Chapter 9: Common 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.

• 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.

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.

In this emergency situation, instruct the patient to place the severed finger directly into a fluid-tight sterile container, such as a plastic bag or sterile specimen jar. Then place this ‘unit’ in a bag containing iced water with crushed ice.

Note: Never place the amputated finger directly in ice or in fluid such as saline. Fluid makes the tissue soggy, rendering microsurgical repair difficult.

Care of the finger stump

Apply a simple, sterile, loose, non-sticky dressing and keep the hand elevated.

A method of applying a dressing (using an adhesive dressing strip) for an injured finger tip is described.

Method

1. Cut a suitable length of the dressing strip almost as long as the finger.

2. Cut through the adhesive margins to the central non-adhesive dressing about 1–1.5 cm from the top (Fig. 9.1).

3. Remove the backing from the lower larger segment and apply to the injured side of the finger. Wrap the adhesive part around the circumference of the finger.

4. Now remove the backing from the upper segment and fold it backwards over the tip, with the adhesive margins wrapped around the finger to provide the most effective dressing.

Abrasions or ‘gravel rash’ vary considerably in degree and potential contamination. They are common with bicycle or motorcycle accidents and skateboard accidents. Special care is needed over joints such as the knee or elbow.

Management (see Chapter 1)

• Clean meticulously, remove all ground-in dirt, metal, clothing and other material.

• Scrub out dirt with sterile normal saline under anaesthesia (local infiltration or general anaesthesia for deep wounds). Adequate local anaesthesia may also be achieved by coating the wound liberally with Xylocaine^® jelly 2% and leaving for 10 minutes.

• Treat the injury as a burn.

• When clean apply a protective dressing (some wounds may be left open).

• Use paraffin gauze and non-adhesive absorbent pads such as Melolin™.

• Ensure adequate follow-up.

• Immobilise a joint that may be affected by a deep wound.

When trauma to the pinna causes a haematoma between the epidermis and the cartilage, a permanent deformity known as ‘cauliflower ear’ may result. The haematoma, if left, becomes organised and the normal contour of the ear is lost.

The aim is to evacuate the haematoma as soon as practicable and then to prevent it re-forming. One can achieve a fair degree of success even on haematomas that have been present for several days.

Method

1. After cleansing the pinna with a suitable solution (e.g. cetrimide), insert a 25-gauge needle into the haematoma and aspirate the extravasated blood.

2. Position the needle at the lowest point while pressing the upper border of the haematoma gently between finger and thumb (Fig. 9.2a).

3. Apply a padded test tube clamp or clothes line peg to the haematoma site and leave on for 30–40 minutes. The test tube clamp has large jaws that allow it to be placed over the haematoma site (Fig. 9.2b).

Generally, daily aspirations and clamping are sufficient to eradicate the haematoma completely.

Septal haematoma following injury to the nose can cause total nasal obstruction. It is easily diagnosed as a marked swelling on both sides of the septum when inspected through the nose (Fig. 9.3). It results from haemorrhage between the two sheets of mucoperiosteum covering the septum. It may be associated with a fracture of the nasal septum.

Note: This is a most serious problem as it can develop into a septal abscess. The infection can pass readily to the orbit or the cavernous sinus through thrombosing veins and may prove fatal, especially in children. Otherwise it may lead to necrosis of the nasal septal cartilage followed by collapse and nasal deformity.

Treatment

• Remove the blood clot on both sides through an incision, under local anaesthetic. This must be done within 2 hours of injury.

• Prescribe systemic (oral) antibiotics, e.g. penicillin or erythromycin.

• Treat as a compound fracture if an X-ray reveals a fracture.

A haematoma over the tibia (shin bone) can be persistently painful and slow to resolve. An efficient method is, under very strict asepsis, to inject 1 mL of 1% of lidocaine and 1 mL of hyaluronidase and follow with immediate ultrasound. This may disperse or require drainage.

A patient who has been injured by a wheel or by rollers passing over a limb can present a difficult problem. An arm caught in the wringers of an old-fashioned washing machine used to be a common example, but a more likely problem now is the wheel of a vehicle passing over a limb, especially a leg.

A freely spinning wheel is not so dangerous, but serious injuries occur when a non-spinning (braked) wheel passes over a limb, and then perhaps reverses over it. This leads to a ‘degloving’ injury due to shearing stress. The limb may look satisfactory initially, but skin necrosis will follow.

