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Ovid: Oxford Handbook of Accident and Emergency Medicine

Editors: Wyatt, Jonathan P.; Illingworth, Robin N.; Clancy, Michael J.; Munro, Philip T.; Robertson, Colin E. Title: Oxford Handbook of Accident and Emergency Medicine, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 9 – Wounds, fractures, orthopaedics Chapter 9 Wounds, fractures, orthopaedics P.388
The approach to wounds Wounds often have medicolegal implications—therefore record notes thoroughly, legibly and accurately (p30). Resuscitation is the initial priority for the seriously wounded patient. Stop bleeding by applying direct pressure. History Key questions are:

  • What caused the wound? (knives/glass may injure deep structures)
  • Was there a crush component? (considerable swelling may ensue)
  • Where did it occur? (contaminated or clean environment)
  • Was broken glass (or china) involved? (if so, obtain an X-ray)
  • When did it occur? (old wounds may require delayed closure and antibiotics)
  • Who caused it? (has the patient a safe home to go to?)
  • Is tetanus cover required? (see p396)

Examination Consider and record the following:

  • Length: preferably measure. If not, use the term ‘approximately’ in the case notes.
  • Site: use diagrams whenever possible (rubber stamps are recommended). Consider taking digital or Polaroid photographs, particularly for compound fractures, in order to minimize the risk of infection by disturbing the wound as little as possible prior to surgery.
  • Orientation: vertical, horizontal or oblique.
  • Contamination: by dirt or other FBs may be obvious.
  • Infection: either localised or spreading, is a feature of delayed presentations and is associated in particular with certain specific injuries (eg ‘reverse fight bites’—see p402).
  • Neurological injury: test and record motor and sensory components of relevant nerves. Be aware that complete nerve transection does not automatically result in complete loss of sensation—some feeling is likely to be preserved (particularly in the hand). Assume that any altered sensation reflects nerve injury.
  • Tendons: complete division is usually apparent on testing. Partial tendon division is easily missed unless the wound is carefully examined—the tendon may still be capable of performing its usual function. Look in the wound whilst moving the relevant joint, and attempt to re-create the position of the injured part at the time of injury (eg clenched fist) to bring the injured structures into view.
  • Vascular injury: check for distal pulses.
  • Depth: wounds not fully penetrating the skin are ‘superficial’. Do not try to judge depth of deeper wounds before formal exploration. In some circumstances (eg neck wounds), formal exploration is not appropriate in A&E).
  • Type of wound: inspection often allows wounds to be described, helping to determine the mechanism of trauma (blunt or sharp injury) and hence the risk of associated injuries. The crucial distinction is whether a wound was caused by a sharp or blunt instrument. If in doubt, avoid any descriptive term and simply call it a ‘wound’. This avoids inaccuracy and courtroom embarrassment! Use the terms as described opposite.

P.389
Forensic classification of wounds and injury The expert forensic evaluation of injury is outside the remit of the A&E specialist, but a simple understanding helps to avoid incorrect use of terminology with associated confusion (and on occasions, embarrassment). Incised wounds (or ‘cuts’) Caused by sharp injury (eg knives or broken glass) and characterized by clean-cut edges. These typically include ‘stab’ wounds (which are deeper than they are wide) and ‘slash’ wounds (which are longer than they are deep). Lacerations Caused by blunt injury (eg impact of scalp against pavement or intact glass bottle), the skin is torn, resulting in irregular wound edges. Unlike most incised wounds, tissues adjacent to laceration wound edges are also injured by crushing and will exhibit evidence of bruising. Puncture wounds Most result from injury with sharp objects, although a blunt object with sufficient force will also penetrate the skin. Abrasions Commonly known as ‘grazes’, these result from blunt injury applied tangentially. Abrasions are often ingrained with dirt, with the risk of infection and in the longer term, unwanted and unsightly skin ‘tattooing’. Record the direction in which the skin is abraded: skin tags may be visible at one end of the abrasion, indicating the edge of skin last in contact with the abrading surface. Burns see p376. Bruises Bruising reflects blunt force (crush) injury to the blood vessels within the tissues, resulting in tender swelling with discoloration: sometimes localised bleeding collects to form a haematoma. The term ‘contusion’ is sometimes used as an alternative for bruise—it has no particular special meaning (or value). Record the site, size, colour and characteristic features of any bruising. It is impossible to determine the exact age of a bruise from its colour. However, yellow colour within a bruise implies (except perhaps in the neonate) that it is >18hrs old. Scratches These may comprise either a ‘very superficial incision’ or a ‘long, thin abrasion’—leave the distinction to an expert. Interpersonal violence—medicolegal implications Victims of violence frequently attend A&E for treatment of their injuries. Some patients (particularly those who have suffered domestic violence) may not provide an accurate account of how the injuries occurred and may not seek involvement of the police. Classical defence wounds include:

  • isolated ulna shaft fracture as the arm is raised to protect against blunt injury
  • incised wounds on the palmar aspects of the palms and fingers sustained in attempts to protect against knife attack

In cases where the police are involved and where injuries are serious or extensive, the police may arrange to obtain photographs and a police surgeon may be involved in the role of documenting injuries. Most A&E patients who have suffered violence do not see a police surgeon. Therefore, A&E staff have a dual role of treating injuries and recording them accurately for medicolegal purposes. P.390
Further assessment of skin wounds Investigation X-ray if there is suspicion of fracture, involvement of joint, penetration of body cavity or FB. Specify on request forms that a FB is being sought, to allow appropriate views and exposure. Most metal (except aluminium) and glass objects >1mm in diameter will show up on X-ray. Some objects (eg wood) may not: USS may demonstrate these. CT or MRI are also occasionally helpful. Note: X-ray all wounds from glass which fully penetrate the skin During X-ray, use radio-opaque markers (eg paper clip) taped to the skin to identify the area of concern. Wound swabs for bacteriology are unhelpful in fresh wounds, but obtain them from older wounds showing signs of infection. By far the most important investigation is: Wound exploration under appropriate anaesthesia This allows full assessment and thorough cleaning of wounds which extend fully through the skin. It is inappropriate to explore the following wounds in A&E:

  • stab wounds to the neck, chest, abdomen or perineum
  • compound fracture wounds requiring surgery in theatre
  • wounds over suspected septic joints or infected tendon sheaths
  • most wounds with obvious neurovascular/tendon injury needing repair
  • other wounds requiring special expertise (eg eyelids)

Obtain relevant X-rays beforehand. Adequate anaesthesia is essential—in adults LA (eg 1% plain lidocaine) is often suitable (p275), but document any sensory loss first (if there is altered sensation, presume nerve injury and refer for formal exploration in theatre). Do not inject LA into the edges of an infected wound: it will not work in that acidic environment and it may spread the infection. GA may be the preferred option for treating some wounds in young children. Using a clean technique, inspect wounds for FBs and damage to underlying structures. Most problems with wound exploration relate to bleeding. If it proves difficult to obtain a good view:

  • Obtain a good light and an assistant. The assistant can retract on a stitch placed on either side of the middle of the wound to allow full exposure.
  • Press on any bleeding point for at least 1min, then look again. Lidocaine with epinephrine (p277) is useful in scalp wounds which are bleeding profusely.
  • If bleeding continues, consider an appropriate tourniquet for up to 15mins. A sphygmomanometer BP cuff inflated above systolic pressure (after limb elevation for 1min) may be used on the limbs, a ‘finger’ of a sterile rubber glove may be used on fingers or toes, but never leave a patient alone with a tourniquet on, lest it is forgotten. It is imperative to ensure removal of the tourniquet afterwards. Record the time of application and removal.

If these measures fail, refer the patient for specialist exploration in theatre. Do not blindly ‘clip’ bleeding points with artery forceps, for fear of causing iatrogenic neurovascular injury. Many small blood vessels in the subcutaneous tissues can be safely ligated using an appropriate absorbable suture [eg 4/0 or 6/0 Vicryl (braided polyglactin) or Dexon]. P.391
The approach to foreign bodies FBs within soft tissues can cause pain, act as a focus for infection or migrate and cause problems elsewhere. Therefore, remove FBs from recent wounds where possible, particularly if lying in or near joints. FBs which can be seen or felt or are causing infection are usually best removed. Finding FBs is frequently difficult without a bloodless field and good light. It may be appropriate to leave some FBs, such as gunshot deeply embedded in buttock soft tissues (antibiotic cover advised). However, most FBs of any size not removed in A&E warrant specialist consideration. Patients not infrequently present with symptoms relating to (suspected) FBs under old healed wounds. In these circumstances, refer to an appropriate expert for exploration under appropriate conditions. Fishhooks The barbs on some fishhooks can make removal difficult. In some cases, it may be necessary to push a fishhook onwards (under LA) and thus out through the skin—wire cutters can then cut through the hook below the barb and allow release. Wear eye protection when doing this. P.392
Wound management Wound cleaning Thoroughly clean all wounds irrespective of whether closure is contemplated, to ↓risk of infection. The standard agent used for wound cleaning is 0.9% (normal) saline. Aqueous chlorhexidine or 1% cetrimide solutions are sometimes used. Do not use hydrogen peroxide or strong povidone iodine solutions. Wounds ingrained with dirt may respond to pressure saline irrigation (19G needle attached to 20mL syringe), or may require to be scrubbed with a toothbrush (use goggles to ↓chance of conjunctival ‘splashback’). Devitalized or grossly contaminated wound edges usually need to be trimmed back (debrided), except on the hand or face. If dirt or other foreign material is visible despite these measures, refer to a specialist, who may choose to leave the wound open. Wound closure There are three recognised types of wound closure: Primary closure Surgical closure (by whatever physical means) soon after injury. Secondary closure No intervention: heals by granulation (secondary intention). Delayed primary closure Surgical closure 3-5days after injury. If there is no underlying injury or FB, treat fresh wounds by primary closure as soon as possible. Accurate opposition of wound edges and obliteration of dead space provides the best cosmetic outcome with least infection risk. Wounds not usually suitable for primary closure in A&E include:

  • stab wounds to the trunk and neck
  • wounds with associated tendon, joint or neurovascular involvement
  • wounds with associated crush injury or significant devitalized tissue/skin loss
  • other heavily contaminated or infected wounds
  • most wounds >12h old (except clean facial wounds)

Methods of closure If in doubt, sutures are usually the best option. Steristrips Adhesive skin closure strips allow skin edges to be opposed with even distribution of forces. They are inappropriate over joints, but useful for pretibial lacerations, where skin is notoriously thin and sutures are likely to ‘cut out’. Before application, make steristrips stickier by applying tincture of benzoin to dry skin around the wound. Leave 3-5mm gaps between steristrips. See also p459. Skin tissue glue Particularly useful in children with superficial wounds and scalp wounds. After securing haemostasis, oppose the dried skin edges before applying glue to the wound. Hold the skin edges together for 30-60sec to allow the glue to set. Ensure that glue does not enter the wound. Do not use tissue glue near the eyes or to close wounds over joints. Staples Quick and easy to apply, particularly suited to scalp wounds. Staple-removers are required for removal. Sutures (‘stitches’ or ‘ties’) Traditional and commonest method of primary closure. Oppose the skin aiming for slight eversion of wound edges, using strong non-absorbable inert monofilament suture material attached to curved cutting needles (eg prolene, polypropylene or nylon) with knots tied on the outside. Interrupted simple surgical knots tied using instruments are relatively easy, economical of thread and have a low risk of needlestick injuries. Specialised continuous sutures (eg subcuticular) are not appropriate for wounds in A&E. The size of thread used and time to removal varies according to the site. Use absorbable sutures (eg Vicryl, catgut) on the lips and inside the mouth. Absorbable sutures may also be used to close subcutaneous tissues to ↓ chance of haematoma and infection. P.393
Suture choice and time to removal

Part of body Suture and size Time to removal
Scalp 2/0 or 3/0 non-absorbable† 7days
glue or staples
Trunk 3/0 non-absorbable† 10days
Limbs 4/0 non-absorbable† 10days
Hands 5/0 non-absorbable 10days
Face 5/0 or 6/0 non-absorbable 3-5days*
Lips, tongue, mouth absorbable eg 6/0 Vicryl/Dexon –
† one size smaller may be appropriate for children
* sutures may be replaced with steristrips at 3 days

Key points when suturing The technique of a basic instrument tie is shown on pages pp394-5.

  • tie sutures just tight enough for the edges to meet
  • do not close a wound under tension
  • handle the skin edges with toothed forceps only
  • avoid too many deep absorbable sutures
  • mattress sutures are useful on some deep wounds—not on hands or face
  • dispose of sharps as you use them—do not make a collection
  • use strategic initial sutures to match up obvious points in irregular wounds
  • if a suture does not look right—take it out and try again
  • if it still does not look right—get help!

P.394
P.395

Figure. Instrument tie

P.396
Tetanus prophylaxis Tetanus causes hundreds of thousands of deaths in the developing world and occasional cases are still seen in the UK. Injecting drug users are at risk (particularly when using SC or IM routes). Production of the exotoxin tetanospasmin, by the anaerobic, spore-forming Gram +ve bacillus Clostridium tetani interferes with neurotransmission (p226). Spore proliferation and toxin production is likely in heavily contaminated wounds with devitalized tissue. However, any wound is a potential portal of entry: ensure tetanus prevention in every case. Tetanus immunization programme Standard active immunization involves an initial course of 3 IM or deep SC doses of 0.5mL tetanus toxoid (formalin inactivated toxin) given at monthly intervals starting at 2months of age, followed by booster doses at 4yrs and 14yrs. A full course of 5 doses is considered to result in lifelong immunity. Single antigen tetanus vaccine has been replaced in the UK by combined tetanus/low dose diphtheria vaccine for adults and adolescents. Immunization required after injury depends upon the immunization status of the patient and the injury. Inadequate immunity against tetanus is particularly likely in immigrants, the elderly, patients with ↓immunity and those who have refused vaccination. Anti-tetanus prophylaxis The need for tetanus immunization after injury depends upon a patient’s tetanus immunity status and whether the wound is ‘clean’ or ‘tetanus prone’: The following are regarded as ‘tetanus prone’:

  • heavy contamination (esp with soil or faeces)
  • devitalized tissue
  • infection or wounds >6h old
  • puncture wounds and animal bites

Follow Department of Health guidelines. See under http://www.dh.gov.uk Do not give tetanus vaccine if there is a past history of a severe reaction: give HATI. Pregnancy is not a contraindication to giving tetanus prophylaxis. Patient is already fully immunized If the patient has received a full 5 dose course of tetanus vaccines, do not give further vaccines. Consider human anti-tetanus immunoglobulin (‘HATI’ 250-500 units IM) only if the risk is especially high (eg wound contaminated with stable manure). Patient had complete initial course, boosters up to date but not yet complete Vaccine is not required, but do give it if the next dose is due soon and it is convenient to give it now. Consider human anti-tetanus immunoglobulin (‘HATI’ 250-500 units IM) in tetanus prone wounds only if the risk is especially high (eg wound contaminated with stable manure). Initial course incomplete or boosters not up to date Give a reinforcing dose of combined tetanus/diphtheria vaccine and refer to the GP for further doses as required to complete the schedule. For tetanus-prone wounds, also give one dose of HATI at a different site. The dose of HATI is 250 units IM for most tetanus prone wounds, but give 500 units if >24hrs have elapsed since injury or if there is heavy contamination or following burns. Not immunized or immunization status unknown or uncertain Give a dose of combined tetanus/diphtheria vaccine and refer to the GP for further doses as required. For tetanus-prone wounds, also give one dose of HATI (250-500 units IM) at a different site. P.397
Antibiotic prophylaxis Antibiotics are not required for most wounds. Thorough cleaning is the best way of preventing infection. After cleaning and closure, consider oral antibiotic prophylaxis (eg penicillin + flucloxacillin) for certain wounds: compound fingertip fractures and wounds in those at extra risk (eg valvular heart disease, post-splenectomy). Co-amoxiclav has activity against anaerobes and is appropriate for bites and heavily contaminated or infected wounds: leave these wounds open. Antibiotics are indicated for penetrating injuries which cannot be properly cleaned (p405). Although a scientific basis is lacking, antibiotics are frequently used for wounds >6h old, complex intraoral wounds and in workers at high risk (gardeners, farmers, fishermen). P.398
Wound aftercare Dressings A large variety of dressings are available, with little scientific evidence to help choose between them: the choice depends upon personal preference/prejudice and local departmental policy. A dry non-adherent dressing will protect most wounds from inadvertent contamination in the first few days. Dressings are not usually necessary for facial and scalp wounds. Beware circulatory problems resulting from encircling dressings/bandages applied too tightly to digits or other parts of limbs. Burns dressings are considered on p382. General advice Advise to keep wounds clean and dry for the first few days. Limb wounds require rest and elevation for the first 24h. After this, restrict movements to avoid undue stress causing the suture line to open up (especially where the wound is over a joint). Warn all patients to return if features of infection develop (redness, ↑pain, swelling, fever, red streaks up the limb). Approximate times to suture removal are shown on p393—these need to be adjusted to meet the occasion. For example, sutures over joints are sensibly left 14 days to avoid dehiscence. Similarly, sutures may need to be left in for longer where wound healing may be delayed (eg DM, the elderly, malnourished and those on steroids). Local policy will dictate where suture removal occurs (GP surgery or A&E). If available, discharge with illustrated instructions about wound care and suture removal. This may particularly help patients with memory impairment or those under the influence of alcohol. Specific advice Patients often ask when they can return to work. If a question of personal safety or safety of the public or work colleagues is involved, advise to return to usual duties only once the wound has healed and sutures are out. This particularly applies to food handlers and some workers with machinery. Provide a sickness certificate for the patient’s employer as appropriate. Review and delayed primary closure Arrange review of heavily contaminated wounds, infected wounds not requiring admission and other wounds at particular risk of infection at ≈36h. Check T° and look for wound discharge and erythema, ascending lymphangitis and regional lymphadenopathy. Systemic symptoms or evidence of spreading infection despite oral antibiotics are indications for admission for wound toilet, rest, elevation and IV antibiotics. Treat other wounds deemed initially to be at less risk of infection, but not suitable for primary closure, with cleaning, light packing/dressing and review at 3-5 days. The ideal dressing is one which keeps the wound moist, so consider the need for dressing changes prior to closure. If the wound is clean, employ delayed primary closure after wound cleaning and debridement under appropriate anaesthesia. If despite further cleaning and debridement, foreign material remains ingrained, the patient may require admission. If there is much exudate and evidence of local infection, take wound swabs for culture, consider removing the sutures, clean and redress the wound, give oral antibiotics and arrange further review. Do not use ‘loose closure’ in contaminated wounds. The technique has all the risks of infection combined with a poor cosmetic result. P.399
Infected wounds and cellulitis Wound infection after injury Although prompt treatment with cleaning and primary closure will ↓ risk, any wound may become infected. The risk of infection is ↑ by:

  • contamination (eg bites) and foreign material (including excess sutures)
  • haematoma
  • devitalized tissue
  • poor nutrition and ↓immunity (eg steroid therapy)

Pain is usually the first clue to wound infection. Note that many soft tissue infections (cellulitis, erysipelas) occur in the absence of an obvious wound (see p503). Examination Indicates the extent of the infection. Erythema and tenderness limited to the area around the wound suggest localised infection. Swelling and fluctuation are evidence of a collection of pus. Remove all sutures, together with pus and devitalized tissue, under appropriate anaesthetic. Send wound swabs for culture. Consider the possibility of a retained FB—X-ray/explore as appropriate. After thorough cleaning, leave the wound open, cover with a dressing and arrange review with a dressing change in 36h. Consider the need for antibiotics (eg co-amoxiclav) particularly for cellulitis, for the immunocompromised and for patients at particular risk (eg those with prostheses and valvular heart disease). Consider admission (for rest, elevation, analgesia, wound/blood cultures and IV antibiotics) in patients with one or more of the following:

  • a red line spreading proximally (ascending lymphangitis)
  • regional (sometimes tender) lymphadenopathy
  • pyrexia >38°C
  • systemic upset

Soft tissue crepitus is ominous, suggesting gas-forming organisms (p227). Infected hand wounds A particularly common problem is an infected wound on the dorsum of the hand over a MCPJ after a punch injury. These are often bite wounds, presenting late with infection in the region of the joint. Refer for exploration in theatre and antibiotics (p402). Infected facial wounds Take infected wounds of the cheek very seriously. They pose a significant threat of sepsis spreading intracranially, resulting in papilloedema and ophthalmoplegia due to cavernous sinus thrombosis. Adopt a low threshold for referring for admission and IV antibiotics. Infected surgical wounds Infection of a recent surgical wound after a planned procedure is a relatively common complication. In addition to the possible threat to life, wound infection can have disastrous implications as far as the success of the preceding operation is concerned (eg hernias may recur). Contact the team which performed the surgery as soon as possible, to allow the surgeon to treat the complication. P.400
Bite wounds Bites and infection Bites cause contaminated puncture wounds, contaminated crush injuries, or both. All carry a high risk of bacterial infection, some also a risk of viral or other infections (eg rabies). Bacterial infection is particularly likely in:

  • puncture wounds (cat/human bites)
  • hand wounds, wounds >24hrs old
  • wounds in alcoholics, diabetics or the immunocompromised.

