Elderly gentleman with ankle injury
View attached: Attachment 1
You are a consultant in a regional ED. Your registrar has asked you to assist with a patient with an ankle injury. The registrar is competent in airway management and procedural sedation. You also have experienced ED nurse to assist you.
The patient is 74 year-old male man who presented with severe pain and the inability to bear weight after sustaining an inversion injury to the right ankle following a one and a half metre fall from a ladder. He has no other injuries.
Briefly interpret X-rays in discussion with registrar
Explain diagnosis to patient and proceed to manage their injury
INSTRUCTIONS FOR REGISTRAR :
You are a senior reg, competent in airway management having completed 6 months of anaesthetics. You are comfortable performing procedural sedation.
If asked confirm that this is a closed injury without neurovascular compromise.
You have not taken a full history in terms of determining if the patient is safe for procedural sedation in ED.
Ortho reg has looked at the X-rays and would like ED to proceed with reduction and call them back once post reduction X-rays have been taken. No OT time to do it upstairs.
INSTRUCTIONS FOR NURSE :
Competent ED nurse
Can complete all tasks as requested but take no initiative
INSTRUCTIONS FOR PATIENT :
74 years old
Up on roof clearing gutters at home.
PHx : hypertension. Osteoarthritis. Cholecystectomy. Knee arthroscope last year.
Medications : something for my blood pressure, not sure what
No cardiac past history. Never have chest pain / angina
No respiratory illness.
No problems with anaesthetics
Ask a few simple questions when gaining consent.
Ate breakfast 6 hours ago, nothing since.
XRAY INTERPRETATION :
AP : intact tibio-talar articulation and the disarticulation between the head of the talus and the navicular, with the navicular and calcaneum being displaced medially.
LATERAL : Avulsion fractures of the posterior process of the talus and anterior process of the calcaneum are seen. The dislocated talonavicular joint is seen. Incongruity of the subtalar articulation gives an indication to the subtalar dislocation.
1) Indications / contraindications :
early reduction is the key to ensuring a good prognosis for recovery
safety checks for procedural sedation :
- medical PHx (note: pt age 74) - all ok
- brief airway anatomy assessment
- checks vital signs before proceeding
2) Gains Informed consent
3) Preparation for procedure :
- Setting : resus
- Staffing : x2 doc, x1 nurse (ideally more than this)
- Patient positioning : sitting in bed
- Monitoring : full
- Communication & comfort :
- Medications : appropriate sedation
- Equipment : airway equipment, plaster trolley
- Departmental issues :
4) Technical skill in performing procedure :
- requires adequate sedation
- grasp toes with dominant hand and calcaneum with non dominant hand
- typical manoeuvers include knee flexion and ankle plantar flexion
- followed by distraction and hindfoot inversion or eversion depending on direction of dislocation
5) Situational Awareness
6) Communication and Consultation : ortho, patient, team
7) Prevention and Management of complications :
- potentially devastating injury - complications range from chronic pain from subtalar arthrosis to talar AVN. Earlier reduction = better outcomes
- Risks associated with procedural sedation : depression of protective airway reflexes, pulmonary aspiration, drug toxicity, individual variations in response to the drugs used, delayed onset of action of drug administration in patients with circulatory impairment
8) Post procedure Mx:
- Apply backslab
- check neurovasc
- Requires post reduction xray and probably CT - associated fracture very common, may beed ORIF
- Admission : ortho
9) Discharge advice to patients / carers & plan for follow up :
- Referral to orthopaedics for admit
- Period of non-weight bearing of 4 weeks with no fracture and 6 weeks with an associated fracture
- Active physio at end of NWB period"