To manage a ‘wheel over the limb’ injury, treat it as a serious problem and admit the patient to hospital for observation. Surgical intervention with removal of necrotic fat may be essential. Fasciotomy with open drainage may also be an option.

This method describes the simple principle of applying axial compression for the clinical diagnosis of fractures of bones. It applies especially to suspected fractures of bones of the forearm and hand, but also applies to all bones of the limbs.

Many fractures are obvious when applying the classic methods of diagnosis: pain, tenderness, loss of function, deformity, swelling and sometimes crepitus. It is sometimes more difficult if there is associated soft-tissue injury from a blow or if there is only a minor fracture such as a greenstick fracture of the distal radius.

If the bone is compressed gently from end to end, a fracture will reveal itself and the patient will feel pain. A soft-tissue injury of the forearm will show pain, tenderness, swelling and possibly loss of function. It will, however, not be painful if the bone is compressed axially—that is, in its long axis.

Walking is another method of applying axial compression, and this is very difficult (because of pain) in the presence of a fracture in the weight-bearing axis or pelvis. Hence, every patient with a suspected fracture of the lower limb should be tested by walking.

Method

1. Grasp the affected area both distally and proximally with your hands.

2. Compress along the long axis of the bones by pushing in both directions, so that the forces focus on the affected area (fracture site; Fig. 9.4a). Alternatively, compression can be applied from the distal end with stabilising counterpressure applied proximally (Fig. 9.4b).

3. The patient will accurately localise the pain at the fracture site.

A simple office test for a suspected fractured mandible is to get the patient to bite on a wooden tongue depressor (or similar firm object).

Ask them to maintain this bite as you twist the spatula (Fig. 9.5). If they have a fracture, they cannot hang on to the spatula because of pain.

• Check the patient’s bite and airway.

• Remove any free-floating tooth fragments and retain them.

• Replace any avulsed or subluxed teeth in their sockets.

  Note: Never discard teeth.

• First aid immobilisation with a four-tailed bandage (Fig. 9.6).

Treatment

Refer for possible internal fixation.

A fracture of the body of the mandible will usually heal in 6 to 12 weeks (depending on the nature of the fracture and the fitness of the patient).

There is a history of a fall onto the outstretched hand or elbow. The patient has pain aggravated by shoulder movement and usually supports the arm at the elbow and clasped to the chest. The most common fracture site is at the junction of the outer and middle thirds, or in the middle third.

Treatment

• St John elevated sling to support the arm—for 3 weeks.

• Figure-of-eight bandage (used mainly for severe discomfort).

• Early active exercises to elbow, wrist and fingers.

• Active shoulder movements as early as possible.

Special problem

Fracture at the lateral end of the bone. Consider referral for open reduction.

Healing time

4 to 8 weeks.

The healing times for uncomplicated fractures are presented in Table 9.1.

A figure-of-eight bandage can be made simply by inserting pads of cotton wool into pantyhose or stockings.

A simple rib fracture can be extremely painful. The first treatment strategy is to prescribe analgesics such as paracetamol, and encourage breathing within the limits of pain.

If pain persists in cases of single or double rib fracture with no complication, application of a rib support is most helpful.

The universal rib belt

A special elastic rib belt can provide thoracic support and mild compression for fractured ribs (Fig. 9.7). Despite its flexibility it gives excellent support and symptom relief while permitting adequate lung expansion.

The elastic belt is 15 cm wide and has Velcro grip fastening, so it can be applied to a variety of chest sizes.

Healing time

3 to 6 weeks.

Towel method

The patient can wrap a standard-sized towel (folded lengthwise to a third of its width) around the chest and secure it with a large safety pin. When the patient is about to cough, the towel can be pulled tight by the patient.

These fractures require as near perfect reduction as possible, careful splintage and, above all, early mobilisation once the fracture is stable—usually in 2 or 3 weeks.

Early operative intervention should be considered if the fracture is unstable.

Angulation is usually obvious, but it is most important to check for rotational malalignment, especially with torsional fracture. A simple method is to get the patient to make a fist of the hand and check the direction in which the nails are facing. Furthermore, each finger can be flexed in turn and checked to see if the fingertips point towards the tubercule of the scaphoid (palpable halfway along the base of the thenar eminence and 1.5 cm distal to the distal wrist crease).

