Ward Round Notes

Open/Closed Open or compound fractures are exposed to the environment and therefore more likely to become infected and lead to complications. Because of this open fractures are often managed differently. Open fractures can be categorised by the gustilo classification depending on the extent of damage to the surrounding tissues: I - Low energy with wound less than 1cm. II - greater than 1 cm with moderate soft tissue damage. III - Wound greater than 1 cm with severe soft tissue damage Where - Bone and part of bone Describe which bone and where on the bone the fracture is, long bones are usually divided into distal (away from body), middle and proximal(closer to body)3rds of the bone,or can be described as a mishaft fracture if the fracture is in the middle. Other bones have particular landmarks which are more prone to fractures or relevant to management. For example, hip fractures can be described as intracapsular or extracapsular fractures.

Resuscitation Reduction Restriction Rehabilitation Eg. A 28 y/o man arrives in ED after a motorbike accident with a fractured tibia and fibula. 1) resuscitate according to ATLS guidelines. Examine limb for neurovascular deficit once patient resuscitated. X rays with 2 views. 2) Reduction - may be closed reduction by manually pulling distal fragment to line up bone under sedation or anaesthesia, or open reduction where pins and plates are put in. Depends on type of fracture etc. Open fractures are managed differently to closed fractures. 3) Restriction - eg. using plaster of paris, External fixation, internal fixation with plates/pins etc. again dependent on injury. 4) Rehab - Encouraging mobilisation, physiotherapy, occupational therapy to help adapt environment etc. References: Gosling A, Stansby G, Surgical Talk- Surgery for Finals , London, Imperial College Press, 2004

AVPU Alert Verbal Pain Unconcious Glasgow coma score Eye 4 – spontaneous eye opening 3 – opens to verbal command 2 – opens to pain 1 – no eye opening Verbal 5 – obeys commands 4- confused speech 3 – inappropriate words 2 – Incomprehensible sounds 1 – no response Motor 6 – Obeys commands 5 – localizes to pain 4 – flexion or withdrawal to pain 3 – abnormal flexion 2 – extension 1 – no response

Ottawa rules are used to decide whether an injury needs an xray to rule out fractures or not.   Ankle rules: x rays are needed if: unable to weight bear after injury and at examination (take more than 4 steps) tenderness of the posterior surface of the distal 6cm of the posterior lateral or medial malleolus. Tenderness over base of 5th metatarsal bone tenderness of the navicular or calcaneum.