ACC579 Treatment profiles 2001

Transcription

ACC5157 Cover a/w.fh8 11/12/00 1:06 PM Page 1
ISBN 0-478-11756-6
ACC 579
Treatment Profiles 2001
Printed December 2000
Treatment
Profiles
2001
Composite
I M P O R TA N T
PLEA SE READ BEFORE CONTINUING
The information contained in these Treatment
Profiles is Copyright to Accident Compensation
Corporation (ACC). December 2000.
All Rights Reserved.
These Profiles are made available by ACC to
the recipient on the basis that they will be kept
and used only by the recipient, and not lent,
sold or otherwise made available to any third
party or reproduced in any way, without ACC’s
prior written consent. By opening these Profiles
the recipient is agreeing to this condition but,
if not agreed to, these Profiles are to be promptly
returned to ACC.
Composite
CONTENTS
1 Return to Work
2 Fractures/Dislocations – Plastering Guide
3 Burns
4 Gradual Onset
5 Sprains
6 Lacerations/Abrasions
7 Contusions/Crush Injuries
8 Miscellaneous
Introduction
KEY POINTS
• Treatment Profiles 2001 are consensus-based (not evidence-based)
guidelines and are NOT rigid protocols. They are intended as a resource
for clinicians to help summarise current practice in management of
common injuries
• Read codes: recording of injury diagnosis as Read codes is essential.
Record the lowest relevant level of Read code
For multiple injuries record Read codes for each injury
If you cannot find a Read code for the injury, use code Z (unspecified
conditions) and provide an accurate written diagnosis
• Incapacity Duration Guides contained in the Profiles should be used
where possible for any “time off work” certification
ACC is responsible for providing access to the most effective treatment,
rehabilitation and support services to help claimants lead as normal a life
as possible after an injury. These Treatment Profiles are available to assist
treatment providers, working with ACC, to achieve this goal.
What is a Treatment Profile?
A Treatment Profile is a guide to the treatment and rehabilitation services
ACC expects claimants to receive for a particular injury. Most of the Profiles
were developed by medical organisations as a summary of current good
practice, which includes diagnosis, investigation, treatment, referral indications
and expected outcomes (including incapacity duration).
The Profiles cover a wide range of common injuries but are not rigid
prescriptions. They are intended to provide flexibility and choice in clinical
judgment according to patients’ individual circumstances.
Why use Treatment Profiles?
• As an aid for clinical management
• To help clinicians manage expectations of patients, providers, employers
and case managers. Experience shows this is the key to achieving timely,
lasting and cost-effective outcomes
• As an insurer, ACC works to balance the interests of premium payers and
claimant needs by purchasing effective, affordable health provider services.
The Profiles provide a benchmark for ACC to effectively monitor these
services
How were the Profiles Developed?
ACC selected approximately 150 Read codes that cover most primary care
injuries. Based on these codes and advice from various health providers, the
Treatment Profiles were organised into several categories.
Treatment Profiles were written by a wide range of health professionals and
subjected to thorough peer review. These Profiles are consensus-based
guidelines and are not evidence based.
continued overleaf...
ACC Treatment Proﬁles – 2001
Introduction
Introduction
Using Treatment Profiles
Content:
Two distinct information sections are contained for each profile.
• The major section of the profile contains the consensus-developed clinical
information as a summary of current good practice
• The section titled Optimal Work Incapacity Duration Guides summarises
data covering the likely incapacity durations. These have not been subjected
to consensus review.
Read Coding
Developed in the UK, this is a multi-level system of diagnosis coding that
aims to help GPs, primary care providers and funders in managing clinical
practice. For example, by using Read codes, a GP can keep track of all
patients who suffer low back strains and implement health management
strategies accordingly.
The New Zealand Health Information Service (NZHIS) is the New Zealand
agent for the codes and is providing the system free of charge to providers
and agencies. NZHIS encourages GPs to adopt the system for their own
benefit as well as to provide accurate reports to NZHIS for planning and
funding purposes. Practice management system developers are also modifying
their systems to incorporate Read codes.
Providers must record Read codes for all ACC claims. For GPs without Read
code software, ACC can provide a quick Read code reference list sorted by
type and location of injury.
Points to note:
• Read codes are a hierarchical coding system – each level provides more
specific diagnosis. Please record the lowest relevant level of Read code.
• Where there are multiple injuries, please record the Read code for each injury
• If you cannot source a Read code, use code Z (unspecified condition)
and provide an accurate written diagnosis. An ACC Case Manager may
contact you to clarify and confirm the diagnosis.
If you have any questions about using Read codes please contact NZHIS or
your local ACC branch.
Incapacity Durations
Each Treatment Profile indicates the possible “time off work” required. This
is based on a return to work duration: when most people without significant
treatment complications or co-morbid medical conditions are likely to be
able to return to work.
Most Treatment Profiles provide five occupational classes based on the
amount and frequency of exertion or force required in their work duties.
For example:
• “Sedentary” work requires sitting most of the time but can include walking
or standing for brief periods
• “Very Heavy” work involves exerting 45kg occasionally, and/or 23kg
frequently and/or 9kg constantly
Introduction
Introduction
Please use the following guide to determine the appropriate occupational
class based on your patient’s usual work duties:
• Sedentary, eg office worker/receptionist
• Light, eg shop assistant/parking warden
• Medium, eg shelf packer/light factory worker
• Heavy, eg mechanic/plasterer
• Very Heavy, eg labourer/drain layer
ACC Case Managers will develop your patient’s rehabilitation plan based on
this guide. The information you provide will help them liaise with the
employer and patient about return to work goals and alternative work duties,
if appropriate.
Please also use the duration guides for any “time off work” certification for
injuries covered by the Profiles. Obviously, some patients may take less or
more time to recover so please modify the durations as required. To help
with rehabilitation planning, an ACC Case Manager may contact you to
discuss these special circumstances.
Any listed injury is not necessarily covered by ACC in every instance: eg an
injury with a gradual onset over several weeks, but caused by a non-work
activity. Cover under the ACC scheme is determined by legislation.
Introduction
Introduction
Thank You
ACC would like to acknowledge the following groups in particular, for their
considerable contribution to the original 1999 Treatment Profiles:
• First Health, Auckland
• Integrated Primary Care Services Ltd, in conjunction with the National
Institute of Health and Safety Ltd
• Pinnacle IPA, Hamilton
• Wellington IPA
• Papanui Medical Centre
Valuable contributions also came from the New Zealand Society of
Physiotherapists, the Royal Australasian College of Radiologists, Smith and
Nephew Limited, the New Zealand Medical Association and the National
Poisons Centre.
The following organisations and people have contributed extensively to this
2001 edition:
• Royal New Zealand College of GPs
Jim Vause, Rob Williams, Carole Atmore, Mick Ozimek, Janet Irvine,
Saji Weerasinghe
• Accident and Medical Practitioners Association
Alistair Sullivan, Rob Kofed
• Australasian College of Emergency Medicine
Michael Roberts, Scott Pearson
• Faculty of Rehabilitation Medicine
Tudor Caradoc-Davies
• New Zealand Orthopaedic Association
Alan Panting
• Faculty of Occupational Health Medicine
Des Gorman
• National Poisons Centre
John Fountain
• Doctors for Sexual Abuse Counselling
Regular updating of these Treatment Profiles will be undertaken. ACC’s
health services subsidiary company (ACC Healthwise) will be responsible
for the Treatment Profiles.
Introduction
CONTENTS
Optimal Work Incapacity Duration Guides –
Fractures/Dislocations
Gradual Onset
Sprains
Miscellaneous
Return to Work
1 return to
work
Section 1 Return to Work
Optimal Work
Incapacity Durations
WORK DEFINITIONS
Five job classifications based on the amount of physical effort required, are used
in this book. The classifications are taken from the Strength Factor classifications
described in the United States Department of Labour’s Dictionary of Occupational
Titles.
Sedentary Work
Exerting up to 4.5kg of force occasionally and/or a negligible amount of force
frequently or constantly to lift, carry, push, pull, or otherwise move objects,
including the human body. Sedentary work involves sitting most of the time,
but may involve walking or standing for brief periods of time. Jobs are sedentary
if walking and standing are required only occasionally and other sedentary
criteria are met.
[*] Reprinted with permission from the Medical
Disability Advisor: Workplace Guidelines for
Disability Duration, Third Edition (1997),
Presley Reed, MD (Reed Group, Ltd. Boulder,
Colorado, USA. (303) 247 1860. All rights
reserved, http://www.rgl.net
Light Work
Exerting up to 9kg of force occasionally and/or up to 4.5kg of force frequently,
and/or negligible amount of force constantly to move objects. Physical demand
requirements are in excess of those for Sedentary Work. Light Work usually
requires walking or standing to a significant degree. However, if the use of the
arm and/or leg controls requires exertion of forces greater than that for Sedentary
Work and the worker sits most the time, the job is rated Light Work.
Medium Work
Exerting up to 22.5kg of force occasionally, and/or up to 9kg of force frequently,
and /or up to 4.5kg of forces constantly to move objects.
Heavy Work
Exerting up to 45kg of force occasionally, and/or in excess of 22.5kg of force
frequently, and/or in excess of 9kg of force constantly to move objects.
Very Heavy Work
Exerting in excess of 45kg of force occasionally, and/or in excess of 22.5kg of
force frequently, and/or in excess of 9 kg of force constantly to move objects.
Other important factors, in addition to kilograms of force, may help define an
individual’s job classification. These factors include posture, biomechanics (size,
shape and manageability of the object being moved), height from and to which
the object is lifted, and frequency of exertion. Each of these factors (and any
other job-specific requirements) should be considered when determining
expected length of disability.
The above classifications focus on physical effort only and may not be relevant
to the duration of some disability.
The guideline tables on the following pages provide the optimum time for each
job classification. This data is most useful when envisioned as a continuum in
the case management process. It does not represent the absolute length of
disability at which an individual must or should return to work. Rather, it
represents an important point of time at which, if full recovery has not occurred,
additional evaluation should take place. This allows for individual differences
in recovery times based on the innumerable variables that impact disability
duration.
The diagnosis for which duration guidelines have been included are those where
an expectation can reasonably be established. Durations for lacerations, contusions
and burns are dependent on the extent and nature of the injury and work
environment. Providers are expected to take these factors into consideration
when determining optimum duration for these injuries.
Optimal Work Incapacity Durations
Read Code - Description
Return to Work Durations* by Occupational Class
Sedentary Light
Medium
Heavy
Very Heavy
S120.
S200.
S22..
Closed Rib Fracture
14
21
21
28
28
Closed and Non-displaced Clavicle Fracture
14
28
56
84
84
Closed Fracture of Humerus
14
28
91
147
119
S2241 Closed Fracture of Distal Humerus, Supracondylar
14
21
91
182
S230.S231.
Fracture of the Proximal Radius and Ulna
14
28
91
119
147
147
S234.S235. Fracture of the Distal Radius and Ulna
14
21
91
182
182
S2401. Closed Fracture of Scaphoid
21
28
119
147
182
147
182
Fracture of Metacarpal Bone
7
14
21
28
42
Fracture of Phalanges of the Hand
14
14
28
42
42
Fracture of Tibia
28
42
182
224
273
Fracture of Fibula
7
14
42
77
98
S340/3 Fracture of the Ankle - Medial or Lateral
14
28
56
84
112
S344/5 Fracture of the Ankle - Bimalleolar
14
28
70
112
S25..
S26..
S33..
S33..
S352.
S36..
S41..
S44..
Fracture of Carpal Bone
21
28
119
112
182
S232.S233. Fracture of the Shaft of Radius and Ulna
14
28
70
91
S242.
Closed Fracture of Other Tarsal/Metatarsal
7
21
42
70
70
Closed Fracture of Phalanges of the Foot
7
14
21
35
35
Dislocation/Subluxation of the Shoulder
14
28
28
42
63
Dislocation/Subluxation of the Finger/Thumb
3
3
3
3
3
Gradual Onset
Sedentary
Light
Medium
Heavy
Very Heavy
F340.
N211.
Carpal Tunnel
7
7
14
Rotator Cuff Shoulder Syndrome
3
3
21
21
28
42
42
N2131 Medial Epicondylitis – Elbow
14
14
21
28
28
N2132 Lateral Epicondylitis – Elbow
14
14
21
28
28
N2165 Prepatellar Bursitis
7-14
14
84
140
140
N2174 Achilles Tendonitis
7
7
14
14
21
S5504 Sprain, Tendocalcaneous (Achilles Tendon)
3-7
7-21
7-28
21-56
21-56
N220. Synovitis/Tenosynovitis
7
7
21
14
14
Gradual Onset
Sprains
Sedentary
Light
Medium
Heavy
Very Heavy
N142.
S572.
N143.
Low Back Pain, Acute Back Pain – Lumbar, Lumbago
1
3
7
10
14
Lumbar Sprain
7
7
7
14
17
Sciatica
7
21
56
91
14
Medical certificates for time off work should seldom, if ever, be provided
for more than 1 week at a time, within the first 4 weeks
N131.
S570.
Cervicalgia – Neck Pain
1
3
7
10
14
Neck Sprain
3
14
21
28
7
Medical certificates for time off work should be seldom, if ever, provided
for more than 1 week at a time, within the first 4 weeks.
N2264 Hand/Wrist Flexor Tendon Rupture
56
70
84
S460.
S461.
S500.
84
84
Meniscal Tear – Medial
7
14
28
35
42
Meniscal Tear – Lateral
7
14
28
35
42
21-70
21-70
Sprain, Acromio-Clavicular Ligament
7-14
7-14
21-42
Grade 3: May not be able to return to heavy or very heavy work
S503.
S504.
S507.
S5Q2.
Sprains
Sprain, Infraspinatus Tendon
7-14
7-14
21-42
28-70
28-70
Rotator Cuff Sprain
7-14
7-14
21-42
28-70
28-70
Sprain Shoulder Joint
3-7
7
14-21
21
21-28
Rupture of Supraspinatus
7-14
7-14
21-42
28-70
28-70
Sprains
Sedentary Light
Medium
Heavy
Very Heavy
S51..
S52..
Sprain Elbow/Forearm
3
3
7
10
21
Sprain Wrist or Hand (includes carpal and carpometacarpal ligament sprains)
14
14-28
21-35
28-42
Sprain Tendon Wrist or Hand
1-14
7-21
14-28
21-35
28-42
S5204 Sprain Radial Collateral Ligament (Thumb)
14
14-21
14-28
21-35
28-42
S524.
S522.
S523.
S53..
S533.
21
Sprain Thumb
21
21
21
42
42
Sprain Finger
7-14
7-14
14-21
21-28
21-28
Sprain Hip/Thigh
3
3
7
10
10
Sprain Quadriceps Tendon
3
3
7
10
10
14-21
14-21
Sprain Cruciate Ligament Knee
7
7
7
14-21
14-21
Sprain Gastrocnemius
7
7
7
14-21
14-21
Sprain Ankle
7
7
21
21
14
21
7
14
21
7
10
10
2
3
3
S540./1 Sprain Collateral Ligament Knee
7
7
7
S542.
S54x1
S550.
7
S5512 Sprain of Metatarso-Phalangeal Joint
7
7
7
S5513
Interphalangeal Joint
7
7
S5Q4. Rupture of Biceps Tendon
3
3
S5y3.
Sprain Rib
1
1
Sprains
Miscellaneous
Sedentary
Light
Medium
Heavy
Very Heavy
F542.