The phalanges

Treatment of uncomplicated fractures

For non-displaced phalanges with no rotational malalignment, strap the injured finger to the adjacent normal finger with an elastic garter or adhesive tape for 2 to 3 weeks, i.e. ‘buddy strapping’ (Fig. 9.8). Start the patient on active exercises.

If pain and swelling is a problem, splint the finger with a narrow dorsal or anterior slab (a felt-lined strip of malleable aluminium can be used) (Fig. 9.9). An alternative is to bandage the hand while the patient holds a tennis ball or appropriate roll of bandage in order to maintain appropriate flexion of all interphalangeal joints.

There are three slings in common use in first aid:

Collar and cuff sling

This is useful for the patient with a fractured humerus, including an undisplaced supracondylar fracture, because it allows gravity to realign the distal and proximal parts of the fractured bones.

Method

1. Using a narrow bandage, make a clove hitch (Fig. 9.10a). The clove hitch is made by fashioning two loops—one towards your body and the other away, leaving one end of the bandage longer than the other. Now place your fingers under the loops and bring them together.

2. Slide the loops over the wrist of the injured arm with the knot of the clove hitch on the thumb side of the wrist.

3. Gently flex the elbow and elevate the injured arm so that the fingers point towards the opposite shoulder (Fig. 9.10b).

4. Place the long end of the bandage around the neck and tie the bandage, using a reef knot (Fig. 9.10c).

The broad arm sling

This has multiple uses but is used mainly for injuries to the forearm and wrist.

Method

1. Place an open triangular bandage over the patient’s chest, with the point of the triangle stretching beyond the elbow of the injured side. Place the flexed forearm over the bandage as shown (see Fig. 9.11a).

2. Carry the upper end of the bandage over the shoulder on the uninjured side, around the back of the neck. Ensure that the injured arm lies slightly above the horizontal position.

3. Tie the long ends of the bandage in the hollow above the collar bone of the injured side (see Fig. 9.11b).

4. Fold the corner adjacent to the injured elbow and secure it with a safety pin.

The St John sling

This sling, used for a fractured clavicle, dislocated acromioclavicular joint, or fractured or infected hand, supports the elbow and keeps the hand in elevation resting comfortably on the shoulder of the uninjured side.

Method

1. Place an open triangular bandage over the patient’s forearm and hand with the point of the triangle to the elbow and the upper end over the far shoulder.

2. Tuck the long edge of the bandage under the whole forearm to make a supporting trough (Fig. 9.12a).

3. Convey the lower dependent end around the patient’s back to the front of the far shoulder.

4. Tie the ends as close to the fingers as possible (Fig. 9.12b).

5. Tuck the triangular point firmly in between the forearm and the bandage.

6. Secure the fold with a safety pin when the sling is firm, comfortable and at the correct elevation.

The makeshift sling

An effective sling can be made with a large jumper or windcheater.

Method

1. Place the sleeves of the jumper around the neck and knot the ends.

2. Guide the affected arm into the sleeve until a suitable recess is found.

• Plain X-rays often unnecessary for some fractures e.g. ‘greenstick’ of arm, clavicle.

• Children under 8 years usually take half the time to heal.

• Have a check X-ray in 1 week (for most fractures).

• Radiological union lags behind clinical union.

Immediate repair of cut tendons by primary suture is important (certainly within 72 hours), preferably by an experienced surgeon. Partial ruptures usually require no active surgery, although primary repair is recommended if greater than 40% of the tendon is severed.

Method for totally cut tendon

1. Debride the wound.

2. Pass a loop suture of 3/0 monofilament nylon on a straight needle into the tendon through the cut surface close to the edge to emerge 5 mm beyond and then construct a figure-of-eight suture as shown in Fig. 9.13a–c.

3. Pull the two ends of the suture to take up the slack without bunching the tendon (Fig. 9.13d).

4. Repeat this with the other end of the tendon (Fig. 9.13e).

5. Tie the corresponding suture ends together in order to closely approximate the cut ends of the tendon (Fig. 9.13f).

6. Bury the knots deep between the tendon and cut the sutures short (Fig. 9.13g).

Post-operation

Hold the repaired tendons in a relaxed position with suitable splintage for 3 to 4 weeks.

