Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent Response - Limb Injury / Fall
• 42-year-old female fallen at home
• Complaining of severe arm pain, deformed arm
• Patient is conscious and alert
• Location: Home address

On Arrival

You arrive at a suburban house. The patient, a 42-year-old female, is sitting on the floor in the hallway, supported by the wall. She is pale, guarding her right forearm, and appears to be in significant pain. There is obvious swelling and deformity of the right forearm. No hazards noted.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (obtained from patient)

Vital Signs/Assessment (Initial)

Physical Examination

• General Appearance: Alert, pale, in obvious pain, guarding right arm.
• Right Upper Limb:
  • Inspection: Obvious deformity ('dinner fork' appearance if distal radius #) and swelling of the mid-distal forearm/wrist area. Bruising may be present. Skin appears intact over fracture site.
  • Palpation: Significant point tenderness over the fracture site. Avoid excessive movement/palpation.
  • Neurovascular Assessment (Distal to injury - CMS):
    • Circulation: Hand warm, pink. Capillary refill < 2 seconds in nail beds. Radial pulse palpable (may be difficult due to swelling/position, compare with left).
    • Motor: Able to wiggle fingers, reduced grip strength due to pain.
    • Sensation: Sensation intact to light touch in fingers and hand.
• Head-to-Toe: Check for other injuries from fall (e.g., head, neck, hip, other wrist). No other injuries reported or found on examination.

Assessment and Treatment

Appropriate Management Focus

• Primary Survey (ABCDE): Confirm no life threats. Focus on limb injury and pain management.
• Communication & Rapport: Explain procedures clearly. Provide reassurance.
• Pain Assessment: Use 0-10 pain scale. Assess frequently, especially after interventions.
• Pain Management: Prioritise early and effective analgesia.
  • Methoxyflurane (Penthrox):** Offer for initial pain relief if no contraindications.
  • IV Access:** Establish intravenous access in uninjured arm.
  • Paracetamol:** Consider IV Paracetamol.
  • Opioids:** Administer IV opioids (e.g., Fentanyl or Morphine titrated doses) for moderate-severe pain per local protocols.
• Immobilisation: Gently immobilise the forearm in position found/position of comfort using an appropriate splint (e.g., padded board splint, vacuum splint, SAM splint). Ensure splint supports elbow and wrist. Check CMS before and after splinting. Elevate arm in a sling if tolerated after splinting.
• Neurovascular Monitoring: Perform and document CMS checks (Circulation, Motor, Sensation) distal to the injury before and after splinting, and regularly during transport.
• Transport: Transport to an Emergency Department, preferably one with orthopaedic services. Transport gently.
• Teamwork & Communication: Clear roles. Calm approach. Clear handover to ED, including mechanism (FOOSH), findings (deformity, CMS status), pain score, analgesia given (time/dose/route), and splint type.