PROTOCOL FOR THE MANAGEMENT OF FOOT ... - NHS Devon

PROTOCOL FOR THE MANAGEMENT OF FOOT INJURIES
(over 2 years of age)
This protocol is operational from February 2011 and expires January 2013
This Protocol has been developed by:
Name Signature Date
Clinical Specialist Deirdre Molloy
This protocol has been ratified for use on behalf of NHS Devon by:
Authorised By (print name): ……………………………………………………
On Behalf Of: ……………………………………………………
Signed: ……………………………………………………
Date Ratified: ……………………………………………………
Authorised By (print name): ……………………………………………………
On Behalf Of: ……………………………………………………
Signed: ……………………………………………………
Date Ratified: ……………………………………………………
Author; Deirdre Molloy Nurse Consultant
Version 2.0
Expiry January 2013
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PROTOCOL FOR THE MANAGEMENT OF FOOT INJURIES (over 2 years of
age)
This protocol is for the use by staff employed by NHS Devon and has achieved the
agreed clinical competencies to work under this protocol.
Author; Deirdre Molloy Nurse Consultant
Version 2.0
Expiry January 2013
PRESENTING SYMPTOMS
Swelling Bruising/redness Deformity/dislocation
Pain Wounds Heat/inflammation
Reduced/Loss of function Difficulty/Inability to weight bear
HISTORY
History: refer to protocol for History Taking and Clinical Documentation and protocol for the Management
of Limb Injuries.
Specific:
• Establish when, where and how the injury occurred.
• Establish the exact mechanism, e.g. inversion or eversion. Was there a fall from a height? Crush
injury?
• Ask whether the patient could weight bear immediately after the injury
• A ‘crack’ felt or heard does not necessarily indicate a fracture
• Was there immediate swelling to the injured limb.
• Pain score at time of injury and on presentation
• First aid treatment received.
• The amount of swelling may depend on whether ice and elevation have been applied
• The amount of pain on examination may depend on whether analgesia has been taken
• Past medical history including previous injuries to effected limb.
• Medication
• Allergies
Refer all patients on Warfarin for further medical review/advice.
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CLINICAL EXAMINATION
Observe where possible patients gait, balance, mobility, ability to weight bear
Look
• Symmetry
• Deformity/dislocations
• Swelling.
• Bruising/discoloration,
• Wounds/grazing
Feel: (palpate from knee down)
Note any tenderness over:
• Calcaneum
• Talus, navicular, cuboid, cuneiforms
• Metatarsal bones1 – 5
• Base of 5 th metatarsal
• Phalanges
Exclude tenderness to
• Proximal fibula
• Tibia and fibular shaft
• Lateral malleolus and ligaments, including the anterior talofibular ligament
• Medial malleolus and deltoid ligament
Move
• Inversion/eversion
• Dorsi/planter flexion
• Internal/external rotation
• Flexion/extension of toes.
• Ability to weight bear
Special tests
• Sensation/circulation
• Anterior draw test (Gently pull the foot forward on the tibia to test for Anterior/posterior laxity
Of the anterior talofibular ligament)
• Achilles tendon: Simmons/Thomson test
• Talar tilt test (Gently invert the ankle, if tolerable, to test for laxity of the whole lateral ligament
complex)
Interpreting Radiographs:
• Request ankle or foot views using the Ottawa ankle/foot rule below
• Fractures are usually obvious, but may only be seen on one view
• If one fracture is seen, look carefully for another fracture or joint space widening
Accessory ossicles adjacent to the tips of the medial and lateral malleoli are common – as are fracture fragments.
A larger accessory ossicle, the os trigonum, is sometimes seen at the back of the talus on Lateral view.
