 4 in this volume and in Volume 2.
• Unlike elective orthopaedics or sports physiotherapy, you will see many patients that have been admitted to hospital following severe accidents.
• The patient may have difficulty talking about their accident in circumstances where they have been involved in a fatal collision possibly involving other family members or where they feel at fault for their accident.
• This will affect patients in different ways, so they must be approached in a caring manner respecting their right to decide when they are ready to start physiotherapy.
• In this chapter the assessment approach covers the period from when the patient is admitted to hospital through to their discharge and subsequent referral to outpatient physiotherapy.
Subjective assessment
• Like any acute ward, there are many different places to gather information about a patient, e.g. medical notes; doctor’s admission sheet; talking to the patient’s nurse and other members of the multidisciplinary team and X-rays.
• It is essential to realise that the subjective examination is an ongoing process and it is not always possible to collect all of the information from a patient on the first day. There are a wide variety of reasons that may prevent you from completing your assessment, such as drowsiness from anaesthesia, pain or confusion due to a head injury or dementia.
• In these cases, if possible, look to find out more information from their relatives or friends.
• In trauma orthopaedics, the type of information that is required may be similar to that required in other clinical settings that enable a clinical picture to be established. Examples of the questions specific to the trauma setting are outlined in Table 17.1.
• Once the subjective assessment has been completed, this should enable the objective assessment to be planned and the formulation of ideas relating to the patient’s treatment goals and their discharge plan.
Table 17.1 A range of trauma-specific questions used during subjective assessment
| Information | Questions |
|---|---|
| Mechanism of injury | Was it a high-energy injury such as a car crash or a low energy injury such as a simple fall? |
| Area and type of fracture | Which part of the body is affected? |
| Was it an open or closed fracture? | |
| Was it a simple transverse or a multifragmented spiral fracture? | |
| Treatment method | Is it non-operative or operative? |
| Are there any casts or braces needed? | |
| Past medical history | Does your patient have any condition that will impact on their rehabilitation? |
| See trauma outpatient section for good examples of this | |
| Previous mobility | Were they: |
| independent with no aids? | |
| using a frame? | |
| having recurrent falls? | |
| Can they do stairs? | |
| Previous ROM/strength | Were they normally fit and healthy or do they have contractures or weakness? |
| Neurovascular status | Have they had previous vascular issues due to diabetes or do they normally have a foot drop? |
| Social history | What job do they need to get back to? |
| Do they: | |
| play sport? | |
| live alone? | |
| have carers? | |
| have children? | |
| live in a house with stairs? | |
| Drug history | What medications are they normally on? |
| Are they a drug user? |
Objective assessment
• It may not be possible to carry out a full objective assessment on the first day.
• This can be an ongoing process that will continue through to discharge.
• The objective assessment will generally follow a standard manual therapy format along the lines of a musculoskeletal textbook (Petty 2006).
• As patients will have different injuries and post operative instructions, it is essential to make the assessment specific to individual circumstances.
• If a patient requires an operation, then both preoperative and postoperative assessment will need to be completed.
Pain
• Pain is a big issue following a traumatic injury and subsequent surgery.
• The amount of pain can be evaluated using various tools, e.g. Visual Analogue Scale (VAS).
• It is essential to assess a patient when they are covered by pain relief, to ensure information gained is as reliable as possible.
• If the patient experiences too much pain to continue then it is possible to request additional pain relief from the nursing staff, or alternatively return to see the patient later when their pain is under control.
Imaging
• A major part of assessment will be reviewing and understanding any imaging the patient may have had.
• The most common images are X-rays, computerised tomography scans (CT scans), ultrasound scans and magnetic resonance imaging (MRI); Table 17.2, outlines where these may be used.
• A physiotherapist will be expected to be able to examine an X-ray and determine whether it is normal or not.
• Although it is useful to be able to interpret CT and MRI scans, it is not expected that physiotherapists will be able to read these.
• A radiologist will review and report on all imaging and this will be a useful adjunct to the assessment.
Table 17.2 Imaging and examples of use
| Imaging type | Examples of use |
|---|---|
| X-rays | Initial imaging for suspected fracture/s |
| CT | Provides a better understanding of the extent of a fracture and potential management, e.g. a multi-fragmented tibial plateau fracture |
| Ultrasound | Tendon ruptures, e.g. quadriceps tendon |
| To determine soft tissue injury in a joint, e.g. ACL rupture | |
| MRI | Assess neurological injury, e.g. sub-dural haematoma or spinal cord injury |
| To visualise a fracture if not visible on X-ray, e.g. undisplaced hip fracture |
Observation
Palpation
• It is good practice to palpate the patient’s affected and unaffected limb.
• Assess for any differences in size due to swelling or muscle wastage, any hot and inflamed areas and any tender areas.
• Good palpation can often lead to diagnosis of complications that can arise due to the patient’s injuries, e.g. compartment syndrome or deep vein thrombosis.
Chest assessment
Neurovascular status
• Due to the high-energy nature of traumatic injuries, pre- and postoperative assessment of a patient’s neurovascular status is often required.
• Neurological damage can be due to a head injury, a spinal cord injury or a peripheral nerve injury.
• The physiotherapist should routinely consider if there are any abnormal sensation, altered pulses, loss of bladder or bowel control or power loss.
• Findings (positive or negative) must be recorded, to assist with identification of the cause of any neuropathy.
• This is especially important for patients with spinal injuries.
• It will help to monitor changes in a patient’s neurological symptoms as a result of surgery.
• Follow the standard neurological assessment as described in a textbook to assess a patient’s neurological status (Petty 2006).
• Any neurological symptoms should be recorded on a body chart and muscle chart. These can be filled out preoperatively, postoperatively and at regular intervals until symptoms have normalised or plateaued.
• In the case of spinal injuries, an American Spinal Injury Association (ASIA) score should be completed (http://www.asia-spinalinjury.org/).
• Swelling is a common outcome of traumatic injuries and operative procedures, entailing assessment of a patient’s vascular system.
• This can be as simple as checking for abnormal skin colour, skin temperature and capillary refill.
• In the acute phase, any abnormal neurovascular status must be reported to a doctor immediately, in case it is due to a limb-threatening condition, e.g. compartment syndrome.
Range of motion (ROM)
• Before assessing ROM of any joint, check for any restrictions imposed by the surgeon.
• Example of instructions could be:
• Measure range using a goniometer and avoid ‘eye balling’ ROM.
• If the patient is not allowed to move their affected limb, it is still essential to assess and document the ROM of their unaffected joints.
• Most patients will have reduced ROM and it is necessary to document any reasons for this, e.g. swelling, wound position, dressings or pain.
• If a wound is found to be oozing, then immediately inform the patient’s nurse.
Muscle power
• Assessing muscle power of the affected limb can be difficult in the acute trauma setting as there are many factors that will affect strength, such as pain, swelling, dressings and wounds.
• Look out for any external agents that can reduce muscle power such as epidurals or nerve blocks used during surgery.
• With this in mind, test each muscle methodically and document any muscles testing weak using the Oxford scale (Kendall and McCreary 2005).
• Patients can become weaker due to prolonged bed rest, therefore it is essential to assess the muscle power in all of the unaffected limbs as well.
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