3
3
0-7 days
SD810 Corneal Abrasion
1-2
1-2
1-2
1-2
1-2
SG00. Corneal Foreign Body
1-2
1-2
1-2
1-2
1-2
Foreign Body in Ear
0
0
0
0
0
Foreign Body in Nose
0
0
0
0
0
Toxic Reaction Bee Sting
0
0
0
0
0
SG2..
TE53.
TE60.
TLxyo
M2y5. Foreign Body in Skin or Subcutaneous Tissue
0
0
0
0
SG1..
Miscellaneous
Tympanic Membrane Perforation
3
3
3
Dog Bite
Human Bite (Also Cat)
Depends on site and severity
Return to Work
KEY POINTS
• Planning a successful return to work (RTW), either to the same job or a
different one, needs to be incorporated in the management of any injury
from the earliest stage. This ensures positive expectations for all concerned.
• Work provides many positive benefits for individuals, in addition to
income generation. Remaining off work deprives people of these benefits.
It also increases the risks of not returning to work with all of the subsequent
negative effects of long-term unemployment.
• The workplace must be an integral part of the work rehabilitation process.
It is inappropriate to think of work merely as a place to return to once
a person is fully recovered.
• A successful and sustainable return to work involves collaboration between
the injured person, the treatment provider, the employer (supervisor or
manager), co-workers, family members, and the case manager (where
applicable).
• Barriers to return to work may arise from the views held by any, or all,
of these key parties. Barriers need to be identified so that specific strategies
can be used to manage them effectively.
• Fear of movement is a strong predictor of not returning to work. These
fears are commonly driven by beliefs arising directly from explanations
given by the treatment provider.
• Allowing the level of activity to be based solely on pain severity has been
demonstrated to produce worse outcomes across a wide range of variables.
Therefore, it is imperative to link activities to a quota or amount based
on time, at the earliest stage for every person.
• Establishing a successful RTW programme requires knowledge of the
specific job demands. Communication with the employer is fundamental.
• Accommodation of functional limitations through modified work tasks
should be time-limited and reviewed regularly.
Benefits of Returning to Work
Benefits include working part-time, being on a graded return to work
programme, or temporarily working on selected/alternate duties.
Work fulfils many roles for people, not just income generation. It maintains
work habits; daily routine; social status as a worker and contributor; workplace
relationships; social contacts; and psychological well-being.
Risks of Staying Off Work Long-Term
It is accepted that the longer a person is off work the greater the chance that
they will never return. The adoption of a passive “sick-role” is clearly
detrimental.
The loss of paid employment due to extended time off work is the most
serious consequence, and significantly compounds the rehabilitation process.
Injured people are equally prone as any others to the major negative effects
of long-term unemployment.
Return to Work Strategies
The only successful return to the workplace is a sustainable one. There are
a number of key techniques and strategies to achieve this outcome. Several
of these involve communication with the employer. A full description of the
employer role is provided in “Active and Working! An Employer’s Guide to
Managing Acute Low Back Pain in the Workplace” (Note 3). Consider referral
to a suitable provider if you are unable or unwilling to undertake this process.
Return to Work
Return to Work
1. Knowledge of the specific job demands
Identify tasks required for work. Examples are sitting, standing, climbing
a ladder, lifting heavy loads such as 50 Kg, or working on a keyboard
most of the day. Ask the employer what the minimum requirements will
be for the person to be useful at work in any capacity.
Check whether the person can complete any of those tasks. Asking the
patient is insufficient and likely to be unreliable. A direct observational
test is the most accurate. This may require referral to a suitable provider
(see below).
2. Identify barriers to RTW
Injury factors
These include safety, biomechanical, cognitive, perceptual, and functional
limitations. Remember pain is not by itself a contraindication to activity
and work. If you identify specific safety concerns remember these probably
apply to only part of the job. Make sure you identify what part of their
job the person can still do. These are the important starting points for
returning the person to work part-time, or using a graduated approach.
Individual factors*
These include beliefs about their injury and symptoms such as pain.
Important examples include the belief that pain intensity always directly
signals significant damage to the body, and that all activity and work must
be avoided until the problem is completely fixed. Fear of movement and
activity (kinesiophobia) is very important to identify early, and counter
with suitable reassurance.
Workplace factors*
These include satisfaction with the job, work organisation issues, and
relationships with managers and co-workers. The willingness and/or
ability of a workplace to offer temporary modifications to work tasks is
very critical.
* See the Guide to Assessing Psychosocial Yellow Flags in Acute Low
Back Pain: Risk factors for long-term disability and work loss for a full
outline of individual and workplace factors (Note 1).
3. Identify parts of the job the person can still do
If the person can undertake all of the tasks involved in their job, then
return them to full-time work.
If there are restrictions or limitations in certain areas, then it becomes
critical to identify those tasks the person can still undertake.
The person may be returned to work in a number of different ways. The
key goal should be to return the person to a full day of selected duties
and activity, rather than to a limited day of full duties.
a Selected/alternate duties. The tasks that the person can still undertake
temporarily become the focus of their work activity.
b Graded RTW programmes. Either full duties or selected duties are
commenced for part of the day, and steadily increased over a limited
period of time such as 3 to 4 weeks.
Return to Work
Return to Work
c Part-time work. This should only be used in exceptional circumstances
such as a significant fatigue problem, or serious medication side-effects,
for example. It should always be time-limited, and is considered the
choice of last resort since the person risks becoming settled into a
different daily routine and set of work habits.
Trouble-shooting RTW plans
The most common problem encountered in returning a person to work is
that they are using “pain as a guide” to all of their movement and activity.
In reality this means that the person is often responding to the anticipation
that it is going to hurt, and this becomes the genesis of a “fear-and-avoidance
cycle”. It is imperative that in the absence of specific safety concerns activity
levels be time-contingent (ie based on a quota) rather than pain-contingent
(based on pain). Patients need to be given clear guidelines about managing
their activity level on a steadily increasing basis. Failure to do this produces
a greatly increased chance that the person will develop long-term withdrawal
from activity and ultimately a disuse or inactivity syndrome.
Another very common problem with RTW plans is the person reaching a
plateau of participation. For example, the Graded RTW programme may not
advance beyond 4 hours per day. These may be completed between midmorning and mid-afternoon. This situation is often predictable, and commonly
occurs when “lifestyle substitution” has become a buffer to progress. The
positive benefits of work (such as the social status as a worker) are being
experienced, but the lifestyle pressures associated with working longer hours
are being avoided. For example, child care of school-aged children may be
considerably easier. A useful method to change this pattern is to direct the
person to work one full day followed by one short day, and then steadily
move toward every day being a full day.
Failing to identify important barriers to RTW also occurs often. This
emphasises the need to remain vigilant for barriers that were not originally
disclosed or identified. Fear of movement and activity is a strong predictor
of poor outcome. It is a common consequence of injury. Overcoming fear
requires reassurance, motivation and encouragement.
Ergonomic reviews of the workplace may be required, along with work
organisation and work processes. This does not imply that these factors
caused the injury, but without alteration they may become barriers to a full
and sustainable return to work. Health professionals who are specialised in
the occupational setting (see referral section) will usually conduct these
reviews.
The received wisdom, based on anecdotal evidence, is that highly motivated
people such as the self-employed return to work faster than other groups
of workers. A minority of the highly motivated people may require close
monitoring to ensure that they do not end up in a boom-and-bust cycle
through unwillingness to temporarily modify their workloads.
Most problems in returning someone to work can be resolved through
contact with the Case Manager and/or the Employer (manager or supervisor).
If this fails to achieve the desired outcome, consider referral.
Return to Work
Return to Work
Referral
There are a number of health professions who are specialised in the
occupational setting. Selection of which to refer to depends on availability
and the problems of the individual claimant.
• Occupational physicians
• Occupational therapists
• Occupational physiotherapists
• Occupational health nurses
• Vocational rehabilitation providers
Notes
1 A full outline of barriers to return to work in acute low back pain is
available in the Guide to Assessing Psychosocial Yellow Flags in Acute
Low Back Pain: Risk factors for long-term disability and work loss (Kendall,
Linton, & Main, 1997) published by ACC and the National Health
Committee.
2 A template for devising a return to work plan with a claimant is provided
in the Patient Guide to Acute Low Back Pain Management published by
ACC and the National Health Committee. Free copies are available in
packs of 50 by contacting Wickliffe Press Fax (03) 477-5682
E-mail [email protected]
3 Full outline of the employer role in facilitating the RTW process is available
in Active and Working! An Employer’s guide to Managing Acute Low
Back Pain in the Workplace published by ACC and the National Health
Committee.
Return to Work
CONTENTS
Read Code
Closed Rib Fracture
S120.
Closed and Non-displaced Clavicle Fracture
S20..
Closed Fracture of Humerus, Proximal Shaft
S22..
Closed Fracture of Distal Humerus, Supracondylar
S2241
Fracture of the Proximal Radius and Ulna
S230./S231.
Fracture of the Shaft of Radius and Ulna
S232./S233.
Fracture of the Distal Radius and Ulna
S234./S235.
Closed Fracture of Scaphoid
S2401
Fracture of Carpal Bone (No Other Symptoms)
S24z.
S25..
S26..
Fracture of Tibia and Fibula
S33..
Fracture of the Ankle
S34..
S352.
S36..
S41..
S44..
Plastering Guide
2 fractures/
dislocations
Section 2 Fractures/Dislocations
Closed Rib Fracture
Read Code: S120..
KEY POINTS
The great majority of rib trauma is mild and can be treated conservatively.
Manubrium
However, certain features are important:
Rib fractures in children can indicate severe trauma because of the usual
elasticity of a child's thorax (see rib contusion)
Rib fractures in the elderly may warrant admission to hospital
• Beware of damage to other structures
• 1st/2nd rib fractures: mortality up to 30% due to aorta and subclavian
artery damage, brachial plexus injury
• Rib fractures can compromise ventilation by:
Causing splinting, leading to atelectasis, and pneumonia
Multiple rib fractures (eg flail chest) interfering with normal
costovertebral and diaphragmatic muscle excursion
Fractured ribs can puncture surrounding tissues and cause haemothorax
and/or pneumothorax
• Posterior rib cage trauma may present as a back injury
• Ensure adequate pain relief to limit pulmonary complications
Body of
sternum
Xiphoid
process
Floating ribs
Vertebra
Complications
• Pneumonia
• Atelectasis
• Respiratory distress
• Pneumothorax
• Haemothorax
• Cardiac contusion
History
• Direct blunt blow to the chest: projectile, fall, collision
• Pain on inspiration
• Motor vehicle accidents with activation of airbags and/or a deformed
steering wheel
• Haemoptysis
Examination
• ABC
• General examination:
Respiratory – ventilatory sufficiency, cyanosis, tachypnoea, trachea,
lung fields, accessory muscle use, oximetry
Cardiovascular – blood pressure, heart rate, heart sounds,
perfusion/shock etc
Gastrointestinal system – bowel sounds, tenderness/guarding etc, mass,
haematuria
• Local examination – tenderness on palpation or crepitus, local chest
wall deformity, paradoxical movements with flail chest
• Depending on location of pain – consider other structures eg:
Lower ribs (L) – spleen
Lower ribs (R) – liver
Ribs 11/12 – kidneys
• Examine other systems as necessary
Closed Rib Fracture S12o.
Closed Rib Fracture
Differential Diagnosis
• Sternal fracture
• Sternoclavicular joint injury
• Scapular fracture
• Acute respiratory distress syndrome
• Aortic dissection
• Pneumothorax
• Pneumonia/RTI
• Pulmonary embolus
• Spinal injury
• Child abuse
• Abdominal trauma, blunt or penetrating
• Abdominal viscus injury
Investigation
• If minor trauma, further investigation not necessary except as for key points
• Urinalysis
• X-rays (only 50% detection on first X-ray):
PA chest (especially to exclude underlying damage)
Lateral chest
Oblique view of the side involved
Coned upper abdominal AP view if lower ribs involved
Others to consider: inspiratory views, plain abdomen
(erect, lateral decubitus)
• Ultrasound: renal, upper abdomen
• IVU
• Oximetry
• Blood tests – FBC
Treatment
• The main focus of treatment is maintaining active breathing – avoid
splinting, taping etc
• Analgesia – NSAIDs may be useful, warn of increased pain after 3-5 days
• Consider admitting single, closed rib fractures if unable to cough, cannot
clear secretions or significant co-morbidity especially in the elderly
• Severe trauma: maintenance of ABC
• Chest drain if tension pneumothorax
Referral to Specialist
• Single, closed rib fractures without significant trauma or complications
do not warrant referral
• Patient with 3 or more fractured ribs
• Any patient with fractured rib 1 or 2
• Other specialists as appropriate for complications eg general/trauma surgeon,
ICU, vascular, cardiothoracic surgeon, plastic or neurosurgeon, urologist
• Physiotherapy for education if breathing or coughing problems
• Elderly living alone may require occupational therapy for Instrumental
Activity of Daily Living (IADL) assessment, and assessment for support
for independence or assisting devices
Closed Rib Fracture S12o.
Closed & Non-displaced
Clavicle Fracture
Read Code: S20..
KEY POINTS
• Clavicular fractures are common injuries.
• Nearly 50% of all clavicular fractures occur before 7 years of age as
greenstick fractures
• In neonates and children clavicular fractures heal very well, whereas in
adults the force required to cause a fracture is greater, healing takes longer
and the potential for complications is greater
• It is almost impossible to immobilise displaced fractures, however nonunion is extremely rare
• Displaced clavicle fragments can injure structures in close proximity
because of the sharp edges of the fracture (major underlying vessels, the
lung, and the brachial plexus)
• Support for the weight of the arm is essential for the comfort of the
patient. Immobilise the upper extremity with a broad arm sling
Clavicle
Acromion
Greater
tubercle
Coracoid process
Head of
humerus
Scapula
Humerus
Glenoid
cavity
Classifications
• Class A: middle third of the clavicle. Site of 80% of clavicle fractures
• Class B: distal or lateral third of the clavicle. Site of 15% of clavicle
fractures:
Type 1, non-displaced (the supporting ligaments remain intact with
no significant displacement of the fracture fragments)
Type 2, displaced (the coracoclavicular ligament ruptures with resultant
upward displacement of the proximal segment of the sternocleidomastoid
muscle)
Type 3, articular surface (involving the acromioclavicular joint)
• Class C: proximal or medial third of the clavicle. Site of 5% of
clavicle fractures
Complications
• Neurovascular injury
• Injury to the underlying lung
• Delayed union/non-union
• Deformity (cosmetic implications)
History
• Clavicular fractures can result from a fall on to the side or an outstretched arm
• Most occur from a direct blow, or fall, on to the point of the shoulder
Examination
• The patient may support the injured limb with the other hand
• Palpation along the length of the clavicle reveals an area of tenderness,
perhaps swelling, crepitus, oedema and deformity
• Ecchymosis can occur especially when displacement causes tenting of the
skin and/or if injury occurred a day or more ago
• Neurovascular exam of the arm and hand is vital
• Lung auscultation to clinically exclude pneumothorax
Clavicle Fracture S2o..