Bacteria responsible include: streptococci, Staphylococcus aureus, Clostridium tetani, Pasteurella multocida (cat bites/scratches), Bacteroides, Eikenella corrodens (human bites). Approach Establish what the biting animal was, how long ago and where the bite occurred. Obtain X-rays if fracture, joint involvement (look for air) or radio-opaque FB (tooth) is suspected. Treatment Cleaning Explore fresh bite wounds under appropriate anaesthetic, debride and clean thoroughly with copious amounts of ‘normal’ saline. Refer significant facial wounds and wounds involving tendons or joints to a specialist. Closure This is controversial. Cosmetic considerations usually outweigh risks of infection for most facial wounds, so aim for primary closure. Elsewhere, choose between primary or delayed primary closure (p392). Do not close puncture bite wounds which cannot be satisfactorily irrigated. Antibiotics Also controversial. Many departments advocate prophylactic antibiotics for all bite wounds. One approach is to give antibiotics for puncture bites, hand bites, infected bites, bites from humans, cats and rats and to those bitten individuals who are immunocompromised. Co-amoxiclav is an appropriate broad spectrum agent, effective against strep, staph, pasteurella and eikenella. Give erythromycin to patients allergic to penicillin/ amoxicillin, although this is less effective against pasteurella. Tetanus Bite wounds are tetanus-prone. Give prophylaxis accordingly (p396). Rabies (covered fully on p242) Rabies results after the ‘bullet-shaped’ RNA rhabdovirus present in saliva of infected animals is transmitted to humans via a mucous membrane or skin break. After thorough cleaning, refer all patients who might have been in contact with a rabid animal to an Infectious Diseases specialist. Obtain further help from the Virus Reference Laboratory, London (020 8200 4400). The long incubation period of the rabies virus (14-90days) allows successful post-exposure prophylaxis at even a relatively late stage, according to agreed guidelines. Hepatitis, HIV Consider possible risks of hepatitis B, C and HIV in anyone who presents following a human bite and treat accordingly (see under ‘needlestick injury’—p404). Quantifying the risks can be difficult, particularly for example, in ‘reverse fight bites’ (p402) where the other person involved may be unknown. If in doubt, take a baseline blood sample for storage (to allow later testing if necessary) and provide cover against hepatitis B. P.401
Treatment of infection Most bacterial infections occur >24h after injury. Pain, inflammation, swelling ± regional lymphadenopathy within 24h suggests P. multocida infection. Take wound swabs of all infected wounds, then treat with cleaning, elevation, analgesia and antibiotics. Oral co-amoxiclav and outpatient review at ≈36h is appropriate for localised wound infection with no systemic symptoms and no suspected underlying joint involvement. Refer patients with spreading infection for IV antibiotics and admission. Septicaemia is uncommon after bite injury, but has been reported with the Gram -ve bacillus Capnocytophaga canimorsus, previously known as Dysgonic Fermenter 2 (DF-2). Infection produces a severe illness with septicaemia and DIC, often in immunocompromised (splenectomized individuals or alcoholics). Take wound swabs and blood cultures, then give IV antibiotics and refer. P.402
Specific bites and stings Human bites and ‘fight bites’ Many human bites occur ‘in reverse’, when an individual punches another in the mouth, causing wounds on the dorsum of the hand over the MCPJs. Underlying joint involvement is common and may progress to septic arthritis unless treated aggressively with exploration, irrigation and antibiotics. Refer all patients for this. Consider hepatitis B, C and HIV, give appropriate prophylaxis (p400) and arrange counselling. Tick bites Ticks are recognised vectors of a number of exotic diseases worldwide. In the UK, patients often present with embedded sheep ticks. Remove ticks by gentle traction with blunt forceps applied as close to the skin as possible. Avoid traditional folklore methods of removal, which may cause the tick to regurgitate, promoting infection. In areas where Lyme disease is endemic (see p221), some physicians provide antibiotic prophylaxis with amoxicillin. Insect bites Minor local reactions are common. Treat with ice packs, rest, elevation, analgesia and antihistamines (eg chlorphenamine PO 4mg tds or a non-sedating alternative such as loratadine PO 10mg od). Occasionally, insect bites may be complicated by cellulitis and ascending lymphangitis requiring antibiotics (p399). Wasps and honey bee stings These may cause local reactions or anaphylaxis requiring prompt treatment (p42). Flick out bee stings left in the skin. Treat local reactions as for insect bites. Snake bites The European adder is the only native venomous snake in the UK. It is usually grey/brown, with a V-shaped marking behind the head and dark zig-zag markings on the back. Most bites occur in the summer. Venom is injected by a pair of fangs. The venom contains enzymes, polypeptides and other low molecular weight substances. Only 50% of bites result in envenomation. Features Envenomation causes pain and swelling: look for 2 puncture marks 1cm apart. Vomiting, abdominal pain, diarrhoea and hypotension may follow. Treatment

  • prehospital: rest and bandage the bitten part (to slow lymphatic flow)
  • clean and expose wound, give analgesia and IV fluids for hypotension
  • treat anaphylaxis urgently according to standard guidelines (p42)
  • give prophylactic antibiotics (eg co-amoxiclav) and ensure tetanus cover
  • Antivenom has its own risk of anaphylaxis, but may be given for: persistent hypotension, WCC >20 × 109/litre, ECG changes or elevated cardiac enzymes, spontaneous haemorrhage or massive limb swelling.
  • obtain specific advice from a Poisons Information Centre (p175).

Jellyfish stings and fish spines Most jellyfish in UK coastal waters are harmless. Wash the bitten part in sea water then pour vinegar (5% acetic acid) over it to neutralize the toxin. Fish spines (typically weever fish) produce a heat labile toxin which may be neutralized by immersion in hot water for 30mins. Occasionally, tiny parts of the fish spines become embedded and cause long-term irritation. Localising and removing these tiny FBs is difficult, so refer to an appropriate expert. P.403
Contact with other wild animals Contact with rats’ urine may cause leptospirosis (Weil’s disease)—see p229. Provide prophylactic penicillin or doxycycline to anyone who presents following an episode of significant exposure (eg immersion in river water or sewage). Unusual bites may pose specific threats, which infectious disease specialists will advise about (eg monkey bites may cause herpes simplex infection: give prophylactic oral aciclovir). Bats may carry rabies (p242). P.404
Needlestick injury A needlestick injury is a specialised form of puncture wound. In a clinical setting it may represent a failure to follow universal precautions (p236) and should provoke a review of policy and procedure. Numerous infective agents have been transferred by needlestick: Blastomycosis, Brucellosis, Crypococcosis, Diphtheria, Ebola fever, Gonorrhoea, Hepatitis B, Hepatitis C, Herpes zoster, HIV, Leptospirosis, Malaria, Mycobacteriosis, Mycoplasmosis, Rocky Mountain Spotted fever, Scrub typhus, Sporotrichosis, Staph aureus, Strep pyogenes, Syphilis, Toxoplasmosis, Tuberculosis. In practice, the principal risks are of hepatitis B and C and HIV. The risk of acquiring hepatitis B following a needlestick from a carrier has been estimated at 2-40%. All hospital workers should be immunized against hepatitis B and have regular checks of their antibody status. The risk of hepatitis C is believed to be 3-10%. In contrast, the risk of acquiring HIV after needlestick with HIV positive source is much less (estimated at 0.2-0.5%, but may be higher if significant volumes are injected). There is a small (≈0.03%) risk of HIV transmission after mucocutaneous exposure (ie exposure of cuts, abrasions, mucous membranes including the eye). The (small) risk of acquiring HIV following needlestick injury from a person with known HIV may be reduced further by post-exposure prophylaxis, but time is of the essence (see below). No proven post-exposure prophylaxis currently exists for hepatitis C. Preventing needlestick injuries and exposure to these viruses is therefore crucial. Management

  • Wash the wound with soap and water.
  • Ensure tetanus cover.
  • Ensure hepatitis B cover: if not previously immunized, give hepatitis B immunoglobulin and start an active immunization course (give first vaccine in A&E and arrange subsequent doses). If previously immunized, check antibody titres. If satisfactory, take no further action. If low, give booster vaccine. If very low give both immunoglobulin and start vaccine course. Many local needlestick policies advise obtaining informed consent from the source patient, prior to taking blood to check hepatitis and HIV status. In practice, however, the identity of the source patient is not always clear: do not withold hepatitis B prophylaxis if there is any doubt.
  • If the source patient is known to be (or suspected of being) HIV +ve, follow local guidelines and/or refer immediately to an infectious diseases specialist to discuss post-exposure prophylaxis. Department of Health guidance is available on http://www.advisorybodies.doh.gov.uk/eaga/publications.htm Combined prophylaxis therapy (eg zidovudine 250mg bd + lamivudine 150mg bd + nelfinavir 1250mg bd) is most effective if started within an hour of exposure, but may be worth considering up to 2wks. However, the prophylaxis has side effects, particularly affecting the GI system. Involve both the healthcare worker and a local expert in deciding whether or not to start prophylaxis. Either way, advise the patient to use barrier contraception and not to give blood as a donor until subsequent HIV seroconversion has been ruled out.
  • Take baseline blood for storing (serology for possible future testing), and in the case of a possible HIV source patient, also take FBC, U&E, LFTs and amylase also).
  • Arrange follow-up counselling.
  • If the incident occurred in hospital, report it to Occupational Health and review procedures.

P.405
Puncture wounds Puncture wounds Puncture wounds are small skin wounds with possible deep penetration. Stab wounds to the trunk and neck are considered elsewhere (p330). Puncture wounds often involve the sole of the foot, patients having trodden on a nail. Examine to exclude neurovascular injury, then obtain an X-ray looking for FB. If significant foreign material is present radiologically, or the patient has associated fracture, tendon injury or neurovascular deficit, refer for formal exploration and cleaning in theatre under a bloodless field. Otherwise:

  • irrigate and clean other wounds under LA where possible (consider nerve blocks). For wounds to the sole of the foot this may be impractical. As a compromise, immerse foot in warm antiseptic (eg povidone iodine solution) for 15mins.
  • apply a dressing and advise review/follow-up at GP as appropriate
  • ensure adequate tetanus cover (p396)
  • prescribe simple analgesia
  • consider prophylactic oral antibiotic cover (eg co-amoxiclav)

Some puncture wounds may become infected despite treatment. This may be due to retained foreign material in the wound. Pseudomonas osteitis is an uncommon, but recognised complication of puncture wounds to the foot. Refer infected wounds for formal exploration and irrigation. P.406
How to describe a fracture Clear, precise, complete descriptions of fractures will aid accuracy and save time when referring patients. System for describing fractures

  • state the age of the patient and how the injury occurred
  • if the fracture is compound, state this first (and Gustilo type—p408)
  • name the bone (specify right or left, and for the hand, whether dominant)
  • describe the position of the fracture (eg proximal, supracondylar)
  • name the type of fracture (eg simple, spiral, comminuted, crush)
  • mention any intra-articular involvement
  • describe deformity (eg displacement, angulation) from anatomical position
  • state grade or classification of fracture (eg Garden IV)
  • state presence of any complications (eg pulse absent, paraesthesia, tissue loss)

Example using this system ‘29 year old male motorcyclist with a Type I compound fractured left humerus. It is minimally displaced and involves the humeral shaft, with no neurovascular compromise…’ Type of fracture Simple—single transverse fracture of bone with only 2 main fragments Oblique—single oblique fracture with only 2 main fragments Spiral—seen in long bones as a result of twisting injuries, only 2 main fragments Comminuted—complex fracture resulting in >2 fragments Crush—loss of bone volume due to compression Wedge—compression to one area of bone resulting in wedge shape (eg vertebra) Burst—comminuted compression fracture with scattering of fragments Impacted—bone ends driven into each other Avulsion—bony attachment of ligament or muscle is pulled off Hairline—barely visible lucency with no discernible displacement Greenstick—buckling or bending of immature bones, often confined to 1 cortex Pathological—fracture due to underlying disease (eg osteoporosis, Paget’s disease) Stress—certain bones are prone to fracture after repetitive minor injury Fracture-dislocation—fracture adjacent or in combination with a dislocated joint Deformity Describe deformity using the terms displacement, angulation and rotation. Displacement Describe the relative position of two bone ends to each other. Give further details by stating the direction that the distal fragment is displaced from the anatomical position (eg volar, lateral). Also estimate the degree of apposition of the bone ends (eg 50%). Angulation Describing angulation (as ‘anterior’ or ‘posterior’) can sometimes be confusing. Although a little long-winded, one way to avoid confusion is to describe the direction in which the distal part points, relative to the anatomical position (eg a Colles’ fracture may be described as a ‘fracture of the distal radius in which the distal fragment points dorsally’). If available, use a goniometer to measure the angle on X-ray. Rotation Describe the degree of rotation from the anatomical position, in terms of the direction (eg external or internal rotation) in which the distal part has moved. P.407
Orthopaedic anatomy Long bone anatomy Each long bone has a shaft or diaphysis with an epiphysis at each end. While the bone is growing these are separated by an epiphyseal growth plate and this narrows down into the bone shaft. The transitional area of bone is the metaphysis. In addition to these landmarks, the femur and humerus have a ball-shaped head, a narrower neck and at the lower ends a widened area consisting of the medial and lateral condyles of the femur and the medial and lateral epicondyles of the humerus. Fractures proximal to these areas of the femur and humerus are termed supracondylar. Intercondylar fractures involve the central, distal and juxta-articular portion. Fractures of the proximal femur between the greater and lesser trochanters are termed intertrochanteric. Bones of the hand There are 14 phalanges and 5 metacarpals (MCs). Naming the metacarpals according to the corresponding fingers (ie thumb, index, middle, ring and little) may avoid confusion. There are 8 carpal bones arranged in 2 rows. The proximal row (radial to ulnar) is comprised of scaphoid, lunate, triquetral and pisiform. The distal row (radial to ulnar) are trapezium, trapezoid, capitate and hamate. P.408
Compound fractures Compound (or open) fractures occur when a fracture is open to the air through a skin wound. All are at high risk of infection and can be associated with gross soft tissue damage, severe haemorrhage or vascular injury. Treat as orthopaedic emergencies requiring rapid assessment and treatment. Classification of compound injuries Gustilo classification of compound injuries: Type I compound fracture where wound is <1cm long and appears clean. Type II compound fracture where wound >1cm, but is not associated with extensive soft tissue damage, tissue loss or flap lacerations. Type IIIA either a compound fracture with adequate soft tissue coverage of bone despite extensive soft tissue damage or flap laceration or any fracture involving high energy trauma or bone shattering regardless of wound size. Type IIIB compound fracture with extensive soft tissue loss, periosteal stripping and exposure of bone. Type IIIC compound fracture associated with vascular injury needing repair. Management Compound fractures require adequate fluid replacement, analgesia, splintage, antibiotics and tetanus prophylaxis prior to surgical treatment. Ensure the following steps are rapidly completed while contacting orthopaedic service:

  • Treat life-threatening injuries before limb threatening injuries. Do not be distracted from initial priorities by dramatic distal limb injuries.
  • Control obvious haemorrhage by direct manual pressure whilst commencing IV fluids and/or blood replacement.
  • Give analgesia in the form of incremental IV opioids (p268).
  • Once analgesia is adequate, correct obvious severe deformities with gentle traction and splint. Certain dislocations may require immediate correction. Remove obvious contaminants if possible (eg large lumps of debris or plant matter).
  • ‘Routine’ wound swabs for bacteriological culture are no longer recommended. They do not alter management and are poor predictors of deep infection.
  • If available, take Polaroid (or digital) photographs of the wound (this helps to avoid the need for repeated inspection by different clinicians).
  • Irrigate with saline, then cover the wound with a sterile moist dressing (eg saline soaked pads). Immobilize the limb in a POP backslab. Do not repeatedly inspect the wound as this greatly ↑ risk of infection. Once dressed and in POP, leave injuries covered until surgery.
  • Give IV antibiotics (eg cefuroxime or alternatives according to local policy). Consider adding gentamicin or metronidazole if the wound is grossly contaminated.
  • Give tetanus toxoid if indicated, and give HATI if gross wound contamination present (p396).

Record presence/absence of distal pulses and sensation and recheck frequently Limb salvage or amputation Orthopaedic surgeons often face a difficult decision as to whether or not a limb can be salvaged. Gustilo type IIIC injuries are associated with a high rate of amputation. The Gustilo classification alone is not always an accurate predictor of outcome: other tools have been developed to assist. For example, the Mangled Extremity Severity Score takes into account the extent of skeletal and soft tissue damage, the extent and severity of limb ischaemia, associated shock and age. P.409
Dislocations A dislocation involves complete loss of congruity between articular surfaces, whereas a subluxation implies movement of the bones of the joint, but with some parts of the articular surface still in contact. Describe dislocations in terms of the displacement of the distal bone. For example, the most common shoulder dislocation is described as ‘anterior’, with the humeral head lying in front of the glenoid. Aim to reduce dislocations as soon as possible in order to prevent neurovascular complications, ↓ risk of recurrence and ↓ pain. However, in general, aim to X-ray (to identify the exact dislocation ± associated fracture) before attempting a reduction. Exceptions to this principle are:

  • dislocations associated with considerable neurovascular compromise requiring urgent intervention (this includes some ankle fracture-dislocations)
  • uncomplicated patellar dislocations (see p454)
  • uncomplicated mandibular dislocations (see p364)
  • some patients with (very) recurrent shoulder dislocations, where there may be longer-term concerns over radiation exposure
  • some patients with collagen disorders resulting in hypermobility (eg Ehlers-Danlos syndrome) and unusual/recurrent dislocations without significant trauma
  • ‘pulled elbow’ in young children (see p684)

Use analgesia/sedation/anaesthesia appropriate to the dislocation and the individual circumstances. For example, patellar dislocations often reduce under entonox, finger PIPJ dislocations with LA digital nerve blocks, shoulder dislocations with IV sedation and analgesia, whereas posterior hip dislocations typically require manipulation under GA. Except in very exceptional circumstances, X-ray after manipulation to confirm adequate reduction and also to check for fractures which may not have been apparent on initial X-rays. P.410
Casts and their problems Plaster of Paris (POP) POP is cheap, easy to use and can be moulded. Usually applied in the form of a bandage or multiply folded as a supporting slab. Disadvantages are susceptibility to damage (POP rapidly disintegrates if wet) and that it takes up to 24h for larger casts to dry fully after application. Cut slabs to shape prior to use and apply over wool roll and stockinette. Mould with palms (not fingertips) to avoid point indentation of plaster. Resin casts More costly, but lighter and stronger than plaster and much more resistant to water or other damage. Made of cotton or fibreglass impregnated with resin that hardens after contact with water. Sets in 5-10mins, maximally strong after 30mins. Resin casts are more difficult to apply and remove and as they are more rigid and less easily moulded there is a greater risk of complications from swelling or pressure necrosis. Be careful to remove or cover any sharp edges on the cast. Complications of casts Ensure that all patients discharged home with casts are given clear written instructions (including a contact phone number) to return if they develop pain or other symptoms in the immobilised limb. Formal cast checks within 24h are only required if there is particular concern about swelling. Simple swelling or discolouration of fingers or toes usually responds to elevation and simple exercises. Is the cast too tight? Act immediately upon suspicion of circulatory compromise from a cast. Look for the ‘five p’s: pain, pallor, paraesthesia, paralysis and ‘perishing cold’—if any of these are present:

  • elevate limb
  • cut wool and bandages of backslab until skin is visible along the whole length of limb
  • split full casts and cut through all layers until skin is visible along the whole length of limb

Any undivided layers will continue to obstruct the circulation until released. If this action fails to completely relieve the symptoms, contact orthopaedic and vascular surgery staff immediately, as angiography and urgent surgical intervention may be required. Note that compartment syndrome may occur in the presence of normal pulses. Is the cast too loose? Test by trying to move the plaster longitudinally along the limb. Replace excessively loose or damaged casts, unless there is an outweighing risk of fracture slippage. Local discomfort If there is local pressure discomfort (eg over a malleolus), cut a window in the cast to allow direct inspection of the skin. Trim or replace plasters which restrict movement unduly. Cast removal Standard POP and selected resin casts may be removed with plaster shears. Use a plaster saw only if instructed in its proper use. In both cases, be careful to avoid skin damage.

