Key Feature 5: Identify and manage limb injuries that require urgent immobilization and/or reduction in a timely manner.
Phase: Treatment, Diagnosis
Key Feature 6: In assessing patients with suspected fractures, provide analgesia that is timely (i.e., before X-rays) and adequate (ex: narcotic) analgesia.
Skill: Clinical Reasoning
Key Feature 7: In patients presenting with a fracture, look for and diagnose high-risk complications (ex: an open fracture, unstable cervical spine, compartment syndrome).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis
There was a 14 year old male who presented to the pediatric ED today with acute wrist pain following trauma. He was given a dose of ibuprofen and plain radiographs were ordered that were later read by the radiologist as being negative for evidence of fracture. My attending's index of suspicion for fracture was high nonetheless, and so we immobilised the injured arm, with arrangements made for followup reassessment. What are the limb injuries that require urgent immobilization and/or reduction, and what should be done about them?
Indications for reduction (aka repositioning)
Indications for immobilization:
Almost any fracture or dislocation may benefit from at least short-term immobilization with little harm. The choice of immobilization method, be it sling or cast, comes with inherent pros and cons. Generally speaking, slings tend to be the choice for an acute injury as they are less restricting and therefore more accommodating of swelling as tends to occur with acute bony injuries. Slings also tend not to limit the ability to apply ice to decrease swelling to the affected area, which may significantly improve pain. Furthermore, swelling in a restricted cast can lead to iatrogenic tissue damage (ex: compartment syndrome*). On the other hand, slings tend not to stabilize the affected area as much as a cast, and depending on the need for swelling vs stability, the cast may be more appropriate (ex: injuries expected to have minimal swelling, or those for which there is an increased need for stability). According to the UpToDate article, "General principles of acute fracture management" (2018), fractures that require casting as opposed to use of a sling include, "...those that required reduction, fracture dislocations, segmental or spiral fractures, and simultaneous fractures of both the ulna and radius."
Given the pros and cons of slings vs casts, my attending physician today chose to opt to immobilize the affected wrist with a short-arm cast. There was minimal swelling, and given the time elapsed from injury, it was expected that there would not be significant further swelling to the area. Furthermore, the teenager was a seriously active person who played soccer and rugby, and without a cast was at increased risk of re-injuring the area before giving it proper time to heal. Plus, in a patient-centered way, he was kinda excited to get his very first cast, and so we made one in his favourite colour blue.
A note on pain control: If pain is a concern, as it usually is when it comes to bony injuries, it is important to prioritise pain relief, because pain sucks. This is something quick and easy to do, managed with the same analgesic ladder as for any other nociceptive (tissue) pain: acetaminophen, NSAID, and/or opioids. Opioids are often unnecessary save for severe injuries, and it is worth a trial of acetaminophen +/- an NSAID first in an injury that is not seemingly too painful. Other nonpharmacological methods of managing pain can be very helpful, and these work by decreasing the pain associated with swelling. These methods include: resting the affected area, applying ice, and elevating the extremity.
*Complications that present with bony injuries include those that are evident upon initial injury assessment and those that present in a delayed fashion. Complicating factors that are evident on primary assessment include
As this post is much about casting, with reference to compartment syndrome as an iatrogenic complication of casting, I will elaborate briefly on what this is. Compartment syndrome occurs when there is so much swelling in an area that arterial flow is cut off. This leads to the four Ps that a clinician should always be suspicious to look for in a patient with a cast (or if there is a fracture to the regions that are more likely to host this complication because of natural tissue compartmentation)