WhiteCoat

I’ll Take That as a Compliment

The image “http://www.davidlnelson.md/images/DistalRadiusFx_fx_lat.jpg” cannot be displayed, because it contains errors.

Fractured Distal Radius (see Arrows)

http://www.wattenbergwrestling.com/images/ElbowDislocation.gif

Complete Posterior Elbow Dislocation

Hello, guest poster ERP here.

If you read my blog, recently I posted about the first “Ice” day of the year. The day that always seems to surprise people, haplessly stepping out onto the stuff in their driveway, front steps, or sidewalk. We always get a big bolus of patients with falls – often with nasty injuries.

Anyway, one of the poor guys I saw that day was the unfortunate owner of the above x-rays (well, ones that were nearly identical to them). He slipped backwards and fell while trying to get into his car. He was in a world of pain (and yes, before everyone goes crayzee, he got PLENTY of IV narcotics!). Realising that I had to reduce that dislocated elbow, and since he had not eaten or drunk anything since the night before, he was a perfect candidate for Dr Conrad Murray’s favourite drug, Propofol (administered by an anaesthesiologist since myself and my PA were doing the reduction – it can be hard to monitor the airway and do a procedure at the same time). Since I had to reduce the elbow (you really should not wait very long to do this), I figured why not try to reduce the distal radius fracture as well? (Not being an orthopaedist, I have only reduced a few of them, usually with the assistance of one). I figured that worse case scenario, he would need another reduction when he followed up with ortho in a few days.

We put the guy out and the elbow reduced easily – return to full range of motion was achieved in short order. Then I bent and yanked on that smashed wrist. The crunching sounds always sort of make me queasy but that is the way it is. I splinted the whole arm from shoulder down to the fingers and ordered the post-reduction X-rays. I thought they looked OK but what do I know? I could tell the elbow was in but I don’t know all those myriad of angles that orthopaedists have to memorise. (for most fractures, there is an angle between the fracture segment and the rest of the bone that you shoot for – and that is what determines if the reduction is successful and not requiring another attempt). About an hour later, the orthopod came in – he had a slew of patients as you can imagine that day – and looked at my handiwork. He deemed the reduction “acceptable” and appeared to be thankful that I had made his day a little easier. I felt like a med student who did his or her first suturing job that did not have to be redone by the attending who came to supervise! Now, I hope he will come in a little faster when I REALLY need him for that drunk guy with an open tib-fib fracture who will inevitably come in at 3am on a Friday night!

Tags:

10 Responses to “I’ll Take That as a Compliment”

  1. BlackSails says:

    Hey White Coat- Nurse K’s blog is down again. When will she be back?

  2. cynic says:

    Mattie in a situation like this do you sue god or mother nature ?

  3. Question about anaesthetics like Propofol, since you mention not wanting to monitor the airway… How does a patient having sleep apnea interact with such anaesthetics?

    Ten years ago, it was a big deal to set up a CPAP when being put under, but this year the Anaesthetist said “don’t worry about it”, and put me under with Propofol. I was not a little concerned at the time, but it seemed to have worked.

  4. RSDS says:

    Tarl N.

    ERP said that the Propofol was administered by an anaesthesiologist, so it was up to the anaesthesiologist to monitor the airway.

    ERP

    Which is the better splint for a distal radius fracture, sugar-tongs or spica thumb splint?

    RSDS

    Who is going to make sure that this guy’s fracture does not develop into Complex Regional Pain Syndrome?

  5. ERP says:

    Distal radius fractures usually get a volar splint – thumb spicas are for things like Schaphoid fractures. As for the other concern, that my friend, is the responsibility of the orthopaedist who ultimately will put the guy in a cast for 6 weeks.

  6. RSDS says:

    About two-and-a-half years ago I fell-over on rough ground, resulting in a simple distal radius fracture, that did not receive any reduction. A Family Practice doctor in the local (less than 3 blocks away) rural ED had a very young, inexperienced, nurse apply a Spica Thumb splint for it, without supervision.

    She had never applied a spica thumb splint before. In fact, the first cast that she ever applied was for the patient just before me. This nurse squeezed the plaster over my thumb very tight, so that there was no room for any swelling. She also pulled the compression bandage very tight over the splint.

    I swelled up, to the point that my fingers more closely resembled sausages, than fingers. When I got the splint switched to a cast at the VAMC (almost 200 miles away), first the ortho PA had to pry the compression bandage out of my skin, then he had to pry the splint off with great difficulty. At the base of my thumb was a deep presure ulcer, that had caused me up to level 9 pain. (Level 9 pain is the type that causes knee buckling or writhing on the floor.) This injury was one of the few (less than half a dozen) times that I have reached level 9.

    When the pain and swelling had not resolved several weeks after the cast was removed, I was diagnosed with Reflex Sympathetic Dystrophy Syndrome / Complex Regional Pain Syndrome.

    The RSDS / CRPS is mostly in remission now, and I have regained *most* of the use of my hand.

    RSDS

  7. ERP says:

    Well, obviously that splint was not applied properly. Proper splint application is something that should have been taught in residency. Sorry to hear about what happened to you and I am glad it is better.

    • Painless says:

      Hey ERP… thought you were on vacation somewhere warm? Whatcha doing replying to posts? Gonna get Mrs. ERP all upset at ya.. LOL.

  8. ERP says:

    We have wifi in the room! No phone, no TV, but wifi!

  9. [...] usually blogs at ER Stories but is working a shift in Whitecoat’s Call Room, is working on the first Ice Day of the year. Foot meets ice; arm meets pavement, patient meets ERP. It’s a logical progression, just like [...]

Leave a Reply


+ four = 5

Popular Authors

  • Greg Henry
  • Rick Bukata
  • Mark Plaster
  • Kevin Klauer
  • Jesse Pines
  • David Newman
  • Rich Levitan
  • Ghazala Sharieff
  • Nicholas Genes
  • Jeannette Wolfe
  • William Sullivan
  • Michael Silverman

Subscribe to EPM