Figure. Cast removal

P.411
P.412
Soft tissue injuries Sprains These occur from overstretching and tearing of ligaments. Sprains vary from sparse fibrous tears to complete disruption of a ligament complex. The results are pain, tenderness and soft tissue swelling. Ligament sprains are traditionally graded into three types, although distinguishing clinically between them may be difficult:

  • First degree sprains involve minor tearing of ligament fibres and are entirely stable
  • Second degree sprains are more severe partial sprains—there may be some resultant slight ligamentous laxity, but with a definite end-point on stressing
  • Third degree sprains reflect completely torn ligaments causing significant laxity: patients sometimes report hearing a ‘snap’ at the time of injury

Ligament sprains are very common, but there is a lack of reliable evidence about treatment. Prolonged immobilization seems to be detrimental to recovery, because of muscle wasting and loss of proprioception. Painful minor sprains do respond well to traditional measures: ice, compression with elastic support/strapping, elevation and progressive mobilization as soon as symptoms allow. Simple analgesics such as paracetamol or NSAID (eg ibuprofen) may help. Complete ligament rupture can be relatively painless, but if associated with gross joint instability will require surgical repair. Associated haemarthroses require orthopaedic appraisal, aspiration and often initially, protection and immobilization in POP. Strains Indirect injury involving muscle-tendon units may be classified in a similar fashion to ligament sprains. Pain on palpation over the site of injury is also reproduced by passive stress or active contraction of the affected muscle unit. Sometimes, a palpable defect may be apparent in complete ruptures (which typically occur at the musculotendinous junction). However, associated swelling may prevent any defect from being easily palpable. Treat minor strains similarly to sprains; consider specialist review for complete ruptures, some of which may require surgical repair. Direct muscle injuries These result from direct impact to a limb, body surface or internal organ causing local pain, bruising and soft tissue swelling. Note that associated bone contusions can occur, such as in the perimeniscal areas of the knee (these are visible on MRI). Treat minor injuries with ice, analgesia and early mobilization within the limits of symptoms. For more significant injuries, consider and treat according to possible risks of compartment and crush syndromes (with rhabdomyolysis) and large haematomas (see below). Haematomas Blood can accumulate as a result of traumatic disruption of the vascular structures within bone, muscle or soft tissues. In the case of intracranial, intrathoracic, intra-abdominal and pelvic haematomas, this is potentially life-threatening. Deceptively large volumes of blood can be accommodated within the soft tissue planes of the chest wall or thigh. In the presence of massive visible bruising of the torso or a limb, check for shock and measure Hb and Hct. Perform a coagulation screen. Blood transfusion may be necessary. Treat minor haematomas with compression dressings, ice and consider ultrasound therapy. Large haematomas or supervening infection require selective surgical drainage, haemostasis and antibiotics. P.413
Other soft tissue problems Myositis ossificans After some muscle or joint injuries, calcification can occur within a haematoma leading to restriction of movement and loss of function. Frequent sites include calcification within a quadriceps haematoma (eg following a rugby injury) where inability to flex the knee >90° at 48h after injury indicates an ↑risk of myositis ossificans. Other sites include the elbow and femur. Passive stretching movements of joints may be implicated in the development of myositis ossificans. This particularly applies at the shoulder, hip and knee where passive exercises are performed for spasticity following paraplegia or head injury. Treatment involves immobilising the limb or joint for a period of weeks, under specialist supervision. Early excision is contraindicated, as it is invariably followed by massive recurrence, but delayed excision (after 6-12 months) can improve function. Tendonitis/tenosynovitis This includes a bewildering range of conditions, some of which may have medicolegal implications (‘overuse’ or ‘repetitive strain’ injury). Examples include:

  • classic tenosynovitis—swelling along a tendon sheath, with pain on passive stretching or upon attempted active movement against resistance.
  • chronic paratendonitis (eg affecting Achilles tendon)—swelling around the tendon with localised pain and tenderness.
  • tendon insertion inflammation causes epicondylitis in adults (see p432) and traction apophysitis in children (p668).

Appropriate initial treatment usually includes rest, immobilization and NSAID. Later, consider involving an appropriate specialist (eg physiotherapist or hand therapist). Bursitis Inflammation of bursae most frequently affects the subacromial, olecranon and prepatellar bursae. There is localised swelling and tenderness: generalized joint effusions and/or tenderness along the whole joint line suggests an alternative diagnosis. In many instances, bursitis is non-infective and responds to rest and NSAID. Significant warmth and erythema raise the possibility of an infective origin. In this case, consider aspiration for bacteriological culture and provide antibiotics (eg co-amoxiclav or penicillin + flucloxacillin). Other problems Other causes of joint or limb pain with no specific history of trauma in the adult patient include: stress fractures, cellulitis and other infections, osteoarthritis and other forms of acute arthritis, nerve compression (eg carpal tunnel syndrome). Apparently atraumatic limb pain in children may present with limping—likely underlying causes vary according to the age (p664). P.414
Physiotherapy in A&E At its simplest, the term ‘physiotherapy’ in an A&E department includes the advice given to each patient following minor injury. At the other extreme, it encompasses the assessment and treatment of selected patients by skilled, experienced physiotherapists. It is valuable for a department to have close links with a physiotherapy unit, preferably with designated physiotherapy staff responsible for A&E referrals. Find out local arrangements for access to, and use of, physiotherapy services. ‘Everyday’physiotherapy Minor soft tissue injuries are amongst the most commonly seen problems in A&E departments. Once bony injury has been excluded (clinically and/or radiologically) ensure that patients are discharged with clear, consistent advice on how to manage their own injuries in every case:

  • be clear and specific about what the patient is to do
  • set a realistic time limit after which the patient should seek further attention if their symptoms are not improving
  • give additional written instructions for reinforcement (eg ankle sprains, minor knee injuries), as patients will forget much of the verbal advice given

Rest/ice/compression/elevation (RICE) forms the traditional basic framework for treatment of most acute soft tissue injuries. Rest With most acute injuries, advise a period of 24-48h rest after an injury. Ice This is often advocated both in the immediate first aid of soft tissue injuries, and in their subsequent treatment. Crushed ice cubes wrapped in a damp cloth (to avoid direct contact with the skin) placed against the injured joint may ↓ swelling and pain. Do not apply for more than 10-15mins at a time. Repeat treatment every few hours initially. A cold pack or bag of frozen vegetables can also be used (do not refreeze if for consumption!). Compression Despite a distinct lack of evidence, injured joints (particularly the ankle) are frequently treated with some form of support. The easiest to use is an elasticated tubular bandage (eg Tubigrip®), either single or doubled over. If provided, advise the patient not to wear it in bed and to discard as soon as convenient. If not provided, explain why, or the patient may feel inadequately treated. Avoid providing support bandages to patients with elbow and knee injuries—the bandage tends to be uncomfortable and ‘dig in’ and in the case of the knee, may affect venous return and ↑chance of DVT. Elevation Initially, advise elevation of injured limbs or extremities above horizontal to ↓ swelling and discomfort. This is particularly crucial in hand or foot injuries. Exercise Start gentle, controlled exercises for any injured joint as soon as symptoms allow. Demonstrate what is expected and confirm that the patient understands what to do. P.415
Formal physiotherapy Physiotherapists are trained in the rehabilitation and treatment of injury, based on a detailed knowledge of relevant limb and joint anatomy, biomechanics and physiology. In A&E, physiotherapy staff are valuable in assessment and treatment of acute soft tissue injuries, patient education and advice and in the provision of appropriate mobility aids (particularly in the elderly) after injury. In order to make the best use of physiotherapy services, follow these guidelines:

  • Refer early if required for acute injury. Aim for the patient to be seen for initial assessment the same day, so treatment needs can be properly assessed.
  • Discuss the problem and treatment options with the physiotherapy staff prior to referral.
  • Use the physiotherapy service for selected cases, not as a general rule.
  • Never use the physiotherapy department to simply offload difficult or problematic patients.

Physiotherapists have a range of different treatments at their disposal, which typically focus upon regaining range of movement and mobility, improving strength and proprioception. P.416
Approach to hand injuries The history Determine and record whether the patient is right or left-handed, their occupation and social situation. These points may have treatment implications, (eg an elderly person living alone with little social support may not cope at home after a dominant hand injury). Suspect patients presenting with wounds on the dorsum of the hand over the 2nd-5th MC heads of having sustained a human bite (‘fight bite’) whatever history is given (p402). Terminology To avoid confusion always refer to fingers by name not number (index, middle, ring, little). Note that the middle finger is sometimes referred to as the ‘long’ finger and the little finger is sometimes called the ‘short’ finger. Use: palmar, dorsal, radial, ulnar (not anterior, posterior, lateral, medial). Examination Injury to the hand’s rich collection of nerves, blood vessels and tendons results in considerable functional deficit. Careful assessment, based on sound anatomical knowledge, is essential. Clinical signs of injury

  • Median nerve
↓sensation in the palm over radial 3½ fingers unable to abduct thumb against resistance
  • Ulnar nerve
↓ sensation palmar and dorsal 1½ fingers little finger held flexed (non-functioning lumbrical) unable to cross index and middle fingers ↓abduction / adduction
  • Radial nerve
↓sensation dorsum first web space (no motor branches in hand, but proximal injury results in inability to extend wrist)
  • Digital nerve
↓sensation along radial or ulnar half of digit distally: note that some sensation is usually preserved, even with significant nerve injuries
  • Superficial flexor
hold other fingers straight (immobilising all deep flexors), then unable to flex PIPJ. This test is unreliable for the index finger. Note also that ≈10% of individuals do not have a flexor superficialis tendon to the little finger.
  • Deep flexor
unable to flex DIPJ
  • Extensors
complete division prevents extension central slip division causes Boutonnière deformity. In recent injuries, hold PIPJ at 90° over table edge, then try to extend against resistance—DIPJ hyperextends in central slip division (Elson’s test).
  • Deformity
a small amount of rotational deformity of one digit (typically associated with a spiral/oblique MC or finger fracture) can have a dramatic effect upon long-term hand function: check carefully to ensure that there is no abnormal overlapping of fingertips in the palm on making a fist.

P.417
P.418
Hand wounds and associated injuries General principles of treating hand wounds

  • Remove rings as soon as possible after any hand or arm injury as swelling can develop relatively rapidly. Try soap or water-based lubricant before using ring-cutters. Alternatively, pass string or 0/0 silk under the ring and wrap it firmly around the finger distally, allowing the ring to come off over the compressed tissues.
  • Elevate to diminish swelling and pain.
  • Avoid subcutaneous sutures.
  • For patients who are uncooperative due to excess alcohol consumption, consider admission for a few hours to allow suture with better cooperation later.
  • X-ray any hand injury caused by glass.
  • Remember to consider tetanus cover.

Exploration under anaesthesia If it is obvious that surgical intervention by a hand surgeon is required, do not explore the wound in A&E. This particularly applies to suspected nerve injuries, where the use of LA renders subsequent assessment difficult. Conversely, clinical assessment of tendon injuries can be misleading if the patient is reluctant to move due to pain. Exploration under anaesthesia is necessary in this situation and to exclude division of >50% of a tendon (where clinical examination may be normal, but repair is required). Use an appropriate LA nerve block (as outlined on pp284-299). During exploration, consider the position of the hand at the time of injury: reproducing this may reveal injuries otherwise hidden. Therefore, put all mobile structures through their full range of movement. Extensor tendon injuries >50% or complete division needs repair (eg 4/0 or 5/0 non-absorbable monofilament using Bunnell or Kessler stitch) by an experienced surgeon. This may be achieved under LA in A&E, depending on facilities and expertise. Follow extensor tendon repair with appropriate immobilization (eg volar slab type POP with finger joints in full extension and slight flexion at the MCPJs). Treat < 50% division by splintage in extension (eg POP slab as above) under the care of the hand surgeon. Flexor tendon injuries Refer immediately for specialist repair. Nerve injuries Complete division of a nerve may cause surprisingly little sensory loss, so take complaints of any altered sensation very seriously. Refer patients with suspected nerve injuries. Digital nerves can be repaired up to the level of the DIPJ, although it may be decided not to attempt to repair injuries which are distal to the PIPJ. Remember that it is functionally important to have intact sensation over the ‘edges’ of the hand (the thumb, the radial aspect of the index finger or ulnar aspect of the little finger). Patients sometimes present late after digital nerve injuries—repair can still be quite successful up to 2 weeks after injury. Reverse fight bites—treat and refer as outlined on p402. Consider transfer of infection as discussed on p400. P.419
Amputations Refer patients with partial or complete digital amputation with bony loss. Recent proximal amputations without crush injury in fit young patients may be suitable for reimplantation: others may be treated with ‘terminalization’ or advancement flap. Let the hand surgeon decide. Meanwhile, dress, bandage and elevate, give IV analgesia, tetanus cover, broad spectrum antibiotics (eg cephalosporin) and keep fasted. Wrap the amputated part in moist saline swabs and place in a sealed plastic bag, surrounded by ice/water mix at 4°C. Note: Do not freeze or place the amputated part directly in solution. Finger pad amputations Skin loss less than 1cm2 without bony exposure may be allowed to heal with non-adherent dressings. Larger areas of tissue loss (particularly in adults) may require skin grafting or advancement flap, but some do heal satisfactorily with simple dressings. Ring avulsions Refer all circumferential and significant degloving injuries. Compound injuries Wounds over dislocations or fractures usually require specialist attention. Distal compound phalangeal fractures may be treated in A&E with wound cleaning, closure, review and prophylactic antibiotics. Crush injuries Frequently cause ‘burst’ injury fingertip wounds. Because of the risk of swelling, clean the wounds, but do not primarily close. Elevate, dress, give analgesia and arrange review. Nailbed lacerations Accurate repair (eg 6/0 vicryl) may prevent nail deformity. Nailfold lacerations extending towards the nailbed require removal of the nail to allow suture. Consider replacing the nail after to act as a temporary dressing. FBs under nail Splinters and other FBs under fingernails are relatively common. Apply a digital block and remove with fine forceps. If the FB cannot be reached easily, cut away an appropriate piece of nail. Subungual haematomas Blood frequently collects under the nail after a crush injury, causing pain by pressure. Trephine the nail distal to the lunula, using a red hot paper clip or battery operated drill. High pressure injection injuries Industrial grease or paint guns may cause small skin wounds which initially appear trivial, disguising a devastating injury with risk of permanent stiffness and significant tissue loss. X-rays may help to identify the extent of foreign material. Refer all such patients to a hand surgeon for immediate exploration and debridement. P.420
Hand fractures and dislocations Distal phalangeal fractures Treat closed fractures of the distal portion (tuft) of the distal phalanx with analgesia and elevation. Treat compound burst injuries (from crushing injuries or hammer blows) with meticulous exploration, wound toilet/repair under LA and arrange follow-up. Antibiotics are not a subsitute for primary surgical treatment. Mallet finger with fracture ‘Mallet finger’ injury may be associated with a small fracture at the base of the distal phalanx at the point of attachment of the extensor tendon. Treat as for (the more usual) mallet finger injury without fracture by plastic mallet splint for ≈6wks, advice and follow-up (see details on p422). Refer larger bony fragments (>1/3 articular surface) with mallet deformity or those with subluxation for possible K-wire internal fixation. Proximal and middle phalangeal fractures Treat undisplaced fractures with elevation, neighbour strapping and analgesia. Manipulate angulated proximal and middle phalangeal fractures under digital or wrist blocks. A useful tip for proximal phalangeal fractures is to use a needle-holder or pencil placed adjacent to the web space as a fulcrum. Maintain reduction using neighbour strapping and a volar slab POP or flexible padded aluminium (Zimmer) splint, although the latter can be difficult to secure. If reduction is unsatisfactory or cannot be maintained, refer for surgical fixation. Phalangeal dislocations X-ray all dislocations prior to reduction for presence of associated fractures. Reduce under digital nerve block (p286) by traction and gentle manipulation, then check integrity of the collateral ligaments. Confirm reduction on X-ray and immobilize the finger by neighbour strapping. Elevate the hand, provide oral analgesia and arrange follow-up. Index, middle and ring metacarpal fractures Check for displacement or rotation deformity and refer if present. Treat with analgesia, elevation and protect in a volar slab POP. Internal fixation may be considered for midshaft MC fractures with marked angulation, but can be complicated by marked post-operative stiffness. Little (5th) metacarpal fractures These often result from punching. Check to exclude rotation deformity by gently flexing fingers into the palm (they should point roughly to the thenar eminence and touch, but not overlap adjacent fingers on flexion). Angulation is common with neck fractures and rarely requires correction, with even up to 40° being accepted. Treat with neighbour strapping, elevation and analgesia. Additional comfort and support may be obtained by a volar slab POP for 2wks. Warn the patient that the 5th knuckle will be shorter than before. Arrange follow-up and advise intensive hand exercises as soon as possible. Refer to orthopaedic team if there is any rotational deformity or significant angulation, particularly with base and shaft fractures, which may need surgery. Also refer patients with associated wounds, remembering that these may be compound human bites (‘reverse fight-bites’—p402). Little (5th) metacarpal dislocations Dislocations at the base of the 5th MC may be associated with a fracture. Refer for reduction and internal fixation. P.421
Thumb fractures and dislocations Dislocation at MCPJ After X-rays and LA block, attempt reduction. If successful, assess and document the integrity of the collateral ligaments (see p422), then immobilize in a small degree (≈15°) flexion in a POP and arrange follow-up in fracture clinic. Reduction may be unsuccessful due to ‘buttonholing’—in this case, refer for open reduction. Gamekeeper’s thumb with associated avulsion fracture Most abduction injuries result in ulnar collateral ligament injury without fracture, but occasionally an avulsion fracture occurs at the point of ligament attachment instead. Treat in a scaphoid POP and refer to fracture clinic, unless the bony fragment is displaced by more than 2mm, in which case internal fixation will probably be required. Thumb metacarpal shaft fractures If undisplaced, treat in scaphoid POP and refer to fracture clinic, but if displaced, refer for internal fixation. Bennett’s fracture-dislocation (p476) This is a fracture through the base of the 1st (thumb) MC with lateral subluxation of the MC, leaving a small proximal fragment still joined to the trapezium. The injury results from a fall onto the thumb or from a fall/blow onto a fist closed around the thumb. Deformity and swelling occur over the base of the thumb and may be mistaken for a scaphoid injury. This is an unstable injury requiring expert attention. If undisplaced, apply a Bennett’s type POP (similar to a scaphoid POP, but with the thumb abducted). If there is any displacement, refer for MUA/fixation. Maintaining reduction often requires the use of screw or Kirschner wire fixation. Thumb dislocations Dislocations usually follow falls onto the thumb or hyperextension injuries. They can occur at any level, including at the IPJ, MCPJ (see above) and at the carpometacarpal joint. Reduce dislocations by traction and local pressure under combined median and radial nerve blocks (p288). Confirm reduction by X-ray, immobilize in a scaphoid POP and arrange follow-up. P.422
Soft tissue hand injuries Mallet finger Injury to the extensor mechanism at the DIPJ is a relatively common injury resulting from forced flexion of the DIPJ or from a blow/fall directly onto the fingertip. In the elderly it can result from minimal trauma. There is loss of full active extension at the DIP joint. Normal flexion is preserved. X-ray to exclude associated fracture—treated as outlined on p420. In the absence of a large fragment, treat in a plastic (mallet) splint secured with tape for ≈6wks. Ensure that the patient understands the importance of wearing the splint at all times and that the finger must be kept straight if the splint is removed for washing (eg hold finger against a flat surface until splint replaced). Warn that there may be a small degree of permanent flexion deformity. Arrange initial follow-up at ≈7-10days, to ensure compliance with treatment and to reassess in case swelling has ↓ and a smaller splint is required. Volar plate injury These are significant injuries, often with prolonged morbidity. Hyperextension at the PIPJ injures the volar plate at the base of the middle phalanx with or without evidence of bony involvement. Examination shows fusiform swelling of the PIPJ with tenderness over the volar aspect. Treat with ‘buddy strapping’ to adjacent fingers (or Bedford splint), elevate, provide analgesia and begin mobilization immediately. Arrange review to ensure full mobility is regained. Gamekeeper’s thumb The ulnar collateral ligament of the thumb is crucial for the stability and function of the thumb. It is typically injured in hyperextension/hyperabduction injuries of the thumb (eg falls while skiing). Complete rupture usually results in the two parts of the ligament being separated by the adductor aponeurosis (the ‘Stener lesion’), so that satisfactory healing cannot occur. If there is tenderness over the ulnar collateral ligament of the thumb MCPJ, obtain X-rays: if this demonstrates a fracture, do not stress the joint, but treat appropriately instead (p421). If there is no fracture, assess stability of the ulnar collateral ligament by gentle abduction of the MCPJ and compare with the other hand. Examine the ulnar collateral ligament with the thumb slightly (15°) flexed. If a ruptured ligament is suspected, but pain precludes adequate examination, consider Entonox and repeat the examination. Significant (>30°) laxity implies complete rupture and need for operative repair. Treat uncomplicated sprains with analgesia, elevation and either criss-cross elastoplast strapping (‘thumb spica’), or a scaphoid POP if symptoms are severe, and arrange follow-up. Refer suspected or demonstrable ulnar collateral ligament rupture to the orthopaedic surgeon, to consider primary surgical repair. A2 pulley injury The finger flexor tendon sheath at the PIPJ is thickened and known as the A2 pulley. Occasionally (especially in rock climbers), the tendon cuts through the A2 pulley, causing characteristic bowstringing on flexion. There may be associated tendon injury. Treat conservatively with buddy strapping (or Bedford splint) and elevation and arrange hand specialist follow-up. Boutonnière deformity (p476) This characteristic deformity from untreated rupture or division of the central slip finger extensor tendon may follow blunt or penetrating trauma. Splint and refer. P.423
Other soft tissue hand problems Pulp infections Infection of the pulp space at the fingertip may reflect underlying FB or osteomyelitis, so X-ray to search for these and treat accordingly. If X-rays are normal, incise the pointing area under LA digital block. Send pus for bacteriology, apply a dressing, commence oral antibiotics (eg flucloxacillin 250-500mg PO qds) and arrange follow-up. Paronychia Infection of the nail-fold adjacent to the nail is common. In the early stages, oral antibiotics (eg co-amoxiclav or flucloxacillin) may cure. Once pus has developed, drain this under LA digital block by an incision over the fluctuance (usually a small longitudinally-orientated incision adjacent to the proximal nailfold suffices, but pus under the nail may require removal of a segment of nail). Antibiotics are unnecessary, unless there is spreading infection (in which case, consider co-amoxiclav). Pyogenic flexor tenosynovitis Infection of a finger flexor tendon sheath may follow penetrating injury. Classical signs (Kanavel’s signs) are:

  • tenderness over the flexor tendon
  • symmetrical swelling of the finger
  • finger being flexed
  • extreme pain on passive extension

