Saturday Shortcut

"I just thought I could nip down the bank as a shortcut..."  Sean tells me at triage in the Emergency Department on Saturday afternoon before yelping and groaning in pain.

He has just arrived by ambulance, with the tell-tale orange "box" splint on his right lower leg.  Patrick, the paramedic who has brought him to us gives me a look that seems to say "I think you should look at this guy's leg sooner rather than later."

The ED is fairly full with the weekend business of lengthening days and the results of adventurous risks that, in hindsight, might not have been worth taking.  No-one plans to spend their day with us, but sometimes you think that some of the choices folks take are not always well thought through.

Sean's choice has left him with a leg that is not how nature intended.  As we open the box splint a fraction, we can see his shin comes to an abrupt halt at his ankle where the foot is now twisted out to the side and sitting behind where it would normally be at the ankle joint.  There is a patch of white blanched skin that is stretched taut over the end of his shin bone, the tibia.  There is no wound, but if we leave the foot where it is for much longer, the area of white skin may break down or tear, converting this into an open or compound fracture, that could become more complicated to recover from.  The foot itself is cool to touch, and whilst I can feel a pulse in the top of the foot, it is thready and faint. 

Patrick completes his handover, and informs us that Sean has had morphine in the ambulance en route to the ED.  This will certainly have helped, but we may need something else to get this foot back into alignment.

As always in the Department, we have to prioritise our space and our staff to do the best for the most.  Sean has a limb-threatening injury that needs an emergency sedation and procedure, something we do around 700 of a year in the Royal Infirmary, but we need to ensure that life-threatening conditions are being treated in a timely fashion also.   On this occasion, we have space in our anaesthetic room, and we move Sean through to attach some monitoring, take some further history, and prepare to provide adequate sedation to allow us to pull his foot back into position and place in a cast. 

I invite a senior doctor in training and a medical student in with us, and check that Sean is happy with this arrangement.  We talk through the indications for the procedure, and Sean's previous history and when he ate and drank.  We decide on using a combination of more pain relief, a hypnotic, and some ketamine. 

Whilst we prepare and check the medicines and monitoring, we get an X-ray that confirms the ankle fracture-dislocation.  The XRays often don't tell the whole story as the anatomy can be quite distorted and the soft tissues will also be severely disrupted, but they give a good impression of how we should be correcting the deformity.

Sean has had some more pain relief, and is now in a more calm if still very uncomfortable state.  This is really important prior to giving ketamine, which can give patients a bad experience if they are agitated beforehand.  We give a small dose and wait the minute or so for it to have its effect.  This is one of the more curious agents we use, and causes a "dissociative" state: the lights are on but no-one is at home. 

Sean's eyes are open, and they have the trademark flickering - nystagmus - that is characteristic of ketamine.  We do a test lift of Sean's broken ankle.  No response, so we can proceed.

I have our medical student lined up to help with the application of the plaster, and with some counter-traction from one of our clinical support workers, I pull the foot down and then rotate the foot clockwise to get the big toe lined up with the knee again.  There is a sucking clunk as the expanded joint space contracts down and the bones slide back into place.  One of the more satisfying parts of our job!

I turn to ask our medical student to come and hold the foot in the air whilst I apply the plaster, but the noisy relocation may have been the final straw and he has gone the same colour as the foot was.  We direct him towards a chair in the corner, and the CSW and I apply the plaster to the back and sides of the leg to hold the ankle in place. 

The whole procedure takes not much more than 10 minutes, and there are occasional mutterings from Sean.  One of the unwritten rules is that whatever is said under sedation (and there are some wonderful revelations, as well as very profound declarations of love) stay in the procedure room.  We also try and preserve the dignity of our medical students when they succumb to first-time experiences of faintness.  Professional confidentiality has many forms!

The post-procedure Xray confirms a good position of the bones, and Sean is able to go home after a few hours of recovery and something to eat.  Our orthopaedic colleagues will follow him up in the next couple of days, and he may need to have an operation on his ankle, but for now his foot and ankle are safe.