Tuesday, February 28, 2012

The Broken Arm and Patient Assessment

Boy just got his sling off last Wednesday after having to wear it for six weeks due to his broken collarbone.  As you recall I was out of the country when he was playing at the school with his cousin on evening and oldest daughter had to take care of this incident. 

On Sunday, Boy and Girl got to stay after Sunday School to hang out and play with the other kids.  One of the moms in particular had requested that I allow Boy to play with her son.  Boy is athletic, competitive (sometimes to a fault), and just likes being outside and moving around.  This friend's son is the same age but doesn't know how to properly hold a basketball, kick a soccer ball, or throw or hit a baseball.  His father is of no use in any of these matters.  So of course Boy can play.  For the last two months there's been no playing.  First there wasn't any Sunday School due to the winter break.  Then Boy broke his collarbone.  No playing for six weeks.  Finally on Wednesday he got the sling off.  Finally he was going to be able to stay and play.

The kids, Boy, Girl, friend's Boy, friend's younger boy, and another person's little girl all stayed after Sunday School to play.  They were all having a great time.  We parents were all inside visiting.  The friend's younger boy came in.  His older brother fell and was hurt.  Friend went outside and walked the older boy back in.  He was not screaming but walking with his arm straight and whining that it hurt.  He wouldn't say where, just IT hurt.  His mom sat him down on a chair and went to get the father who was off in another room. 

I got up and went over to the boy.  ABCs airway, breathing, circulation.  No problems with the airway.  He's breathing because he's talking.  All's good.  Since the arm or neck seemed to be the problem I started off with the fingers.  Capilary refill.  Good. 

Let's talk about the patient assessment.  You always try to get the patient talking.  Why?  Because the more they talk to you the more calm they become.  Get their information.  I already knew this kid but I told him, "I'm going to ask you some questions even though I already know the answer."  First get their information.  What's their name, weight, date of birth/age, chief complaint.  Then see if they are oriented.  Can they orient themselves to a person, place, time, or purpose?  How do they respond to pain?  Purposeful, no response, non-purposeful, or are they unconscious?  How about their breathing?  As I said before if you can talk you are breathing.  But how is it?  Normal, unequal, rales (sounds like popping), stirdor (a rattling noise which means something is blocking the airway), wheezes, apnea, anything else of note?  How about the skin?  Color: normal, pale, cyanotic, flushed?  Moisture: normal, dry, moist, profuse (dripping sweat)? Temperature: normal, hot, cool, cold?  How about the pupils?  equal and reactive to light, unequal, fixed, dilated? How about the patient's history?  Cardiac, seizure, diabetes, hypertension, other, unknown history?

This was just a nine year old boy who either broke or sprained something or just got scared because he fell.  In this case I was just trying to figure out whether his parents should take him to the hospital or just give him a pat on the rear and send him back out to play.  First off, what happened? The kids were all playing chase on the trampoline.  He fell out through the little hole in the netting where you climb in and out.  This meant he fell about three feet to the ground.  What hit?  His shoulder, elbow, wrist, hand. Basically his left side.  His eyes looked fine, his breathing was good, skin normal.  Let's do a little bit of touching and moving.  Can you lift your arm?  No.  It hurts.  OK.  Let me touch your shoulder.  No whining.  Collarbone, no whining.  Elbow.  No whining.  Wrist.  No whining.  Can you move your wrist?  He did a little then complained it hurt.  Joints good.  How about the bones? How about here  on your upper arm?  Loud yell.  Sorry.  How'd you like to have your parents bring you to the hospital so you can get a sling just like Boy had.  Boy piped up that he would even lend his friend his sling now that he doesn't need it. 

Fortunately the humerus was broken but in just about the best place to break it, which is not at the joint.  He broke the bone just below the shoulder.  What is the best thing for a break like this?  Let it hang.  The sling that he has to wear isn't one that bends at the elbow to keep the shoulder immobilized.  This one is more straight with the arm pinned to the side rather than across the body.  The intent is to let the bone naturally grow.  Even sleeping is done sitting up or at least propped up in bed with a bunch of pillows.  Usually surgery isn't necessary unless the bones end up too far apart or if the nerve ends up getting pinched in the bone.  Fortunately it's just a simple break.  His hand and fingers may feel numbness for three or four months even if the bone is better in two. 

Boy was really excited that I was there and got to work on his friend.  After all, I missed out taking care of his fracture.  The boys got exactly one hour of play in.  They now have to wait another two months. 

1 comment:

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