Ensure tetanus prophylaxis, then refer urgently for exploration, irrigation and IV antibiotics. Other infections These include palmar space infections and septic arthritis—refer immediately for specialist treatment. Locked finger Elderly patients with underlying OA sometimes present with locking at a finger MCPJ. A fixed flexion deformity is present, such that the patient can flex, but not fully extend at the MCPJ. There is usually no particular history of trauma—the underlying cause is entrapment of the palmar plate on an osteophyte. Refer for an early hand surgeon opinion: surgery may be required. Trigger finger/thumb This is relatively common, but not particularly related to trauma. Most cases are satisfactorily treated by steroid injection into the flexor tendon sheath, but leave this to a specialist. P.424
Carpal bone fractures and dislocations Scaphoid fractures Assess and document whether there is tenderness over the scaphoid in all wrist injuries. Scaphoid fractures occur from falling onto an outstretched hand or from ‘kick-back’ injuries (eg from a starting handle or steering wheel in a car crash). Pain and swelling over the radial aspect of the wrist may be accompanied by difficulty gripping. Look for

  • tenderness in anatomical snuffbox: compare both sides (do not press too hard)
  • tenderness over palmar aspect of scaphoid (scaphoid tubercle)
  • scaphoid pain on compressing the thumb longitudinally
  • scaphoid pain on gentle flexion and ulnar deviation of the wrist
  • tenderness over dorsum of scaphoid

X-rays Request specialised scaphoid (not wrist) views. Four views are usually taken (AP, lateral, right and left obliques). Remember that scaphoid fractures may not be visible on initial X-rays. The scaphoid mostly fractures through the waist, but sometimes through the tubercle (the latter does not give rise to significant complications). Treatment If there is clinical or radiological evidence of fracture, apply a scaphoid POP and arrange for review in 10-14days. Treat minimal snuffbox tenderness without radiologically visible fracture with analgesia and a wrist splint and arrange review as above. Persisting symptoms require careful follow-up, further X-rays and occasionally bone scan or MRI. Complications Include non-union, avascular necrosis and OA. The combination of radiologically invisible fractures and significant complications renders follow-up of suspected fractures an important process. Follow-up of clinically suspected scaphoid fractures (but with normal initial X-rays) is often undertaken in A&E clinic. Review at 10-14days after injury. If reassessment at this time reveals no clinical evidence of fracture, patients may be discharged. If, however, there is contining pain and/or scaphoid tenderness, repeat X-rays: treat visible fractures in POP; but if X-rays are still normal, treat in POP or splint and arrange bone scan or MRI to definitively answer whether a scaphoid fracture is present, or whether there is significant injury to the carpal ligaments. Lunate dislocations These injuries are rare but often missed. They follow falls onto the outstretched wrist and result in pain and swelling anteriorly over the wrist. Median nerve paraesthesia may be a clue to the diagnosis. X-ray shows dislocation and rotation of the lunate so that it is shifted in front of the carpus and its concave surface faces towards the palm instead of distally. The AP view may look relatively normal, so carefully scrutinize lateral views. Refer for immediate MUA. Complications Median nerve injury, avascular necrosis and Sudeck’s atrophy. Other carpal dislocations Isolated dislocations of other carpal bones occur, but often injuries are more complicated and involve dislocations (and fractures) of one row of carpal bones (eg trans-scapho-perilunar dislocation). Surprisingly perhaps, given the almost inevitable significant swelling, these injuries can be missed. Give analgesia and refer for reduction by the orthopaedic team. P.425
Flake avulsion carpal fractures Small avulsions from the dorsum of the carpus are often from the triquetrum. Treat with immobilization in a POP backslab or wrist support splint, analgesia and refer to fracture clinic. Fractured hook of hamate Local palmar tenderness may give rise to suspicion of a fracture of the hook of the hamate. Diagnosis can be difficult: specialised X-rays or CT may be required to demonstrate the fracture. Immobilize in POP and refer to fracture clinic.

Figure. Wrist: normal lateral
Figure. Perilunate dislocation
Figure. Lunate dislocation

P.426
Wrist fractures Colles’ fracture Defined as a fracture of the radius within 2.5cm of the wrist, such that the distal fragment is angulated to point dorsally. These common fractures usually result from a fall onto an outstretched hand. Osteoporosis contributes to ↑ frequency in post-menopausal women. Careful treatment is required to avoid complications (wrist stiffness, malunion, carpal tunnel syndrome, Sudeck’s atrophy). Colles’ fractures produce characteristic deformity comprising:

  • posterior and radial displacement of the distal fragment.
  • angulation of the distal fragment to point dorsally (the articular surface of the distal radius normally has a 5° forward tilt on the lateral wrist X-ray).
  • angulation of the distal fragment to point radially (the articular surface of the distal radius is normally tilted 22° towards the ulnar side on AP wrist X-ray).
  • impaction, leading to shortening of the radius in relation to the ulna.
    Figure. Colles’ fracture.

Check for scaphoid tenderness, distal sensation and pulses in all cases. Treatment Provide analgesia, immobilize in a backslab POP and elevate with a sling. Discharge those with undisplaced fractures (if they will manage at home) and arrange fracture clinic follow-up. For others, decide if MUA is indicated. Arrange MUA for:

  • grossly displaced fractures.
  • displacement of the ulnar styloid (this implies serious injury and disruption of the inferior radio-ulnar joint).
  • loss of normal forward radial articular surface tilt on lateral wrist X-ray. Neutral or minimal tilt may be acceptable in the very young or very old (particularly in the non-dominant limb). Seek senior advice if unsure.

Advise the patient to keep moving fingers, thumb, elbow and shoulder. Smith’s fracture Unstable distal radius fracture where the distal fragment is impacted, tilted to point anteriorly and often displaced anteriorly. It usually follows a fall onto a flexed wrist. Give analgesia, immobilize in a backslab POP and refer for MUA or ORIF using a buttress plate. Barton’s fracture (p476) Intra-articular fracture involving only the anterior portion of the distal radius. Give analgesia, immobilize in a POP backslab and refer for ORIF and plating. Isolated radial styloid fracture Caused by similar mechanisms of injury as scaphoid fractures (ie falls onto an outstretched hand or kickback injuries). Treat with analgesia, backslab POP, elevation sling and fracture clinic. Internal fixation is occasionally required. P.427
Soft tissue wrist injuries/problems Wrist sprain Exclude scaphoid or other fracture (or dislocation) before considering the diagnosis of ‘wrist sprain’. Can occur following hyperextension or flexion of the wrist, causing swelling and tenderness around the wrist joint. Treat with a wrist splint or tubigrip support, analgesia or NSAIDs and progressive exercise. TFCC injury The triangular fibrocartilage complex at the distal end of the ulna may be injured with associated structures. Often, these injuries only become apparent later, when what was diagnosed as a ‘simple wrist sprain’ fails to settle—pain and tenderness persists over the TFCC. Arrange specialist follow-up for further investigation (eg MRI) and treatment. Rupture of wrist/hand tendons Rupture of tendons may occur without penetrating trauma. The most common rupture involves extensor pollicis longus a few weeks after (usually undisplaced) fracture of the distal radius. Rupture of other extensor (and occasionally flexor) tendons occurs in association with OA, RA, scaphoid non-union, CRF, SLE. Refer to a hand surgeon. Radial tenosynovitis (‘intersection syndrome’) Typically follows unaccustomed repetitive activity such as gardening, DIY or decorating. Over hours to days, a painful fusiform swelling develops over the radial aspect of the distal forearm. Movement of the wrist produces pain and palpable (occasionally audible) crepitus. Immobilize in a simple adjustable wrist splint and unless contraindicated, prescribe NSAID for 7-10days. After this, allow gradual mobilization of the wrist and educate about eliminating the cause. Immobilize severe cases in a forearm POP for 2weeks before beginning mobilization. De Quervain’s tenosynovitis Affects the tendon sheaths of abductor pollicis longus and extensor pollicis brevis. Pain, swelling and crepitus occur over the lateral (dorso-radial) aspect of the radial styloid. Symptoms can be reproduced by thumb or wrist movement. Finklestein described grasping the patient’s thumb and rapidly ‘abducting the hand ulnarward’, but probably more useful is pain on ulnar movement of the wrist with the thumb clenched in a fist. Treat with NSAID and splintage for 7-10days. A removable fabric wrist splint (including the thumb) may suffice, but consider a scaphoid type POP for severe pain. Persistent symptoms may respond to steroid injection of the tendon sheath using an aseptic technique. P.428
Forearm fractures and related injury If one forearm bone is fractured, look for a fracture or dislocation of the other. Obvious deformity in an adult forearm indicates fracture of the radial and ulna shafts. Initially treat with:

  • analgesia (eg increments of IV morphine + anti-emetic until pain relieved)
  • immobilization in backslab POP
  • if one or both fractures are compound, give IV antibiotics, tetanus cover and dress the wound

Always check distal pulses and sensation and examine for associated injuries at the wrist and elbow. Only once this has been done and the patient is comfortable, can he/she be sent for X-ray. Ensure X-rays demonstrate the whole lengths of the radius and ulna shafts, including both the elbow and wrist joints. Fractures of both radius and ulna shafts Adult fractures, unlike those in children, may be markedly displaced with little or no bony contact between the fragments. Rotational deformity is common. Check carefully for clinical evidence of neurovascular injury. Closed reduction is difficult and often fails or is complicated by late slippage. Treat fractures with analgesia/immobilization as above and refer for ORIF. Isolated ulna shaft fracture These usually occur from a direct blow to the outer edge of the forearm (it is typically seen as a defence injury) or from a fall striking the ulnar shaft. X-ray the whole ulna and radius to exclude associated fracture or dislocation of the radial head (see below). If undisplaced, treat in an above elbow POP with the elbow flexed to 90° and the forearm in mid-supination. Refer all displaced or angulated fractures for ORIF. Monteggia fracture-dislocation (see p479) Defined as a fracture of the ulna associated with dislocation of the radial head. Occurs from forced pronation of the forearm (eg fall onto an outstretched, fully pronated forearm). Can also occur by a direct blow or fall onto the proximal ulna, displacing the head of the radius. Treat with analgesia and immobilization in a temporary above-elbow POP backslab. Refer to the orthopaedic team for ORIF (or sometimes in children, for treatment with MUA and POP). A related injury is the Hume fracture (p478) in which anterior dislocation of the radial head is combined with an olecranon fracture—refer for ORIF. Note: Monteggia fracture-dislocations are not infrequently missed at initial presentation, due to attention being distracted by the ulna fracture. To avoid this:

  • request elbow and wrist X-rays in any patient with forearm shaft fracture
  • check all elbow X-rays carefully to ensure that the radial shaft is normally aligned and that the radial head abuts the capitellum

Galeazzi fracture-dislocation (see p477) Defined as a fracture of the radius associated with dislocation of the inferior radio-ulnar joint at the wrist. Always look for subluxation of the ulna in radial fractures. Treat with analgesia and immobilization in a temporary POP backslab. Refer for ORIF. Isolated radial shaft fracture These are very uncommon: always treat and assume that there is some associated damage to the inferior radio-ulnar joint at the wrist. P.429

Figure. Monteggia fracture-dislocation
Figure. Galeazzi fracture-dislocation

P.430
Elbow injuries In any injured elbow look specifically for:

  • elbow effusion (felt as a tense, bulging swelling halfway between the lateral epicondyle and the point of the olecranon)
  • the normal relationship between the olecranon and the lateral and medial epicondyles—all should form an equilateral triangle with the elbow flexed
  • range of movement: X-ray patients who cannot fully extend the elbow and flex to touch the shoulder tip

Olecranon fractures Follow falls onto the point of the elbow. The olecranon fragment may displace proximally due to pull of triceps tendon. Swelling, tenderness or crepitus are present on examination. In the young, the olecranon epiphysis may cause confusion on X-rays. Treat undisplaced or hairline fractures in an above elbow backslab POP at 90°, provide analgesia and arrange fracture clinic follow-up. Refer fractures which are displaced or which involve the elbow joint for ORIF. Radial head/neck fractures Occur following a fall onto an outstretched wrist (the radial head impacts against the capitellum) or from direct trauma to the elbow. Examine movements: extension and flexion are usually limited, but supination and pronation may be relatively normal. Look for an elbow effusion and palpate for tenderness over the radial head while supinating and pronating the elbow. X-ray will confirm an elbow effusion (fat pad sign—see below), but fractures may be difficult to see. Treat undisplaced fractures with analgesia and a collar and cuff sling. If very painful, immobilize in an above elbow POP backslab at 90°. Arrange fracture clinic review. Refer comminuted or displaced fractures as they may require MUA, internal fixation or occasionally excision of the radial head. Elbow effusion, no visible fracture Always assume that a radial head/neck fracture is present: provide analgesia, a collar and cuff sling and arrange review to ensure that full movement is regained. Extra symptomatic relief may be achieved by aspiration of the elbow joint (via a point midway between the olecranon and lateral epicondyle) under aseptic conditions.

Figure. Elbow fat-pad sign

P.431
Dislocated elbow Examination reveals loss of the normal triangular relationship between the olecranon and epicondyles. Check distal pulses and sensation as brachial artery, median and ulnar nerves may be damaged. Elbow dislocations may be classified according to the direction of dislocation and the presence of associated fractures (eg fractured coronoid). The most frequent injury is postero-lateral dislocation (ie movement of the distal part in a postero-lateral direction). After analgesia and X-ray, most dislocations may be reduced in A&E under IV sedation with full monitoring (p300). However, GA is sometimes required. Reduction Choose between the following techniques for reduction of postero-lateral dislocations:

  • Flex the elbow to 60° with countertraction on the upper arm. Pull on the fully pronated forearm at this angle—slight flexion at the elbow may be necessary.
  • Alternatively, lever the olecranon forward with both thumbs while holding the elbow flexed and while an assistant provides traction on the forearm.

Reduction is confirmed by a ‘clunk’ and restoration of the normal triangular relationship of the elbow landmarks. Once reduced, recheck pulses and sensation, immobilize in an above elbow POP backslab at 90° and X-ray again (looking for associated fractures). Consider admission for analgesia and observation for possible significant limb swelling. If unable to reduce, refer for reduction under GA. Supracondylar fractures (see p682) Fractures of the distal third of the humerus usually occur from falls onto the outstretched hand. They are most common in children (p682), but also occur in adults. The elbow may be grossly swollen and deformed, but the normal triangular relationship of the olecranon and epicondyles is characteristically preserved. Check distal pulses and sensation carefully as the brachial artery, ulnar, median and radial nerves can all be damaged. Immobilize in an above elbow backslab POP and give analgesia. Refer to the orthopaedic surgeon as MUA/ORIF are usually required. Fractures of the capitellum occasionally occur in isolation. If undisplaced, treat conservatively with analgesia and POP. Refer patients with displaced fractures of the capitellum for specialist treatment (possibly ORIF). Medial collateral ligament injury Instability on stress testing of the medial (ulnar collateral) ligament implies a significant injury. Treat in backslab POP with the elbow flexed to 90° and supported in a sling. Arrange fracture clinic follow-up. Other elbow injuries Elbow injuries are relatively common in children. Specific injuries in children are considered as follows: supracondylar fracture—p682 lateral condylar injury—p684 medial condylar injury—p684 pulled elbow—p684 P.432
Soft tissue elbow problems Lateral epicondylitis This is commonly called ‘tennis elbow’. It follows repetitive or excessive stress to the origin of the forearm and hand extensor muscles at the lateral epicondyle. It can occur spontaneously, but usually follows repetitive lifting, pulling or sports (eg as a result of an incorrect backhand technique in tennis). Inflammation, oedema and microtears occur within the extensor insertion. Look for localised swelling, warmth or tenderness over the lateral epicondyle and immediately distal to it. Examine movements: dorsiflexion of the pronated wrist against resistance will reproduce symptoms. X-ray if the problem follows acute injury—refer to the orthopaedic surgeon if there is an avulsion fracture. Treat with analgesia (preferably NSAID) and ice application. Support the arm in a broad arm sling and advise rest, followed by progressive exercise and avoidance of aggravating movements. If symptoms are recurrent or prolonged, refer as steroid injection, forearm clasp, physiotherapy and occasionally surgery may be required. Medial epicondylitis Often called ‘golfer’s elbow’, this condition has a similar pathophysiology to lateral epicondylitis: it is frequently seen in racquet sports and golf. Examine for localised tenderness and swelling over the forearm flexor insertion at the medial epicondyle. Flexion of the supinated wrist against resistance will reproduce symptoms. There may be ↓ grip strength and ≈60% of patients have some symptoms of associated ulnar neuritis. Treat as for lateral epicondylitis. Olecranon bursitis Inflammation, swelling and pain in the olecranon bursa may follow minor trauma or occur spontaneously. Other causes include bacterial infection (sometimes following penetrating injury) and gout. Elbow movements are usually not limited. Look for overlying cellulitis, wounds and systemic symptoms and check for ↑ T° (these suggest infection). Gout or bacterial infection can be confirmed by aspiration of the bursa under aseptic conditions and immediate microscopy for crystals or bacteria. Aspirate using a small needle at a shallow angle and try to aspirate the bursa completely. Non-infective bursitis Provide analgesia, NSAID and rest the arm in a broad arm sling. Symptoms should resolve with rest over a period of weeks. Rarely, persistent symptoms require surgical excision of the olecranon bursa. Gout bursitis Treat as above. Arrange follow-up through the patient’s GP. Infective bursitis If there is evidence of underlying infection, treat with rest, NSAID and start antibiotics (eg co-amoxiclav or flucloxacillin + penicillin). Occasionally, infection requires referral to the orthopaedic surgeon for surgical drainage. Olecranon bursa haematoma A history of blunt trauma to the olecranon followed rapidly by ‘golf ball-sized’ swelling over the olecranon, but with a full range of elbow movement (and no evidence of fracture), implies a haematoma in the olecranon bursa. Treat conservatively: attempts at drainage may result in secondary infection. P.433
Injuries to biceps and brachialis Inflammation of biceps and/or brachialis at the site of attachment at the elbow can cause persistent symptoms: treat with rest and NSAID. Biceps brachii can rupture either at its long head in the bicipital groove or near the elbow insertion. Long head ruptures typically affect the elderly and result in a characteristic abnormal shape and low biceps position on attempted elbow flexion against resistance: unless the patient is young, fit and active, surgical repair is rarely indicated. Distal ruptures are often treated conservatively, but some may benefit from repair: arrange orthopaedic review to consider this. Osteochondritis dissecans This can affect the elbow and cause locking of the elbow joint. X-rays may reveal a defect and/or loose body. Refer to the orthopaedic team. Nerve compression Ulnar nerve entrapment at the elbow (‘cubital tunnel syndrome’) is the second most common upper limb nerve entrapment (median nerve compression in carpal tunnel syndrome is the commonest): refer these chronic conditions back to the GP. Acute radial nerve palsy above the elbow presents with sudden wristdrop following a history of compression (eg crutch use, falling asleep with arm over the back of a chair). The underlying injury is usually a neuropraxia which has the potential to recover completely given time with conservative measures. It is crucial to ensure that flexion contractures do not develop in the meantime: provide a removable wrist splint, advise regular passive wrist exercises and refer for physiotherapy and follow-up to ensure recovery. P.434
Shoulder dislocation Anterior dislocation Common and usually the result of forced external rotation/abduction of the shoulder. The humeral head usually dislocates to lie anterior and slightly inferior to the glenoid. Patients may present holding onto the affected arm. Examine for:

  • step-off deformity at the acromion with palpable gap below the acromion.
  • humeral head palpable antero-inferiorly to the glenoid.
  • evidence of complications: check especially for distal pulses and ↓ sensation over the lateral aspect of the shoulder (the ‘badge’ area) supplied by the axillary nerve.

Give analgesia and support in a temporary sling. X-ray before reduction to exclude associated fractures. X-rays show loss of congruity between humeral head and the glenoid. The humeral head is displaced medially and inferiorly on an AP shoulder X-ray. Treatment Reduce under sedation/analgesia with full monitoring, using one of the methods described below. The choice of technique is personal and depends upon familiarity. Apply minimal force to prevent humeral fracture or further soft tissue damage. In patients with habitual recurrent dislocation, reduction may be easily achievable with minimal use of drugs (eg Entonox). External rotation method This simple technique has a good rate of success. With the patient reclining at 45°, slowly and gently (without force) externally rotate the shoulder to 90°. If the dislocation has not yet reduced, forward flex (elevate) the shoulder slowly. Kocher’s method Lie the patient back almost flat and once sedation and analgesia are adequate:

  • with the elbow flexed to 90°, slowly externally rotate the shoulder. Pause if there is any resistance and continue only when muscles relax.
  • slowly adduct the upper arm across the chest with the shoulder still held in external rotation.
  • once adducted as far as possible, internally rotate the shoulder by flipping the forearm towards the opposite shoulder.

Reduction may occur at any time during the manoeuvre: success is more likely if the patient is relaxed (avoid traction) and if initial external rotation reaches 90°. A ‘clunk’ or return of normal glenoid contour confirms success. Modified Milch method Slowly abduct the straight arm to 110°. With the elbow extended, apply gentle steady traction to the arm, while an assistant controls movement of the humeral head back into the glenoid. Other techniques Scapular manipulation With the patient lying prone, the scapula is ‘manipulated’ onto the glenoid by pushing the inferior tip of the scapula medially and the superior part laterally. Stimson’s technique A more traditional method with the patient prone. Apply a weight strapped to the forearm/wrist of the affected side as it hangs down, and await reduction. Hippocratic methods Many techniques have been described over many centuries, but are probably of historical interest only. P.435
Post-reduction After reduction, recheck pulses and sensation (including axillary and radial nerves) and obtain a check X-ray. Immobilize in a collar and cuff and body bandage. Local policy sometimes includes shoulder immobilisation webbing or braces as standard. Provide analgesia (eg co-dydramol) and arrange follow-up. If unsuccessful, difficult or if shoulder has been dislocated >24h, refer for reduction under GA. Fracture-dislocation of the shoulder Most involve fractures of the greater tuberosity associated with anterior dislocation of the shoulder. Reduce under sedation as with uncomplicated dislocations—in most cases the fracture will reduce satisfactorily along with the dislocation. Refer large or complex fracture-dislocations involving the humeral head, neck or shaft.

