Broomfield Orthopaedic Virtual Fracture Clinic

Swelling and Pain

Injury to a bone or soft tissue leads to acute inflammation. The signs and symptoms of acute inflammation can include pain, swelling, warmth and redness of the affected body part. The initial treatment should be to treat and reduce this inflammation. Follow the steps below to help manage your symptoms.

• Rest — rest your affected body part to prevent further damage and allow healing to occur. It's also important to gently exercise your injured limb/joint to prevent stiffness developing.
• Ice — Ice is useful to help reduce swelling, limit bleeding into the tissues and decrease muscle spasm and pain. Apply ice packs or a bag of frozen peas wrapped in a thin towel to the site of the injury for five to ten minutes every two hours or as often as possible over the first 48 hours of your injury. You may also find it helps to apply ice before and after completing your exercises. Do not apply ice directly to the skin and do not leave the ice pack on for prolonged periods.
• Elevation — It's normal to experience swelling after an injury. Elevating the affected area reduces swelling, which in turn, relieves pain and speeds up your healing. Keep your injured limb elevated above the level of your heart as much as possible during the first 72 hours.
• Painkillers — If necessary, you should take painkillers that are available over the counter without a prescription such as paracetamol and ibuprofen. Ibuprofen is an anti-inflammatory that can help reduce your inflammation. You should follow the manufacturer’s instructions on the correct dose and if there are reasons why you shouldn’t take them.

Driving

To be able to drive, you must be able to demonstrate that you are in full control of your vehicle. It's your responsibility to make sure that you are fit to drive and while you can ask for guidance from our team, ultimately you are accountable for your actions and decisions when driving.

If you have an injury to your lower limb, you cannot drive with a boot or a cast and can return to driving when you can control the foot pedals safely and perform an emergency stop.

If you have an upper limb injury, you can begin driving when you are no longer using your sling and when you have sufficient pain-free strength in your arms, such that you can safely control the steering column, gear stick and handbrake.

Work and sport

Decisions to return to work are made on an individual basis and should be discussed with the team, your GP and your employer. You may need a period of time off work and when you return you may need light or amended duties.

The advice given will depend on your profession and your injury.

Advice regarding return to sport will be given during your telephone consultation.

Deep Vein Thrombosis (DVT)

Immobility puts you at higher risk of developing a blood clot, otherwise known as a deep vein thrombosis (DVT). Some patients need medication to reduce this risk. In ED, your individual risk assessment for developing a DVT will have been considered by the clinical team and medication prescribed if indicated.

While every effort is made to try and prevent a DVT developing, it is important to recognise the signs that may suggest a clot is forming.

If you develop signs of a DVT, you need to seek urgent medical attention, by attending your local ED.

The signs of a DVT may include:

• Pain, swellings, redness and warmth in your calf and lower leg.
• A change in colour of your toes (typically purple), compared with the opposite side.
• While calf pain is the most common presentation, pain in the groin or sudden onset of acute chest pain and shortness of breath might indicate a more serious blood clot.

For further information on DVT diagnosis and treatment you can refer to the http://www.nhs.uk/Conditions/Deep-vein-thrombosis/Pages/introduction.aspx under the heading 'blood clots'.

Smoking with an injury

Medical evidence suggests that smoking delays fracture healing. In extreme cases it can stop healing altogether. Please consider this information with relation to your recent injury. Stopping smoking during the healing phase of a fracture will give you he best opportunity to recover from this injury.

For advice on smoking cessation and local support available, discuss this with your GP or visit http://smokefree.nhs.uk.

As you will no longer be able to move your affected limb as freely as you were able to before the injury, there is risk that a blood clot could form. This is usually in the deeper veins of the legs, which is commonly known as a Deep Vein Thrombosis (DVT). This can be very painful, resulting in swollen and sometimes discoloured calves.

Am I at risk?

Blood normally flows quickly through veins, and does not normally clot. Blood flowing in the leg veins is helped along by movements, because muscle action squeezes the veins. Whilst your leg is immobilised you will find it difficult to have a full range of movement you are used to and may potentially be at risk of a DVT.

Your doctor or nurse will perform a risk assessment whilst you are in the  emergency department and a decision will be made whether to prescribe you medication or not to prevent a blood clot.