Closed & Non-displaced Clavicle Fracture
• Assessment of the extent of injury and presence of signs and symptoms
of complications
• Acromioclavicular injury
• Dislocation of the shoulder
• Fracture of the ribs
• Pneumothorax/tension and traumatic
• Rotator cuff injuries
• Sternoclavicular joint injury
Investigation
Recommended X-rays:
AP shoulder girdle
AP clavicle with 15° cranial angulation
• Apical lordotic views may be required to demonstrate the degree
of displacement
• Other tests may be necessary to assess the possibility of other injury
associated with the fracture:
Chest X-ray if pneumothorax suspected
Angiography if vascular injury suspected
Treatment
• Adequate pain relief
• Apply ice cold pack to the injury
• Support for the weight of the arm is essential for the comfort of the patient
• Undisplaced closed fractures will require:
A broad arm sling
Wearing the sling underneath clothing may add further fixation
The sling should be worn for 2 weeks or until tenderness disappears
from the fracture site
Appropriate pain relief should be prescribed
• Use of a figure of 8 bandage has no advantage over sling or collar and
cuff and likely to press on fracture site, increasing pain
Referral to Orthopaedic Specialist
• Multi-system involvement
• Open fracture
• Displaced fractures
• Neurovascular damage
Other Referral
• Referral to a physiotherapist is generally not required. The elderly patient
may acquire shoulder stiffness and require range of motion exercises
• Referral to occupational therapy for ADL assessment may be needed for
the elderly, particularly those who live alone
• Consider home help for elderly living alone
• Consider child care/home help for primary parent of young children
Claimant Education
• Education on use of the sling
• Report back to doctor if changes develop:
Swelling
Closed & Non-displaced Clavicle Fracture
•
•
•
•
•
Skin breakage
Loss of sensation of the extremity
Pain relief as required
Mobilise shoulder as comfort permits
Resume sport when fracture consolidated at approximately 3 months
Re-X-ray at 4-6 weeks for evidence of fracture union. Children do not
require re-X-ray
Union at the fracture site may have a lump in both children and adults.
In children this generally resolves over 2-3 months, but in adults may
always be present
Closed Fracture of Humerus,
Proximal Shaft
Read Code: S22..
KEYPOINTS
• In children greenstick fracture of the surgical neck is the most common type
• The patient gives a history of trauma:
By a direct blow to the arm or shoulder
By a fall on to an outstretched hand
• Elderly patients more prone to fracture due to osteoporosis
• Non-displaced fracture of the greater tuberosity in children and adults
can be managed in primary care
• Non-displaced fractures require support, then mobilisation after 1-2 weeks
• Impacted fractures of the neck of humerus are often missed
Complications
• Nerve injury:
Neuropraxia of the ulna nerve from inadequate padding over the
medial epicondyle when applying the splint
Radial nerve
Axillary nerve
Brachial plexus
• Avascular necrosis seen in fractures of the surgical neck of the humerus
or multiple (3-4) part fractures
• Problems of maintaining the position of any cast
• Joint stiffness, particularly in the elderly
• Non-union of a shaft fracture
History
• The patient gives a history of trauma:
By a direct blow to the arm or shoulder
By a fall on to an outstretched abducted arm
By axial loading through elbow
• Pathological fractures may occur with minimal trauma
• Patients with a history of the following are most at risk of pathological
fractures:
Metastatic cancer of the bone
Paget's disease
Osteoporosis
Bone cyst
• Pain
• Oedema
• Decreased range of motion
RED FLAG:
A humerus fracture in a child presenting
with a trivial or inconsistent injury
should raise suspicion of nonaccidental injury
Acromion
Glenoid cavity
Head of humerus
Scapula
Humerus
Lateral epicondyle
Medial epicondyle
Capitellum
Trochlea
Radius
Ulna
Examination
Proximal Humeral Fracture:
• The proximal humerus has 4 parts: the joint surface, greater tuberosity,
lesser tuberosity and humeral shaft – all should be examined radiologically
for a fracture:
• The Neer classification describes these fractures and amounts of
displacement in detail
• Surgical treatment options are based on the number of segments involved
and degree of displacement. If unsure of the classification always discuss
or refer to orthopaedic surgeon
• Note that in children the epiphyseal line is frequently mistaken for a fracture
Humerus Shaft Fracture:
• Can be transverse, oblique or spiral and may require CT or MRI evaluation
• Rarely occurs in children
Humerus Fracture S22..
• Neurovascular examination of the affected limb – radial nerve damage
following humeral fracture is relatively common
• Pain occurs with palpation and/or movement of the shoulder or elbow
(especially humeral rotation)
• Ecchymosis is usually present
• Dislocation of the shoulder
• Fracture, clavicle
• Fracture, elbow
• Fracture, scapula
• Rotator cuff tear
Investigation
Recommended X-rays:
AP
Lateral
+/- transthoracic and axillary views
Treatment
Initial treatment:
• Immobilise
• Provide adequate pain relief
• Sitting is frequently more comfortable than lying down
• Consult or refer to orthopaedic surgeon if required or unsure of treatment
Non-displaced fracture of the proximal humerus:
• Arm support in a collar and cuff sling until the acute symptoms have
resolved (1-2 weeks)
• Under a T-shirt often more comfortable
• Commence mobilisation when acute symptoms resolved
• In children the collar and cuff may be adequate, although some children
(and their parents) often feel more secure with a U slab that goes up over
the acromion
• Consider U slab protection for adults for first 2 weeks
• Watch for late displacement (may need X-raying weekly for 4 weeks)
• Intra-articular damage
• Humeral shaft fracture
• Open fractures require surgery and should be referred immediately
• Displaced or angulated fractures
• Penetrating trauma requires careful neurological assessment and therefore
consultation or referral
• Neurovascular damage
• Associated gleno-humeral dislocation
• Additional fractures eg fracture of forearm bones
Other Referral
Non-displaced neck of the humerus:
• In adults: consult physiotherapist when sling removed and pain free
• Early referral to physiotherapist in elderly patients for education and
rehabilitation programme to avoid a frozen shoulder
• In children: not generally necessary unless nerve paralysis
• Elderly living alone may require assessment of ADLs and IADLs, provision
of assistive equipment, and referral to community services for bath/shower
and dressing
• Children with radial or ulna nerve injury will require assessment and
intervention in ADLs, play to ensure continuing normal development
• Radial nerve paralysis may require sensation testing, education and
dynamic extensor splinting
• Neuropraxia of the ulna nerve may require sensation testing, education,
treatment and splinting to prevent contractures
• Young people may require a writer to continue education or sit exams
Closed Fracture of Distal
Humerus, Supracondylar
Read Code: S2241
KEY POINTS
• A supracondylar fracture of the humerus occurs just proximal to the bone
masses of the trochlea, capitellum and often runs through the apices of
the coronoid and olecranon fossae
• The fracture line is generally transverse
• Most common fracture of the elbow in children 3-11 years
• 20-30% have little or no displacement, 20% are greenstick
• Rare in adults, and they usually require surgical intervention
• In children non-displaced, non-angulated fractures can be splinted with
90° of flexion
Complications
• Nerve injuries following a fracture can be as high as 12%. The most
common is damage to the anterior interosseous branch of the median nerve
• Arterial damage – brachial artery
• Compartment syndrome and the sequelae – Volkmann’s Contracture
• Cubitus varus resulting from the initial fracture may lead to a
Gunstock deformity
RED FLAG:
Document neurovascular status on an
ongoing basis
Absent radial pulse, pallor, coldness,
pain or paraesthesiae in the forearm
=> urgent referral
Inability to fully extend fingers or pain
on passive extension of fingers are
important signs suggesting ischaemic
changes or development of
compartment syndrome of the forearm
Check vascular status after any elbow
movement
History
• Usual mechanism of injury is a fall on an outstretched hand with an
extended elbow which can cause posterior displacement
• Always suspect when a child complains of pain in the elbow after a fall
Examination
• Tenderness and swelling over the distal humerus
• Examine the wrist and shoulder on the affected side
• Assess and document circulation as the brachial artery may be disrupted
• Assess and document neurological status (the median nerve especially)
at regular intervals
• The olecranon and medial and lateral epicondyles preserve their normal
equilateral triangular relationship (unlike dislocation of the elbow)
• Dislocation of the elbow
• Fracture forearm
• Pulled elbow
• Septic arthritis
Investigation
• Radiography is essential and interpretation requires care
• Films of the other side should be taken for direct comparison, if there is
any doubt in interpretation
Humerus
Lateral epicondyle
Capitellum
Head of radius
Neck
Olecranon
fossa
Medial
epicondyle
Trochlea
Radial
tuberosity
Radius
Ulna
Head of ulna
Styloid
process
Styloid process
Distal Humerus Fracture S2241
Recommended X-rays:
AP
Lateral
Oblique
If study is performed to evaluate the elbow:
AP
Lateral
Lateral tube angulated 45°
• In adults (the fracture line tends to lie a little more proximal than in
children) comminution, obliquity or spiralling and medial or lateral tilting
are common
• The epiphyses make interpretation of the X-rays difficult in children
• Fat-Pad signs (both anterior and posterior) may be the only evidence of
a fracture in growing children
• Check for Baumann’s angle. The normal carrying angle of the elbow is
about 10˚
Treatment
Type 1: Minimal or no displacement:
• These are stable fractures which require splinting of elbow at 90˚ (for
child's comfort)
• Long arm backslab and collar and cuff or broad arm sling with no less
than 90° flexion, or as much as the circulation can tolerate without
compromise
• Elbow flexion greater than 90° may produce neurovascular compromise
• Assess and document the neurovascular examination during and after
treatment
• Neurovascular compromise requires urgent specialist advice
Follow-up care Type 1:
• Re-X-ray at 7-10 days to exclude displacement
• Assess union by tenderness and X-ray at 3-4 weeks for children, 6-8 weeks
for adults
• If satisfactory union mobilise from a sling. Remove sling 3-4 times a day
for 10 minutes and actively exercise. Discard sling when discomfort settles
• Note any cubitus varus or valgus and refer early if concerned
• X-ray weekly if risk of displacement
Type 2: Angulated fractures which are not completely displaced:
• The extremity needs immobilisation with a posterior long arm splint
(axilla to metacarpal heads)
• The person should be hospitalised for potential neurovascular compromise
Type 3: Completely displaced fractures:
• Require immediate orthopaedic assessment
• The potential for neurovascular injury and compartment syndromes is high
• Fractures associated with limb-threatening vascular compromise should
be reduced by experienced doctor only if an orthopaedic specialist is not
acutely available
• Discuss with or refer to orthopaedic specialist for all or any concerns
• Neurovascular compromise
• All displaced and angulated fractures
• Adult fractures usually require surgery
• Lateral condylar fractures
• Cubitus varus and cubitus valgus deformities – do not remodel well
Other Referral
• Physiotherapy referral may not be required in children, although recovery
of full elbow extension may take 3 months
• Median nerve damage – referral for possible splinting and education
regarding functional activities and sensory deficits
Fracture of the Proximal
Radius & Ulna
Read Code: S230./S231.
KEY POINTS
• The majority of radial head fractures can be managed conservatively
• Radial head dislocation/fracture can easily be missed
• Hand dominance/occupation may affect management
Complications
• Fracture slipping; redisplacement or late angulation
• Neurovascular injuries
• Radial head fractures generally get good recovery of pronation/supination
but full extension may be long delayed
Humerus
Lateral
epicondyle
Capitellum
Olecranon
fossa
Medial
epicondyle
Head of radius
Trochlea
Neck
Radial
tuberosity
Radius
Ulna
History
• Mechanism of injury:
Fall on outstretched hand
Direct blow to the elbow
• Pain (location, radiation)
Head of ulna
Styloid
process
Styloid
process
Examination
• Swelling, localised tenderness
• Skin for open wound
• Range of movement
• Specific findings:
Radial head # - pain on pronation/supination
Olecranon # - decreased elbow extension
• Neurovascular examination
• Always examine elbow and wrist +/- shoulder
• Distal humerus fractures
• Dislocation/subluxation of proximal radio-ulnar joint
• Ligamentous injuries around the elbow
• Soft tissue injuries eg contusions to forearm
• Dislocation of elbow
• Pulled elbow in children
Investigation
Recommended X-rays:
AP
Lateral
Radio-capitellar
• Both views should include the elbow and wrist on the films
• Check anterior and/or posterior fat pad signs
• It may be helpful to have comparison views of the other wrist
Treatment
Initial treatment:
• RICE
• Splint
• Analgesia
Fractures of the radial head and neck:
• Radial head – non-displaced => sling, range of motion exercises after 7 days
Proximal Radius & Ulna Fracture S23o./S231.
Fracture of the Proximal Radius & Ulna
• Radial head – displaced/comminuted => refer
• Radial neck – undisplaced/angulated less than 15˚ => above elbow cast
3-4 weeks (child), 6-8 weeks (adult)
• Radial neck – angulated more than 15˚ => refer
• Radial neck – comminuted/displaced => refer
• Slipped upper radial epiphysis => refer if displaced, else put in POP for
3 weeks at 90° flexion
Coronoid process fractures:
• Fractures involving 50% or more of the process => refer acutely
• If less than 50% => above elbow cast. Mobilise at 3 weeks
Fractures of the olecranon:
• If undisplaced, above elbow cast and refer non-acutely
• Refer all displaced acutely for orthopaedic assessment
• Non-operative fractures – start range of motion exercises after a few weeks
Follow-up care:
• Plaster check at 24 hours and plaster completed if a backslab has been applied
• Clinical exam the next day should include assessment for neurovascular
status and pain control
• Follow-up X-ray at 7 days if potential instability
• Any open fracture
• All displaced olecranon fractures refer acutely
• Fractures of the proximal head of the radius if there is angulation at the
neck greater than 15˚ or if greater than 1/3 of the articular surface of the
head is involved and displaced more than 2mm
• Comminuted or major chip fractures
Proximal Radius & Ulna Fracture S23o./S231.
Fracture of the Shaft of
Radius & Ulna
KEY POINTS
This includes:
Isolated fractures of middle third of radius and/or ulna, including
greenstick fractures in children
Galeazzi fracture dislocation (often missed)
Monteggia fracture dislocation (often missed)
Fractures of both radius and ulna shafts in adults and children
• The outcome following forearm fractures in terms of function and bony
union is related to degree of trauma and type of fracture. It is optimised
by early and appropriate treatment
• Morbidity is high in missed/late diagnosis of open fracture or fracture
plus dislocation
• There is a higher frequency of morbidity from forearm fractures than
elbow or wrist fractures
• In children most are greenstick in pattern
• Treatment is largely determined by the amount of angulation and the
amount of displacement
Humerus
Lateral
epicondyle
Capitellum
Olecranon
fossa
Medial
epicondyle
Head of radius
Trochlea
Neck
Radial
tuberosity
Radius
Ulna
Head of ulna
Styloid
process
Styloid
process
Complications
• Compartment syndrome
• Complex regional pain syndrome
• Growth arrest
• Radio-ulnar synostosis after delayed treatment
• Axial mal-rotation may occur in fracture of the radius. Rarely present in
fracture of the ulna
History
• Mechanism of injury – indirect violence such as a fall on to an outstretched hand
• Direct blow to the arm
Examination
• Pain – location, swelling
• Skin – open wound, tenting, infection (note high frequency of open
fractures of forearm)
• Neurovascular status
• Deformity/angulation/displacement
• Examine elbow and wrist always
• Dislocation of elbow or wrist
• Fractures elbow/wrist
• Contusions forearm
Investigation
Radiology:
Standard X-rays
AP
Lateral
Radius, Ulna Shaft Fracture S232./S233.