Clinical correlation is important. In addition, and accessory ossicle has a well defined
(I.e. sclerotic) outline; a fracture fragment is usually ill defined on one of its sides
Ankle Anterior/posterior mortice view:
• The joint space should be uniform all the way around. Widening of the medial joint space indicates damage to the medial
ligament
• Look for a small bone fragment within the joint or a defect in the cortex of the talus, which indicates an osteochondral
fracture
• Inspect the lateral and medial malleoli
Author; Deirdre Molloy Nurse Consultant
Lateral view:
Version 2.0
• Inspect
Expiry
the lateral
January
and
2013
medial malleoli, and the posterior aspect of the tibia
Inspect the calcaneum, as well as the navicular and base of 5 th metacarpal if shown
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The Ottawa Ankle Rule
• The rule avoids unnecessary X-rays by identifying patients likely to have significant ankle fractures
• It has almost 100% specificity for clinically significant fractures, and can save up to 40% of X-rays
• It is based on assessment of the ability to bear weight (four steps), and the areas of bony tenderness
• It applies to children and adults presenting with acute (within 10 days) ankle injuries
The Ottawa Ankle Rule
1. A 2-view ankle series (Anterior/posterior (AP) and lateral) is required only if there is any pain in the malleolar
zone and any of the following:
• Bone tenderness at A, the posterior edge or tip of the lateral malleolus
• Bone tenderness at B, the posterior edge or tip of the medial malleolus
• Inability to bear weight both immediately and in the Emergency Department
2. A 3-view foot series (Anterior/posterior (AP), oblique and lateral) is required only if there is pain in the midfoot
zone and any of the following:
• Bone tenderness at D, the navicular
Inability to bear weight both immediately and in the Emergency Department
3. A 2-view foot series (Anterior/posterior (AP) and oblique) is required only if there is any pain in the midfoot zone
and:
• Bone tenderness at C, the base of the fifth metatarsal
Note:
• Allow a lower threshold for radiography in the very young, the elderly, those who are difficult to assess (e.g.
intoxication, learning difficulties, stroke, presence of other injuries), and after injury from violent mechanism, (e.g.
fall from a height, road traffic collision).
• The rule does not apply to heel injuries e.g. fall from a height. These must be assessed independently with
calcaneal views if relevant history and local tenderness.
Mid/Fore foot: Injuries to mid/forefoot require AP and oblique views where bony tenderness identified
Always request a true lateral view as well as AP and oblique if there is navicular tenderness or malalignment
is suspected
Calcaneal Au views: thor; Deirdre required Molloy where Nurse tenderness Consultant of calcaneal identified or clear history of significant calcaneal injury.
• In the lateral Version and 2.0 axial views most displaced fractures are obvious
• For subtle
Expiry
fractures
January
scrutinise
2013
carefully both views for breaks in the cortex or trabeculae
• A sclerotic line in the body of the calcaneum suggests an impacted fracture
• Some subtle compression fractures will only become apparent when Bohler’s angle is assessed:
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REFERRAL PATHWAY
Calcaneal Fractures
Specific history
• Usually follow a fall from a height but may be caused by a twisting injury. Examine the calcaneum
in all ankle injuries
Clinical Examination: Refer to foot and ankle examination.
• Look for swelling, bruising and tenderness over the heel and sides of the calcaneum
• In major fractures the heel appears flattened and tilted laterally
• Test the Achilles tendon (see Achilles Tendon Rupture)
• After falls from a height look for associated injuries of the other ankle and heel, cervical and lumbar
spine, pelvis, hips and knees.
Refer to Orthopaedics – treat as advised by orthopaedics prior to transfer
Talar fracture (displaced/undisplaced
• Commonly from forced ankle dorsiflexion (e.g. against car pedal in a RTA), or a fall from a height
• Displaced fractures disrupt the blood supply to the bone and frequently result in avascular necrosis.
Skin necrosis and open fracture also occur (emergency referral)
• Early reduction is imperative to minimise complications – seek emergency advice from Emergency
Consultant whilst awaiting ambulance
Talar Dome Fracture
• In the ankle AP view a portion of the upper articular surface of the talus is seen to have sheared
off, and occasionally is inverted and unable to unite. Refer to Orthopaedics,
• Refer to Orthopaedics – treat as advised by orthopaedics prior to transfer
SUBTALAR AND MIDFOOT DISLOCATIONS
• Follow violent twisting, inverting or everting injuries of the foot
• Subtalar dislocation may be peritalar between the talus and calcaneum, or an isolated dislocation
of the talus
• Midtarsal dislocations involve the talus and calcaneum posteriorly and the navicular and cuboid
anteriorly
• Urgent reduction under general anaesthetic is required to minimise damage to skin and circulation
Refer as Emergency to Orthopaedics via Emergency department, Adequate analgesia, elevation,
monitor neurovascular integrity whilst awaiting ambulance.