Burns can be caused by flame/fire, hot liquids, hot objects such as irons and heaters, ultraviolet radiation, electricity and certain chemicals. Scalds are burns from hot liquids, hot food or steam.

First aid, including safety rules

The immediate treatment of burns, especially for smaller areas, is immersion in cold running water such as tap water, for a minimum of 20 minutes. Do not disturb charred adherent clothing but remove wet clothing.

• Ensure you and the burnt person are safe from further injury or danger.

• Cool a burnt or scalded area immediately for at least 20 minutes with cool to cold (around 15°C; preferably running) water.

Safety first rules

• Stop the burning process and remove any source of heat, if possible.

• Flames: Smother with a blanket (preferably a ‘fire blanket’ if available).

  • Direct flames away from the head or douse with water.

  • Roll person on ground if clothing still burning.

  • Remove clothes over the burnt area IF not stuck to skin.

• Scalds: Remove clothing that has been soaked in boiling water or hot fat.

  • Remove clothing carefully only if the skin is not blistered or stuck to it.

  • Cool with cool or tepid water for at least 20 minutes.

• Chemical burns: Remove affected clothing.

  • Wash or irrigate the burn for at least 30 minutes.

  • Do not try to neutralise the chemical.

• Electrical: Disconnect the person from the electrical source.

  • Use a wooden stick or chair to remove person if you cannot switch off the electricity. (Don’t approach if connected to high-voltage circuit.)

Some useful rules

• It is best to cut clothing with sharp scissors especially from limbs.

• Remove possible constricting items, e.g. bracelets, watches, rings.

• Cover the burn with plastic cling wrap (not the first 6 cm). Apply this in strips and not wrapped circumferentially.

• A burnt hand can be placed in a plastic bag.

• Give basic analgesics for small burns e.g. paracetamol.

• Cool running water is useful for 3 hours after a burn.

• Cool the burn; warm the patient.

Some don’ts

• Prick blisters (leave this to medical attendants).

• Apply creams, ointments, grease, lotions.

• Apply adhesive, sticky or fluffy cotton dressings.

• Put butter, oils, ice or ice water on burns to children.

Types of burns

There are three levels of burns.

• Superficial—affects only the top layer of skin. The skin will look red and is painful.

• Partial thickness—causes deeper damage. The burn site will look red, blistered, peeling and swollen with yellow fluid oozing and is very painful.

• Full thickness—damages all layers of the skin. The burn site will look white or charred black. There may be little or no pain.

Remember

Consider your own safety as you stop the burning process:

• if on fire—stop–drop–roll

• if chemical—flush with copious water

• if electrical—turn off power.

Refer the following burns to hospital:

• > 9% surface area, especially in a child

• > 5% in an infant

• all deep burns

• burns of difficult or vital areas (e.g. face, hands, perineum/genitalia, feet)

• burns with potential problems (e.g. electrical, chemical, circumferential)

• suspicion of inhalational injury

• suspicion of non-accidental injury in children or vulnerable people

• burns in the elderly, children < 12 months and pregnant women.

Always give adequate pain relief. During transport, continue cooling by using a fine mist water spray.

Major burns

A major burn is an injury to more than 20% of the total body surface for an adult and more than 10% for children. As a guiding rule, one arm is about 9%, one leg 18%, face 7% in adults and 16% in toddlers. The surface area of burns for a child is shown in Figure 9.14, which includes the useful Lund–Browder chart for estimating the extent of the burn.

Major burns are a medical emergency and require urgent treatment: call triple zero (000) or your local emergency number.