Fracture of the Shaft of Radius & Ulna
Other:
Include wrist and/or elbow in film
Must do separate elbow X-ray views because radio-ulnar dislocation
often missed unless X-ray beam is centred on joint
Obliques as necessary
Treatment
Initial treatment:
• Ice, elevate, splint
• Analgesia
• If deformity exists that is threatening the overlying skin it may be advisable
to correct this with gentle repositioning of the limb, with analgesia
administered
Undisplaced non-angulated greenstick fractures in children:
• Small child can be treated in an above-elbow backslab
• An above elbow POP cast is required where deformity has been corrected
• Patient should have a broad arm sling or a collar and cuff
• Child should be seen within 24 hours of the plaster application. Check
neurovascular status
• Compartment syndrome associated with these fractures
• In unstable fractures the position of the fracture should be X-rayed and
checked each week for 3-4 weeks
• Arm should remain in plaster for 4-6 weeks in 5-10-year-olds and 3-5
weeks in 1-4-year-olds
• Mobilisation should be started from a sling
Undisplaced fracture of ulna and radius in adults:
• Above elbow POP for 6-8 weeks
• All should be reviewed by orthopaedic surgeon
• Compartment syndrome associated with these fractures
• Plaster must be checked weekly for looseness and changed if necessary
• Patients treated conservatively should have a broad arm sling, not a collar
and cuff
• Check position after 1 week with X-ray
• After POP removal mobilise with an active exercise programme
Isolated fracture ulna shaft (eg nightstick fracture):
• Treat in AE cast for 6-8 weeks in adult, 3-5 weeks for child if undisplaced
• If >5mm displacement or >10º angulation then refer for ORIF
Galeazzi fracture/dislocation:
• Fracture of the radius with dislocation of the inferior radio-ulnar joint
• Refer all
Monteggia fracture/dislocation:
• Fracture of the ulna with dislocation of the superior radio-ulnar joint
• Refer all
Follow-up care:
• Plaster check at 24 hours
• Clinical exam the next day should include assessment for pain control
Fracture of the Shaft of Radius & Ulna
• Fracture displaced or at risk of displacement
• Fractures of shafts of both radius and ulna will generally require internal
fixation in adults
• Angulation of the fracture
• Displaced fractures of either radius, ulna or both
• Axial rotation usually of the radius, rarely of the ulna
• Any open/comminuted fracture
• Fracture dislocation (Galeazzi and Monteggia fractures) require surgery
• Fractures which do not reduce well
Other Referral
• Any complication to appropriate specialist
• Physiotherapy – refer early for mobilisation
• In the elderly, especially those living alone, assess ADLs and IADLs and
need for support for independence
Fracture of the Distal
Radius & Ulna
KEY POINTS
Includes:
Isolated distal radius or ulna fractures, adults and children
Combined distal radius and ulna fractures in adults and children
Colles’ type fractures
Smith’s type fractures
Growth plate injuries in children
Fractures of the distal radius and ulna are common in children (lower
end of radius and ulna)
• Reduction may be difficult
• In adults Colles’ fracture is common and often associated with fracture
of the ulna styloid
• Complications are common with Colles’ and Smith’s fractures
Complications
• Extensor pollicis longus rupture especially Colles’
• Subluxation/dislocation of distal radio-ulnar joint
• Ulnar nerve injury
• Median nerve injury/carpal tunnel syndrome
• Osteoarthritis
• Growth arrest
• Ulnar artery damage
• Non-union especially ulnar styloid fracture
• Wrist joint ligament ruptures and/or triangular fibro-cartilage injuries
associated with ulnar styloid fractures
Humerus
Lateral
epicondyle
Capitellum
Olecranon
fossa
Medial
epicondyle
Head of radius
Trochlea
Neck
Radial
tuberosity
Radius
Ulna
Styloid
process
Head of ulna
Styloid
process
History
• Mechanism of injury – fall on to an outstretched hand
• Direct blow to the arm (rare)
• Occupation/pastimes
• Handedness
• Previous fractures in elderly
Examination
• Location of pain, swelling
• Skin – open wound, tenting, infection (note high frequency of open
fractures of forearm)
• Deformity/angulation/displacement
• Examine elbow, hand and wrist always
• Other fractures of the radius or the ulna
• Fractures of the hand, elbow, forearm
• Dislocations of wrist, elbow
• Contusions of wrist, forearm, hand
Distal Radius, Ulna Fracture S234./S235.
Fracture of the Distal Radius & Ulna
Investigation
Radiology:
Standard X-rays:
AP
Lateral
Other:
Include hand and/or elbow in film
Must do separate elbow X-ray views because radio-ulnar dislocation
often missed unless X-ray beam is centred on joint
Obliques as necessary
If the study is performed to evaluate the distal forearm:
AP
Lateral
45° oblique
• It may be helpful to have comparison views of the other wrist
Treatment
Initial treatment:
• Ice, elevate, splint
• Analgesia
• If deformity exists that is threatening the overlying skin it may be advisable
to correct this with gentle repositioning of the limb, with analgesia
administered
Undisplaced greenstick fractures in children:
• No reduction required if angulation less than 10°
• Can be treated in a backslab or below elbow cast unless >2 cm from
epiphysis (treat as mid-shaft fracture)
• Patients should have a broad arm sling or collar and cuff
• See within 24 hours of the plaster application. Check neurovascular status
• In unstable fractures the position of the fracture should be X-rayed and
checked each week for 3-4 weeks. In stable fractures fortnightly checks
should be adequate
• The arm should remain in plaster for 4-6 weeks in 5-10 year-olds and
3-5 weeks in 1-4 year-olds
• Mobilisation should be started from a sling
Colles’ type fractures in adults:
• Reduce under anaesthesia if experienced, otherwise refer
• Post reduction put in backslab or splint below elbow plaster and review
neurovascular status in 24 hours
• Complete POP when swelling decreased and review at 1 week (re-X-ray)
• Ensure patient mobilises fingers, elbow and shoulder regularly from the
time of injury
• Plaster must be checked weekly for looseness and changed if necessary
• Patients treated conservatively should have a broad arm sling, not a collar
and cuff
• Weekly X-rays to check for early slipping for 2 weeks
• After POP removal mobilise with an active exercise programme
Fracture of the Distal Radius & Ulna
• All Smith’s type fractures
• Epiphyseal fractures
• Any open fracture
• Comminuted or complicated fractures
• Any fracture which does not reduce well
Read Code: S2401
Distal phalanx
Middle phalanx
Metacarpals Phalanges
KEY POINTS
• Often missed initially owing to the relative absence of pain
• Predominantly an injury of young adults and adults (less common in
children and the elderly)
• Occurs frequently from a fall on an outstretched hand
• Majority of clinically suspected scaphoid fractures will not be evident on
X-ray but have to be treated as such due to the potential for avascular
necrosis of the scaphoid (a severe and permanent disability)
• In a true scaphoid fracture tenderness will be present when pressure is
applied over the dorsal and palmar aspects of the scaphoid. Tenderness
in the anatomical snuffbox, while a very sensitive sign, is non-specific
• Lunate dislocations may be missed on initial assessment
• Initial X-rays often show no fracture: repeat views at 10-14 days are
important. Bone scan also helpful
• Delayed union, non-union and avascular necrosis are relatively common
• Displaced fractures need referral
Proximal
phalanx
5
4
3
2
1
Hamate
Pisiform
Lunate
Ulna
Distal
phalanx
of thumb
Proximal
phalanx
of thumb
Trapezoid
Trapezium
Capitate
Scaphoid
Radius
Complications
• Avascular necrosis of proximal fragment
• Sudeck’s atrophy (Reflex Sympathetic Dystrophy/complex regional pain
syndrome)
• Non-union seen at 3-6 months
• Osteoarthritis
History
• Direct significant force to outstretched dorsiflexed hand (axial loading
from base of hand towards elbow) eg fall on to an outstretched hand
(snowboarding)
• A direct blow to the scaphoid area or a twisting injury to the wrist is
highly unlikely to fracture the scaphoid and therefore does not need to
be treated as a clinical scaphoid fracture if X-rays are normal
• Kickback when using starting handles on internal combustion generators,
pumps, compressors and inboard marine engines
• First presentation may be a number of days after injury
Examination
• Tenderness over the scaphoid tubercle especially the dorsal and palmar aspects
• Intolerance of dorsiflexion of the wrist
• Tenderness in the anatomical snuffbox (although this is less specific)
• Bennett’s fracture of the thumb metacarpal
• Fracture of the radial styloid
• Dislocations of the wrist
• Tendonitis
• Wrist sprain without #
• Rupture of the scapho-lunate ligament
Investigation
Radiology:
Recommended X-rays:
PA
PA with ulnar deviation
Oblique 45°
Lateral
Scaphoid Fracture S24o1
• Follow-up views at 14 days if clinical suspicion is high; repeat all 4 views
Additional scaphoid views may be useful:
PA ulnar deviation at 12° caudal
PA ulnar deviation at 30° caudal
PA ulnar deviation 12° cranial
• The fracture may be very difficult to visualise
• An AP view with the wrist in ulnar deviation may make the fracture more
apparent
• X-rays may or may not confirm a fracture even if there is strong clinical
suspicion
• A bone scan is an excellent and cost-effective investigation to confirm or
rule out a scaphoid fracture when suspected clinically with normal
X-rays. It is likely to save the patient 2 weeks of time off work and
unnecessary cast immobilisation
Treatment
• Because of likelihood of complications caution is essential
Clinically suspected (signs and symptoms above) but normal X-ray:
• Scaphoid plaster 10-14 days, then repeat X-rays after removal of plaster
X-ray proven undisplaced fracture:
• Scaphoid plaster 6 weeks: check at 24 hours and 2 weeks
• At 6 weeks remove plaster, assess clinically and repeat scaphoid views
• If the fracture appears united on X-ray (this is rare) and there is no
tenderness over the dorsal surface or at the snuffbox, the plaster should
be removed and the wrist checked in 2 weeks
• If the fracture is still present on X-ray or indicates union, but there is
continued tenderness, re-apply the plaster for another 4 weeks, then
remove, X-ray and re-examine
• Refer early if uncertain about management or concerned about progress
• If the fracture is displaced or at risk of displacement and non-union eg
oblique fracture through waist of scaphoid
• If it was initially unclear if a fracture was present, a cast was applied and
at re-X-ray it is still not clear and symptoms/signs persist
• If there is incomplete healing at 8 weeks
Other Referral
need for support for independence
Scaphoid Fracture S24o1
Fracture Carpal Bone
(No Other Symptoms)
Read Code: S24Z.
Distal phalanx
Middle phalanx
KEY POINTS
• The function of the hand, especially gripping, is dependent on the stability
and integrity of the carpal bones and ligaments
• There are 8 carpal bones arranged in 2 rows
• The motion of the wrist occurs between the radius and carpal bones
• The major types of injuries include fractures of the carpal bones,
dislocations and fracture/dislocations
• Because of the potentially serious consequences of these types of injuries,
always document the neurovascular status of the hand at initial examination
and at regular intervals
• A fall on to an outstretched hand is the primary mechanism
• Usually requires rest in plaster
• Carpal instabilities may develop early or late after a carpal injury
• The more energy involved in the injury the increased likelihood that there
will be severe injury even in the presence of a normal X-ray
• Major ligament injuries, bone surface injuries and triangular fibrocartilage
injuries are frequently missed because wrist injuries with normal X-rays
are dismissed as sprains
Hamate
Pisiform
Lunate
Ulna
Proximal
phalanx
Distal
phalanx
of thumb
5
4
3
2
1
Proximal
phalanx
of thumb
Trapezoid
Trapezium
Capitate
Scaphoid
Radius
Complications
• Ulnar nerve palsy may occur with fractures of the Hamate and Pisiform
• Carpal instabilities may develop early or late after a carpal injury
• Median nerve damage is associated with lunate dislocation and perilunate
fracture and is manifested by sensory disturbances in the thumb, index
and long fingers
History
Dislocations:
• Lunate/perilunate – usually the result of extreme flexion/extension injuries
of the wrist. These require urgent assessment and treatment with ORIF
Fractures:
• # Lunate – Dorsiflexion injury, or impact of the heel of the hand with a
hard surface
• # Capitate – 15% of all carpal bone #s.
• Caused from direct blow or fall on to hard surfaces with the hand in
dorsiflexion and are often associated with other injuries
• Small chip fractures of the carpus are common and generally result
from hyperflexion or hyperextension injuries of the wrist
• Fractures through the bodies of the carpal bones except the scaphoid are rare
Examination
Dislocation (lunate/perilunate):
• Pain is usually severe and located on the dorsal or volar aspect of the
wrist over the lunate
• Movement causes pain
• Wrist deformity and swelling
Fractures:
• Although ecchymosis is not always present, oedema and point tenderness
may indicate a fracture
• A thorough range of motion examination with pronation and supination
to document pain and limitation of movement
• Lunate fractures are associated with point tenderness over the lunate fossa
Carpal Bone Fracture S24Z.
Fracture Carpal Bone (No other Symptoms)
•
Triangular fibrocartilage injuries
•
Chondral fractures
•
Major ligament injuries
•
Fractures of the forearm
•
Dislocations of the wrist
•
Tendonitis
•
Scapholunate instability
Investigation
Recommended X-Rays:
• The majority can be adequately assessed by good AP and lateral. On the
lateral X-ray 11˚ of palmar angulation of the articular radial surface is
normal
• Consider scaphoid views
• Consider clenched fist AP views
• Consider bone scan for occult fractures
Treatment
Initial treatment:
• Urgent reduction of a fracture (or dislocation) is necessary when the
neurovascular status is compromised
• Lunate fractures often associated with wrist ligament injury. Splint the
wrist and refer for orthopaedic evaluation in 2-4 days
• Rest small chip fractures of the carpus in plaster for 3 weeks
• Rest undisplaced fracture through the body of a carpal bone for 6 weeks
in a Colles or scaphoid plaster with check X-ray at 1 week
• Refer immediately if fracture displaced
• Peri-lunar and peri-scapholunar dislocation of the carpus require immediate
specialist management
Follow-up care:
• Check X-ray in POP at 1 week
• Unstable fractures
• Hook of Hamate fracture
• Lunate fractures
• Inability to reduce fracture or hold in acceptable position
• Significant soft tissue injury
• Multiple fractures
• All dislocations and fracture dislocations
• Major ligament injuries
• Unsure of diagnosis
Other Referral
• May be required to mobilise the wrist, after full period of immobilisation
• In the elderly, especially those living alone, assess ADLs and IADLs
and need for support for independence
• Sensation testing and education if nerve damage present
• May require splinting if ulna nerve damage present
Carpal Bone Fracture S24Z.
Read Code: S25..
Complications
• Loss of functioning, eg hand stiffness, is the most common
• Delayed/mal-union
• Avascular necrosis
• Post-traumatic arthritis
Distal phalanx
Middle phalanx
KEY POINTS
• Terminology varies but it is best to refer to metacarpals as relating to
fingers eg thumb MC, index MC, middle MC, ring MC, little MC
• This code includes fractures to head, neck, shaft and base of each metacarpal
(plus Bennett’s, Rolando’s and some Gamekeeper’s fractures)
Hamate
Pisiform
Lunate
Ulna
History
• Document side of injury
• Document any pre-existing disability or deformity
• Document occupation or hobbies that require dexterity
• Identify the dominant hand of the patient
• Note the time, mechanism (eg potential for FB), environment (clean,
dirty) of injury
Proximal
phalanx
5
4
3
2
1
Distal
phalanx
of thumb
Proximal
phalanx
of thumb
Trapezoid
Trapezium
Capitate
Scaphoid
Radius
Examination
Compare with uninjured hand and document:
• Skin/soft tissue injury eg crushing, bruising, lacerations, deformity
• Location of tenderness
• Hand function should dictate management
Function:
Range of motion of hand; CMC joints, fingers
Neurovascular status
Mal-rotation of fingers, shortening
Interpret X-rays with regard to:
Fractures – site, angulation, rotation, displacement, number, relation
to joint surfaces, stability
Presence or absence of related injuries eg air, FB, infection
Acceptable angulation in MC neck fractures:
If not rotated and stable:
<15˚ for index and middle MC
<30˚ for the ring and little MC
Acceptable angulation in shaft fractures:
<10˚ in index and middle MC
<20˚ in ring and little MC
• At least 50% bony contact is required
• Wrist fractures/dislocations
• Metacarpophalangeal dislocation
• Contusions/sprains
Metacarpal Bone Fracture S25..