Figure. Anterior dislocation of the right shoulder

Posterior dislocation This uncommon injury is easy to miss. It results from a blow or fall onto the anterior shoulder. It may also occur during seizures or after an electric shock. The patient presents with the arm held with the shoulder internally rotated. AP shoulder X-ray may appear normal, but careful inspection reveals an abnormally symmetrical appearance of the humeral head (‘light bulb sign’) and loss of congruity between the humeral head and the glenoid. A modified axial shoulder X-ray (from above) or a translateral view will confirm posterior dislocation of the humeral head. Manipulate under sedation by applying traction and external rotation to the upper limb at 90° to the body. If difficult, refer for reduction under GA. Treat and follow-up as for anterior dislocation. Luxatio erecta Rare inferior dislocation of the humeral head. Presents with arm held abducted above head. Check carefully for neurovascular complications. Reduce under sedation by traction in line with the abducted upper arm, followed by adduction of the shoulder. May require reduction under GA. Treat and follow-up as for anterior dislocation. P.436
Other shoulder injuries Acromio-clavicular (AC) joint injury Common injuries which usually occur following falls onto the shoulder or violent sudden movements of the upper limb. Examine for local pain, swelling or a palpable step in the region of the AC joint. X-ray will show fractures or AC joint disruption (separation or subluxation of the AC joint >1-2mm). The diagnosis may be made more obvious by asking the patient to hold a heavy object while the X-ray is taken. AC joint injuries can be classified as follows:

Grade I Minimal separation. Only acromio-clavicular ligaments involved.
Grade II Obvious subluxation, but still some overlap of the bony ends.
Grade III Complete dislocation of AC joint, indicating rupture of the conoid and trapezoid ligaments, in addition to the acromio-clavicular ligaments.

Treat with analgesia, support in a broad arm sling and arrange follow-up for grade II and III injuries. These measures allow complete recovery in most cases. Occasionally, selected patients benefit from internal fixation.

Figure. Acromio-clavicular (AC) joint injury.

Clavicle fracture This common injury results from direct trauma or from falls onto the outstretched hand or point of the shoulder. Check carefully for neurovascular complications (these are rare, but potentially life-threatening). Treat with analgesia, a broad arm sling and arrange fracture clinic follow-up. The vast majority of fractures unite satisfactorily with this conservative treatment. Rarely, grossly displaced fractures are internally fixed. Scapular fracture Usually result from direct trauma and imply a forceful mechanism of injury. Check carefully for associated injuries to the thorax, such as rib fractures or haemo-pneumothorax. Treat isolated fractures with a broad arm sling, analgesia and arrange follow-up. P.437
Humeral neck/head fracture These result from direct trauma to the upper arm or from falls onto an outstretched hand. Examine for tenderness or swelling over the proximal humerus. Shoulder movements are usually limited by pain. X-rays typically reveal impacted or oblique fractures, with or without associated fractures of the greater and lesser tuberosities. Fractures may be classified as 2, 3 or 4-part fractures according to the number of fragments resulting (eg a fractured humeral neck combined with a fractured greater tuberosity will be a ‘3 part fracture’). Treat with a collar and cuff support and analgesia. Arrange follow-up. Refer all comminuted, displaced or markedly angulated humeral neck fractures, as MUA and occasionally, internal fixation/hemiarthroplasty are indicated. Shaft of humerus fracture Results from a fall onto an outstretched hand or onto the elbow. The fracture may be obvious and palpable. Check distal pulses, radial nerve and elbow joint. X-ray reveals a transverse, comminuted or spiral humeral shaft fracture. Provide analgesia and support the fracture in a POP U-slab (slab of plaster from the axilla down to and around the olecranon and up the outside of the upper arm). Apply with the elbow flexed to 90° and hold in place with a bandage. Alternative treatment includes a ‘hanging cast’ POP (above elbow POP at 90°—weight of POP and arm hold fracture in satisfactory position). Refer if displaced, comminuted or angulated or if neurovascular complications are suspected. MUA and internal fixation are required in these cases. Rotator cuff tears Tears (supraspinatus rupture most commonly) usually follow chronic rotator cuff disease in patients >40yrs. May follow trauma (eg falls with hyperabduction or hyperextension of the shoulder). Examine for ↓range of movement, weakness, crepitus and tenderness over the cuff insertions and subacromial area. Examine supraspinatus strength by testing resistance to abduction. Look for bony avulsions on X-ray (tensile strength of the cuff exceeds adjacent bone). Treat conservatively initially with analgesia and support in a broad arm sling, followed by exercises/physiotherapy at ≈10days. Arrange follow-up for patients with significantly ↓range of movement—complete tears (particularly in younger patients) may require surgical repair. Ruptured biceps The long head of biceps can rupture at its proximal insertion on lifting or pulling (see p433). This may follow little force (and with little pain) in the elderly. Look for the ruptured biceps muscle as a bulge above the elbow. Treat with initial analgesia and support in a sling, followed by later exercises. Surgical repair is rarely indicated. P.438
Soft tissue shoulder problems The shoulder joint is vulnerable to degenerative disease and acute injury, due to its extreme mobility and hence relative instability. Stability relies mainly on the rotator cuff, a sheath of muscles which wrap around and insert into the humeral head under the deltoid. The rotator cuff comprises supraspinatus (initiates abduction), infraspinatus (externally rotates), teres minor (externally rotates), and subscapularis (internally rotates). The rotator cuff may be damaged acutely or as a result of a chronic degenerative process (eg impingement syndromes or rheumatoid arthritis). Other structures around the shoulder joint, including the biceps tendon and brachial plexus, may be affected by disease or injury. Impingement syndromes The acromion process may compress or ‘impinge’ on the underlying subacromial bursa and rotator cuff during repetitive or strenuous shoulder use. Supraspinatus and its tendon are most commonly affected. Minor degrees of impingement (eg subacromial bursitis) are associated with inflammation, pain and loss of function and are reversible with treatment. Rotator cuff tendonitis is a more chronic pattern of injury which, unrecognised or untreated, leads to degeneration or tearing of the cuff. Although rotator cuff tendonitis and degenerative tears usually occur in later life, acute tears can also occur in younger patients following violent hyperabduction or hyperextension of the shoulder. Examination of the shoulder Examine both shoulders for comparison with the patient sitting relaxed. Proceed slowly and gently. Look for deformity of the clavicle or sternoclavicular joint, AC joint deformity (eg OA or injury), wasting of the deltoid muscle (axillary nerve damage), a step in the deltoid contour or a gap below the acromion (subluxation or dislocation). Feel for tenderness over sternoclavicular joint, clavicle, AC joint, subacromial area, rotator cuff insertion, biceps tendon insertion. Move the shoulder gently in all directions to test passive movements. Test strength of active movements. Test abduction (normal range 0-170°), forward flexion (0-160°), backward extension (0-60°), external rotation (put hand on back of head), internal rotation (put hand behind back to touch shoulder blade). Examine for crepitus on movement, restriction, pain (note any painful arc) and weakness of particular movements. Test sensation over the badge area (upper outer arm) supplied by axillary nerve. Examine the cervical spine when shoulder examination does not reveal a cause for symptoms. In suspected impingement syndromes the following specific tests may help: Neer’s impingement test Fully abducting the straight arm will re-create symptoms. Hawkin’s impingement test Hold the arm at 90° abduction and 90° elbow flexion. Rotation of the arm across the body will recreate symptoms. LA injection of 10mL 1% plain lidocaine into the subacromial bursa (easiest approach is just under acromion process from behind) should improve pain, but will not affect strength or range of movement, aiding assessment. Adding hydro-cortisone, methylprednisolone or triamcinolone to LA injection is useful for first presentation of acute impingement. Warn that symptoms may ↑briefly after steroid injection. Avoid repeated injection as it can precipitate tendon rupture. Differential diagnosis of shoulder pain Includes referred pain from a degenerative cervical spine, C5/6 disc prolapse, brachial plexus neuritis, axillary vein thrombosis, suprascapular nerve compression, Pancoast’s syndrome or cervical rib. P.439
Subacromial bursitis Early form of impingement in younger patients. Follows unaccustomed activity or exercise. Look for a painful arc of 60-100° abduction with dull, aching pain, worse on activity. Differential diagnosis includes gout, sepsis or RA. Treat with analgesia, NSAID and ice. Demonstrate simple exercises (eg gentle pendulum swings and circling movements of the arm, crawling fingers up a wall). LA injection will improve pain, movement and help confirm diagnosis. Consider steroid injection if first presentation. Rotator cuff tendonitis Usually a longer history, chronic pain (± sleep disturbance), in patients aged 25-40yrs. Examine for tenderness and crepitus over humeral insertions of the rotator cuff and ↓active and passive shoulder movements. X-ray may show osteophytes or subacromial calcification. LA injection may ↑pain, but usually does not ↑strength or range of movement. Treat as for subacromial bursitis. In more severe cases, consider formal physiotherapy and orthopaedic referral. Calcific tendonitis A poorly understood process of calcium deposition and resorption within the rotator cuff tendon. Commoner in women. May be related to degenerative change or follow minor trauma. Most common site is within supraspinatus 1-2cm proximal to humeral insertion. Acute pain (occurs during periods of calcium resorption, granulation and healing) often starts at rest, worsens on movement and at night. Examine for tenderness at the rotator cuff insertion. There may be crepitus, painful limitation of movement or a painful arc. The calcium deposits may be evident on X-ray. Most episodes spontaneously resolve in 1-2wks. Treat with analgesia, NSAID and ice. Immobilize briefly in a broad arm sling but start gentle exercises (as above) once symptoms allow. Arrange orthopaedic follow-up: steroid injection and/or physiotherapy and rarely, surgical treatment, may be required. Adhesive capsulitis A misleading term, since it is caused by a generalized contracture of the shoulder capsule, not adhesions. Causes include immobilization, injury or diabetes. Commoner in women and rare <40yrs or >70yrs old. Insidious onset results in diffuse, aching pain (worse at night) and restricted active and passive shoulder movements. The cuff is usually not tender. X-rays exclude posterior dislocation (p435). Refer to orthopaedics for MUA, arthroscopy and capsulotomy. P.440
Soft tissue neck injuries Neck sprains Neck injuries which do not involve fractures, dislocations, ligamentous laxity or spinal cord damage are common. Most follow road traffic collisions involving neck hyperextension. These injuries have been referred to as: ‘whiplash’ or ‘whiplash-type’ injuries, ‘hyperextension’ or ‘acceleration flexion—hyperextension’ injuries or most simply, ‘neck sprains’. Patients with continuing symptoms are often referred to as having a ‘whiplash-associated disorder’. MRI (which rarely changes management) reveals many to have significant soft tissue injuries. History Neck pain and stiffness may not appear until 12hrs after injury—symptoms are typically maximal at ≈48hrs. Ask about associated symptoms, such as visual disturbance, dizziness, tinnitus, vertigo, headache, backache, altered sensation or loss of limb power. Examination Perform a neurological examination. In fully alert, neurologically intact patients examine for any midline or paravertebral tenderness, muscle spasm or deformity. If there is no midline tenderness, assess active neck movements. If there is localised bony tenderness, pain on active movements or any neurological symptoms, immobilize fully and X-ray. X-ray (see p370) Arrange cervical X-rays (AP, lateral and odontoid peg views) in the presence of high energy trauma, neurological symptoms or signs, ↓conscious level or serious injury elsewhere. In the absence of these, do not routinely X-ray if the patient is fully conscious, has no midline neck tenderness, and can rotate the neck by 45° to right and left. Check carefully for evidence of fracture or dislocation. The most common abnormality is loss of the normal cervical lordosis (‘straightening’ of the neck)—this implies neck muscle spasm and does not necessarily indicate cervical spine injury. If the patient has severe pain or any abnormal neurology, but the initial plain X-rays are normal, consider requesting a CT scan. Treatment If there is any clinical or radiological suspicion of vertebral or spinal cord injury, refer urgently, maintaining cervical spine immobilization. Treat patients in whom there is no suspicion of spinal cord or vertebral injury with initial analgesia (preferably NSAID, eg ibuprofen 400mg PO tds) and GP follow-up ± arrangements for subsequent physiotherapy. Do not provide a soft collar, but instead encourage early mobilization. Prognosis The rate of resolution of symptoms after neck sprains is highly variable. Many patients continue to complain of pain, stiffness and other symptoms for many months following injury. Continuing symtoms are more likely if there is:

  • radiological evidence of pre-existing degenerative neck disease
  • loss of the normal cervical lordosis on X-ray
  • clinical evidence of nerve injury (eg altered sensation)

P.441
Non-traumatic neck pain Neck pain without injury may result from a variety of causes:

  • Cervical disc herniations—present with neck pain, sensory and motor signs. Even if X-rays are normal, refer for further investigation (such as MRI) and treatment.
  • Acute torticollis (‘wry neck’) reflects painful sternocleidomastoid spasm which may occur on waking or after sudden neck movement. It responds to NSAID, local heat (eg heat pad or hot water bottle) and (in severe cases), physiotherapy.
  • Referred pain—eg tonsillitis/quinsy.
  • Dystonic reactions—eg drug-induced.
  • Cervical arthritis—including both OA and RA.

P.442
Facial wounds See also the section on bony facial injuries on pp358-365. Cosmetic considerations These are very important. The final appearance of a scar depends partly upon the orientation of the wound and its relation to natural skin lines (modified from Langer’s description), but also upon initial management. Cleaning is crucial, but do not perform debridement with tissue excision in A&E. It may be acceptable to suture facial dog bites (p400) and non-contaminated facial wounds up to 24hrs after injury, but get senior advice first. For the best cosmetic outcome, close facial wounds in layers, using 5/0 dexon or vicryl for deeper layers, with knots tied on the deep aspect. Aim to remove skin sutures (interrupted 6/0 non-absorbable monofilament) at 3 days and replace with steristrips to minimize scarring. GA may be required to properly treat facial wounds in children (also consider NAI—see p690). Damage to parotid duct/gland and facial nerve This is particularly likely with incised wounds in the preauricular area. The facial nerve emerges through the parotid gland to supply the muscles of facial expression: unrepaired injury results in permanent disfigurement. The parotid duct runs transversely forwards from the anterior portion of the gland, parallel and inferior to the zygomatic arch, before entering the mouth opposite the second upper molar (look for blood here, as this implies proximal duct injury). Refer for exploration in theatre if there is clinical suspicion of involvement of any of these structures. Associated head injury Consider the possibility of significant head or neck injury in all patients with a facial wound. Specific wounds Lip wounds Oppose the vermilion border accurately (it is often easiest to do this first). Remember that even a 1mm mismatch will result in a permanent visible abnormality. Close in layers if the wound extends into subcutaneous or muscle layers. Tongue and oral wounds Check the teeth: if any are broken or missing, consider obtaining soft tissue lateral X-rays of the lips in a search for embedded fragments. Small superficial lacerations need not be closed, but close deeper ones in layers, using absorbable sutures (eg 4/0 or 5/0 Vicryl/Dexon for mucosal surfaces). Close through and through oral lacerations in layers (mucosa, muscular and subcutaneous tissue, skin). Eyebrow wounds Do not shave the eyebrows. Exclude an underlying fracture by palpation (and X-rays, as appropriate). Eyelid wounds Many may be sutured with 6/0 non-absorbable monofilament. Full eye examination, excluding a FB, is necessary. Refer wounds if there is involvement of lid margin, loss of tissue, or if lacrimal duct (medial canthus) or gland (superolateral) injury is suspected. Ears If cartilage is involved, it requires suture with fine absorbable material (by an ENT specialist) prior to skin closure. Give prophylactic antibiotic cover (eg co-amoxiclav) if there is any contamination. P.443

Figure. Langer’s lines

P.444
Pelvic fractures Major pelvic fractures result from very high energy trauma and are true orthopaedic emergencies. Associated thoracic or abdominal injuries occur in 10-20%—the principal immediate risk is massive haemorrhage and exsanguination. Compound fractures of the pelvis have a mortality of >50%. Associated bladder or urethral damage is common. Assessment

  • Resuscitate as for any severely traumatized patient (p312).
  • All patients with multisystem injury must have a pelvis X-ray (p314).
  • Look carefully for evidence of hypovolaemia and treat appropriately.
  • Examine pubis, iliac bones, hips and sacrum for tenderness, bruising, swelling or crepitus. Do not try to ‘spring the pelvis’ to assess stability—this is unreliable, unnecessary and may cause additional haemorrhage/damage. Similarly, avoid log rolling patients with obvious pelvis fractures—instead, enlist a number of helpers and perform a straight lift.
  • Look carefully for wounds especially in the perineum.
  • Perform a rectal examination for anal tone, palpable fractures and to detect bleeding, rectal tears and urethral damage (high riding, boggy prostate).
  • Test urine for blood, but do not catheterize if urethral injury is suspected.
  • Look at X-rays carefully for disruption of normal pelvic contours (Shenton’s lines), asymmetry and widening of the pubic symphysis or sacroiliac joints.

Classification of pelvic fractures Tile classification of pelvic injuries:

Type A (Stable injuries) include avulsion fractures (see below), isolated pubic ramus fractures, iliac wing fractures or single stable fractures elsewhere in pelvic ring.
Type B (Rotationally unstable but vertically stable)
B1 ‘Open book’ antero-posterior compression fractures, causing separation of the pubic symphysis and widening of one or both sacroiliac joints.
B2 Ipsilateral compression causing the pubic bones to fracture and override.
B3 Contralateral compression injury resulting in pubic rami fractures on one side and compression sacroiliac injury on the other.
Type C (Rotationally unstable and vertically unstable) The pelvic ring is completely disrupted or displaced at 2 or more points. Associated with massive blood loss and very high mortality. Subdivided into C1 (unilateral), C2 (bilateral) and C3 (involving acetabular fracture).

Treatment Stable type A injuries require analgesia and bed rest until able to mobilize (usually 3-6wks). Isolated pubic ramus fractures are common and often missed in the elderly (particularly when a fractured neck of femur is being excluded). Refer to orthopaedics for analgesia, inital bed rest, then mobilization. Unstable type B and C fractures are an orthopaedic emergency Resuscitate as for any major trauma (p312). Correct hypovolaemia, anticipate coagulopathy and ensure blood is rapidly available as massive transfusion may be required. If DPL (p336) is required, use a supra-umbilical approach, as pelvic haematoma may track up the abdominal wall. Minimize movement, but support an obviously unstable pelvis fracture associated with severe haemorrhage using sandbags, MAST suit or with a sheet tied tightly around the hips (or commercial equivalent). Reduction and immobilization using an external fixator applied either in the resuscitation room or operating theatre may be required to halt haemorrhage. If this fails, angiography and selective embolization are indicated. P.445

Figure. Examples of pelvic fractures

Avulsion fractures around the pelvis The following avulsion fractures occur at the point of attachment of various muscles as follows:

  • Anterior inferior iliac spine—rectus femoris (typically results from a miskick into the turf)
  • Anterior superior iliac spine—sartorius
  • Ischial tuberosity—hamstrings

In most instances, symptomatic treatment based upon rest and analgesia suffices. Larger avulsions (particularly of the ischial tuberosity) may require internal fixation (to avoid complications such as non-union). P.446
Hip dislocations and acetabular fractures Acetabular fractures Often accompany traumatic hip dislocation following violent injury such as falls or blows to the hip. Transverse or posterior rim fractures are the most common. Complications include massive haemorrhage, sciatic nerve damage, myositis ossificans and secondary OA. Resuscitate and deal with priorities first. Give analgesia if required. Additional X-rays (eg 45° oblique ‘Judet’ views) or CT scanning are often required to make an exact diagnosis. Refer to orthopaedics for traction, protected weight-bearing or in some cases internal fixation. Central dislocation of the hip This injury is essentially a serious pelvic fracture which involves the head of the femur being driven through the (fractured) acetabular floor following a fall or force directed along the length of the femur (eg car dashboard). The diagnosis is usually obvious on an AP pelvis X-ray. Treat associated injuries, shock and give analgesia. Contact the orthopaedic surgeon immediately. Traumatic posterior dislocation of the hip Implies major trauma, often with other critical injuries (eg when knees strike the dashboard in a road traffic collision). This injury is often associated with fractures of the posterior acetabular or femoral shaft. Look for the typical deformity of shortened, internally rotated leg with flexion and adduction at the hip. This appearance may be absent if there is also a femoral shaft fracture. Check for sciatic nerve damage—dorsiflexion of foot and sensation below the knee. Complications include sciatic nerve injury, avascular necrosis of the femoral head (the risk ↑ the longer the hip is dislocated) and secondary OA. Diagnosis is usually obvious on AP X-ray, but lateral views may be required to adequately exclude dislocation. Treat as follows:

  • resuscitate the patient and deal with A,B,C priorities first
  • give analgesia—posterior dislocation causes severe pain.
  • refer for reduction under GA. In unconcious, multiply injured patients, consider an early attempt to reduce the dislocation.

Reduction technique for posterior dislocation (‘Allis technique’):

  • stand on the trolley (in theatre, it may be easier and safer to place the anaesthetized patient on the floor for reduction) and have an assistant hold the patient’s pelvis down as counter-traction.
  • flex hip and knee both to 90° and correct adduction and internal rotation deformities.
  • grip the patient’s lower leg between your knees and grasp patient’s knee with both hands.
  • lean back and lever the knee up pulling the patients hip upwards. A ‘clunk’ confirms successful reduction. X-ray to confirm reduction.

