Patient resources

The RMH Virtual Fracture Clinic website has a comprehensive list of initial management guidelines and links to many highly useful patient information PDFs.

Lower limb immobilisation and VTE prophylaxis

If your patient is immobilised with a lower limb injury and being discharged, consider whether they require VTE prophylaxis.

Safer Care Victoria guidelines provide risk stratification (pp52-54):

• Prophylaxis indicated if major risk factors present:
  • Previous VTE
  • Oestrogen therapy
  • Thrombophilia
  • Active cancer
• Consider if other risk factors are present:
  • Age >60
  • BMI >30

Pharmacological options (p41):

• Enoxaparin 40mg subcut
• Rivaroxaban 10mg daily

Carefully consider dosing (e.g. in renal impairment and low body weight) and contraindications.

Paediatric Fractures

RCH guidelines

Note the tabs on this excellent resource for

• for Emergency Department
• for Fracture Clinic
• Education
• Family resources - information PDFs to print and hand to the patients

Scaphoid fracture and suspected scaphoid fracture pathway

There are a few important things to consider when managing a suspected (i.e. clinical suspicion but no X-ray evidence) scaphoid fracture.

1. Scaphoid fractures can be X-ray negative
2. Scaphoid fractures can lead to avascular necrosis and chronic wrist immobility and pain
3. X-ray negative scaphoid fractures might be amongst those that have a bad outcome
4. Immobilising these in plaster of some sort might make a difference to the rates of those bad outcomes
5. Wearing plaster for 10 days is a real pain in the neck, especially if you work with your hands, have both of them in plaster or have others to care for.

For these reasons please:

• Make a proper clinical assessment of the chance of an occult scaphoid fracture
• Always use a removable thumb spica slab rather than a full cast for the X-ray negative possible scaphoid fracture
• Consider whether early diagnosis today or tomorrow with CT or MRI is worth the money and resource use. If there is a clear benefit to the community in early diagnosis (e.g. police officer who will be off work on sick leave for a week in POP or back at work in 2 days with a negative MRI; elderly person who can't self care in POP and will need to come in to a rehab bed but who could go home from SSOU with a negative CT/MRI), then advanced imaging here may be warranted.
• Consider whether early diagnosis might be so valuable to the patient that they are willing to pay for it privately (e.g. self-employed builder)
• If you are opting for traditional management with immobilisation and fracture clinic, ensure that follow up Xrays are taken out of plaster.

Other online orthopaedic resources

Wheeless’ Textbook of Orthopaedics from Duke University