Investigation
Recommended X-rays:
Thumb metacarpal
AP
Lateral
Index to little metacarpals
PA
45˚ (oblique)
Lateral
• Compare with uninjured side if required
• Scrutinise points of insertion of ligaments and tendons and the alignment
of articular surfaces
Treatment
• Initial: ice, elevate, splint, analgesia
• If there is no significant soft tissue damage, the fracture is in an acceptable
position and the fracture is stable:
Elevation of the arm in a broad arm sling
Mobilise early
Metacarpal head fractures:
• Often comminuted
• If undisplaced, POP/splint as appropriate, refer non-acutely
• Refer acutely or discuss all fractures that are complicated (displaced,
comminuted, tendon injury, mal-rotation, FB, infection, joint surfaces
involved, air, unstable)
Metacarpal neck fractures:
• Often occur after direct blow (note all little MCP fractures are boxer’s
fractures until proven otherwise)
• There is debate over the significance of acceptable volar angulation
• Check carefully for rotational deformity (common)
• If patient can fully flex and extend their small finger without any tendency
to claw then closed manipulation under anaesthesia and immobilisation
in a volar POP/splint for up to 3 weeks
• Refer acutely or discuss all fractures that are complicated (displaced,
comminuted, tendon injury, mal-rotation, FB, infection, joint surfaces
involved, air, unstable)
Metacarpal base:
• Index, middle (uncomplicated) – splint as appropriate eg volar POP/splint
5-10 days, mobilise early
• Index, middle (complicated) – refer or discuss acutely
• Ring – refer acutely or discuss (often associated with subluxation of CMC joint)
• Thumb (Bennett’s or Rolando’s fracture) – refer all
Mid-shaft fractures:
• Uncomplicated eg stable solitary fracture, no rotation, no shortening, and
acceptable angulation: rest on volar slab 5-10 days, mobilise
• Complicated – refer or discuss acutely
• Any shortening
• Infection, FB
• Any rotational deformity
• Significant angulation or displacement
• Metacarpal head fractures
• Bennett’s/Rolando’s fracture
• Multiple metacarpal fractures
• Intra-articular fractures
• Open fractures
Other Referral
• Physiotherapist for early mobilisation
• Other specialist as appropriate eg plastics, vascular, neurosurgeon
need for support for independence. May need assistive devices while in
POP and hand therapy for stiffness and reduced function after POP is
removed
Read Code: S26..
Distal
phalanx
Middle
phalanx
Phalanges
KEY POINTS
• Much of the morbidity and disability can be prevented if proper
management is begun early
• Do not underestimate fractures in children. Remodelling can occur only
in those fragments angulated in the line of the pull of the tendons. Lateral
angulation and rotational mal-alignment, not obvious on X-ray will never
remodel and require accurate reduction
• If angulation greater than 10˚ refer for reduction
• Internal fixation or traction splinting if the fracture is unstable
• Mobilise early to avoid stiffness. From 7-14 days is ideal
• Reduction can be performed under an ulna nerve block or mixed
median/radial nerve block as required
• Where possible referrals should be to a hand surgeon/orthopaedic surgeon
Metacarpals
Hamate
Pisiform
Lunate
Ulna
Complications
• Finger stiffness due to joint adhesions is the most common and can result
in permanent loss of range of motion and function
• Infection from open fractures
• Mal-union
• Mallet finger
Proximal
phalanx
Distal
phalanx
of thumb
5
4
3
2
1
Proximal
phalanx
of thumb
Trapezoid
Trapezium
Capitate
Scaphoid
Radius
History
• Establish mechanism and force of injury
Axial compression from ball versus fingertip
Rotational injury
Crush injury
• Potential compound wound
• Joint injury
• Social and occupational activity
Examination
• Compare with the uninjured side
• Note erythema, ecchymosis and swelling
• Check vascular status by noting capillary refill
• Assess the extent of nerve, tendon or skin loss and document carefully
• Assess neurovascular status prior to administration of local anaesthetic
or regional block
• Determine the exact location of tenderness
• Assess the degree of displacement
• Assess the stability of the fracture
• Assess any rotational deformity
• Sprains of the fingers
• Lateral subluxation of finger
• Avulsed tendons or damaged tendons (eg extensor hood damage causing
boutonniere deformity, or extensor avulsion causing mallet finger)
• Volar plate injury
• Missed dislocations of the IP joints
Investigation
Recommended X-rays:
AP
45˚ oblique
Lateral
Hand Phalanges Fracture S26..
• Compare with uninjured side if required
• Scrutinise points of insertion of ligaments and tendons and the alignment
of articular surfaces
RED FLAG: The position of function of
Treatment
• Control swelling
• Compound wounds require comprehensive irrigation
• Minimise movement at the fracture site
• Stabilise the fracture site by controlling movement at the joint proximal
and distal to the fracture
• Hand function should ultimately dictate management
• Unaffected fingers should be left free and exercised
• The splint or slab should be removed as soon as possible (pain free) to
allow exercise of the fingers
• The splint or POP can, in some circumstances, be replaced with buddy
strapping after 2 weeks
• The metacarpal joints should never be fixed in extension
• Early return to work should be encouraged
joints at 90˚ and the wrist dorsiflexed
the hand for splinting purposes is with
the IP joints held in extension, MCP
at 45˚ (the “cobra” position)
Internal fixation may be necessary:
• If angulation is greater than 10˚
• If the fracture is unstable
• If the bony fragment is large (greater than 30% of articular surface)
• Rotational deformity
Fractures of the proximal and middle phalanges:
• Non-displaced and stable fractures of the shaft, base, neck, intercondylar
region or epiphyseal injuries:
Should have splint applied for 1-3 weeks and checked at weekly intervals
If symptoms are marked, apply a Zimmer splint (in position of function)
Re-examine and re-X-ray in 1 week to ensure no displacement (if any
concerns refer early to hand specialist)
• Seek advice for any displaced fractures, angulated fractures, compound
fractures, growth plate injuries, and fractures extending into a joint.
Fractures of the terminal phalanx (the neck and the base):
• Most common injury is a comminuted fracture of the terminal tuft. There
is usually no angulation or displacement. Associated subungal haematomas
may be treated with trephination (antibiotics are usually not required)
• For displaced or angulated fractures seek advice early
• Prioritise soft tissue injury treatment
• Pain relief may be gained by strapping the finger to a spatula or using a
plastic finger splint
• Fractures or fracture/dislocations at the base of the terminal phalanx can
lead to mallet finger deformity. Therefore test the power of extension at
the DIP joint. If there is a possibility of a mallet finger splint DIP joint
in full extension for 8 weeks, seek advice early if unsure. Tell the patient
that the finger must at all times be held in full extension to help prevent
a permanent disability
• Any rotational fracture
• Significant angulation
• Multiple phalanges fractures
• Displaced intra-articular fractures and those that will interfere with
joint movement
• Unstable fractures
• Bony fragment 30% of joint surface
Other Referral
• Physiotherapy assistance often required
• Should be established as soon as the affected finger can be exercised
• Hand therapy, sensation testing and education if nerve damage present
• Buddy strapping to encourage movement
• If dominant hand, may require assistive devices and work site modification
Fracture of Tibia & Fibula
Read Code: S33..
KEY POINTS
• Fractures of the tibia are generally associated with fractures of the fibula,
although isolated fractures of either can occur
• Most common long bone fractured
• Fractures are often open because of the length of the tibia, which is in
close proximity to the skin
• Admission of tibial fractures to hospital may be necessary for elevation,
pain relief and monitoring of the circulation
• Toddler’s fracture is a distal spiral fracture of the tibia most common in
the age group 9 months to 3 years
• Suspect child abuse with mid-shaft fractures of the tibia unrelated to
history of significant trauma
• Ensure X-ray visualisation of the whole length of the fibula before
diagnosing an isolated tibia fracture
• Non-displaced, closed fractures of the tibia and fibula treated with long leg cast
Complications
• Delayed union
• Non-union (tibia is the most common long bone non-union)
• Arthritis
• Fat emboli
• Peroneal nerve injury
History
Causes:
• Often tortional injuries from sport, for example skiing
• Falls from a height on to feet
• Direct blows, for example motor vehicle accidents
• Oblique and tortional injuries are common
• Pain and swelling and inability to weight bear are associated with
tibial fractures
Fibula
Tibia
Medial
malleous
Talus
Lateral
malleous
Femur
Lateral
epicondyle
Femur
Patella
Medial
condyle
Lateral
condyle
Patella
Fibula
Tibia
Tibial
tuberosity
Tibia
Examination
• Establish that the fracture is closed
• Assess neurovascular status
• Assess the degree of soft tissue damage
• The popliteal artery is vulnerable to damage in displaced upper tibial fractures
• Ability to walk (isolated fibula fractures are able to walk)
• Check the whole leg
• Note any deformity, ecchymosis, point tenderness, oedema and crepitance
• Ankle, soft tissue injuries
• Compartment syndrome, extremity
• Fracture, knee (tibial plateau)
• Fracture, ankle
• Paediatrics, child abuse
• Peripheral vascular injuries
• Tendonitis
Investigation
Recommended X-rays:
AP
Lateral
Both views should include the knee and ankle joint
• X-ray the length of the leg to ensure fractures at other sites are ruled out
Tibia, Fibula Fracture S33..
Fracture of Tibia & Fibula
• In all cases of fracture of the tibia in high energy accidents it is essential
to check hip clinically and X-ray
• Consider a bone scan for suspected stress fractures
Treatment
Initial treatment:
• ABCs
• Splint the affected leg if transporting
• Patient may need to be admitted
• Check neurovascular status
Non-displaced, closed tibia fractures in adults (discuss with or refer to
orthopaedic specialist):
• Apply a long leg plaster
• Re-check X-rays of the limb. The knee should be at 5-10˚ flexed
• Split the cast and review indications for admission
• Patient should be able to mobilise the next day – NWB and crutches
• Complete cast after 3-7 days
• Patient should be seen weekly with X-rays and for review of the cast
• Avoid full replacement of the cast until 3-4 weeks when the fracture is
more stable
• Sarmiento or patellar tendon bearing cast could be applied at this time
(if appropriate experience exists)
• Partial weight bearing may commence when swelling settled (about 7-10 days)
Non-displaced closed tibial fracture in children (discuss with or refer to
orthopaedic specialist):
• As above, POP backslab or split-cast, above knee, non-weight bearing for 1 week
• At 1 week, re-X-ray for position, replace cast only if necessary and
encourage weight bearing as tolerated
• If there was any displacement, X-ray at 2 weeks and review at 4-6 weeks
depending upon age
• All displaced fractures, angulated fractures and high violence trauma
require admission for elevation, analgesia, circulatory observation and
fracture management
• Open fracture
• Isolated fibula fractures associated with severe ligament rupture at the ankle
require open reduction and internal fixation (Maissoneuve type fractures).
These are found with isolated fractures of the proximal fibula where the cause
was NOT from a direct blow to the fibula but rather as a result of ankle
trauma (eg twisting injuries on a weight bearing fixed foot). Where the force
of the injury can rupture the medial ligament of the ankle followed by rupture
of the inferior tibiofibular ligament followed by a fracture of the proximal
fibula. This is a significant injury and requires early referral
Other Referral
• If ankle and subtalar joints stiff may need physiotherapy
• Is advisable to encourage knee flexion, to develop the quadriceps and to
help restore the gait
• Elderly living alone may require ADL and IADL assessment and assistive
devices while in POP and on crutches. May require support for independence
Tibia, Fibula Fracture S33..
Read Code: S34..
KEY POINTS
• Ankle fractures can result from eversion, inversion and external rotation injuries
• The most common ankle injury is when the talus is rotated in the mortise,
fracturing one or both malleoli
• Excellent results from conservative treatment can be obtained in the
majority of ankle fractures
• Open fractures have a high risk of infection
• Internal fixation should be considered in the presence of significant
diastasis or unstable bimalleolar or trimalleolar fractures
• Undisplaced single malleolus fracture can be managed in a POP cast for
4-5 weeks
• Delay in treatment increases the risk of complications
• Diligent follow-up is required
Complications
• Swelling persisting for weeks or months after fracture union is very common
• Suspect Sudeck’s atrophy where pain or swelling is gross and especially
if the toes are involved or if the patient complains of cold and sweating
• Stiffness, weakness and disturbance of gait respond well to physiotherapy
after good union
• Instability due to lateral ligament ruptures may occur
• Osteoarthritis is common if the initial fracture is not adequately managed
• Late complications include osteochondral fractures. Re-X-ray and refer
if ankle not clinically improving after appropriate treatment
• The more severe the fracture the greater the likelihood of arthritis
History
• Understanding the mechanics of the injury may aid in diagnosis
and treatment
• Can involve severe trauma or subtle trauma (eg stepping from a curb
causing sudden pain in an elderly patient)
Fracture types:
• Weber type A: transverse fibular avulsion
(below horizontal ankle joint line).
These result from internal rotation and
adduction injuries. Usually stable
• Weber type B: oblique fracture lateral
malleolus, with or without rupture
of the tibiofibular syndesmosis and medial
ligament injury (either medial malleolar
fracture or deltoid ligament rupture). These
result from external rotational injuries and
are either unstable or potentially unstable
• Weber type C: high fibular fracture with
rupture of the tibiofibular and
transverse avulsion fracture of the medial
malleolus. Result from adduction
or abduction with external rotation
Fibula
Tibia
Medial
malleous
Talus
Examination
• Check neurovascular status (posterior tibial pulse, dorsalis pedis pulse
and capillary return)
• Examine the joint and lower limb carefully
• Note presence of haemoarthosis, any changes in the relation of foot to
the ankle, any deformity, swelling and bruising, any point tenderness,
discolouration, temperature (especially cold) and inability to weight bear
– these are all indicators of a fracture and need to X-ray (also refer to
Ottawa ankle rules)
• Fractures of the lateral malleolus can often be differentiated from
ligamentous strains as the area of maximal tenderness is over the lateral
malleolus (or just above it), as distinct from over one of the collateral
ligament fasiculi
• Diastasis is diagnosed on X-ray when the talus is not positioned
symmetrically in the ankle mortise
Lateral
malleous
Tibia
Fibula
Navicular Talus
Cuneiforms
Distal
phalanx
Metatarsals
Proximal
phalanx
Calcaneus
• Ankle sprain
• Ankle dislocation
• Fracture, foot
• Fracture, tibia
• Lateral or medial ligament injury
Ankle Fracture S34..
