Chapter 9: Common Trauma

ESSENTIAL TIPS FOR DEALING WITH TRAUMA

Common traps

• Failure to diagnose a foreign body

• Failure to diagnose a ruptured tendon

• Exposed joint capsule in the fist

• Beware of bites, high pressure guns and puncture wounds

Stab wounds

Always assume (and look for) the presence of nerve, tendon or artery injury.

Foreign bodies

Buried wooden splinters, gravel and slivers of glass are old traps—if suspected and not found on simple exploration, order high-resolution ultrasound, which is good at detecting wood and glass. CT is best.

Falling on the outstretched hand

Consider the following fractures: Colles (distal radius); scaphoid; radius and ulna shafts; head of radius; supracondylar (children); neck and shaft of humerus, clavicle and the dislocations—lunate and shoulder.

Jumping or falling from a substantial height onto feet

Always consider a fractured calcaneum, talus, spine (especially lumbar) or pelvis and central dislocation of hip. Concussion can follow.

Cut finger or toe

Always look for a peripheral nerve injury.

Finger tourniquet

If using a small tourniquet such as a rubber band for haemostasis, clip on a small artery forcep so it is not forgotten when you finish.

OTHER CAUTIONARY TIPS

• You can get concussion from a heavy fall onto the coccyx/sacrum.

• Think of a sewing needle in the knee or in the feet of children for unexplained pain.

• Treat (evacuate) haematomas of the nasal septum and ear because they can collapse cartilage.

• Beware of pressure gun injuries into soft tissue, especially those involving oil and paint.

• Beware of a painful immobile elbow in a child—look for a fracture that can cause trouble later.

• Beware of the scaphoid fracture after a fall onto an outstretched hand.

Finger injuries can be treated by simple means, providing there is neither tendon nor nerve injuries complicating the lacerations or compound fractures involved.

FINGER TIP LOSS

Not all finger tip loss demands an immediate graft or tidy-up amputation. If there is no exposed phalanx tip and the area of exposed subdermal tissue is small, conservative management is best. Remember that a grafted finger tip is insensate. If the amputated skin tip is available it should be replaced (use Steri-Strips™ or a couple of small sutures), as it may take as a graft or merely act as a good biological dressing.

Large skin loss

Apply a split skin graft, preferably using a Goulian knife with three spacing devices.

AMPUTATED FINGER

In this emergency situation, instruct the patient to place the severed finger directly ...