Dislocated hip prostheses Relatively common, follows minor trauma. Confirm posterior dislocation of hip prosthesis by X-ray. Treat with IV opioid and refer to orthopaedics for MUA under GA. Anterior dislocation of the hip This is less common. The leg is held abducted and externally rotated. Complications include damage to the femoral nerve, artery, and vein. Give analgesia and refer for reduction under GA. P.447
Sacral and coccygeal fractures Fractures of the sacrum Usually occur from violent direct trauma such as falls. Damage to sacral nerve roots may occur. Check carefully for saddle anaesthesia, ↓anal tone, lower limb weakness or bladder dysfunction. Refer to the orthopaedic team. Fracture of the coccyx Follows a fall onto the bottom. Do not X-ray routinely—diagnosis is clinical. Perform a rectal examination and check for local coccygeal tenderness, palpable fractures or evidence of rectal damage. Refer patients with rectal tears to the general surgeon. Refer to the orthopaedic team if the coccyx is grossly displaced, as it may require manipulation under LA or even excision. Treat the remainder symptomatically (eg suggest a ring cushion and provide analgesia). P.448
Hip fractures Intracapsular fractures of the neck of femur These can follow relatively minor trauma. Risk ↑ in the elderly, because of osteoporosis, osteomalacia and ↑rate of falls. Fractures are more common in peri- or post-menopausal women. These fractures can disrupt the blood supply to the femoral head, leading to avascular necrosis. Fractures around the hip in younger patients imply violent, high energy injury: the incidence of non-union or avascular necrosis may be as high as 20%. Diagnosis Typically follows a fall onto the lateral aspect of the hip or directly onto the bottom. Pain may radiate down towards the knee. The affected leg may be shortened and externally rotated. Check for hypothermia and dehydration (the patient may have been lying on floor for hours). Examine for pain over the hip joint or greater trochanter, particularly on rotation. Be suspicious of:

  • any elderly person with a history of sudden inability to WB. There may be no history of injury, particularly in the presence of confusion or dementia.
  • inability to WB with pain in the knee (hip movements may not be painful).
  • any elderly person who has ‘Gone off her feet’. Look for any evidence of hip fracture and adopt a low threshold for X-ray.

X-rays Obtain both AP pelvis and lateral hip X-rays of the suspected side. Scrutinize closely for disruption of trabeculae, inferior or superior cortices and abnormality of pelvic contours (Shenton’s lines). Fractures of the femoral neck are not always visible on initial X-rays. Repeat X-rays, bone scanning or even MRI may be required if symptoms continue. Intracapsular neck of femur fractures may be graded radiologically according to the Garden classification:

Garden I trabeculae angulated, but inferior cortex intact. No significant displacement.
Garden II trabeculae in line, but a fracture line visible from superior to inferior cortex. No significant displacement.
Garden III obvious complete fracture line with slight displacement and/or rotation of the femoral head.
Garden IV gross, often complete, displacement of the femoral head.

Treatment

  • obtain IV access and draw blood for U&E, glucose, FBC and X-match
  • start IV infusion if indicated (eg dehydration or shock)
  • give IV analgesia plus an antiemetic. Provide all analgesia IV in small increments every few mins until pain is controlled.
  • obtain an ECG to look for arrhythmias or evidence of MI
  • consider obtaining a CXR
  • arrange other investigations as indicated by history/examination
  • arrange admission to orthopaedic ward

Intertrochanteric fracture These affect the base of the femoral neck and the intertrochanteric region. Initial management is identical to neck of femur fractures outlined above. Isolated trochanteric avulsion fracture Sudden violent force may avulse the insertion of gluteus medius (greater trochanter) or iliopsoas (lesser trochanter). Provide analgesia and refer for orthopaedic follow-up for gradual mobilization and symptomatic treatment. P.449

Figure. The Garden classification

P.450
Shaft of femur fractures Enormous force is required to break an adult femoral shaft in the absence of osteoporosis, metastatic or other disease. Fractures of the femoral shaft imply violent high-energy injury and are frequently associated with multisystem trauma. Treatment of significant head, neck, thoracic, abdominal, or pelvic injuries must take priority. Transverse, spiral, or segmental shaft fractures usually result from falls, crushing injuries or high-speed road traffic collisions (eg driver’s knees striking a dashboard or a motorcyclist’s thighs striking handlebars). There is often associated dislocation of the hip or other serious injury to the pelvis, hip, and knee. Complications Closed fractures of the femoral shaft, even without obvious vascular injury, may be associated with marked blood loss. Up to 1.5L of blood may be lost without visible thigh swelling. Rarely, gross blood loss may occur from compound femoral fractures. Later complications include ‘fat embolism’/ARDS. The incidence of complications is ↓ by early splintage and early definitive treatment (usually closed intramedullary nailing). Diagnosis The diagnosis is usually clear on examination with deformity, shortening, external rotation, and abduction at the hip on the affected side. The fracture may be felt or even heard on movement of the lower limb. Carefully check for associated pelvic, knee, or distal limb injuries or the presence of associated wounds. Document sensation and pulses in the limb and re-check frequently. Treatment Before X-rays, resuscitate, exclude life-threatening injuries, replace IV fluids, give adequate analgesia and splint fractures as follows:

  • assess ABC’s, establish priorities and resuscitate
  • start fluid replacement via 2 large-bore IV cannulae
  • obtain blood for X-matching
  • administer IV analgesia—give small increments of opioid (with an antiemetic) until pain is controlled
  • strongly consider a femoral nerve block (p296)
  • whilst the block is becoming effective (usually 5-10mins) prepare splintage and immobilize limb in Thomas or other traction splint (see below)
  • arrange X-rays of the femur and contact the orthopaedic team

Subtrochanteric fractures These involve the most proximal part of the femoral shaft, at or just distal to the trochanters. Like femoral shaft fractures, they tend to involve high-energy trauma in younger patients and are often associated with other serious injuries. They can also occur as isolated injuries following relatively minor trauma in those with osteoporosis or metastatic disease. Treat as for femoral shaft fractures and refer to the orthopaedic team once splinted and comfortable. Supracondylar fractures Fractures of the distal third of the femur usually occur as a result of violent direct force. They are frequently comminuted and often intra-articular with associated damage to the knee joint. In adults, the distal fragment of the femur tends to rotate distally due to pull from gastrocnemius. Treat as for femoral shaft fractures. Note that femoral nerve block may not be as effective in these fractures—additional analgesia will almost certainly be required. P.451
Splints for fractured femoral shaft The Thomas splint is traditional, but other forms of telescopic, metal or pneumatic traction splints are increasingly being used. These are convenient and particularly suitable for temporary immobilization in patients going directly to theatre or in transit to hospital. Ensure adequate padding around the groin and the ankle to avoid pressure necrosis of the skin. Application of a Thomas splint

  • Measure circumference of the uppermost part of the uninjured thigh in cm.
  • Select splint of appropriate ring size (also have sizes above and below ready).
  • Prepare splintage: wrap ring in wool roll.
  • Slide sleeve of tubigrip over splint to support leg from ring to distal calf. Secure tubigrip by tying to ring or taping along sides of splint. If the ring has a buckle this should be on the upper half of the ring.
  • Prepare the limb for skin traction—gently. If time permits, shave hair from medial and lateral aspects of limb.
  • Apply splint (if using femoral nerve block wait until this is effective). Start with adhesive skin traction, making sure the foam part adequately covers the malleoli. Remove backing and apply adhesive tape along sides up limb, extending as far up the limb as possible. Trim off the remaining tape.
  • Wrap the leg from ankle to mid-thigh with gauze bandage.
  • Apply traction to the leg. Gently pull the ankle with one hand and support the knee with the other. Correct the abduction and external rotation while pulling steadily.
  • Slide the Thomas splint over the leg until it is against the perineum. Take care not to snag the skin or genitalia. If the splint does not fit, replace it while maintaining traction.
  • Tie the cords from the heel end of the skin traction to the end of the splint while maintaining traction. Insert 2 tongue depressors between the cords and twist them until the cords are reasonably taut.
  • Place wool roll padding under the thigh and if necessary, add more padding around the groin.
  • Bandage around the whole splint from thigh to lower calf with a broad bandage.
  • Support and elevate the leg on a pillow.
  • Check distal pulses.
  • Arrange X-rays.

P.452
Approach to knee injuries History Many knee injuries seen in A&E result from sports, particularly football and rugby. Carefully document the exact mechanism of injury as it provides clues to the diagnosis. Valgus or varus stresses can damage the medial and lateral collateral ligaments respectively. Flexed, twisting knee injuries are frequently associated with meniscal injuries. The anterior cruciate ligament (isolated or associated with medial collateral and/or medial meniscal injuries) may tear during forced flexion or hyperextension. Posterior cruciate ligament injuries may follow falls or dashboard impact where the tibia is forced backwards violently (often associated with medial or lateral ligament injuries). Rapid onset tense swelling in a knee is usually an acute haemarthrosis. Swelling developing more gradually over several days is more likely to represent a reactive effusion. Ask about previous knee problems: swelling, clicking, locking or giving way (the last two suggest underlying meniscal pathology). Document any previous knee surgery or the presence of other joint problems. In a hot, swollen, painful and stiff knee without a history of significant trauma consider and exclude septic arthritis. Examination Always examine both legs with the patient suitably undressed and lying supine. If there is much discomfort, consider giving oral analgesia and re-examine in 10-15mins. Reassure him/her that you will not suddenly pull or move the leg without warning. Look for bruising, swelling, redness, abrasions, or other wounds. Feel for warmth, crepitation, or the presence of a knee effusion (patellar tap or ballottable fluid). Ask the patient to straight leg raise ability to do this against resistance virtually excludes quadriceps or patellar tendon rupture or transverse patellar fractures. If unable (possibly due to pain), ask the patient to kick forwards whilst sitting with the affected leg dangling free. Assess tone and bulk of quadriceps muscle and compare with the other side. Assess knee movement gentle encouragement or supporting the limb may be required, but do not use any force. Assess the cruciate ligaments try to bring the knee to 90° flexion, sit on the patient’s foot and hold the leg with both hands around the upper tibia. Ensure the quadriceps and hamstring muscles are relaxed. Using body weight, gently rock backwards and forwards looking for anterior glide of the tibia (indicating rupture of the anterior cruciate ligament) or posterior glide of the tibia (indicating rupture of the posterior cruciate ligament). Up to 5mm movement is normal—always compare both legs. If unable to flex to 90°, assess with slight flexion ≈10°. Repeat the procedure with the tibia slightly internally rotated. Assess the collateral ligaments : with the leg straight, gently apply a valgus stress to the knee joint (ie move the lower leg laterally) examining for laxity or pain in the medial collateral ligament. Next apply a varus stress (ie move the lower leg medially) examining for laxity or pain in the lateral collateral ligament complex. Repeat the procedure with the knee in ≈20° flexion as this will relax the cruciate ligaments. Compare both sides. Palpate around the knee joint examining all the structures around the knee for tenderness, swelling, warmth, or crepitus (eg bony landmarks, ligament insertions and over the joint line medially and laterally). P.453
X-rays for knee injuries X-rays form the mainstay of initial imaging for knee trauma: other imaging (eg tomography, CT, MRI) may be indicated after specialist consultation. Obtain X-rays following knee injuries where there is suspected fracture or other significant injury. Use the Ottawa knee rules to assist the decision (in those aged between 18 and 55 years) as to whether or not to X-ray: X-rays are only required if any of the following are present:

  • there is isolated bony tenderness of the patella
  • there is bony tenderness over the fibula head
  • the patient cannot flex the knee to 90°
  • the patient could not weight-bear (at least 4 steps) both immediately after the injury and at the time of examination

Adopt a lower threshold for obtaining X-rays in those aged <18yrs or >55yrs, patients intoxicated with alcohol or suffering from bone disease (eg RA, documented osteoporosis). P.454
Knee fractures and dislocations Patellar fracture This may follow a direct blow or fall onto the patella or sudden violent knee flexion or contraction of the quadriceps muscle. Look for pain, swelling, crepitus, and difficulty extending the knee. Displaced, transverse fractures result in an inability to straight leg raise (this is also a feature of rupture of the quadriceps tendon or patellar tendon—p456). There may be an associated haemarthrosis. X-rays may be difficult to interpret as the patella overlies the distal femur on the AP view and can obscure subtle fractures. Do not routinely order ‘skyline’ views of the patella. Take care not to mistake a bipartite patella for a fracture (the accessory bone is typically in the upper, lateral part of the patella). Treatment

  • Treat vertical fractures with analgesia, immobilize in a non-weight-bearing cylinder POP, supply crutches and arrange orthopaedic follow-up.
  • Transverse fractures tend to displace due to the pull of quadriceps. Treat with analgesia, immobilization in a POP backslab and refer to the orthopaedic team for probable ORIF (occasionally, the orthopaedic team may decide to treat an undisplaced transverse fracture conservatively).

Dislocation of the patella The patella typically dislocates laterally. This often follows medial stress to the knee—the dislocation may reduce spontaneously. There may be a history of recurrent dislocation. The patient has a painful knee, held in flexion with obvious lateral displacement of the patella. X-rays are not generally required prior to reduction of the dislocation. Reduction can usually be achieved using Entonox—IV analgesia is seldom required. Stand on the lateral side of the affected limb and hold the affected knee gently. Using both thumbs, lever the patella medially in one smooth, firm movement. It often helps to have an assistant gently extend the knee as this is done. Succesful reduction is obvious and should rapidly relieve symptoms. Once reduced, obtain X-rays, immobilize in cylinder cast POP (or in the case of a recurrent dislocation, a canvas back-splint), provide analgesia and arrange orthopaedic follow-up. Spontaneous reduction/patella subluxation The patient who has experienced spontaneous reduction and/or subluxation prior to arrival at hospital will typically have maximal tenderness over the medial aspect of the upper patella reflecting damage to the attachment of vastus medialis. There may be ‘apprehension’ when gentle lateral pressure is applied to the patella. If clinical features are dramatic, treat with POP or splint, otherwise refer for physiotherapy and orthopaedic follow-up. Dislocation of the knee Although rare, this injury indicates severe disruption of the ligamentous structures and soft tissues of the knee. Look carefully for associated injuries (eg femur or lower limb) and document distal pulses and sensation—the popliteal artery or nerve are often injured. Reduction requires adequate (IV opioid) analgesia and usually sedation with full precautions. Reduce by simple traction on the limb and correcting deformity. Check distal pulses and sensation after reduction, immobilize in a long leg POP backslab and arrange admission. Check the circulation repeatedly, since popliteal artery damage may not become apparent for some hours. P.455
Tibial plateau fractures Falls onto an extended leg can cause compression fractures of the proximal tibia. Valgus stresses crush or fracture the lateral tibial plateau. These injuries are commonly seen in pedestrians injured following impact with car bumpers. Varus injuries result in crushing or fracture of the medial tibial plateau and are usually associated with rupture of the opposite collateral ligaments. Examine for tenderness over the medial or lateral margins of the proximal tibia. Look for swelling, haemarthrosis or ligamentous instability (also try to assess the cruciate ligaments—p452). Look carefully on X-rays for breaks in the articular surfaces of the proximal tibia, avulsions from the ligamentous attachments or loss of height from the medial and lateral tibial plateaux, but beware, this may be subtle. Treat with immobilization in a long leg POP backslab following adequate analgesia and refer to orthopaedic staff. Fractures of the tibial plateau often require elevation ± ORIF with bone grafting. Admit all patients with an acute haemarthrosis. Treat small, isolated avulsions without haemarthrosis with immobilization, crutches and analgesia and arrange orthopaedic follow-up. P.456
Soft tissue knee injuries Acute haemarthrosis Rapid onset swelling following a knee injury, often warm, tense and painful. Common causes include cruciate ligament rupture, tibial avulsion, tibial plateau or other fractures. An acute haemarthrosis indicates serious injury. Refer for orthopaedic appraisal following splintage, analgesia and appropriate X-rays. Aspiration of a haemarthrosis should only be performed under strict aseptic technique. Cruciate ligament rupture The combination of considerable pain and swelling can make it difficult to elicit classical physical signs of a fresh cruciate tear. A history of an audible ‘pop’ at the time of injury is highly suggestive of anterior cruciate rupture. Anterior cruciate tears often occur in association with tears of the medial collateral ligament and/or medial meniscus. Examine for the presence of haemarthrosis, abnormal ↑anterior glide of the tibia (‘+ve anterior drawer test’) and injuries to the medial collateral ligament or other structures. Look carefully at X-rays for avulsion of the anterior tibial spine (anterior cruciate insertion). Give analgesia and refer to the orthopaedic surgeon. In tears of the posterior cruciate ligament, the tibia may appear to sag back when the knee is in flexed position, so the tibia can be pulled into a more normal position causing the appearance of a ‘false +ve’ anterior drawer sign. The corresponding posterior tibial spine may be avulsed on X-ray. Provide analgesia and refer suspected cases. Collateral ligament injuries Tenderness over the medial or lateral collateral ligament, with pain at this site on stress testing, indicates collateral ligament injury. Most injuries are isolated and have no associated haemarthrosis and no abnormality on X-ray. Compare the injured knee with the uninjured one. The degree of laxity on stress testing will help to guide treatment:

  • Local tenderness with no laxity (or very slight laxity) implies a grade I injury. Treat with analgesia, physiotherapy (± crutches) in the expectation of full recovery in 2-4wks.
  • Local tenderness with minor/moderate laxity but with a definite end-point implies a grade II injury. Provide analgesia, crutches, instruction on quadriceps exercises and refer for orthopaedic follow-up.
  • Major laxity (ie the joint opening up >1cm) with no end-point implies complete rupture. Consider a POP cylinder (or splint), and provide crutches, analgesia, quadriceps exercises and orthopaedic follow-up.

Ruptured quadriceps Complete rupture of the distal quadriceps insertion can result from a direct injury or from sudden, violent contraction of the quadriceps muscle. Examination reveals complete inability to straight leg raise—never assume this is just due to pain. There may be a palpable defect in the muscle insertion. Refer to the orthopaedic surgeon for repair. Ruptured patellar tendon Examine for complete inability to straight leg raise, a high-riding patella, a palpable defect in the patellar tendon. There is frequently an associated avulsion of the tibial tuberosity. Refer to orthopaedics for repair. P.457
Other knee problems Acutely locked knee A springy block to full extension (which varies from just a few degrees to much more) in the knee indicates an underlying meniscal injury or other loose body in the knee joint. Obtain knee X-rays (including a tunnel view) which may show a loose body. Do not attempt to unlock the knee by manipulation as this is usually painful and futile. Give analgesia and refer for arthroscopy. Prepatellar and infrapatellar bursitis This results from inflammation of the fluid-filled bursa in front of or just below the patella (respectively), typically from unaccustomed kneeling. Treat with rest (which may involve the use of crutches), a short course of NSAID and avoidance of the causative activity. Persistent symptoms may necessitate elective excision of the bursa. Infective bursitis may occur (↑T° and cellulitis are clues to this): aspirate fluid for culture and sensitivity and start antibiotics (eg co-amoxiclav). Other causes of knee pain Patients present not infrequently with knee pain of variable duration and no history of trauma. In adults, causes include Baker’s cyst, osteoarthritis (especially in the elderly) and acute arthritic conditions, including septic arthritis (rare but important). Also rare, but worthy of consideration is osteosarcoma, which typically affects teenagers or young adults, producing pain and swelling. In children, causes include sepsis (including both septic arthritis and osteomyelitis p665), Osgood-Schlatter’s disease (p668), osteochondritis dissecans (p668), Johansson-Larsen’s disease (p668), chondromalacia patellae, referred pain from the hip. P.458
Tibial and fibular shaft fractures Adult tibial fractures are usually a result of direct blows or falls onto the tibial shaft. Spiral fractures of the tibia or fibula follow violent twisting injuries, usually from sports (eg soccer, rugby, skiing). Displaced fractures typically involve both the tibia and the fibula. A large portion of the tibia has relatively little soft tissue covering—compound injuries are common. Displaced tibial shaft fractures may be complicated by injury to the popliteal artery and compartment syndromes (p384). Fractures of the proximal fibula may be associated with injury to the common peroneal nerve. Checks for distal pulses and sensation must be performed and repeated regularly. Diagnosis is usually easy. Look for deformity, localised swelling or tenderness. Regard all wounds near the fracture site as potential compound injuries. X-rays Ensure X-rays show the whole length of tibia and fibula. Examine closely for the presence of other injuries (eg around the knee or ankle). Undisplaced stress fractures can occur, particularly in adults involved in sports, and may not be visible on initial plain X-rays. Persisting symptoms suggestive of stress fracture require orthopaedic follow-up (and may eventually require specific coned X-rays or even bone scanning). Tibial shaft fractures Treat undisplaced transverse tibial shaft fractures with analgesia and immobilization in a long leg POP backslab. Spiral and oblique fractures should be immobilized in the same way, but are potentially unstable. Refer to the orthopaedic team for admission. Immobilize displaced fractures in a long leg POP backslab following IV analgesia and refer (these may require MUA or closed intramedullary nailing). Badly comminuted or segmental fractures may require ORIF. Contact the orthopaedic service immediately in any cases with suspected vascular injury, sensory deficit or gross swelling. Treat compound fractures initially as described on p408 and refer to the orthopaedic surgeon for urgent wound toilet, debridement, and fixation (closed intramedullary nailing or an external fixator). Fibular shaft fractures These can occur in combination with a tibial fracture, as a result of a direct blow (eg from a car bumper) or from twisting injuries. The common peroneal nerve may be damaged in proximal fibular injuries. Examine specifically for weakness of ankle dorsiflexion and ↓sensation of the lateral aspect of the forefoot. Treat undisplaced proximal or fibular shaft fractures with analgesia and elevation. Support in a tubigrip or padded bandage. If unable to WB, use a below knee POP for comfort with crutches until WB is possible. Arrange follow-up in all cases. Refer displaced or comminuted fractures to the orthopaedic team. Stress fractures of the fibula are relatively common, typically affecting the fibular neck of military recruits and athletes following vigorous training. Treat symptomatically with rest and analgesia. Maisonneuve fracture (p478) Transmitted forces may fracture the proximal fibula following an ankle injury. This usually involves fracture of the medial malleolus, fracture of the proximal fibula or fibular shaft, and implies damage to the distal tibio-fibular syndesmosis. Examine the proximal fibula in all ankle injuries and X-ray if locally tender. P.459
Pretibial lacerations Common in the elderly following relatively minor trauma. Most pretibial lacerations can be satisfactorily treated in A&E with adhesive strips (‘Steristrips’). Clean and irrigate to remove clot and close using Steristrips under appropriate anaesthesia. Aim to leave gaps of ≈0.5cm between the Steristrips. Apply a non-adherent dressing and light compression bandage. Instruct the patient to elevate the limb whenever possible. Arrange follow-up (A&E or GP) for 5 days’ time for wound inspection and dressing change (but leave underlying Steristrips until the wound is healed). Consider admission for patients with poor social support. Note Suturing pretibial wounds is not usually recommended as the pretibial skin is friable and undue tension compromises wound healing. Complications are likely in patients with large, distally based and poorly viable skin flaps and patients on steroids or anticoagulants (check clotting control). Refer to plastic surgeons large lacerations where skin edges cannot be opposed, or where complications are likely.

