Long bone fracture — elderly female

Patient Information

Dispatch: You are called to a patient (Margaret Hollis, 75YO female) at the FAP during the Fremantle Community Fair. Bystanders report she has fallen and is complaining of severe right leg pain and is unable to stand.
Patient: Margaret Hollis — 75yr (60kg)
Incident History: Pt was walking between market stalls when she caught her foot on a tent peg and fell heavily onto her right side. She is conscious and alert but unable to bear weight. Bystanders assisted her to the ground.
Emergency Contact: Robert Hollis (Husband) — 0412 338 794

Initial Rapid Assessment

Response: Alert
Airway: Patent. Nil airway obstruction. Nil airway swelling or stridor.
Breathing: Adequate. RR 18, no increased work of breathing, no accessory muscle use.
Circulation: Radial pulse strong and regular. Skin pale and slightly diaphoretic. No external haemorrhage visible. Obvious deformity and swelling to mid-shaft right femur region.
Disability: GCS 15 (E4V5M6). Orientated to time, place and person. Complaining of severe right thigh pain.
Exposure: Obvious deformity and swelling to right mid-thigh. No open wound or exposed bone. No other injuries identified. Skin intact over injury site.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	18	96	124/78	<2s	15	3 3 ++	36.8	–	8
10 mins	97% (RA)	Nil	16	88	120/76	<2s	15	3 3 ++	36.8	–	5

History Taking

Treatment Response

Diagnosis

This patient is suffering from a suspected right mid-shaft femur fracture following a mechanical fall at a community event.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not assess distal neurovascular status — colour, warmth, movement, sensation, and CRT to the right foot — before and after splinting, prompt: 'The patient asks if her foot feels normal — what are you checking for?')
! (If trainees do not remove jewellery from the right ankle/foot before oedema develops, prompt: 'You notice a ring and ankle bracelet on her right foot — is there anything you should do with these?')
! (If trainees do not immobilise the joints above and below the injury site, prompt: 'The patient winces each time her leg moves slightly — what can you do to minimise movement?')
! (If trainees attempt to walk the patient or allow weight-bearing, prompt: 'Margaret tries to stand up saying she will be fine — how do you respond?')
! (If pain is not reassessed after splinting, prompt: 'It has been 10 minutes since you applied the splint — what assessments are still required?')

Treatment Objectives

1 Ensure scene safety and don appropriate PPE.
2 Perform Primary Survey — confirm patent airway, adequate breathing, and circulation. Identify deformity to right mid-thigh as the primary injury.
3 Reassure Margaret continuously and instruct her not to bear weight or attempt to stand.
4 Perform initial pain assessment — document pain score of 8/10.
5 Assess and document distal neurovascular observations to the right foot BEFORE splinting: check CRT, skin colour and warmth, pedal pulse, sensation, and movement (CWMS).
6 Remove any jewellery from the right lower limb (ankle bracelet) before swelling develops.
7 Apply soft splinting using a pillow or blanket moulded around the right leg, securing with broad bandages above and below the injury site to immobilise the knee and hip — the joints above and below.
8 Reassess and document distal neurovascular observations to the right foot AFTER splinting — confirm no new neurovascular compromise.
9 Reassess pain score following splinting — document improvement.
10 Position Margaret supine on the stretcher and keep her warm with a blanket.
11 Perform full Secondary / CNS Survey to identify any other injuries from the fall.
12 Record full observations every 10 minutes and monitor for signs of hypovolaemic shock (femur fractures can result in significant internal blood loss — up to 1.5L).
13 Monitor for signs of ischaemia: pain, pallor, paresthesia, pulselessness, or cool/cold limb.
14 Administer Methoxyflurane (Penthrox) 3mL via inhaler for pain management if pain score remains high and patient is able to self-administer — confirm patient is co-operative and able to understand instructions. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
15 Arrange urgent ambulance via CSP and advise CSP of findings — time critical due to age, mechanism, and suspected femoral fracture.
16 Scenario ends on arrival of ambulance and IMISTAMBO handover.
17 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Limb Trauma · Haemorrhage · Fractures & Dislocations — Splinting · Pain Assessment · Methoxyflurane (Penthrox) · Primary Survey · Secondary & CNS Survey

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