The impact of medication

DVT and more rarely pulmonary embolism (PE) occur in between one in 50 and one in 18 people who have their lower limb immobilised in a plaster cast, splint or walking boot. If you are unable to bear weight, are over 60 years old, have other risk factors such as previous DVT, PE or active cancer, then this puts you at much higher risk of developing a DVT or PE. One or two people out of every 5 with multiple risk factors will develop a DVT or PE.

Medication will reduce the risk of developing a DVT or PE by around half but does not completely remove the risk. If you develop any signs of DVT and PE as list below despite being on treatment you should see urgent medical attention or call 111.

What happens if I don’t need medication?

If your doctor or nurse has decided that you don’t need any anticoagulation medication as you are at low risk of developing a blood clot, then you will be discharged home without any anticoagulation medications. All patients will receive a follow up for the fracture clinic as an outpatient normally within seven days.

General advice to anyone with their lower limb immobilised would be to stay as active as possible within the limitations mentioned to you by the healthcare professional in the ED. Drink plenty of fluids (not alcohol) to stay hydrated and be alert for any signs of DVT.

Recognising the signs of DVT

When you have DVT the blood flow in the vein is partially or completely blocked depending on the width of the clot. A calf vein is the common site for a DVT. A thigh vein is less commonly affected. Rarely, other deep veins in the body form clots.

The affected area of the blood clot may become swollen or painful, and possibly turn red as the flow of the blood is blocked. You may also develop oedema, which is the build-up of fluid in the skin tissues surrounding the clot. If the clot is somewhere other than in your leg, there may be no physical signs of DVT.

Sometimes bits of the clot can break up and lodge in the lungs causing a pulmonary embolism causing chest pain and difficulties with breathing.

Sometimes a DVT occurs for no apparent reason, and it becomes more common with age. Each year, one in every 1,000 people in the UK is affected by DVT.

If you develop any of these signs or symptoms listed above, seek medical attention immediately.

Reducing the risk of DVT if you are treated in a splint or a cast and not weight bearing through it.

Below explains important information about the care of your plaster cast and about the risk of blood clots or VTE.

The risk of blood clots and plaster casts

• Most people in plaster casts do not go on to develop blood clots. However, plaster casts can increase the risk of blood clots forming in the veins. These clots can block the flow of blood and cause pain and swelling (DVT).  Occasionally, the clot can travel through your circulation and reach the lungs. This is called a pulmonary embolism and can cause coughing (sometimes with blood), chest pain and breathlessness.
• It can be dangerous and needs urgent treatment.

Reducing the risk of developing a DVT

Some people have a higher risk of developing clots. Your doctor may recommend preventive treatment in the form of injections or tablets. If any of the following apply to you, please tell a member of the healthcare team:

• You have ever had a DVT or PE
• You are on cancer treatment or have a current cancer diagnosis
• You are pregnant (or if you gave birth fewer than 6 weeks ago)
• You have injured your Achilles’ tendon.

If your injury needs treating in a way that you cannot walk fully on that leg, a  clinician will risk assess you and discuss a treatment plan. This will also happen if you have an injury which is treated in a walking boot and you can fully walk on the injured leg then normally medications are not needed. 

It's difficult to predict who will get a blood clot, and there are steps that can be taken to try and reduce this risk:

• Drink plenty of fluids.
• Move around as much as is comfortable.
• Stop smoking - this will also help your bone to heal.
• Perform the exercises described below.
• Exercises for reducing the risk of DVT in lower limb casts.
• While you must wear a cast, any activity which promotes contraction of muscles and increased blood flow is helpful.

Exercises

Try and do the following at least three times a day.

For any cast on the legs

• Wiggle your toes while lying in bed or whilst sat up with your leg elevated.
• Try and do this for at least 10 seconds and as often as you can. This promotes blood flow and can help reduce the risk of blood clotting.
• Inside the plaster cast, if it is safe to do so, try and move your ankle up and down. It will not move very much as the cast will stop it. Repeat 10 times. If the cast feels loose or is rubbing, contact the hospital using the numbers on the front of the leaflet.

For below knee casts only

• Regularly bend your knee. Sit down, bend your knee and then straighten your knee. Repeat ten times.
• Lie on your tummy on the bed and bend your knee, bringing Your heel towards your bottom. Slowly lower your foot back down to the bed, keeping he movement slow and controlled.
• Lie on your bed or sit up with your leg raised. keeping your leg straight, brace the knee and keeping the leg straight, lift the whole leg up approximately 5cm, Hold for five seconds then slowly lower it down again.