Investigation
Recommended X-rays:
AP
Mortise view – radiographic AP
Lateral
• The whole fibula should be examined. High shaft fractures can be associated
with ligament damage at the ankle
• If in doubt about ligament integrity, stress films may be helpful
• X-rays should include base of 5th metatarsal if tenderness or pain localised
to lateral aspect of the foot
Ottawa ankle rules:
• X-ray patients who are
Unable to take 4 weight-bearing
steps at time of examination
Tender behind or at distal end of
either malleolus
• Does not include calcaneal fractures
Treatment
• Urgent reduction or referral is necessary when the neurovascular status
is compromised
• Stabilise and elevate limb
• Excellent results from conservative treatment can be obtained in the
majority of ankle fractures
• If transfer is required ensure adequate pain relief, reduce the deformity
if possible (with gentle traction) and splint securely
Undisplaced single malleolus fractures:
Discuss or refer Weber B or C fractures
BKPOP non-weight bearing for 2 weeks then weight bearing for
4 weeks
Crutches
Follow-up and re-X-ray after 1 week (and fracture clinic review)
Further weekly follow-up is required for up to 3 weeks, with assessment
of the need for re-application of the plaster
Supportive elastic bandaging after the POP is removed
Replace POP if loose or breaking up (risk losing the reduction)
Isolated stable laterial malleolus and tibial fracture may not require
POP (discuss with specialist if unsure)
Avulsion fractures (Weber A):
May not require cast. Be guided by the degree of discomfort
An airsplint may be adequate
A below knee cast or backslab is a good option for 1 week to control
pain and excessive movement which may exacerbate swelling
• All bimalleolar and trimalleolar fractures
• Any displaced fracture
• Any fractures with the potential for lateral shift of the talus in the ankle
mortise (Weber B, C)
• Any open fractures
• Where there is potential rupture of the deltoid ligament ie medial joint
tenderness (Weber B)
Other Referral
• Gait and muscle strength advice
• Physiotherapy may not be required for single malleolus fractures, but
generally is required for displaced fractures
• Any persistent swelling, weakness, stiffness or disturbance in gait indicates
a need for physiotherapy
• May require ADL and IADL assessment, assistive devices/support for
independence if elderly or living alone
Closed Fracture of Other
Tarsal/Metatarsal
Read Code: S352.
KEY POINTS
The code includes:
Metatarsals 1-5 fractures (including March and Jones)
Lis-Franc fractures/dislocations
Talus fractures (including avulsion fractures, talar dome and lateral process)
Navicular fractures
Os Calcis fractures (including avulsion fractures)
• Fracture of the 5th metatarsal is the most common fracture of the lower
limb (the patient may complain of having sprained their ankle, as the
injury is the result of an inversion injury)
Complications
• Gait disturbance
• Compartment syndrome (a very dangerous acute complication in fracture
of the foot – after a crushing incident)
• Non-union (especially base 5th metatarsal)
• Avascular necrosis (talar neck, navicula body)
• Complex regional pain syndrome (Lis-Franc)
• Post-traumatic arthritis (Lis-Franc)
Middle
Metatarsals
Proximal
Distal
Laterial
cuneiform
Cuboid
Calcaneus
Talus
Medial
Navicular
cuneiform
Intermediate
cuneiform
Tibia
Navicular Talus
Distal
phalanx
Fibula
Cuneiforms
Metatarsals
Proximal
phalanx
Calcaneus
History
• Inversion eg base 5th metatarsal
• Crushing eg metatarsals 2-4
• Twisting/torsion eg Lis-Franc
• Fall from height eg Os Calcis
• Snowboarding eg lateral process of talus
Examination
• Compare with the other foot
• Assess weight bearing/gait
• Look for bruising, swelling, deformity, lacerations/open wounds
• Palpate – site of tenderness
• Range of motion all joints – ankle, subtalar, TMT, MTP
• Associated structures eg tendon power
• Sprain eg ankle, MTP joint
• Dislocation eg subtalar
• Contusions foot/ankle
• Arthritis eg gout
Investigation
Recommended X-rays:
Foot:
AP (dorsiplantar)
Oblique
Lateral
Other Tarsal, Metatarsal Fracture S352.
If the study is to evaluate the mid-foot:
Coned AP mid-foot
Coned oblique mid-foot
Lateral foot
If the study is to evaluate the calcaneus:
Lateral hind-foot
Tangential view (axial) hind-foot
• With the multiple growth centres in children it may be helpful to have
view of the uninjured foot
Treatment
• Rest, ice and elevation of the limb
Fracture of the 5th metatarsal base:
• Usually non-displaced, but marked displacement warrants reduction and
internal fixation
• If symptoms are mild, use a compression bandage for support for 2-3
weeks with crutches
• Below knee walking plaster or plaster boot for 3-6 weeks if symptoms are
more severe
• Occasionally delayed union requires surgery
Second metatarsal stress (March) fracture:
• Often not seen on X-ray – refer if suspected in runner
• If seen on X-ray at an early stage and severe pain exists, a below knee
walking plaster until union has taken place may be necessary, otherwise
light support for 2-3 weeks
First metatarsal fractures:
• Undisplaced – crutches + BKPOP
• Displaced or complicated – refer acutely or discuss
Fractures metatarsals 2-4:
• Undisplaced + single – symptomatic treatment eg nil to BKPOP 1-3 weeks
• Displaced/multiple/complicated – refer or discuss acutely
Lis-Franc joint fracture/dislocations:
• The most commonly missed foot fracture
• To diagnose, look for diastasis of 2-5mm between 1st and 2nd metatarsal
base, or diastasis between medial cuneiforms, or fracture of base of 2nd
metatarsal
• Refer all acutely for ORIF, discuss all suspected
Talus fractures:
• Neck/body: undisplaced 6-10 weeks BKPOP, refer non-acutely. Displaced
– refer all acutely
• Talar dome (osteochondral): refer all. Often delayed presentation with
pain, crepitus, locking
Lateral process:
Snowboarders fracture, increasing frequency. BKPOP and refer non-acutely
Navicular fractures:
• Often stress fractures
• Undisplaced – BKPOP refer non-acutely
• Displaced – refer all acutely (high risk of avascular necrosis) for ORIF
Os Calcis fractures:
• High rate of associated injuries eg lumbar spine fracture, forearm fractures
• Intra-articular – refer or discuss all – check Bohler’s angle; if <20˚ needs ORIF
• Extra-articular – discuss or refer acutely. BKPOP or ORIF
Minor avulsion fractures from Os Calcis, navicular:
• Often associated with ligamentous insertions
• Treat symptomatically eg small – early mobilisation, large – BKPOP 1-4 weeks
• All open or complicated fractures (displaced, multiple, comminuted, malunion, tendon injury, mal-rotation, joint surfaces involved, air, unstable,
suspected compartment or complex regional pain syndrome)
• Lis-Franc fractures/dislocations, Jones fractures, all talar dome and
displaced navicular or talar neck fractures
Other Referral
• Other specialists eg neurosurgeon, vascular, pain as needed
• Early physiotherapy because most fractures associated with ligamentous,
proprioceptive, or gait problems and subsequent muscle weakness
Closed Fracture of
Phalanges of the Foot
Read Code: S36..
KEY POINTS
• Toe fractures nearly always heal with very little treatment
• Fractures in children are more difficult to recognise because of the multiple
growth centres
• Ensure fracture will heal in shape to fit comfortably into a shoe
Complications
• Infection
• Non-union
• Gait disturbances
• Arthritis
• Inability to fit into shoes
History
• Establish mechanism and force of injury
• Common fractures in men, often caused by a heavy object dropped on
to the foot
• The big or little toes stubbed on an immovable object is another cause
Metatarsals
Middle Proximal
Laterial cuneiform
Distal
Cuboid Calcaneus
Talus
Medial cuneiform
Navicular
Intermediate
cuneiform
Tibia
Navicular Talus
Cuneiforms
Fibula
Distal
phalanx
Metatarsals
Proximal
phalanx
Calcaneus
Examination
• Compare with the other foot
• Assess weight bearing/gait
• Look for bruising, swelling, deformity, lacerations/open wounds
• Palpate – site of tenderness
• Range of motion all joints – IP, MTP
• Associated structures eg tendon power
• Mild deformity in children may increase with age
• Toe dislocations
• Contusions/sprains
• Tendon injuries
• Metatarsal fractures
Investigation
Recommended X-rays:
AP
Oblique
Lateral
Treatment
Initial treatment:
• Rest, ice and elevation of the limb
• Splint
• Toe fractures will often heal with very little treatment
• Buddy splint the broken toe to the adjacent toe with gauze pads between toes
• Consider managing by wearing a stout shoe with the toe cut out for
comfort or an orthopaedic shoe
Foot Phalanges Fracture S36..
Great toe fractures:
• Undisplaced: splint + crutches. Consider BKPOP with toe platform
• Displaced: refer acutely or discuss
Toes 2-5:
• Undisplaced: buddy splint as above +/- crutches
• Displaced especially little toe: reduce if significant deformity under local
block, splint as above
• Displaced great toe fracture
• All open or complicated fractures (tendon injury, FB, infection)
Other Referral
• May assist in mobilisation and gain correction in the elderly
Foot Phalanges Fracture S36..
Dislocation/Subluxation
of the Shoulder
Read Code: S41..
KEY POINTS
• First time dislocations cause severe pain, decreased range of motion and
follow history of trauma, but subsequent or recurrent dislocations may
be much less painful
• Anterior dislocations account for 95% of shoulder dislocations
• The key to a successful reduction is slow but steady manipulation with
adequate analgesia and relaxation
• The rate of recurrence is high, particularly in the under 20-year age group
• Children are more likely to fracture the proximal humerus
• Patients over 40 years have a high incidence of complete rupture of the
supraspinatus tendon
Sternoclavicular joint
Clavicle
Acromion
Coracoid
process
Sternum
Humeral
head
Scapula
Humerus
Complications
• Axillary nerve palsy is the most common neurological complication
• Recurrence
• Associated fractures eg greater tuberosity, Hill-Sachs, Bankart lesions
• Vascular injury, axillary artery most common
History
• History of significant trauma unless recurrent
• Mechanism of anterior is abduction, external rotation, extension. Falls
on to an outstretched hand a common cause in older adults
• Posterior dislocations are caused by severe internal rotation and adduction
usually during a seizure, fall on an outstretched arm and occasionally by
a direct blow or electric shock
• Inferior usually caused by indirect forces hyperabducting the arm
Examination
Anterior:
• Look for loss of normal shoulder contour cf other side
• The humeral head may be felt lying anteriorly and inferiorly to clavicle
and coracoid
• Arm is usually held slightly abducted and externally rotated
• Neurovascular assessment – note peripheral pulses on both sides. The
axillary nerve (regimental) must be evaluated.
Posterior:
• Arm held in adduction and internal rotation
• Anterior shoulder is squared off, flat with the prominent coracoid process
when viewed from above
• Neurovascular deficits infrequent
• Patient resists external rotation
Inferior:
• Arm fully abducted with elbow commonly flexed or behind the head
• Humeral head may be palpable on the lateral chest wall
• Acromioclavicular injury
• Fractures of the humerus
Shoulder Dislocation, Subluxation S41..
Investigation
Recommended X-rays:
AP joint space (Glenoid fossa view)
Transcapular lateral or axillary view
AP internal rotation shoulder girdle
Posterior dislocations are often missed, so careful examination of the
appropriate X-rays is important
Treatment
• Reduce. The degree and route of analgesia and sedation will be determined
by the experience of staff and the number of doctors on duty
• A variety of techniques may be used for reduction: Kochers, Hippocratic,
Stimson, scapular rotation etc
• In paediatric patients gentle reduction is used as the epiphyseal plate is
prone to fracture
• Successful reduction is evidenced by a palpable or audible relocation,
marked reduction in pain and increased range of motion
• 1st dislocation, broad arm sling 3-6 weeks with orthopaedic review if
aged >40 or complication present
• If the dislocation is recurrent, sling and rest until comfortable. Specialist
review for all. Start physiotherapy and mobilise at 1 week
• Check dislocations in elderly patients at 1 week for rotator cuff injury
• Unreduced posterior dislocated shoulders of greater than 3 weeks should
be admitted as there is a danger of rupture of the brachial artery during
reduction
• In the posterior dislocated shoulder and fracture of the humeral neck
there may be a need for shoulder spica, if the reduction is unstable
Post reduction:
• Post reduction X-ray should be done
• Axillary nerve status assessed and documented again
• In the elderly mobilisation should be started at 1 week to reduce the
occurrence of stiffness
• NSAIDs for pain relief
• Recommended for all complicated first time dislocations, any dislocation
age >40 years, all recurrent
• In axillary nerve palsy with loss of deltoid function refer for stabilisation
• Dislocations with surgical neck fractures
• Inability to reduce
• Supraspinatus tendon rupture or associated complication
Other Referral
• Physiotherapy
• In the elderly, especially those living alone, assess ADLs and IADLs and need
for home help. May require assistance for housework and bath/shower etc
• Children with axillary nerve palsy require retraining in daily activities,
play and education for continuing normal development
• School or work site assessment and modifications may be necessary,
especially if dominant arm is involved
Shoulder Dislocation, Subluxation S41..
Dislocation/Subluxation
of the Finger/Thumb
Read Code: S44..
Complications
• Late or delayed reduction may result in loss of joint motion, joint instability
and limitation of hand function
• Gamekeeper’s Thumb – if unrecognised and untreated, may lead to
progressive MP subluxation with interference with the grasp, causing
significant disability
Distal phalanx
KEY POINTS
• Typically associated with forced hyperextension or hyperflexion of the
digit and requires immediate reduction
• Check for concentric reduction
• Splint in 30˚ flexion (Zimmer splint) for 2-3 weeks
• If stable consider mobilisation after pain and swelling have settled (3-5 days)
• If unstable refer for specialist management
• Hand dominance may affect management
Hamate
Pisiform
Lunate
Ulna
Middle phalanx
Proximal
phalanx
Distal phalanx
of thumb
5 4 3
2
Proximal
phalanx
of thumb
1
Trapezoid
Trapezium
Capitate
Scaphoid
Radius
History
• Jammed or bent backwards during sport is typical
• Identify the patient’s dominant hand
• Occupation – may impact work situation
Examination
• 2-phase test for functional stability done under digital or wrist block:
Active stability: the patient moves the digit through its normal range
of motion. Full range of motion indicates adequate joint stability and
only brief immobilisation is required
Passive stability: gentle lateral stress is applied to each collateral
ligament as well as shear stress in the PA plane to test volar support.
Compare with normal contralateral joint
• The diagnosis of incomplete or partial ruptures (sprains) is made when
the joint is stable to active and passive stress but is significantly swollen
with pain elicited on stress of the involved ligament. In such cases, stress
the joint obliquely to put tension on the accessory collateral ligament
• Neurovascular assessment
• Test for rupture of the ulna MCPJ collateral ligament of the thumb by
examining for passive abduction of more than 30˚ in a radial direction
• Dislocations, hand
• Fractures, hand
• Hand injuries, soft tissue
• Gamekeeper’s Thumb (Skier’s Thumb)
Investigation
Recommended X-rays:
AP
Lateral
Oblique
• Always X-ray even where the dislocation has been reduced
Finger Dislocation, Subluxation S44..
