Category: MSK

VTE prophylaxis in lower limb Immobilisation (ED – 2022)

In the Emergency Department (ED) lower leg immobilisation after injury is a necessary treatment but is also a known risk factor for the development of venous thromboembolism (VTE). This accounts for approximately 2% of all VTE cases which are potentially preventable with early pharmacological thromboprophylaxis.

We now have ORAL prophylaxis available!!

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Penthrox (Methoxyflurane)

Penthrox is an inhaled, patient controlled analgesic for use with moderate to severe acute pain associated with trauma.  Not to be used in atraumatic pain, chronic pain, children or pregnancy.

Rapid onset of analgesia lasting 25-60 minutes depending on rate and depth of inhalation.  Wears off 10 minutes after last inhalation.

Contraindications (CHECK ALLL):

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#Limb Injury – Trust Treatment & Follow-Up

Select the appropriate body area for guidance table

No Spinal injuries, back pain, Cauda Equina, foot drop etc to be referred to VFC

Patients that will not be suitable & need a “face-to-face” as below

  • Homeless patients
  • Prisoners
  • Non English Speaking Patients
  • Inpatients
  • Patients with Hearing Difficulties
  • Phoneless Patients
  • Injuries Associated with Domestic or Child Abuse
  • Children under 2 Years of Age
InjuryED TreatmentDischarge Pathway
ClavicleAdult – Undisplaced Polysling/BASVFC
Adult – Displaced Polysling/BASVFC
Paediatric – UndisplacedPolysling/BASDischarge sling for 2 weeks then Mobilise as pain allows
Advice Sheet: HERE
Paediatric – DisplacedPolysling/BASDischarge
Open #/threatened skin/Floating shoulder
Polysling/BASOrtho On Call
Proximal Humerus #Paediatric – Undisplaced/minimal displacement/angulationCollar & CuffDischarge C&C for 2 weeks, mobilise as pain allows
Paediatric – Significant Displacement /angulationCollar & CuffVFC
AdultCollar & CuffVFC
Shoulder Dislocation-NO #!First time & RecurrentReduce ED + Polysling
MSK shoulder Physio Clinic
Unreducible Ortho On-Call
Fracture Dislocation Greater Tuberosity #ED Reduction- PolyslingVFC
Unreducible / Multi-fragmentaryPolysling for comfort Ortho On-Call
ACJ DislocationAll GradesPolysling /BASMSK shoulder Physio Clinic
Open Injury / Threatened skinPolysling /BASOrtho On-Call
Rotator Cuff InjuryPolysling/ BASMSK shoulder Physio Clinic
Humeral Shaft
(documentation of Radial Nerve function
pre/post application of brace)
No Nerve InjuryHumeral Brace with Check XRVFC
Radial Nerve InjuryHumeral Brace with Check XROrtho On-Call
InjuryED TreatmentDischarge Pathway
Elbow dislocationReduce ED,
Above Elbow Backslab
Supracondylar #
Distal Humerus (Paediatric)
UndisplacedAbove Elbow Backslab
(>90 Degrees Flexion)
Check XR in cast
DisplacedAbove Elbow Backslab
(Comfortable position)
Ortho On Call
Paediatric Epi/condylar #UndisplacedAbove Elbow Backslab VFC
Above Elbow Backslab Ortho On Call
Radial Head/Neck Undisplaced / Minimally displacedCollar & CuffDischarge
Comminuted/significantly displacedCollar & Cuff
(Above Elbow Backslab if pain ++)
Paediatric Radial
Head Subluxation
(with Ulna Plastic deformation)
Above Elbow Backslab VFC
OlecranonUndisplacedAbove Elbow Backslab
DisplacedAbove Elbow Backslab Ortho On-Call
Fat Pad +ve ElbowCollar & CuffDischarge – Encourage ROM,
discard C&C as comfort allows
InjuryED TreatmentDischarge Pathway
FingertipCrush # Terminal Phalanx? Mallet splint to protect

NailbedWound Management
GP Practice Nurse Wound review
Significant Soft Tissue
Injury/? terminalisation
Mallet FingerExt Tendon (No Bony Injury)Well-fitting Mallet splint
(Ensure allows PIPJ Flexion)
8/52 then 4/52 at night
Avulsion # <50%
Joint Surface
6/52 then 4-6/52 night
(XR in splint to ensure joint congruence)
Avulsion # >50%
Joint Surface
6/52 then 4-6/52 night
(XR in splint to ensure joint congruence)
Undisplaced Phalangeal # /
Metacarpal #
StableNeighbour strapping 2/52
+/- Splint
Concern over stabilityNeighbour strapping 2/52
+/- Splint
Displaced phalangeal # ED Reduction
N/S +/- Volar Slab
(check Rotation)

IP DislocationExtensor Mechanism - Intact
(post reduction)
ED Reduction & NS
Extensor Mechanism - Disrupted
(post reduction)
ED Reduction & Capner SplintVFC
Metacarpal Neck #Neighbour strap Discharge
Bennett’s/ 1st MC Basal #Bennett’s Slab (Ensure IPJ Mobile)VFC
ScaphoidFracture IdentifiedScaphoid SlabVFC
Query FractureScaphoid Slab/SplintFace-Face # Clinic
2/52 post injury
Thumb MCPJ Injury StableSplintVFC
? UnstableBackslabFace-Face # Clinic
Volar Plate Injury
(+/- Avulsion #)
Neighbour Strap 2/52Discharge Advice Sheet-HERE
Minor Trauma
Evidence of OA No #
Symptomatic Treatment
? Splint 2/52
Paediatric Torus #
Distal Radius
Futura splint 3-4/52Discharge Advice Sheet-HERE
Paediatric Radius /Ulna UndisplacdAE backslabVFC
Displaced/AngulatedAE backslabOrtho On-Call
InjuryED TreatmentDischarge Pathway
No TraumaSymptomatic Treatment