If you have a plaster cast, it has been applied to your limb to support and protect your fracture while the bones heal. It's important to follow the instructions below to make sure that the cast remains intact and your limb is supported.

Do

• Keep your limbs elevated as much as possible.
• Keep your fingers and toes moving.
• Keep the cast dry as possible.

Don't

• Trim your cast yourself.
• Scratch inside your cast.
• Get your cast wet.

Contact the plaster team if:

• Your plaster is too tight, loose, uncomfortable or cracked.
• You have numbness or pins and needles.
• Pain under the cast that has become severe or was not present before.
• If your fingers / toes become more swollen or painful.
• If you can smell a nasty odor coming from beneath your cast, especially if you have had a surgical procedure as this might indicate an infection developing.

Contact us

If you need advice or to make an appointment to have your cast checked, call us on 01245 514506, Monday to Friday between 8.30am and 5pm.

If we do not pick up, please leave an message on the answerphone with your name, NHS number and contact details.

Out of these hours, if you feel you have a problem with your cast that cannot wait, please contact the emergency department.

If you have injured your wrist and/or hand, the emergency department may have fitted you with a wrist splint to stop moving the injury and support it to heal.

It's important that you wear the wrist splint as advised. The splint can be removed to allow you to wash, but make sure you dry your wrist and hand before reapplying. Our team team will give you specific advice on how and when to do this safely.

The instructions below shows you how to fit and adjust your wrist splint correctly.

Wrist splint fitting instructions

1.    Place your hand in the opened brace and position the thumb in the cut out area.

2.    Wrap the outer part of the brace over the wrist and fixate it by the 3 hook straps, applying moderate tension.

3.    Attach the palm strap to the outer part of the brace.

4.    Make sure that it's a comfortable fit that allows your fingers to move freely.

Cleaning and care

The wrist splint is hand or machine washable (using the gentle wash cycle at 30ºC).

Remove the metal stay from its pocket and fasten the straps before washing. Do not bleach, dry clean, tumble dry or iron the wrist splint and allow it to dry completely before wearing it again.

If you have a knee injury, the emergency department may have fitted you with a knee brace to support your knee and to help manage your symptoms. These come in two forms:

1. Cricket Pad Splint.

  2. Hinge brace.

It's important that you wear the knee brace as advised. Usually your brace can be removed to allow you to wash and dress — our team will give you specific advice on how and when to do this safely. You will be advised whether or not you need to wear the knee brace in bed.

Cricket pad splint fitting instructions

1. Place the cricket pad splint under your leg ensuring the wider end section of the splint is above the knee and the narrower end section is below the knee.
2. Your patella (knee cap) is in the middle of the hole of the splint when it's closed around your knee.
3. Fasten the straps across the front of the leg, starting with the top strap, then the bottom strap and finally the middle straps.

Brace care and maintenance

• Wash periodically by hand with a damp cloth and mild soap.
• Use a towel to absorb most of the dampness and then allow to dry at room temperature.
• Do not hang up or iron and do not expose to direct heat sources such as stoves, heaters, radiators, direct sunlight etc.
• Do not expose to alcohol, ointments or solvents.

Hinge brace fitting instructions

Your brace should have been fitted and adjusted especially for your knee by a health care practitioner. Putting your hinged knee brace on and off should be a simple maneuver.

1. Open up the brace making sure that the wider sections (thigh wrap) are towards your groin and the narrower sections (calf wrap) are towards your ankle.
2. Place the brace under your leg. Your knee should be centered between the hinges.
3. Bring the two sides of the brace together and fasten the buckles of the two straps above and below your knee first.
4. Fasten the buckles of the remaining two straps.
5. If your straps have loosened you can tighten these up by pulling the straps through the buckles and velcroing them back down. Please ensure that the two metal hinge bars either side of your knee remain at the sides of your leg and do not move towards the front of your knee.

Adjusting the active range of movement hinge

1. You should not adjust the active range of movement hinge unless directed by a health care practitioner. To adjust the hinge pull the small plastic stop out (C) and move it to the desired position and ensure you then reinsert it back down to lock that range of movement.
2. The brace can be locked into a position so it will no longer bend or straighten, sometimes this can happen by mistake, if this occurs check and unlock the quick fastening button (D).