Treatment
• Control swelling
• Elevate limb
For reduction:
• Digital block anaesthesia 10-15mins prior to reduction
• Remove rings
• Brace the hand securely, grasp the dislocated finger (a dry gauze wrapped
around the finger will improve grip)
• Hyperextend the joint slightly with gentle longitudinal traction for a
dorsal dislocation and hyperflex for a volar dislocation. Gradually push
the finger into its normal position
• Do not apply vigorous traction in a child as it may interpose soft tissue
or an interchondral fragment into the joint space and prevent reduction
• After reduction examine the joint for instability of the medial-lateral or
dorsal-volar directions, range of motion, localised tenderness and flexorextensor tendon function
• Check for concentric reduction – do not accept anything less than perfect
• Should have normal range of motion
• Note that some dislocations will require open reduction, therefore do not
try excessively
Dorsal:
• Immobilise in Zimmer splint for 3-4 days, then:
Mobilise strapped to the adjacent digit for 2-3 weeks or leave free
Additional strapping during sport for a further 3 weeks
• If not stable it may indicate need for repair of the collateral ligament
Volar:
• Apply the splint only to the DIP joint on the volar aspect; the distal
inter-phalangeal joint should be in full extension
Chronic instability:
• Assess clinically and refer to specialist for repair and reconstruction
• Any neurovascular compromise
• Open joint dislocation
• Ligament or volar plate rupture
• Joint instability
• An associated fracture
• Re-evaluation by an orthopaedic specialist is advisable for all dislocations
Other Referral
• Not generally required
• Lightweight, short-term splinting
• ADL and IADL assessment and work modification – especially for
dominant hand
Finger Dislocation, Subluxation S44..
Plastering Guide
Support Material for the Fracture Treatment Profiles
OVERVIEW
Plaster of Paris (eg Gypsona) is a useful, cheap and efficient material
commonly used to treat orthopaedic conditions.
However, Plaster of Paris does have drawbacks. The problems of pressure
and neurovascular damage from badly applied casts can have serious
consequences. The person applying the cast is responsible for ensuring it
functions efficiently and does not cause the patient any harm.
The applications shown in this publication are not the only effective methods.
They are samples of procedures to ensure an efficient, safe and comfortable
cast can be achieved every time.
This publication has two sections:
• General Application
• Applying Basic Casts
Plastering Guide
General Application
Principles, Problems and Answers
BEFORE YOU START
Immobilise Joints in the Position of Function
Some exceptions include when a specific treatment position is ordered:
• Ankle plantarflexed after repair of the Achilles tendon
• Wrist in flexion after flexor tendon repair
Remember: There is a risk of stiffness with any immobilisation. If a joint stiffens
in a non-functional position, a serious disability may result. This is especially
true with the hand.
Wrong
Full Range of Movement of Unaffected Joints
The patient must be instructed to move all joints not immobilised in the
cast. This is especially important in the upper limbs.
Remember: An elderly patient with a simple wrist fracture, immobilised in a
below the elbow cast and full arm sling, will need clear instructions on how to
avoid shoulder, elbow, and finger stiffness or serious functional impairment.
Right
All Acute Injuries Should be Immobilised in a Padded Split Cast
A padded split cast consists of an encircling layer of padding over the
whole limb. Then a complete cast is applied and split longitudinally.
To prevent the cast spreading apart, a wet gauze bandage (eg Easifix)
is then applied.
For exceptions to this rule, see Dorsal Slab, Above Elbow Back Slab,
Scaphoid Cast and U slab.
This type of cast does not prevent swelling. If elevation does not control
swelling, or if you notice any neurovascular impairment of the extremities,
the cast is designed so that it is relatively simple to check the problem.
• Remove gauze bandage
• Spring the cast apart
• Cut all padding to expose the skin. This is essential because the cast
padding can also cause constriction, especially if there has been any
bleeding or serous ooze into it
In situations where excessive swelling is anticipated, instead of just splitting
the cast, remove a 1 cm strip of plaster. This ensures that no threads of
plaster remain, and then it is quite simple to cut the cast padding.
General Application
General Application
Splitting Wet Casts
• The best method is to use a B.P. handle with a No. 20 blade
• The movement of the blade should be down, never along the cast
• Simple pressure on the cast padding will not cut it, but dragging
the blade across or along it will
Remember:
• Always cut over soft tissue – not over the bony prominences – as the soft
tissue will ‘give’
• Always rest the limb on a pillow so that the ‘dead’ space within the cast is
where you are cutting
• Always split along a line away from nerves and vessels
Back Slabs
Back slabs can be used for most acute fractures but are best on lower limbs
if the patient is mobile. They are appropriate if:
• You anticipate increased swelling and/or full examination of a joint or
limb is required (eg acute osteomyelitis, cellulitis)
• Supervised joint movement is prescribed (eg following internal fixation
of ankle fractures)
• Redressing of large wounds means you need to be able to completely
remove the cast
In situations where immobilisation with wound inspection and/or redressing
is required, a full cast with a window is often more suitable than a back slab
(eg lacerated knee). This enables a well fitting, stronger, lighter cast to be
applied and movement will not cause the cast to slip.
These casts are often quicker and easier to apply and are less easily discarded
by a patient who cannot see why a ‘cut’ needs a cast.
Patient Information
Patients must be given information about how to care for their cast. They
need to know how to recognise a problem and what to do about it. Followup plaster check appointments and future care should also be arranged.
For acute injuries, every patient should have a ‘plaster check’ 24 hours after
its application. This check should include:
• Neurovascular state of limbs
• Movement of extremity
• Cast comfort
• Cast integrity
General Application
General Application
APPLCATION TECHNIQUES
Water
Remember: Plaster + Water = Heat
Warn your patients of this.
Always start your ‘plastering career’ using cold water – you’ll have more
time to work. When you become more comfortable, start using more tepid
water. Never use warmer than tepid water or you’ll end up with a very quick
setting, brittle cast with little time to smooth or mould the cast.
Padding (eg Soffban)
• Apply padding firmly, but without tension – loosely applied padding
results in a bulky, ill fitting cast
• Tear to negotiate corners
Remember: Extra padding will not protect your patient from a badly applied
cast and it may cause pressure and constriction.
Stockinette
• Choose the correct width
• When in doubt, use a smaller size that has been stretched
• Wrinkles and tucks in the stockinette can cause pressure
Plaster (eg Gypsona)
• Use a suitable size for the limb
Adult
Leg – 15 cm
Arm – 10 cm
Child
Leg – 10 cm
Arm – 7.5 cm
• Hold the bandage with the end free so after soaking the end will be easy
to detach from the bandage
• Immerse the bandage in water until the bubbles stop
• Squeeze gently to remove excess water. Too much will make the bandage
set, and not enough will make the bandage hard to manage
• Roll the bandage around the limb from the outside in, using pleats to
change direction
• Keep the ‘body’ of the bandage roll against the limb; Two reasons:
The bandage cannot be applied with too much tension, or in
constricting bands
The limb being plastered helps to support the bandage – acting as a
‘third’ hand
• You’ll need to do a quick smoothing between layers. If the successive
layers are applied quickly, all the smoothing can be done after you complete
each section. This will ensure you achieve a strong light cast that will
not delaminate
Remember: When each section of the cast is complete, it should still be soft
enough for the surgeon to perform any moulding that is required.
Soaking Slabs
• Fold as shown
• Hold ends loosely and soak while it is still folded
• Remove from water and squeeze gently
• Pull out the slab – it will be straight and ready to apply.
General Application
General Application
Moulding
• Always use the flat of the hand and keep the hands moving – sustained
pressure in one place will cause pressure on the limb
• When your hands will not slide easily on the plaster, maintain the moulding
position until the cast is fully set – constant movement of the cast will
break it
Joining Two Sections of the Cast
When a cast is applied in sections (eg an above knee cast where the below
knee section is applied first), it is important to ensure adequate immobilisation
to avoid causing pressure at the junction.
Unfortunately it is not uncommon to see patients with their fractured tibia
‘immobilised’ in a cast where the above knee section can swivel around the
below knee section. This lack of stability can be painful for the patient. It
will also hinder free movement and it could move the fracture position.
When attaching one section to another:
• Apply the cast padding to both sections at the start of the procedure
• Before starting the second section, ensure the edges of the first section
do not press into the limb
• Cover at least 15-20 cm of the first section with the next layer of plaster
– this does not need to be a thick layer
Caring for the Newly Applied Cast
• Handle all casts with the flat of your hand. Never clutch at a wet
cast – the indentations may cause pressure on the underlying skin
• Support the length of the cast to prevent cracking
• Use pillows when resting wet casts so they can conform to the contours
• X-ray plates are hard so always use foam pads to protect the cast
• In lower limb casts which include the foot, avoid pressure on the heel by
making sure it is free from the pillow
• In casts where the foot is not included, support the heel to prevent pressure
on the Achilles tendon
Check
• Don’t ruin your cast by careless handling after completion.
General Application
General Application
Watch Out for Potential Complications
Neurovascular Damage
It is important to make frequent and regular neurovascular observations.
These need to be recorded and the plaster should be opened at the first sign
of a neurovascular problem.
A rigid cast on a swelling limb may cause neurovascular compromise. This
is why padded split casts are preferred for all acute and post-operative casts.
Local pressure on a nerve may also cause symptoms (eg a common peroneal
nerve may be affected by cast pressure over a fibula head).
Pressure
Local pressure can be caused while the cast is being made or by incorrect
handling.
Any complaint of pressure, burning, pain or discomfort under a cast must
be investigated immediately by cutting a window and inspecting the area.
Remember: Some patients will not, or cannot, complain (eg infants, patients
with head injuries, or patients with anaesthetic limbs).
CUTTING A WINDOW
• Mark the area
• Remove the window with an oscillating cast cutter
• Inspect the area and pad
• When repadding the area, to prevent pressure, make sure it extends
beyond the edges of the window
• Replace the window, ensuring the edges do not cause pressure, and
plaster back in position
It is important that the window is replaced to prevent further damage to the
skin and to prevent swelling of the soft tissues through the window. This
is especially true for independent areas such as the heel or elbow. If it is
necessary to reinspect the area, use a non-stretch adhesive plaster to hold
the window in place.
Remember: After a few hours of pressure, skin becomes insensitive. This means
the patient may not feel pain but full thickness skin loss may result.
POSITIONING THE PATIENT
Your patient should be comfortable during the application of the cast. It is
hard to plaster a moving target.
In many cases you will need an assistant to support the limb. Your patient
should be positioned so your assistant can do this without having to strain.
General Application
General Application
NOTES FOR THE ASSISTANT OR HOLDER
• Decide the position in which the limb is going to be immobilised and
position the limb correctly at the start of the procedure
• Do not alter the position of the joint after the procedure starts. Flexing
or extending a joint once the padding and/or plaster has been applied
will cause pressure and constriction
• Allow the plasterer to complete each section of the cast before you start
to mould. Hopefully, by allowing the plasterer uninterrupted access to
the limb, the cast will still be plastic enough to mould
FINAL CHECK
• Have you applied the right type of cast to the right area?
• Is the cast comfortable – no pressure or rough edges?
• Can the patient move all other joints?
• Does the patient know the movements allowed and encouraged?
• Does the patient understand about plaster care and what to do if
problems arise?
• Have you remembered the follow-up?
REMOVING THE CAST
As a general rule, all limb casts should be bivalved (eg split both sides of
the cast). If the cast is split along one side only, this could create a twisting
force as the limb is extricated from the cast.
Bivalving provides a ‘back-slab’ for the limb to rest in if there is a delay in
reapplying the cast or reaching a clinical decision to remove it.
It is possible to tie both sections of the cast together if the patient needs to
be moved to another area.
Remember: Patients should not bear weight on a bivalved cast.
The Procedure
• Mark the cast where you intend to cut
• Ensure you’re not cutting over a bony prominence (eg when removing a
cast from the lower limb you may elect to cut behind the medial malleolus
and in front of the lateral malleolus)
• Use either plaster shears or an oscillating plaster cutter
Remember: Explain the procedure to your patient – both these tools look
pretty frightening if you’re inside the cast!
Shears Technique
• Insert the blade between the cast and the padding
• Keep the near arm of the shears parallel to the cast
• Move the outer arm towards the cast – this brings the blade away from
the limb
Remember: Short ‘bites’ will prevent the shears from jamming. If the cast is well
padded, withdraw the blade frequently and re-insert between the cast and the padding.
General Application
General Application
Oscillating Saw Technique
• Hold the blade at right angles to the cast
• Hold the moving blade against the cast until you feel it start to go through,
then withdraw immediately – the sound will change when it is through
• Continue moving along the cast in a series of cuts – never use one
continuous sweep along the cast
• Only one part of the blade is being used so it will become hot. Make sure
you change to a different part of the blade after making three or four cuts.
This is especially important with synthetic casts
Remember: It’s better to use an oscillating saw with a dust extractor – it protects
both patient and clinician (eg De Soutter CCS saw and extractor).
General Application
Applying Basic Casts
This section shows one method that can be used to apply some common casts.
• Use reinforcing slabs to give a strong, yet light cast. Commercial slabs
are available, or slabs can be made from a plaster bandage
• For an average adult the following sizes are suggested:
Four layers of 10 cm bandage for upper limb
Six layers of 15 cm bandage for lower limb
• For acute and post-operative casts, do not use a stockinette. A padded
split cast should be applied instead
• For definitive casts, use a stockinette with minimal padding over bony
prominences and sections where the cast may be joined
DORSAL SLAB
Use this slab for below elbow immobilisation in the acute injury. It is better
than a padded split cast for several reasons:
• With the wrist in a functional position, the forearm has no well defined
contours. The amount of padding needed for safe splitting means the
cast tends to become loose as the swelling subsides. The position can
be lost and the cast then needs changing
• A well constructed dorsal slab offers the same safety features as a
padded, split cast (eg if swelling can’t be controlled by elevation, the cast
can easily be split – there’s no plaster on the ventral aspect of the forearm)
• When the swelling subsides and an X-ray checks the position, the cast
can be completed and, if necessary, tightened by removing the outer
bandage and replacing it with a plaster bandage. Since the cast has
not been changed, there is no risk of losing the fracture position
Method
Apply a stockinette and a thin layer of Soffban or just a thin layer of padding
to the whole area being immobilised. (Loose padding will prevent a ‘good
fit’ when applying a dorsal slab.)
• Measure from 3 cm below the elbow crease to the metacarpal heads
• Make a slab using a whole 15 cm plaster (eg Gypsona) and spread it
approximately 20 cm wide
• Trim as shown in the diagram
• Apply the slab to the radial aspect first
• Fit the slab around the thumb and then smooth it round to the ulnar
border. Take care to keep it up to the metacarpal heads
• Check the slab does not overlap, turn back the edges if necessary.
Allow a gap of at least 2 cm
• Bind with a wet gauze bandage (eg Easifix)
• If the slab is too narrow and does not support the ulnar aspect of the
forearm, simply cut another 10 cm slab to the correct length and apply
it to fill the gap
Check
• Full flexion and extension of the MCP joints
• Full flexion and extension of the elbow joint
• Opposition of the thumb
Teach the Patient
• All above movements
• Shoulder movements
BELOW ELBOW CLAM SLABS
To support the hand in a functional position. Particularly suitable for soft
tissue injuries since it can be removed for wound inspection, and reapplied.
Method
• Make two slabs (eg Gypsona) 8-10 layers, 10 cm wide at the required length
• Cut two double layers of cast padding (eg Soffban), twice the length of
the slabs
• Soak the slab
• Lay the slab on padding and fold the rest of padding back over slab
• Repeat with second slab
• Apply dorsal and ventral slabs
• Bandage with crepe or cotton (eg Elastolite crepe bandage)
• Hold until set
Check
• Hand is in functional position
• Elbow movements
• Thumb opposition
Teach the Patient
Elbow and shoulder movements
BELOW ELBOW CAST
To immobilise the wrist in non-acute injuries, or when swelling is unlikely.