Guidelines for going straight to hospital (burns unit)

• Full thickness burns—adults over 10% and children over 5% of body surface

• Burns including partial thickness burns to difficult and vital areas—hands, feet, face, joints, perineum and genitalia

• Circumferential burns—those that go right around a limb or the body

• Respiratory/inhalation burns (effects may be delayed for a few hours)

• Electrical burns

• Chemical burns

Commonly used appropriate burns dressings

• Open weave retention stretch adhesive material (e.g. Acticoat™, Fixomull^®, Mefix^®). Requires daily or twice daily cleansing of the serous ooze and reapplication of outer bandage. Leave 7 days

• Semipermeable transparent (e.g. OpSite^®, Tegaderm™)

• Hydrocolloids (e.g. Comfeel^®, Duoderm^®)

• Paraffin impregnated gauze (e.g. Jelonet™, Unitulle)

Treatment

1. Very superficial—intact skin: Can be left with an application of a mild antiseptic only. Review if blistering.

2. Superficial—blistered skin: Apply a dressing to promote epithelialisation (e.g. hydrocolloid sheets, hydrogel sheets) covered by an absorbent dressing (e.g. paraffin gauze or Melolin™)

   or

   a retention stretch adhesive material (e.g. Fixomull^®, Mefix^®, OpSite^®) with daily or twice daily cleaning of the serous ooze and reapplication of outer bandage. Leave 7 days.

Acticoat™

A silver impregnated dressing favoured by several burns units including Royal Perth Hospital. Preferred for deeper superficial wounds. Main indications—acute burns, partial thickness and infected or contaminated wounds.¹

Method for acute burns—after first aid

• Apply Acticoat™ dressing over cleansed burnt area with dark side facing wound

• Apply two layers of Jelonet™, followed by dry gauze or padding

• Secure with loose bandages or loose stretch netting

If wound bed is dry, apply gel (e.g. Intrasite^® gel) over the wound before applying Acticoat™.

Rule: Wound must be kept moist otherwise skin damage and delayed healing occurs.

Guidelines to patient for retention dressings

• First 24 hours: keep dry. If there is any ooze coming through the dressing, pat dry with a clean tissue.

• From day 2: wash over dressing twice daily. Use gentle soap and water, rinse then pat dry. Do not soak. Rinse only. Do not remove the dressing as it may cause pain and damage to the wound. If the wound becomes red, hot or swollen or if pain increases, return to the clinic.

• From day 7: return to the clinic for removal of the dressing. Two hours prior to coming into the clinic, soak the dressing with olive oil then cover with cling wrap.

Note: Dressing must be soaked off with oil (e.g. olive, baby, citrus or peanut). Debride ‘popped blisters’. Only pop blisters that interfere with dermal circulation.

1. Deep burns. If considerable ooze, apply the following in order.

   • Solosite^® gel, Solugel^® or similar

   • non-adherent neutral dressing (e.g. Melolin)

   • layer of absorbent gauze or cotton wool (larger burns).

Change every 2 to 4 days with analgesic cover. Surgical treatment, including skin grafting, may be necessary.

Exposure (open method)

• Keep open without dressings (good for face, perineum or single surface burns).

• Renew coating of antiseptic cream every 24 hours.

Dressings (closed method)

• Suitable for circumferential wounds.

• Cover creamed area with non-adherent tulle (e.g. paraffin gauze).

• Dress with an absorbent bulky layer of gauze and wool.

• Use a plaster splint if necessary.

Burns to the hand

For superficial blistered burns to the hand or similar ‘complex’ shaped parts of the body apply strips of the retention stretch adhesive dressings as described above. They conform well to digits. Apply an outer bandage. At 7 days soak the dressings in oil for 2 hours prior to coming into the clinic.

Following an injury to the arm or hand that has the potential for a nerve injury, it is important when one examines a hand to have a knowledge of simple tests that detect injuries to the three main nerves—the median, the ulnar and the radial.

The ‘quick’ hand test for nerve injury

Get the patient to make the following configurations:

• ‘4-fingered cone’ (Fig. 9.15a)—if the patient can do this, the ulnar nerve is intact

• ‘5-fingered cone’ and ability to approximate the thumb (Fig. 9.15b)—success means the median nerve is intact

• ‘trigger test’ for the thumb—that is, extension—if normal, the radial nerve is intact (Fig. 9.15c).

Summary of arm nerve injuries

• Ulnar nerve—inability to abduct little finger

• Median nerve—inability to abduct thumb

• Radial nerve—inability to extend thumb

Froment’s sign

Ask the patient to grip a sheet of paper forcefully between the thumbs and index fingers while the examiner tries to pull the paper away. A positive Froment’s sign is a weak pinch with marked flexion of the interphalangeal joint of the thumb. This occurs because of loss of action of adductor pollicis caused by injury to the deep branch of the ulnar nerve. Flexor pollicis longus overcompensates.