Navicular body fracture
• Fractures of the body or widely displaced fragments may require accurate surgical reduction
• Analgesia, elevate and refer to the Orthopaedics
TARSOMETATARSAL (LISFRANC) DISLOCATION
• There is disruption of one or more of the joints, usually with associated fracture of the metatarsal,
cuboid or cuneiform bones
• Prompt reduction is necessary because of the risks of swelling, circulatory impairment (especially
dorsalis pedis) and compartment syndrome
Refer directly to orthopaedics - treat as advised by orthopaedics prior to transfer monitoring
neurovascular status
1 st Metatarsal fracture
• Refer to Orthopaedics - treat as advised by orthopaedics prior to transfer
Displaced Author; or multiple Deirdre metatarsal Molloy Nurse fractures Consultant
• Analgesia, Version 2.0 elevation, refer to the Orthopaedic team - treat as advised by orthopaedics prior to
transfer Expiry January 2013
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Treatment pathway
Talar minor Avulsion Fractures: May result from ankle injuries.
Treatment
• Treat as for ankle sprain (see management of ankle injury and lower leg protocol) – may require
Emergency Department or orthopaedic opinion
Mid Foot Avulsion Fractures
Avulsions of the navicular and cuboid may be part of an ankle sprain, e.g. the tuberosity of the navicular
may be fractured by avulsion of tibialis posterior.
Treatment – may require Emergency Department or Orthopaedic opinion
• Analgesia as per patient group direction or advise on Over the counter analgesia e.g. NSAID’s
and/or paracetomol.
• Rest/elevation.
• Support bandage. Crutches
• Fracture clinic follow up.
Undisplaced metatarsal fractures
Treatment
• Analgesia as per patient group direction. Or advise on Over the counter analgesia e.g. NSAID’s
and/or paracetomol.
• Rest and elevation.
• Support bandage. Crutches
• Fracture clinic follow up.
Avulsion Fracture of the 5 th metatarsal base
Following inversion of the ankle the peroneus brevis may avulse its bony attachment.
Treatment
• As for sprained ankle. – refer to management of ankle and lower leg protocol
• Fracture clinic follow up.
• Crutches
• Pop is may be required if patient is in significant pain.
Metatarsal Stress fractures
• A fatique fracture, usually of the second metatarsal neck or shaft.
• There may be localised tenderness or pain on longitudinal compression of the bone.
• Initial radiographs may be normal and the diagnosis is made clinically
• Callus or periosteal reaction will be seen at 2-3 weeks.
Treatment
• Analgesia as per patient group direction. Advice Over the counter analgesia.
• Rest, modify daily activity as required.
• Consider a padded insole or plaster of paris for pain relief.
• Fracture clinic follow up.
Toe Injuries Radiography
• Apart from Hallux, most isolated toe injuries do not require radiography.
• X-ray only if there is obvious deformity, gross swelling, suspected dislocation, compound injury,
or MTPJ tenderness.
•
Hallux Fractures
Usually from a heavy weight falling on an unprotected foot.
May involve Author; the Deirdre IP joint Molloy and may Nurse be Consultant open
Treatment Version
2.0
• Expiry Haematoma January present 2013 -trephine nail as necessary, or remove if virtually separated.
• Treat open fracture with wound toilet under LA digital block
• Antibiotic prophylaxis according to patient group direction.
• Tetanus prophylaxis according to patient group direction
• Proximal phalanx fractures may require toe spica or a walking plaster with toe platform for pain
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• Analgesia as per patient group direction. Rest and elevation.
• Fracture clinic follow up.
Displaced fractures. Refer to duty Minor Injury doctor or Emergency Department.