Figure. Application of Steristrips

P.460
Calf and Achilles tendon injuries Calf muscle tears Acute tears of the gastrocnemius muscle often occur during sports. They can also occur simply from stepping from a bus or kerb, or from a sudden jump. Sharp or burning pain in the calf is followed by ↑stiffness or pain on weight-bearing. Examine for localised tenderness and/or swelling over the calf muscle bellies. The medial head of the gastrocnemius is more commonly injured. Carefully check the Achilles tendon for signs of rupture (see below). Differential diagnosis includes DVT (p116) or rupture of a Baker’s cyst. Treat with analgesia, NSAID and initial ice application. Raising the heel with a pad may also help. Advise elevation of the leg and progressive weight-bearing as guided by symptoms. Use of crutches may be required if symptoms are severe (in this case, arrange follow-up and early physiotherapy). Calf muscle bruising Direct blunt trauma to the calf can result in haematoma formation and considerable swelling. Be alert to the possibility of compartment syndrome, particularly where there is a significant mechanism of injury (eg crush injury—see p384). Achilles tendon rupture Rupture of the Achilles tendon can occur without prior symptoms during sudden forceful contraction of the calf muscle. Usually this occurs during sports (notoriously badminton). It also occurs in other situations (eg running for a bus or missing a step and landing heavily). Patients on oral steroids or with a history of steroid injection of the Achilles tendon area are at ↑risk. The patient often describes a sudden sharp pain behind the ankle like a ‘bang’ or similar description. Patients often mistakenly initially believe that they have sustained a blow to the back of the ankle. Examination may reveal swelling, pain, bruising or sometimes a palpable defect (gap) in the tendon ≈5cm above the calcaneal insertion. Plantar flexion against resistance will be weaker than on the normal (uninjured) side, but do not rely on this when making a diagnosis. Beware Plantar flexion (and hence standing on tip-toes) at the ankle may still be possible due to the action of the tibialis posterior, peroneal and toe flexor muscles. Calf squeeze test (Simmonds test) Have the patient kneel on a chair, facing the back, with feet hanging free over the edge. Alternatively, have the patient lying prone on a trolley with ankles over the end. Gently squeeze the calf and look for normal plantar flexion of the ankle. To avoid confusion do not describe the result as +ve or -ve, just state ‘calf squeeze test normal’ or ‘abnormal’. Treatment Remains controversial, so follow local policy. Treatment options are:

  • Conservative management—most ruptures are managed with crutches, analgesia and immobilization for 6wks in a long leg plaster with the ankle in plantar flexion and knee flexed to ≈45°. This is followed by careful rehabilitation under the care of the orthopaedic team and physiotherapist.
  • Primary surgical repair is often employed in young patients and athletes. Refer to the orthopaedic team to consider this.

Note Sometimes a ‘partial’ Achilles tendon rupture is suspected. In this instance, the safest initial treatment is immobilization in a non-weight-bearing BKPOP with ankle flexion, crutches and orthopaedic follow-up. USS can be helpful in determining the state of the tendon. P.461
Other calf and Achilles tendon problems Achilles tendonitis/paratendonitis This frequently follows unaccustomed activity or overuse (eg dancing, jumping, running or even walking). There is usually a history of ↑pain, aggravated by ankle movements. Examine for localised pain, swelling and palpable crepitus over the Achilles tendon (the most common site is ≈5cm from its insertion). The calf squeeze (Simmonds) test is normal. Treat with analgesia, NSAID and a brief period of rest (eg 1-2 days) before gradually returning to normal activities as guided by symptoms. Occasionally, 1-2wks in a BKWPOP may be useful. A heel pad inserted into footwear may help. Athletes may benefit from removal of heel tabs from training shoes if implicated. Avoid local steroid injection which may ↑risk of tendon rupture by impeding healing or by allowing premature resumption of activity. Calf/leg pain with no history of trauma A variety of conditions may be implicated, including:

  • Shin splints—a variety of pathophysiological processes have been suggested, including tibial periostitis. This condition is characterized by pain over the anterior distal tibial shaft after running on hard surfaces. Advise rest and NSAID.
  • Stress fractures—can affect the tibia (as well as the fibula—see p458). Treat with analgesia and POP with orthopaedic follow-up.
  • Bursitis—inflammation of the bursae around the insertion of the Achilles tendon responds to conservative measures.
  • DVT—see p116
  • Cellulitis—see p399
  • Ischaemia—see p508
  • Ruptured Baker’s cyst

P.462
Approach to ankle injuries Ankle injuries are among the most common problems presenting to A&E. Adopt a logical, consistent approach to identify which patients are likely to have a fracture and to avoid unnecessary X-rays in patients with uncomplicated sprains. History Establish the exact mechanism of injury. Most are inversion injuries (where the sole of the foot turns to face medially as the ankle is plantar flexed) causing damage to structures around the lateral malleolus (most notably, the anterior talofibular ligament). Eversion injuries occur less commonly and damage the structures around the medial malleolus. Hyper-dorsiflexion and plantar flexion injuries occur less frequently. The following are relevant in the initial assessment of ankle injuries:

  • A fracture is more likely in patients who are unable to WB immediately following the injury.
  • A ‘crack’ or ‘snap’ may be heard and is not indicative by itself of a fracture.
  • Ice, analgesia and elevation may influence the appearance of an ankle injury.

Examination Examine from the knee down for tenderness over:

  • proximal fibula
  • lateral malleolus and ligaments
  • medial malleolus and ligaments
  • navicular
  • calcaneum
  • Achilles tendon
  • base of 5th MT

Is an X-ray required1? Follow the Ottawa ankle rules for adults and X-ray ankles if patients:

  • were unable to WB for 4 steps both immediately after the injury and at the time of examination
  • have tenderness over the posterior surface of the distal 6cm (or tip) of the lateral or medial malleolus

Note that tenderness over the navicular, calcaneum, base of 5th MT or proximal fibula require specific X-rays to exclude fractures. Adopt a lower threshold for X-ray in the very young, the elderly and in patients who are difficult to assess (eg intoxicated). Footnote 1Steill IG JAMA 1993; 269: 1127-32. P.463
The Ottawa ankle rules

Figure. The Ottawa ankle rules

Guidelines for X-ray in a simple ankle splain. Bony tenderness over the points indicated requires an X-ray. X-ray is also required if the patient is unable to weight-bear immediately after the accident or to walk 4 steps is the A&E department. X-ray the ankle for malleolar tenderness and the foot for metatarsal/ tarsal tenderness. If the patient is not X-rayed then they are given instructions to return after 5 days if they have trouble weight-bearing. (Adapted from Stiell et al.) P.464
Ankle fractures and dislocations Clinical assessment and imaging after ankle injury is outlined on p462. Ankle fractures Fractures around the ankle most commonly involve the malleoli—medial, lateral, and what is commonly referred to as the ‘posterior malleolus’ (the posterior part of the distal tibia). The mortice joint formed by the talus and the distal tibia, fibula, ligaments, and the distal tibio-fibular syndesmosis allows very little rotation or angulation at the ankle joint. As a consequence, forced twisting or angulation of the ankle joint causes fractures asssociated with ligamentous injuries and in severe cases, disruption of the distal tibio-fibular syndesmosis. Treatment depends upon a combination of clinical findings and X-ray appearances. Look carefully for talar shift.

  • Small avulsion fractures essentially reflect ligament/joint capsule damage. Treat with rest, elevation, analgesia and early mobilization as for sprains.
  • Larger avulsion fractures may require initial immobilization in BKPOP with crutches and orthopaedic follow-up.
  • Undisplaced, isolated medial or lateral malleolar fractures are usually stable and do well with conservative measures. Provide analgesia, crutches and immobilize in a well padded BKPOP cast. Advise limb elevation and arrange orthopaedic follow-up. Note that an isolated ‘high’ lateral malleolus fracture may only be apparent on the lateral X-ray and may be associated with deltoid (medial) ligament injury with instability—some require ORIF.
  • Displaced fractures of the medial or lateral malleolus require ORIF. Give analgesia and as appropriate, IV sedation to allow reduction of talar shift. Immobilize the limb in a BKPOP slab and refer to the orthopaedic team.
  • Bimalleolar or trimalleolar fractures are unstable. Having attempted to reduce any significant talar shift, place in a BKPOP, obtain fresh X-rays and refer to the orthopaedic team.

Ankle dislocation Dislocation of the ankle is an orthopaedic emergency. Treat promptly on diagnosis. Examination shows gross deformity of the ankle, severe stretching of the skin (resulting in fracture blisters, skin necrosis or even converting the injury to a compound fracture) and often deficits in peripheral pulses or sensation. The ankle can dislocate in the absence of associated fractures, but this is uncommon. Treatment Prompt closed reduction and immobilization in POP might need to precede X-ray (unless X-rays available immediately). ‘Prompt treatment’ does not mean reduction without analgesia or sedation.

  • Give Entonox, IV analgesia or sedation as appropriate with full precautions.
  • Warn the patient there may be a brief ↑ in discomfort as the ankle reduces.
  • With the knee flexed and supported, gently grasp the heel with one hand and support the patient’s calf with the other.
  • Pull smoothly on the heel—it may be necessary to slightly exaggerate the deformity in order to obtain reduction. Success is indicated by return of normal ankle contours, relief of skin tension and often dramatic relief of pain.
  • Once reduced, re-check pulses and sensation, immobilize in a POP slab and arrange check X-rays.
  • Refer the patient to the orthopaedic team immediately.

P.465
Ankle sprains Clinical assessment and imaging after ankle injury is outlined on p462. The structures most frequently injured in inversion injuries are the lateral joint capsule and the anterior talofibular ligament. Increasing injury causes damage in addition, to the calcaneofibular ligament and posterior talofibular ligament. Treatment Historically, treatment of sprained ankles has been based upon ‘RICE’ (rest, ice, compression, elevation), but the scientific basis for all the elements of this is distinctly lacking! Advise the patient initially to rest the ankle, elevate it above hip level and to consider applying ice intermittently during the first 2days for periods of 10-15mins. Begin WB as soon as symptoms allow, but elevate the ankle at all other times. An elastic support from toes to knee is traditional, but of no proven value. If used, ensure that it is not worn in bed. Advise the patient to gently exercise the ankle in all directions and to use simple analgesia regularly until symptoms improve. Patients with minor sprains can expect full recovery within ≈4wks. It may be possible to resume sports gradually within 1-2wks, depending on progress. Inability to WB implies more severe injury. Provide crutches to those completely unable to WB despite analgesia, with advice to elevate the ankle. All such cases require review. Some units review at 2-4days before commencing early physiotherapy. Other approaches include immobilization in POP for 1wk to allow symptoms to abate, or the use of elastoplast strapping, self-adhesive bandage strapping, or preformed ankle braces. All may be useful in selected cases. Patients can usually expect good functional recovery and should not regard the ankle as ‘weak’. Long term problems (eg weakness/instability whilst walking over rough ground) are often related to ↓ankle proprioception following immobilization, so aim to mobilize as soon as possible. Long-term complications Do not regard ankle sprains simply as trivial injuries: patients may suffer long-term morbidity (which often causes them to return to A&E):

  • Instability often manifests itself by recurrent ankle sprains. Refer to physiotherapy (to include isometric exercises).
  • Peroneal tendon subluxation reflects a torn peroneal retinaculum, allowing the peroneal tendons to slip anteriorly. The clinical presentation includes clicking and a sensation of something slipping. Movement of the foot/ankle (especially eversion) reproduces the subluxation. Refer for orthopaedic follow-up—surgery is an option.
  • Peroneal nerve injury is relatively common, but not frequently sought for. Neuropraxia results from stretching of branches of the peroneal nerve at the time of injury, with subsequent ↓sensation over part of the dorsum of the foot and ↓proprioception at the ankle joint (reflecting injury to the articular branches).

P.466
Foot fractures and dislocations Crushing or other violent injuries to the foot can result in significant long-term disability. Multiple fractures or dislocation of the tarsals or MTs are often overlooked in the presence of other severe injuries. Delayed or inadequate treatment result in high rates of post-traumatic OA. Compartment syndromes (p384) or vascular injuries may occur. Amputations or severe mangling injuries of the foot are rarely suitable for reconstruction/re-implantation due to poor long-term functional results. Talar injuries Falls onto the feet or violent dorsiflexion of the ankle (eg against car pedals in a crash) can result in fractures to the anterior body or articular dome of the talus. Displaced fractures and dislocations frequently result in avascular necrosis. Treat with analgesia, immobilization in a backslab POP and refer promptly for orthopaedic treatment (may require MUA and/or ORIF). Dislocations of the talus require prompt reduction under GA. Upper/midfoot dislocations These injuries follow violent twisting, inverting or everting injuries of the foot. Peritalar/subtalar dislocations involve the articulation between the talus and the calcaneum. Give adequate analgesia and refer to orthopaedics for prompt reduction under GA. Midtarsal dislocations involve the midtarsal joint (comprising the calcaneum and talus posteriorly and the navicular and cuboid anteriorly) and are treated similarly. Isolated dislocation of the talus is rare and requires prompt reduction under GA. Calcaneal fracture Calcaneal fractures most often follow a fall from height directly onto the heels. Always exclude associated injuries of the cervical and lumbar spine, pelvis, hips or knees. Examine for swelling, bruising and tenderness over the calcaneum, particularly over the sides. Examine both calcanei for comparison, remembering that fractures are commonly bilateral. Examine the Achilles tendon for injury (p460). Request specific calcaneal X-rays and scrutinize carefully breaks in the cortices, trabeculae or subtle signs of compression (reduction in Bohler’s angle—see below). Refer all fractures to orthopaedic staff. The majority will require admission for elevation, analgesia and in selected cases, ORIF following CT scanning. Bohler’s angle (normally 35-45°)

Figure. Bohler’s angle (normally 35-45°)

P.467
Metatarsal fractures and dislocations Multiple MT fractures may follow heavy objects falling onto the feet or more commonly, after being run over by a vehicle tyre or wheel. In all such cases, consider the possibility of tarso-metatarsal (Lisfranc) dislocation. This can be easily missed on standard foot X-rays, which do not usually include a true lateral view—look to check that the medial side of the second MT is correctly aligned with the medial side of the middle cuneiform. Check for presence of the dorsalis pedis pulse. Multiple, displaced or dislocated MT fractures require urgent orthopaedic treatment. Support in a POP backslab following analgesia and refer for MUA, K-wire fixation, or occasionally, ORIF. MT stress fractures are discussed below. Isolated avulsion fractures of the 5th MT base These follow inversion injuries of the ankle, the base of the 5th MT being avulsed by the tendon of peroneus brevis. Always examine this area in ankle injuries and request foot X-rays if tender. Do not mistake accessory bones or the apophysis (which runs parallel, not transverse to the 5th MT base). Treat with analgesia, elevation and support in a padded crepe bandage or temporarily, in a BKPOP if symptoms are severe. Arrange orthopaedic follow-up. Jones fracture (of the 5th MT) This is a transverse fracture of the 5th MT just distal to the intermetatarsal joint. It is a significant fracture as it is prone to non-union. Treat with analgesia, crutches, BKPOP and orthopaedic follow-up. Stress fractures of the MTs Fatigue fractures of the MTs are common. They typically follow prolonged or unusual exercise (hence the term ‘march fracture’), but often occur without an obvious cause. The commonest site is the 2nd MT shaft, but the 3rd MT or rarely the navicular or other MTs may be affected. Examine for swelling over the forefoot (there may be none) and localised tenderness over the MT shaft or on longitudinal compression of the MT shaft (do this by pressing on the MT head below the toe—pain will be felt along the MT shaft). X-rays are usually normal initially. Callus or periosteal reaction seen at ≈2-3wks on X-ray will confirm the diagnosis, but this is not required for treatment. Treat symptomatically with analgesia, elevation, rest and modified daily activity as required. A padded insole may help. Firm shoes or boots may be more comfortable than flexible trainers. Expect full recovery in 6-8wks. If unable to WB, consider a brief period in a BKPOP (or ‘Aircast’ boot) until symptoms improve. P.468
Toe injuries Most toe injuries do not require X-ray The treatment of isolated closed fractures of the toe phalanges without clinical deformity or other complicating factors is not altered by X-rays. X-ray the following:

  • obvious deformity, gross swelling or suspected dislocation
  • suspected compound injuries
  • if any tenderness over the MT head or MTPJ
  • suspected FB

Toe fractures Treat uncomplicated phalangeal fractures with simple analgesia, elevation and support with padded buddy strapping. Advise the patient to resume normal activities as soon as possible, but explain that some discomfort may be present for up to 4-6wks. Hospital follow-up is not normally required. Manipulate displaced fractures under LA digital block (as described for fingers on p286). Angulated toe phalangeal fractures can be difficult to manipulate—a useful trick is to use a pen (or needle holder) placed between the toes as a fulcrum. Once satisfactorily reduced, buddy strap and confirm the position with X-rays. Dislocated toes Untreated, toe dislocations may cause troublesome, persistent symptoms. Reduce promptly under LA digital block and splint by buddy strapping. Always confirm reduction by X-ray and discharge with analgesia and advice on elevation and gradual mobilization. Compound toe injuries Careful wound toilet, debridement and repair is essential to ensure rapid healing and avoid infective complications. Ensure that there is adequate tetanus prophylaxis. Always clean wounds thoroughly under adequate anaesthesia (usually LA digital block), provide antibiotics and analgesia. Advise the patient to elevate the injured foot and arrange follow-up according to local practice. More severe injuries will require exploration and repair under GA. Refer these cases to orthopaedic team. Mangled or amputated toes Functional results of attempted re-implantation of amputated toes or repair of badly mangled toes are often poor. Provide analgesia and refer to the orthopaedic surgeon for wound management and amputation of unsalvageable toes. P.469
Soft tissue foot problems Puncture wounds to the foot ‘Simple’ puncture wounds—see p405. Weever fish injuries—see p402. FBs embedded in the foot Searching for small FBs in the sole of the foot has been likened to searching for a needle in a haystack. Follow the principles set out in pp390-391. Nerve blocks (p298) can be useful to allow exploration of foot wounds. Morton’s metatarsalgia A burning discomfort radiating to the toes may result from an interdigital nerve neuroma at the level of the MT heads. The nerve between the 2nd and 3rd MT heads is frequently affected. There is localised tenderness, which is also reproduced on compression of MT heads together. Advise simple analgesia and GP follow-up to consider referral to a foot surgeon. Plantar fasciitis Plantar fasciitis can occur spontaneously or as a chronic overuse injury. Inflammation develops in the plantar fascia, typically at its calcaneal insertion. This results in gradually increasing, burning pain in the sole of the foot and heel which is worse on WB. Examine for localised tenderness over the calcaneal insertion of the plantar fascia and heel pad. X-ray may reveal the presence of a calcaneal spur, but this is not a diagnostic feature. Treat with analgesia, NSAID, rest and elevation for 1-2days. Suggest the use of a padded shoe insole or sorbothane heel pad. Severe, persistent cases occasionally require referral to orthopaedics for local steroid injection or even surgical division of the plantar fascia. Osteochondritis dissecans (p668) Osteochondritis of a MT head (usually the 2nd—Freiberg’s disease) causes gradual onset pain on WB. The cause is often unclear, but it may follow minor injury. Examination may reveal local tenderness but little else. X-ray for evidence of flattening, widening or fragmentation of the MT head or narrowing of the MTPJ. Treat initially with simple analgesia. Refer persistent cases to orthopaedics to consider excision of the MT head. Ingrowing toenails Refer back to the GP for elective treatment, unless there is evidence of infection. In this case, consider oral antibiotics (eg flucloxacillin or co-amoxiclav), or if there is an acute paronychia, incision and drainage under LA. On occasions, it may be appropriate to excise a wedge of nail under LA. P.470
Low back pain Low back pain is the commonest cause of lost work days in the UK. The initial A&E approach is to identify any patients who may have immediately life-threatening problems (eg leaking aortic aneurysm) and sort the rest into:

  • simple (‘mechanical’) back pain—no investigations or referral required
  • nerve root pain—referral and investigation needed if symptoms persistent or progressive
  • possible serious spinal pathology—referral and investigation required
  • suspected cord compression—immediate neurosurgical/orthopaedic referral mandatory

Psychogenic back pain is not an A&E diagnosis. If in doubt, refer. History General Document patient’s age, sex and employment. Note onset and duration of symptoms, character, position and radiation of pain, exacerbating or relieving factors. Precipitants include injuries, falls, heavy lifting or unaccustomed activity. Past history Detail any previous back problems or surgery, other medical conditions (eg rheumatoid arthritis, OA, osteoporosis). Drug history Is the patient using analgesia (and has it helped?). Ask about corticosteroids and contraindications to NSAIDs ? Social history Ask about home circumstances, work and stress. Systemic enquiry Weakness, altered sensation, weight loss, anorexia, fever, rigors, cough, spit, haemoptysis, bowel or urinary symptoms. Examination ‘Unwell’ patient Immediately assess airway, breathing and circulation. Look for evidence of shock and examine for a pulsatile abdominal mass, peritonism, evidence of blood loss, radial-femoral pulse discrepancies or asymmetry. ‘Well’ patient Look for signs of weight loss, cachexia, anaemia, clubbing or muscle wasting. Inspect the back for muscle spasm, scars, scoliosis or other deformity. If possible, watch the patient walk, looking for spasm, abnormal posture or limping. Palpate for tenderness over the spine, lower ribs and renal angles. With the patient supine on a trolley, look for muscle wasting in the legs. Examining both sides:

  • straight leg raise—note the angle which reproduces pain (lumbar nerve root irritation)
  • crossed straight leg raise—nerve root symptoms reproduced by lifting contralateral leg strongly suggests lumbar disc prolapse and nerve root entrapment

Perform a neurological examination Check tone, power, sensation and reflexes in the lower limbs:

  • L4 covers sensation of medial lower leg; quadriceps power; knee jerk.
  • L5 covers sensation of lateral lower leg and great toe; extensor hallucis longus power; hamstrings jerk.
  • S1 covers sensation of little toe and lateral foot; foot plantar flexors power; ankle jerk. Always check perineal and perianal sensation. Perform a rectal examination for anal tone, masses or blood. Examine the abdomen for masses. Document peripheral pulses and perfusion.