OASymptomatic Treatment Discharge
Atraumatic Acute
swollen Knee
Ortho On Call
Tibial Plateau/ Femoral Condlye #ImmobiliseOrtho On Call
Patella DislocationFirst Time – no OC#
Knee Splint WBATMSK Lower Limb Physio Clinic
First Time – OC# Knee Splint VFC
Recurrent Knee Splint WBATMSK Lower Limb Physio Clinic
Patella Tendon/ Quads Tendon Rupture
Knee Splint Ortho On Call
?Meniscal, ?Ligament Injury Knee Splint
MSK Lower Limb Physio Clinic
InjuryED TreatmentDischarge Pathway
Isolated avulsion # tip
of lateral/medial malleolus
Treat as sprain WBAT, RICE
Ankle Brace/Walker boot if necessary

Isolated Weber A distal fibula #sTreat as sprain WBAT, RICE
Ankle Brace/Walker boot

Advice to contact VFC if symptoms > 3/12
Isolated Weber B Lateral Malleolar #
(Documentation must include:
Is there medial swelling? Yes/No
Is there medial tenderness? Yes/No
Is there medial bruising? Yes/No)
Talar shift/displacement - PresentBackslabOrtho On-Call
Talar shift/displacement - NONEWalker Boot WBAT
Isolated Weber C fibula #
(Also Need Assessment for medial injury& syndesmotic injury)
Ortho On-Call
UndisplacedWalker Boot WBAT
Bimalleolar/ TrimalleolarBackslab
Ortho On-Call
Tarsal fractures - Small avulsions without
disruption of tarsal alignment
Treat as sprain -Walker boot, analgesia, WBATDischarge
If UnsureTreat as sprain -Walker boot, analgesia, WBAT

Tarsal or cuneiform #Walker boot, analgesia, WBAT
Metatarsal #Intra-articular/basal # ? Lis FrancWalker boot, analgesia, WBATVFC
Definite Lis Franc/ Significant displacementBackslabOrtho On-Call
Neck & Shaft #s
Minor Trauma/Minimally displaced/stress #Walker boot /flat post op shoe WBATDischarge Advice Sheet-HERE
High Energy/ Multiple / Significant displacement
BackslabOrtho On-Call
Isolated 5th Metatarsal Base
(diagram below)
Zone 1Walker boot /flat post op shoe WBATDischarge
Zone 2/3 Walker bootVFC
Lesser Toe Injuries #’s/dislocationsED reduction (if needed)
Neighbour Strap
WBAT flat shoe/ Normal footwear
Discharge Advice Sheet-HERE
Achilles Tendon RuptureEquinous Slab, NWB,
VTE prophylaxis
Face-Face # Clinic
Talus Neck/Body #BackslabOrtho On-Call
Calcaneal #Walker boot NWBOrtho On-Call
Tongue Type #Equinous Slab NWB (Keep NBM) Ortho On-Call

5th MT zones


LA – Toxicity

We are regularly doing femoral blocks next to major vessels. So warn the patient of the symptoms, & keep them monitored(at least 15 min).

Symptoms of local anaesthetic toxicity

  • Circumoral and/or tongue numbness
  • Metallic taste
  • Lightheadedness/Dizziness
  • Visual/Auditory disturbances (blurred vision/tinnitus)
  • Confused/Drowsiness/Fitting
  • Arrhythmia
  • Cardio-Resp Arrest

Remember – Do basics WELL

Intralipid – in antidote cupboard (Green Majors treatment room)

    1. Bolus – 1.5ml/kg 20% lipid solution over 1min
    2. Then start Infusion – 15ml/kg/hr 20% lipid solution
    3. 5 mins reassess if Cardiac instability/deterioration
      • Rpt Bolus 1.5ml/kg over 1min (max 3 boluses inc. initial)
      • Increase infusion rate – up to 30ml/kg/hr
      • Total Max dose 12ml/kg

Propofol is not a suitable substitute for lipid emulsion

Without Cardio-Resp Arrest

Use conventional therapies to treat:

  • Seizures
  • Hypotension
  • Bradycardia
  • Tachyarrhythmia (Lidocaine should not be used as an anti-arrhythmic therapy)

In Cardio-Resp Arrest

  • CPR – using standard protocols (Continue CPR throughout treatment with lipid emulsion)
  • Manage arrhythmias – using standard protocols
  • Consider the use of cardiopulmonary bypass if available
  • Recovery from LA-induced cardiac arrest may take >1 h
  • Lidocaine should not be used as an anti-arrhythmic therapy



Rabies [notifiable disease]

Recent Incident: Bat contact was not recognized (effectively touching a bat without gloves means treatment is recommended)

Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in  “Rabies-Free” counties the bat population posse a risk.

In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.

Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.

Risk Assessment

To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]

Exposure Category

Combined Country/Animal & Exposure Risk


Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.

If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)


You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]

Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400



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C-Spine Injury

C-spine injury ranges from the obvious fracture-dislocation to the less obvious ligamentous injury, affecting about 2.5% of blunt trauma patients. However, ALL of them are serious and can lead to life changing injuries, that we obviously don’t want to miss.  Unfortunately reported miss rates range from 4-30%. [IJO 2007]

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Tetanus – Wounds

Tetanus prone and High Risk definitions

Immunisation schedule

  • Primary: 2, 3 & 4 months old
  • Boosters: 3½ – 5yrs and 13-15yrs


  • Immunisation only started nationwide in the UK in 1961 (people born before 1961 are unlikely to have completed a primary course)
  • Immunocompromised patients are unlikely to produce adequate antibodies

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