Other Toe Fractures
Treatment
• Treat open factures as above.
• Treat closed fractures with analgesia, padded neighbour strapping and elevation.
• Advise that discomfort may be present for 4-6 weeks.
• GP follow up as required.
Refer to doctor for displaced fractures requiring manipulation.
Toe Dislocations
Treatment
• Reduce under nitrous oxide (as per PGD) or LA digital block.
• Apply neighbour strapping and do check X-ray.
• Analgesia (OTC) elevation and follow up as for toe fracture above.
DOCUMENTATION TO BE COMPLETED
Discharge pathway
Clinical treatment record as per local practice
Copy of clinical treatment record to General Practitioner; to be sent to surgery as per local policy
For patients being transferred to secondary care, ensure a copy of the clinical treatment record is sent with patient. A copy
will also be sent to surgery in normal manner.
For patients seeing their General Practitioner in next 24 hours ensure patient is given a copy of the clinical treatment
record to take with them. A copy will also be sent to surgery in normal manner.
BEFORE DISCHARGE ENSURE:
Those patients who have been referred for further acute intervention has appropriate transport to meet there needs, all
relevant treatment has been prescribed and administered and correct information & documentation is given to the patient.
The patient understands that if condition deteriorates or they have further concerns they should seek further advice
The patient demonstrates understanding of advice given during consultation
The patient has been provided with written advice leaflet to re-enforce advice given during consultation
The patient demonstrates an understanding of how to manage subsequent problems.
Author; Deirdre Molloy Nurse Consultant
Version 2.0
Expiry January 2013
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DOCUMENTS CONSULTED FOR THIS PROTOCOL
Sources
• J Wyatt, R Illingworth, M Clancy, P Munro, C Robertson, Oxford Handbook of Accident & Emergency
Medicine 1999
• R McRae, Orthopaedics and Fractures 1999
• Bristol Royal Infirmary A&E Handbook
• N Raby, L Berman, G de Lacey, Accident & Emergency Radiology 1995
• RDE Fracture & Orthopaedic Guidelines (ED guidelines 2009)
• British National Formulary 56 September 2008
References
1. Stiell et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle
injuries. BMJ 1995; 311: 594-7
2. Bachmann LM, Kolb E, Koller MT, Steurer J. Accuracy of Ottawa ankle rules to exclude fractures of the
ankle and mid-foot: systematic review. BMJ 2003; 326: 417-419
3.Plint AC, Bulloch B, Osmond MH, Stiell I, Dunlap H, Reed M, et al. Validation of the Ottawa ankle rules in
children with ankle injuries. Acad Emerg Med 1999; 6: 1005-1009
Revision of Exeter, Mid & East Devon PCTs, Teignbridge & South Hams PCT protocols written by Deirdre Molloy
Nurse Consultant Emergency/Unscheduled Care & Urgent Care Lead Devon PCT:
Version Date Brief Summary of Change Owner’s Name
2.0 19/12/07 Review prodigy 2007 – no new changes Deirdre Molloy
Author; Deirdre Molloy Nurse Consultant
Version 2.0
Expiry January 2013
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Author; Deirdre Molloy Nurse Consultant
Version 2.0
Expiry January 2013
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PROTOCOL FOR THE MANAGEMENT OF FOOT INJURIES (over 2 years of
age)
Version 2.0
Protocol operational from February 2011 and expires January 2013
The registered health professionals named below, being employees of NHS Devon based at
………………………………………….......... have received training and are competent to operate under this protocol
NAME
(please print)
PROFESSIONAL
TITLE
SIGNATURE AUTHORISING
MANAGER
(please print)
MANAGER’S
SIGNATURE
Keep original with the authorising manager and send a copy to Deirdre Molloy, Consultant Nurse in
Emergency/Unscheduled Care, Exmouth Hospital Annex, Claremont Grove, Exmouth Devon EX8 2JW
Author; Deirdre Molloy Nurse Consultant
Version 2.0
Expiry January 2013
DATE
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Author; Deirdre Molloy Nurse Consultant
Version 2.0
Expiry January 2013
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