P.471
Investigation Check T° and urinalysis. X-ray is indicated for some patients aged < 20yrs or > 55yrs, or those who are systemically unwell, with a history of trauma (except clinical coccyx fracture), or where malignancy, infection or HIV is suspected. In the latter cases, also check CRP, FBC, U&E. Treatment Refer urgently patients with lower limb weakness, altered perineal or perianal sensation, sphincter disturbance. Refer patients with the following: aged < 20yrs or > 55yrs, unremitting or increasing symptoms, widespread neurological signs, weight loss, systemic illness, pyrexia, chronic corticosteroids, osteoporosis or HIV +ve patients with thoracic pain. Treat simple ‘mechanical’ back pain with regular simple analgesia and/or NSAID. Avoid the routine use of opioids. Small doses of benzodiazepines (eg diazepam 2-5mg tds) may be useful, but tend to cause drowsiness. Advise the patient to aim to return to normal activity, even if some discomfort persists. Avoid bed rest. Expect recovery in 4-6wks. Nerve root symptoms mostly resolve over weeks to months with the above treatment, physiotherapy or manipulation. In all cases, give written and verbal advice for immediate return if limb weakness, numbness, bladder or bowel problems occur. Advise follow-up with the GP. P.472
Acute arthritis 1 Approach Whenever a patient presents with a painful joint, try to distinguish whether the source of pain is articular or periarticular. Painful joints of articular origin produce warmth, tenderness and swelling about the entire joint, with painful movement in all directions. Pain of periarticular origin (outside joint capsule), such as bursitis/tendinitis tends to result in tenderness and swelling localised to a small area, with pain on passive movement only felt in limited planes. It is important to exclude a septic cause in every patient who presents with acute arthritis. Useful investigations include WBC, ESR or CRP and joint aspiration. Joint aspiration The most important diagnostic test in patients presenting with acute arthritis is examination of the synovial fluid. When joint aspiration is performed, ensure that an aseptic technique is employed. Avoid joint aspiration through an area of cellulitis. Send fluid for Gram stain, culture, crystal examination and cell count. Remember that the absence of bacteria on Gram staining does not exclude septic arthritis.

  Normal Reactive Infectious
Colour Colourless/pale yellow Yellow Yellow
Turbidity Clear, slightly turbid Turbid Turbid, purulent
Cell count/mm3 200-1000 3000-10,000 >10,000
Predominant cell type Mononuclear Neutrophil Neutrophil
Gram stain None None +ve
Culture -ve -ve +ve

Septic arthritis Pyogenic infection usually reaches a joint via the bloodstream, but may also develop from adjacent osteomyelitis or external skin puncture wounds. Sepsis may progress to complete joint destruction within 24hrs. Infective agents Staph aureus, Haemophilus (commonest type at 6-24 months), Gonococcus, Strep, TB, Salmonella. There is an ↑ incidence in patients with rheumatoid arthritis, those taking steroids, the immunosuppressed and at the extremes of age. Do not overlook septic arthritis superimposed on a non-infectious joint (eg gout, rheumatoid joints). Presentation Typically only 1 joint is affected and is red, painful and swollen. No movement is usually tolerated (but steroids and analgesics can mask many of the common features of septic arthritis). The joint is held in position of most comfort, usually slight flexion. There may be fever, shaking and rigors. Note that hip joint infection may not produce obvious external findings due to its deep location. Do not overlook a septic joint with signs obscured by concomitant antibiotic use. IV drug abusers may have involvement of uncommon joints of the axial skeleton (eg sacroiliac, vertebral and sterno-clavicular joints). Investigation FBC, ESR or CRP, blood cultures, joint aspiration (see above).X-rays may be initially normal or show only soft tissue swelling with displacement of capsular fat planes. Later, features of bone destruction occur. Treatment Commence IV antibiotics (ampicillin if < 5yrs old, flucloxacillin + benzylpenicillin if > 5yrs old). Refer urgently to the orthopaedic team for joint irrigation/drainage, analgesia, splintage of the joint. P.473
Note—Prosthetic joint infection can be difficult to detect, but pain is constant and present at rest. Suggestive radiologic features include widening and lucency of the bone-cement interface by > 2mm, movement of the prosthesis, periosteal reaction and fractures through the cement. Causes of polyarthritis

  • rheumatoid arthritis
  • ankylosing spondylitis
  • Reiter’s disease
  • psoriatic arthritis
  • arthritis associated with inflammatory bowel disease
  • viral arthritis
  • rheumatic fever
  • gonococcal arthritis
  • gout

P.474
Acute arthritis 2 Acute gout Most commonly affects the 1st MTPJ or knee. Acute gout may be precipitated by trauma, diet, diuretics, renal failure, myeloproliferative disease and cytotoxic drugs. There may be a past history of renal stones and tophi evident on examination. Joint aspiration reveals -vely birefringent crystals. X-rays initially show soft tissue swelling, followed later by punched out lesions in the periarticular bone. Serum uric acid may be ↑, but can be normal during an acute attack. Treat initially with rest and NSAID (or colchicine if NSAID contra-indicated). Do not alter drug treatment of patients already on long-term gout therapy. NB: Septic arthritis can occur in patients with gout—therefore ensure joint aspirates are Gram stained and cultured, even if birefringent crystals are present. Acute pseudogout Typically affects the knees, wrists or hips of an elderly person with history of arthritic attacks precipitated by illness, surgery or trauma. Acute pseudogout is associated with a variety of diseases: hyperparathyroidism, haemochromatosis, hypothyroidism, Wilson’s disease, diabetes, hypophosphatemia. X-ray shows calcification in joint, menisci, tendon insertions, ligaments, bursae. Aspiration reveals weakly +ve birefringent crystals on polarizing microscopy. Treat symptomatically (with NSAID) and refer. Traumatic arthritis Joint pain, tenderness, ↓ range of movement and haemarthrosis after injury implies intra-articular fracture. Note, however, that septic arthritis may occur in association with trauma, even in the absence of penetrating injury. Osteoarthritis An elderly patient with known OA may present with an acute ‘flare up’ of a chronically affected joint. Constitutional symptoms are not a feature. X-rays may show asymmetrical joint space narrowing, osteophyte formation at the joint margins and subchondral cyst formation. Treat with NSAID and/or paracetamol, plus graduated exercises. Rheumatoid arthritis Presentation Persistent symmetrical deforming peripheral arthropathy typically starts with swollen, painful, stiff hands and feet, which gradually get worse, with larger joints becoming involved. Other modes of presentation are: persistent or relapsing monoarthritis of different large joints, systemic illness with minimal joint problems, sudden onset of widespread arthritis, vague limb girdle aches. Hand signs These include MCPJ and PIPJ swelling, ulnar deviation and volar subluxation at the MCPJs, Boutonnière and ‘swan-neck’ finger deformities. Extensor tendon rupture may occur. Neck problems Degeneration of the transverse ligament of the dens carries the risk of subluxation and cord damage. Extra-articular features Include SC nodules, vasculitis, pulmonary fibrosis, splenomegaly, anaemia, pleurisy, pericarditis, scleritis and kerato-conjunctivitis. Rhematoid factor is +ve in 70% of cases. X-rays show soft tissue swelling, peri-articular osteoporosis, joint space narrowing, bony erosions/subluxation. Complete carpal destruction may occur. Treatment Refer patients who are systemically unwell. Others may benefit from NSAID, splintage and rheumatology clinic referral. P.475
Viral arthritis Rubella, hepatitis B, mumps, Epstein-Barr virus and enteroviruses may cause arthritis. In hepatitis B, arthritis usually affects PIPJ, MCPJ or knee and precedes the onset of jaundice. Rubella is associated with an acute symmetrical arthritis and tenosynovitis. Rheumatic fever (see p636) This is a non-infectious immune disease which follows infection with Group A ß-haemolytic streptococci. Typically, a migratory or additive symmetrical polyarthritis affects the knees, ankles, elbows and wrists. Diagnosis is based on revised Jones criteria: evidence of previous streptococcal infection (ie recent scarlet fever, +ve throat swab, or anti-streptolysin titre > 200units/mL) plus 2 major or 1 major plus 2 minor criteria. Major criteria: carditis (pericarditis, myocarditis or endocarditis), migratory polyarthritis, chorea, SC nodules, rash (erythema marginatum). Minor criteria: ↑ ESR/CRP, arthralgia, fever, history of previous rheumatic fever (or rheumatic heart disease), ↑ PR interval on ECG. Investigations Throat swab, ESR, CRP and anti-streptolysin titre. Treatment Refer for admission, rest, aspirin, benzyl penicillin and splintage. Sero-negative spondyloarthropathies These have the following common features: involvement of the spine and sacroiliac joints, inflammation then calcification of bony tendon insertions, peripheral inflammatory arthropathy and extra-articular manifestations such as uveitis, aortic regurgitation and pulmonary fibrosis. Ankylosing spondylitis Usually presents with chronic low back pain in men aged 15-30yrs. Progressive spinal fusion ultimately results in a fixed kyphotic spine (which is particularly prone to fracture after injury), hyperextended neck and restricted respiration. Hips, shoulders and knees may be involved. Other features are: iritis, apical lung fibrosis, plantar fasciitis and Achilles tendonitis. There may be normochromic anaemia and ↑ ESR. X-rays show ‘bamboo spine’ (squared vertebrae), eroded apophyseal joints and obliterated sacro-iliac joints. Reiter’s syndrome Triad of urethritis, conjunctivitis and sero-negative arthritis may follow infection (urethritis, cervicitis or dysentery). May cause large joint mono-arthritis of a WB leg joint. Other features: iritis, keratoderma blenorrhagicum, circinate balanitis, plantar fasciitis, Achilles tendonitis, aortic incompetence. Joint aspirate yields inflammatory cells, with -ve culture. WCC and ESR are ↑. Psoriatic arthritis Arthritis rarely precedes skin involvement. Enteropathic arthropathies Inflammatory bowel disease is associated with spondyloarthritis and large joint mono-arthropathy. There may also be a migratory polyarthritis. Gonococcal arthritis May present with fever, migratory tenosynovitis and polyarthralgia, arthritis (knee, ankle or wrist) and skin rash. Genital infection may be silent, especially in women. Take swabs with special culture media and refer for investigation. P.476
Eponymous fractures 1 Correctly applied, the one or two words that comprise an eponymous injury convey succinctly an otherwise involved description of a complex fracture. Aviator’s astragalus Fractures of the neck of the talus, previously commonly observed amongst World War II pilots who crash-landed their damaged planes on returning from bombing raids. The injuries resulted from the upward thrust of the rudder bar, causing dorsiflexion forcing the talus against the anterior tibia. Bankart lesion Avulsion of the joint capsule and glenoid labrum resulting from anterior dislocation of the shoulder joint. It is implicated as a causative factor for recurrent dislocations. Barton’s fracture First described by Barton in 1839, this complex distal radial fracture is intra-articular. Displacement of the distal radial fragment allows subluxation of the carpal bones anteriorly. A rare variety is called a Lentenneur’s fracture. Bennett’s fracture dislocation These intra-articular fractures of the base of the first MC are notorious for allowing the main MC fragment to slip into a poor position. If conservative treatment (POP) is preferred to internal fixation, careful follow-up will be needed to ensure a satisfactory outcome. Boutonnière deformity Rupture of the central slip of the extensor tendon at the PIPJ allows the base of the middle phalanx to ‘button-hole’ through. The remaining two parts of the extensor expansion slip along the side of the finger and act as flexors at the PIPJ, whilst still extending the DIPJ. This produces the characteristic deformity. Boxer’s fracture Fracture of the neck of the 5th MC rarely occurs during a formal boxing bout when gloves are worn. It is much more commonly seen following impromptu street or bar-room brawls: innocuous-looking overlying wounds are often compound human (‘reverse fight’) bites (p402). Bumper fracture The height of the average car bumper renders the adult pedestrian (who is unfortunate enough to be knocked down) particularly vulnerable to a fracture through the lateral tibial condyle into the tibial plateau. There is often an associated tear to the medial collateral knee ligament. Chance fracture A horizontal fracture through a vertebral body, associated arch and spinous process may result from an injury involving distraction and flexion. It typically involves the lumbar spine of car passengers restrained only by a lap belt in a road traffic collision. Clay-shoveller’s fracture Resistance against neck flexion may produce an avulsion of the tip of a spinous process of the lower cervical or upper thoracic spine. The lesion typically affects C7. P.477
Colles’ fracture Abraham Colles, Professor of Surgery in Dublin, described this common distal radial fracture in 1814. The classic dinner fork deformity results from posterior displacement and angulation of the distal fragment (p426). Dashboard dislocation A high speed head-on road traffic collision causing the dashboard to impact upon the flexed knee often results in posterior dislocation of the hip. Dupuytren’s fracture-dislocation A highly unstable ankle injury in which there is a fracture of the distal fibula shaft, disruption of the medial ankle ligament and posterior tibio-fibular ligament. The result is gross diastasis and dislocation of the talus laterally. Essex-Lopresti fracture-dislocation A heavy fall on the outstretched hand may produce a comminuted fracture of the radial head. It is associated with tearing of the interosseous membrane (diastasis), allowing subluxation of the distal ulna. Galeazzi fracture-dislocation Describes the combination of a fracture of the distal radial shaft with dislocation of the distal radioulnar joint (p428). A Moore’s fracture dislocation is a similar injury, except that the radial fracture involves the distal radius, not the shaft. Gamekeeper’s thumb Rupture of the ulnar collateral ligament of the 1st MCPJ was originally described as an occupational injury amongst gamekeepers, sustained whilst breaking the necks of wounded rabbits. It is now most commonly seen after skiing accidents, particularly on artificial slopes, when the thumb is caught in the diamond latticework matting. The injury requires prompt diagnosis and treatment in order to avoid the long-term complication of a weak pinch-grip. Hangman’s fracture Although no longer a part of modern life in the UK, executions were previously achieved by hanging. The victim was allowed to fall several feet before being arrested by a noose. This produced rapid death from severance of the cervical spinal cord. The mechanism of injury is a combination of distraction and extension, causing an unstable (hangman’s) fracture of the pedicles of the axis (C2) and disrupting the intervertebral disc between C2 and C3. The fracture may also result from extension and axial compression and may occur without neurological damage. Hill-Sachs lesion This is an impacted compression fracture of the humeral head which occurs during anterior shoulder dislocation. It is produced by the recoil impaction of the humeral head against the rim of the glenoid as the former dislocates. It is believed by some to be an important causative factor for recurrent dislocation. Horse rider’s knee Frontal impact at the level of the proximal tibio-fibular joint may result in posterior dislocation of the fibular head. Reduction usually requires an MUA. P.478
Eponymous fractures 2 Hume fracture-dislocation This refers to the combination of an olecranon fracture with dislocation of the radial head. Hutchinson fracture Also referred to as a ‘chauffeur’ fracture, this is the name sometimes given to a fracture of the radial styloid. It is classically caused by forced radial deviation of the wrist when the starting handle of an old-fashioned motor car ‘kicks back’. Ice skater’s fracture Children aged 2-8yrs are susceptible to stress fractures of the distal fibula. Jefferson fracture An unstable ‘blowout’ fracture of C1 follows an axial load. One third are associated with a C2 fracture. Jones fracture This is a transverse fracture of the base of the 5th MT just distal to the intermetatarsal joint. It is a more significant injury than an avulsion fracture at the insertion of peroneus brevis, as it is prone to non-union (p467). Le Fort facial fractures Experiments by Le Fort in 1901 were followed by descriptions of facial fractures and classification into three anatomical types (p360), including the Guérin fracture (Le Fort I). Lisfranc fracture-dislocation Fracture dislocation at the tarso-metatarsal joint is a significant injury. It is named after the surgeon who described the surgical operation of partial amputation of the foot at the level of the tarso-metatarsal joint. Luxatio erecta First described in 1859, this is an uncommon shoulder dislocation (inferior glenohumeral dislocation). The term is derived from Latin and describes the erect hyperabducted position of the arm after dislocation. The injury follows a hyperabduction force, most often after a fall. Axillary nerve damage occurs in 60%. Reduction of the dislocation may follow overhead traction or conversion to an anterior dislocation to which conventional techniques can be applied. Maisonneuve injury An unstable injury in which rupture of the medial ankle ligament is associated with a diastasis and proximal fibula fracture. Malgaigne’s fracture An unstable injury in which the pelvic ring is disrupted in two places: anteriorly (through both pubic rami) and posteriorly (sacroiliac joint disruption, or fracture of ilium or sacrum). Mallet injury Stubbing a finger may rupture the extensor tendon (or avulse its phalangeal attachment) at the DIPJ, causing a ‘mallet deformity’, in which the DIPJ is held flexed. The mechanism of injury is forced flexion of the extended DIPJ. March fracture This refers to a stress fracture of the (usually 2nd) MT shaft after heavy and unaccustomed exercise. Traditionally, it was observed after heavy marching in new army recruits. P.479
Monteggia fracture-dislocation Fracture of the proximal ulna shaft is associated with dislocation of the radial head. The latter is relatively easy to miss. Never accept an ulna fracture as an isolated injury without obtaining complete views of both forearm bones, including the elbow and wrist joints. Nursemaid’s elbow Alternative name for a ‘pulled elbow’ in a pre-school child (p684). Nutcracker fracture Lateral force applied to the forefoot may cause the cuboid to be fractured as it is compressed between the calcaneum and the base of the 4th and 5th MTs. O′Donahue’s triad A torn medial meniscus, ruptured anterior cruciate ligament and ruptured medial collateral ligament combine to produce a significant knee injury. Pelligrini-Stieda’s disease Ossification of the medial collateral knee ligament may follow avulsion of the superficial part from its attachment to the medial femoral condyle. Pilon fracture These intra-articular fractures of the distal tibia are uncommon, but may also be subdivided into three types. Pipkin fracture-dislocation This refers to a posterior hip dislocation in which part of the femoral head is avulsed by the ligamentum teres and remains attached to it within the acetabulum. The avulsed fragment is rarely large enough to be reattached. Pott’s fracture This term has come to be applied indiscriminantly to any ankle fracture, which may be simply subdivided into ‘uni-’, ‘bi-’ or ‘tri-malleolar’. Rolando fracture Essentially a comminuted Bennett’s fracture, the classic description is of Y or T shaped intra-articular fractures at the base of the 1st MC. Treatment is difficult. Runner’s fracture Stress fractures of the distal fibula are particularly common amongst runners who chalk up many miles of running on roads each week. Smith’s fracture The so-called ‘reversed Colles’ fracture’ was first described by Smith in 1847. Straddle fracture Falls astride classically produce bilateral vertical pubic rami fractures. Tillaux fracture An avulsion fracture of the distal lateral tibia may occur due to the pull of the anterior tibio-fibular ligament. Toddler’s fracture Undisplaced spiral fractures of the tibial shaft in children < 7yrs often follow minimal trauma and not be visible on initial X-ray. Subperiosteal bone formation is usually apparent radiologically by 2wks (see p686).

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