Left wrist and left leg pain


• Scene – splint and ice pack for L wrist, bandage L elbow.
• En Route – IV 20g, 2x 25mcg Fentanyl – brought pain from 10+ to a 3 without movement.


• Taken to hospital
• Diagnosis – displaced radial, ulnar, and femur fractures.


• Mark Shelton Paramedic Woodburn Ambulance
• Matthew Hansen, MD Associate Professor Oregon Health & Science University


• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center
• Mohamud Daya, MD Professor Oregon Health & Science University
• Toni Grimes, EMT-P Woodburn Ambulance

• Radial fracture
• Ulnar fracture
• Femur fracture

Differential Diagnosis

• Working DDx – R/O L wrist fracture/dislocation, L hip/femur fracture.

Patient Workup

• History
• Physical exam – slight deformity L wrist, small skin tear L elbow, bleeding controlled. Pelvis stable, no leg shortening or rotation. L leg extreme pain w movement.

Key Points

• In ground level falls of the elderly (who are on anti-coagulation meds), the main concern is determining the possibility of a head injury that could result in intracranial hemorrhaging necessitating the need for a trauma system activation.
Editor’s Notes
Another point to make with the elderly ground level falls is to rule out potentially serious underlying conditions occurring/causing the fall. Many new medics tend to focus just on the resulting injury but do not do a thorough history to rule out underlying issues such as M.I. or arrhythmias that caused the fall especially one such as this where the patient has a history of arrhythmia. Continuous ECG monitoring, in my opinion, would be advantageous in this patient to ensure she was not experiencing intermittent brady/tachy arrhythmias. Looking at the PHCR, it appears the EMS team did do this during transport and she remained in a normal sinus rhythm.

Suggested Approach

• The algorithm for trauma stabilization in the elderly is similar to that for younger patients with a few extra cautions. Generally speaking, the approach should be more conservative than for younger patients. For example, the existing cervical spine clearance protocols have not been studied in the elderly, so “clearing” the cervical spine in an injured elderly patient usually requires imaging and should not be done in the field. Elderly patients with seemingly minor injuries in the initial assessment may be hiding significant injuries such as fractured ribs, intracranial hemorrhage, or a fractured pelvis.
• Elderly patients suffer much higher morbidity and mortality from trauma, so providers should take care in not under-triaging elderly patients and consider transporting elderly patients to trauma centers though the injuries may not initially seem significant. A brief AMPLE (allergies, medications, past history, last meal, and events) history should be taken with focus on potential anticoagulant use, insulin use, and cardiac medication use.
• GLF are common, therefore it is important to decipher 2 things on scene and en route: 1) why the person fell, and 2) consequences of the fall. Many factors contribute to the “why”: Lost balance and agility due to aging, medication side effects, loss of postural tone, occult bleeding (GI or retroperitoneal), dysrhythmia, acute coronary syndrome, TIA, dehydration, and other factors all can lead to near syncope or syncope. EMS personnel must put thought into the cause as well as the consequence.

Suggested references

• Falls in the elderly


• Gender: Female
• Age: 88 years
• Height: Not Available


• Temperature: Not Available
• Blood Pressure: 153/82
• Heart Rate: 106
• Respiratory Rate: 18
• Pulse Oximetry: 96% RA

Signs and Symptoms

Traumatic injury, bleeding, pain


• Asthma, arrhythmia, abdominal aortic aneurysm (AAA), hypertension (HTN).
• S/P breast cancer w R mastectomy.
• Allergies: Unknown arthritis medication.
• Dispatch info: Lifeline Activation. Traumatic injury, ground level fall (GLF) with possible arm fracture and uncontrolled bleeding. Takes anti-coagulant therapy.


• None


• digoxin, Lasix, verapamil, KCl, losartan, pravastatin, NTG, fluticasone, warfarin, Qvar, ProAir

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