Fall from height (teaching RMO)

Scenario.

A resident comes to you to your assistance regarding the management of patient complaining of foot pain after a fall.
Please give advice on assessment and management of the patient

Domains being examined

  • Medical expertise
  • Communication
  • Scholarship and teaching

Instructions for the actor (RMO)

Pt background:
– 31yo gentleman
– hopped into triage helped by coworkers
– slipped off scaffolding  and fell 4m landing standing upright
– severe pain in right heel
– no LOC, full recollection of events
– unable to weight bear and in severe pain in the heel

Examination
– the patient is sitting in fast-track chairs
– exam: left heel extremely tender, visibly swollen, malleoli mildly tender,

mid/fore-foot non-tender, distally neurovascularly intact
– knee exam NAD
– no other examination has been performed

Mx to date:
– analgesia (5mg morphine IV)
– in an ambulance cardboard backslab

X-ray:
1d0e159d9dfa3c776880c5a4f04748 screen-shot-2013-03-03-at-3-22-13-pm fe914eef20766bd6cc57cd01425558_jumbo

Assessment

Issues to be addressed

1. full trauma assessment
– identification of major mechanism
– need for a trauma team approach

– pt to be moved from fast-track into a bed, ideally in the resuscitation bay
– full primary and secondary survey with usual supplements (CXR/PXR/EFAST)
– look to identify injuries specific for a fall from height (contralateral calcaneous fracture, talar dome, NOF, acetabular fracture, lumbar fractures etc

2. asssessment and management of the calcaneous injury
– ensure this is a closed injury
– risk of compartment syndrome —> need to leave cast open and regularly assess NV status
– teaching of Boeler’s angle
– need to involve ortho and likely ORIF
– NBM, IVF, analgesia, elevate, limb obs

 

fall-from-height-osce (printable)

 

Leave a Reply

Your email address will not be published. Required fields are marked *

Protected with IP Blacklist CloudIP Blacklist Cloud