Brace care and maintenance

• Wash periodically by hand with a damp cloth and mild soap. Use a towel to absorb most of the dampness and then allow to dry at room temperature.
• Do not hang up, or iron and do not expose to direct heat sources such as stoves, heater, radiators and direct sunlight.
• Do not expose to alcohol ointments or solvents.

 If you have a foot or ankle injury, the emergency department may have fitted you with a boot to reduce movement and support your injury.

It's important that you wear the boot as advised. Usually your boot can be removed to allow you to wash and dress. We will give you specific advice on how and when to do this safely. You will be advised whether or not you need to wear your boot in bed.

The instructions below show you how to fit and adjust your boot correctly.

Boot fitting instructions

Step one

• Open the boot liner without removing it from the boot.
• Place the boot flat on the floor and put the foot inside the boot.
• Make sure the heel is all the way to the back of the boot.

Step two — secure the lining on the leg by overlapping the liner on the top of the foot and the front of the lower leg.

Step three — secure the closure straps beginning with the straps closest to the toes.

Step four — the boot is ready to use.

Boot cleaning and care

• Plastic parts – boot walker frame including the closure straps can be cleaned using a damp cloth dipped in lightly soapy water.
• Textile parts – boot liner can be cleaned by hand using a gentle detergent and rinse thoroughly. Gently squeeze out the excess water and allow to air-dry on a line. Avoid direct heat or sunlight. Do not bleach, iron or dry clean.

If you have a lower limb injury, you may have been given some elbow crutches. You will have been advised how much weight you should put through your injured limb.

Please follow the instructions below to help you use your crutches properly.

Height

• Rest your arm by your side. Hold your crutch next to your arm - you may need to ask someone to help.
• The handle of the crutch should be in line with your wrist.
• To adjust the crutch, push the pins in and slide the crutch to the correct height

 

Safety

• 

  Check the feral (rubber stopper) at the bottom of your crutch. Picture one on the right.
• If the rings are worn away, it needs replacing. You can contact our team to arrange this. Picture two on the right.
• If your crutches are damaged in any way, contact our team.

 

How to stand up

1. 

   Hold both crutches in one hand in a 'H' shape, place your other hand on the arm of the chair.
2. Push up from the chair to stand up. Once standing, put your hands into the crutches ready to walk.
3. Place the crutches in front of you to maintain your balance.

 

 

How to sit down

1. 

   Take both your arms out of the crutches before sitting down.
2. Place both crutches in one hand in a 'H' shape.
3. Feel for the arm of the chair with the other hand. Sit down gently. 

 

How to walk with crutches - if you are allowed to put some weight through your injured leg.

1. 

   Place both crutched ahead of you.
2. Sept your injured leg into the crutches (grey leg).
3. Support your weight through your arms onto the crutches.
4. Step you uninjured leg past the crutches.
5. Repeat.

 

How to walk up and down the stairs with crutches - if you are allowed to put some weight through your injured leg

Going upstairs

1. Leave your crutches on the step below.
2. Step up onto the step with your un-injured leg.
3. Step up with your injured leg (grey leg).
4. Lift your crutches up onto the same step.

Going downstairs

1. Place crutches on step below.
2. Step down with your injured leg (grey leg).
3. Step down with your non-injured leg.

When you no longer need your crutches please return them back to the hospital.

 

How to mobilise with crutches Non Weight Bearing – You should not put any weight on your injured leg

1. Put both crutches forwards in front of you, just wider than hip-width apart. Keep the njured leg off of the ground (grey leg).
2. Take your weight onto your hands. Hop forward on your good leg to land between crutches.
3. Repeat this action.

 

 

How to hop up and down the stairs with crutches non-weight bearing - you should not put any weight through your injured leg.

Going up stairs non-weight bearing

1. Leave your crutch on the step, hold on to a rail, keep your injured leg bent up behind you.
2. Push down with your hands through your crutch and the hand rail and hop up onto the next step.
3. Lift your crutch up onto the same step you are now standing on.

Going down stairs non-weight bearing

1. Place both your crutches on the step below. Or 1 crutch and hold onto the rail. Keep your injured leg out ahead of you (grey leg).
2. Take your weight through your arms on the crutches / hand rail and hop down onto the next step below.