A secondary survey begins only after the primary survey is complete, abnormalities have been reassessed, resuscitation is underway, and the patient’s observations are improving. It involves a full head-to-toe assessment, including history, examination, and vital sign review.
At this stage, review the admission history and past medical history—especially prior falls, fracture risk, spinal conditions, and medications (notably antiplatelets or anticoagulants). Combine this with ward staff input and your initial assessment to consider possible causes of the fall.
i. History
- Is the patient reporting pain in their groin/hip/thigh?
ii. Examination
- Bruising around genitalia, blood at urethral meatus indicating ruptured urethra
- Shortened, externally rotated leg (note: not all patients with fractured neck of femur will present with this finding)
- Gentle palpation of bony pelvis for tenderness
- Ask patient to perform an active straight leg raise
- Assess (if possible without causing pain):
> external rotation and abduction of each leg
> pain elicited with rotation of the limb
> distal pulses and sensation. (20)
If the patient is still on the floor and hip or pelvic fracture is suspected, you will need flat-lifting equipment to transfer the patient onto a bed.
If a pelvic fracture suspected and there is hypotension, consider an unstable fracture and use of pelvic binder – call for urgent orthopaedic/trauma expertise.
If an isolated injury is suspected, X-ray the pelvis and/or hip. If multiple injuries or unstable pelvic fracture are suspected, perform trauma CT (21). If clinically suspicious for a hip fracture and the X-ray is normal, consider MRI or CT scan to assess further (22).
If a fracture is confirmed, refer urgently to orthopaedic services to allow access to specialist review.
A pelvic or sacral insufficiency fracture, which commonly accompanies a simple pubic ramus fracture, will at least cause back pain and may render the pelvis unstable. All patients with fractures of the pelvic ring should undergo review of their imaging and have a documented management plan. All patients who fail to mobilise despite adequate analgesia should be considered for CT scanning within 72 hours of their fall (15).
Imaging to exclude hip and pelvic fractures is urgent and should not be deferred to working hours. For comparison, emergency department expectations for patients presenting with suspected hip fracture are:
- analgesia within 15 mins if moderate or severe pain and then reassessed within 15 mins of receiving analgesia, then hourly until settled (19)
- X-ray as soon as possible (within 90 mins of arrival) (22)
- consider fascia iliaca block (ortho StR, anaesthetic StR)
- refer to orthopaedic services as soon as possible to ensure prompt surgery (within 36 hours) (23).
If a hip fracture is confirmed, a fascia iliaca block (FIB) is recommended if oral analgesia is insufficient and local resource is available (23,24). See appendix 3 for guidance on FIB.
iv. In a community setting (without access to flat lifting equipment)
- Call 999 for an emergency ambulance and report a suspected hip/pelvic fracture.
- Consider keeping the patient comfortable on the floor if ambulance transfer is likely to be rapid, to avoid unnecessary transfers.
- Continue medical assessment (if medical cover is available).
- Consider giving analgesia if ambulance support is likely to take longer than 30 minutes.
- If a prolonged wait for ambulance support is anticipated, consider the risks of moving the patient (increased pain) against the risks of a prolonged period on the floor (pressure ulceration, hypothermia, rhabdomyolysis) and, if moving is indicated, arrange to use an alternative safe moving and handling technique to move the patient into bed. In such an event, it may be necessary to use a sling hoist or other lifting device.
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