Chapter 134

### Introduction

The variety of foreign bodies which have found their way into the rectum is hardly less remarkable than the ingenuity displayed in their removal.

A turnip has been delivered PR by the use of obstetric forceps.

A stick firmly impacted has been withdrawn by inserting a gimlet into its lower end.

A tumbler, mouth downwards, has several times been extracted by filling the interior with a wet plaster of Paris bandage, leaving the end of the bandage extruding, and allowing the plaster to set.

Bailey and Love, Short Practice of Surgery, 1943

Injuries to the skin, including simple lacerations, abrasions, contusions and foreign bodies, are among the commonest problems encountered in general practice. To manage these cosmetically important injuries well is one of the really basic and enjoyable skills of our profession.

Key facts and checkpoints

• A well-prepared treatment room with good sterilisation facilities, instruments, sterile dressings and an assistant facilitates management.

• With lacerations, check carefully for nerve damage, tendon damage and arterial damage.

• Beware of slivers of glass in wounds caused by glass—explore carefully and X-ray (especially with high-resolution ultrasound) if in doubt.

• Beware of electrical or thermal wounds because marked tissue necrosis can be hidden by slightly injured skin.

• Beware also of roller injuries such as car wheels.

• Beware of pressure gun injuries such as oil and paint. The consequences can be disastrous.

• Avoid suturing the tongue, and animal and human bites, unless absolutely necessary.

• Keep drawings or photographs of wounds in your medical records.

• Have a management plan for puncture wounds, including medical needle-stick injuries.

• Gravel rash wounds are a special problem because retained fragments of dirt and metal can leave a ‘dirty’ tattoo-like effect in the healed wound.

### Contusions and haematomas

A contusion (bruise or ecchymosis) is the consequence of injury causing bleeding in subcutaneous or deeper tissue while leaving the skin basically intact. It might take weeks to resolve, especially if extensive.

A haematoma is a large collection of extravasated blood that produces an obvious and tender swelling or deformity. The blood usually clots and becomes firm, warm and red; later (about 10 days) it begins to liquefy and becomes fluctuant.

#### Principles of management

• Explanation and reassurance

• RICE (for larger bruises/haematomas) for 48 hours

• R = Rest

• I = Ice (for 20 minutes every 2 waking hours)

• C = Compression (firm elastic bandage)

• E = Elevation (if a limb)

• Analgesics: paracetamol/acetaminophen

• Avoid aspiration (some exceptions)

• Avoid massage

• Heat may be applied after 72 hours as local heat or whirlpool baths

• Consider possibility of bleeding disorder if bleeding is out of proportion to the injury

#### PROBLEMATIC HAEMATOMAS

Some haematomas in certain locations can cause deformity and other problems.

##### Haematoma of nasal septum1
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