Method
Make two reinforcing slabs (eg Gypsona) using four thicknesses of
10 cm plaster:
for the ulnar border
for the hand, this slab is split.
• Apply the stockinette to the limb and add a layer of cast padding
(eg Soffban) around the wrist to protect the styloid processes
• Apply the slabs as shown in the diagram
• Turn back the edges of the stockinette and complete the plaster with a
10 cm plaster bandage
Check
• Full flexion and extension of the MCP joints
• Full flexion and extension of the elbow joint
• Opposition of thumb
Teach the Patient
• All above movements
SCAPHOID CAST
To hold the thumb in opposition following fractures of the carpel scaphoid.
This may be applied over stockinette even in the acute stage, unless associated
with other injuries (eg fracture radius) which are likely to cause swelling.
During the cast application, the thumb should be held in opposition and the
wrist in slight radial deviation. The plaster should be moulded well into
the palm. The plaster does not need to extend to the metacarpal heads.
Method
• Make two reinforcing slabs (eg Gypsona) using four thicknesses of 10 cm plaster:
A radial slab which is split
A palmar slab
• Make a third slab with one layer of plaster 15 cm long, folded in three
lengthwise
• Apply a stockinette to the limb, with a layer of cast padding round the
wrist and thumb to the IP joint
• Apply slabs as shown in the diagram
• Turn back the stockinette, and complete the cast with a 10 cm plaster
Check
• Flexion and extension of MCP joints
• Flexion and extension of elbow joint
Teach the Patient
• Above movements
ABOVE ELBOW CAST
To immobilise the forearm and elbow. A padded plaster is used for acute
injuries. It is applied over padding and is split lengthwise from palm to
medial epicondyle to axilla. A non-padded plaster is used for non-acute
injuries. It is applied over a stockinette with padding (eg Soffban) round
the elbow and wrist.
Method
Make two reinforcing slabs (eg Gypsona) using four thicknesses
of 10 cm plaster:
For the ulnar border
For the hand, this slab is split.
• Apply as shown in the diagram
• Turn down the edges of stockinette
• Complete the cast with two or three 10 cm bandages
4
3
5
2
1
Hints
It may be easier to apply one Plaster of Paris bandage (eg Gypsona) before
applying the slabs. This makes the slabs easier to apply because they adhere
to wet bandage better than to stockinette and undercast padding.
This first bandage should be applied as shown.
Caution
• To prevent any pressure in the antecubital fossa, it is important that the
Soffban is torn as it crosses the anticubital fossa, and that the first turns
of plaster are applied as shown.
• Make sure the elbow is held in the correct degree of flexion throughout
the application of the cast
Check
Flexion and extension of MCP joints
Teach the Patient
Finger and shoulder movements
ABOVE ELBOW BACK SLAB
To immobilise the elbow and lower end of the humerus (especially
supracondylar fractures of the humerus in children).
The slab is applied so there is no plaster or padding in front of the antecubital fossa.
Method
• Apply a double layer of cast padding (eg Soffban) across the back of the
elbow joint
• Hold in place and roll on as shown for the first bandage of the above
elbow cast, avoiding the antecubital fossa
• Three six-thickness slabs (eg Gypsona) are applied as shown, and held
in place with a crepe or cotton bandage (eg Elastolite crepe) using the
same method of bandaging
Remember: The size of cast padding used depends on the size of the limb. Don’t
end the slab at the wrist because this often results in increased pressure. Support
with a collar and cuff sling. A stockinette sling may be used for
small children.
Check
• Finger movements
• Access to radial pulse
Teach the Patient
• Finger movements
• Shoulder movements within the limitation of sling
BELOW KNEE CAST
This cast immobilises the ankle and should extend from the tibial tuberosity
to the web of the toes. It should be low enough behind the knee to allow
full knee flexion. If necessary (eg injuries to the metatarsals) the plaster
may extend to form a toe platform, but otherwise it is trimmed back to allow
toe movement.
Method
• Rest the knee on a wedge and have an assistant hold the foot in the
plantargrade position
• For a padded split plaster, apply padding (eg Soffban) to the limb. For
an unpadded cast apply a stockinette with a layer of padding (eg Soffban)
to protect the malleoli and the heel
• Start below the knee, apply the cast. For the average adult cast you’ll need:
One 15 cm plaster (eg Gypsona)
A 15 cm reinforcing slab (eg Gypsona)
One or two more bandages (eg Gypsona)
• If the cast is to be weight-bearing, reinforce the sole with a 15 cm slab
(eg Gypsona) attached with a 10 cm bandage. A walking block, or a cast
boot may be used
Check
• Knee flexion
• That there is no pressure over common peroneal nerve at the fibula head
Teach the Patient
• Elevation when not moving
• Toe movements
• Crutch walking
ABOVE KNEE CAST
To immobilise knee or tibial injuries.
Method
• Apply padding (eg Soffban) to the whole limb for a padded split cast
• Apply stockinette and a layer of padding around the knee and ankle
for a definitive cast
• Rest the knee on a wedge, and have an assistant hold the foot in the
plantargrade position
• Complete the below knee section just as you would for a below knee cast
• Ensure that the knee is held on the wedge in the required amount of
flexion (usually 10-15 degrees)
• Commence the above knee portion of the cast
• Apply one 15 cm plaster (eg Gypsona) bandage from upper thigh to
below the knee, using figure eight turns around the wedge
• Keep close to the wedge so that there is only a small gap behind the knee
• Repeat with a second bandage
• Check that there is sufficient overlap of the two portions of the cast
• When the cast is sufficiently set, remove the wedge
• Apply a posterior slab (eg Gypsona) as shown in the diagram at right.
This completes the gap left by the wedge, and reinforces the back of
the thigh cast
• Use a final bandage (eg Gypsona) to complete the cast and attach the
slab. Make sure the degree of knee flexion is not altered
Check
• Toe movement
• No pressure behind knee
Teach the Patient
• Elevation when not moving
• The patient should protect the back of the cast when sitting, by either
sitting with their leg elevated and supported, or by ‘perching’ on a
chair with the cast free
• Crutch walking
CYLINDER CAST
Used to immobilise the knee.
Method
• It is important to position the patient carefully – raise the buttocks on
a sandbag or pillow
• Use two wedges to rest the leg in the required position, usually with
the knee straight, but not hyperextended
• Protect the malleoli and Achilles tendon with felt or sponge
• Apply cast padding (eg Soffban) for a padded split cast, or a stockinette
with padding (eg Soffban) around knee and ankle for a definitive cast
• Apply two 15 cm plaster (eg Gypsona) bandages, starting at the thigh
and covering the whole area, using a figure eight method around
the wedge
• Apply anterior slab (eg Gypsona), and then two more bandages
• Mould cast on either side of the thigh, just proximal to the femoral
condyles, and on either side of the calf just above the malleoli. This
will help to prevent the cast slipping down
• Trim plaster at the ankle front and back so the ankle movement is not
restricted. Check there is no pressure on the Achilles tendon
• When the plaster is firm, remove the knee wedge
• Apply second slab as shown in the diagram and attach with a
fifth bandage
For padded split casts, apply the anterior slab slightly medially, and split
the cast slightly laterally. This avoids cutting through the slab.
Check
• Ankle movement
• No pressure over Achilles tendon
Teach the Patient
• Elevation
• Crutch walking
• Cast protection when sitting (see ‘Above Knee Cast’)
BELOW KNEE TOTAL CONTACT CAST (TCC)
Sometimes referred to as Patella Tendon Bearing Cast – Sarmiento Cast.
Conservative management of tibial fractures.
Control of the tibia fracture is achieved by:
• A closely moulded, unpadded cast
• Moulding the upper section in a triangular fashion, with the apex
anteriorly and a flattened base in the popliteal space
• Carefully moulding over the patellar tendon and round the femoral condyles
Remember: This is a definitive cast and is best applied at 2-3 weeks post injury
– when the swelling has subsided but before the knee stiffens.
Method
Preparation
• Bivalve the above knee cast and inspect the limb for any contraindications to a TCC (eg skin defect, excessive swelling)
• Bind both sections of the cast together firmly
• Split the posterior half below the knee so the posterior thigh cast can
be removed. This allows knee flexion to be achieved whilst maintaining
the position of the fracture
• Position the patient comfortably, supporting the unaffected leg with pillows
• Slowly flex the affected leg over the end of the couch and support the
thigh on a sandbag. (The plasterer should use a low stool)
• Flex the knee to 90 degrees
• Remove the cast and use the plasterer’s knee to support the patient’s foot
Remember: The ability of this cast to maintain the correct fracture alignment
depends on careful moulding of a closely fitted cast.
The cast must be moulded firmly in a triangular fashion at the upper end
of the tibia, the apex of the triangle being over the tibial tuberosity.
When the knee is flexed to 45 degrees to relax the quadriceps, the upper
section of the cast is moulded well over the patellar tendon and around the
femoral condyles.
Application
• Roll on a stockinette to above the femoral condyles
• Place one layer of padding over the heel and malleoli
• Apply one 10 cm bandage (eg Gypsona) round the foot and ankle.
Check the foot is plantargrade
The next step depends on the type of fracture.
Low fracture that needs corrective moulding:
• Apply two 15 cm plaster (eg Gypsona) bandages about 7 cm below
the tibial tubercle to the heel
• Overlap the previously applied plaster
• Mould the fracture
• When plaster sets, add 15 cm plaster (eg Gypsona) bandage from the
tibial tubercle to join with the second layer. This allows two separate
mouldings to be made – the triangular moulding round the upper end
of the tibia is vital
Low fracture that does not need corrective moulding:
• Use two or three bandages (eg Gypsona) to complete this section in
one piece
• Extend the knee to 45 degrees to relax quadriceps tendon
• Apply slab and attach with a 10 cm bandage
• Hold the back of the cast firmly against the limb to prevent a loose fit
• Mould well over the patellar tendon and around the femoral condyles.
The patient must be relaxed for this moulding
• Trim the top of the cast to expose the proximal border of the patella.
The lateral wings should fit snugly around the femoral condyles
• Trim the back of the cast to allow knee flexion
• Apply walker
Check
• That there is no pressure near fibula head
• Patient can flex knee comfortably
Teach the Patient
Crutch walking, progressing to weight bearing
Section 3 Burns
CONTENTS
Read Code
Burn Eye and Adnexa
SH0..
Burn Face, Head, Neck
SH1..
Burn Trunk/Burn Arm - (Excluding Wrist, Hand)/
Burn of Lower Limbs
SH2../SH3../SH5..
Burn Wrist(s) and Hand
SH4..
3 burns
Burns Overview
Burns Overview
KEY POINTS FOR MANAGEMENT
Resuscitation
• Assess and treat as appropriate
• Airway, breathing, circulation, neurological state (if reduced level of
consciousness or confusion, suspect carbon monoxide exposure and give
high flow oxygen)
• Assessment for potential airway compromise
Depth
Colour
Blisters
Capillary Refill
Sensation
Healing
Superficial/Erythema
Red
No
Present
Present
Yes
Superficial
Partial thickness
Pale pink
Small
Present
Painful
Yes 7-10 days
Deep
Partial thickness
Blotchy red Larger absent
Absent
Absent
Prolonged
Full thickness
White
Absent
Absent
No
No
History
• Time and duration of exposure
• Nature of exposure
• First aid measures
• Co-morbidities
• Medications/allergies
• Tetanus immunisation status
• Fire in contained space, exposure to fumes, smoke or gases
• Drug or ethanol intoxication
Examination
• Location
• Body surface area
• Depth
• Singeing of nasal hair
• Carbonaceous sputum
• Dysphonia/hoarseness
• Stridor
• Intraoral/pharyngeal burns
• Identify other significant injuries
Treatment
Cooling:
• 15 minutes under running tap water OR saline/water soaked dressings
• Avoid ice (may exacerbate tissue injury)
• Be aware of potential for hypothermia, especially in children with large burns
Analgesia:
• Oral OR intravenous (aliquots of morphine) OR inhaled eg nitrous oxide
– if possible avoid intramuscular/subcutaneous routes (erratic absorption
and slower onset of action)
Overview
Burns Overview
Dressings:
All contaminated burns should be washed with dilute antibacterial agent
such as aqueous chlorhexadine 0.1-0.2% OR, if not available, with bland
soap and water.
Superficial:
• No treatment other than moisturising ointment eg liquid paraffin OR film
dressing eg Opsite, Tegaderm, OR retentive dressing eg Hypafix, Mefix
Partial Thickness:
• There are many commercial dressings available for use on these burns
and selection is controversial. The following represents a number of
approaches in current use:
1
Retentive dressings eg Hypofix, Mefix
2
Tulle gras multi-layered dressing eg Jelonet with overlying absorbent
dressing
Change of absorbent layer at 48 hours
Remove absorbent dressing and tulle gras at 5-7 days and reassess
wound
Reapply if necessary
Reassess earlier if signs of infection eg increasing pain, fever, offensive
discharge
3
Silver sulphadiazine (SSD) applied to burn and covered with absorbent
dressing
Reassess and redress daily
After 3 days then tulle gras dressing as above unless concerns ie infection
4
Hydrocolloid dressing eg Duoderm
Change every 3-5 days, earlier if signs of infection
Blister Management:
• If burst: carefully deroof
• If intact and not impairing function, leave intact
• If intact and impairing joint function, aspirate with needle/syringe
• NB see individual profiles
Full Thickness:
• Daily SSD dressings as above OR as advised by specialist, with whom the
patient has been discussed
Overview
Burns Overview
Tetanus Toxoid Immunisation
• If required (see Laceration/Abrasion section)
Chemical Burns
• Majority are acids and alkalis
• Injury may occur as a result of direct tissue burn and/or toxicity from
systemic absorption
• Management focuses on decontamination, antidotes where appropriate
and treatment of systemic toxicity
• Initially brush off dry chemical particles then copious irrigation with
running water or saline
• Duration of irrigation dependent on agent. Alkalis may require prolonged
irrigation, especially the eye
• pH testing with litmus paper can be used to guide duration of irrigation
• Metal fragments embedded in skin should be covered with mineral oil or
sand NOT water
• Seek immediate advice regarding management of chemical burns, especially
exposure to hydrofluoric acid (HFA), metals or alkalis
• Hydrofluoric acid burns: individuals should have calcium gluconate gel
applied to the area (if available) prior to transfer to hospital (made by
mixing KY jelly with calcium gluconate to make a 2.5-10% solution)
Electrical Burns
• May be superficial – full thickness
• Deeper structures, particularly nerves and blood vessels, may be severely damaged
• Ensure full assessment to exclude other injuries
• Ongoing management of individuals with electrical burns (unless trivial)
should be discussed immediately with hospital specialist
• Pregnant women suffering an electrical injury should be referred urgently
to hospital for foetal assessment
• Individuals exposed to low voltage electrical injuries (ie domestic supply)
should have an ECG performed:
If normal – cardiac monitoring is not necessary unless known ischaemic
heart disease
If abnormal – patient should be transferred immediately to hospital by
ambulance for assessment
• Individuals exposed to high voltage electrical injuries should be transferred
to hospital by ambulance for immediate assessment
Overview
Burns Overview
Overview
A “RULE of NINES” diagram
B Lund and Browder chart
for estimation of % body surface area in adults
for estimation of % body surface area in children
Burn Eye & Adnexa
Read Code: SH0..
KEY POINTS
Ocular burns:
• Potentially blinding
• Commonly caused by contact with chemicals or over-exposure to UV
light (welding, sun-beds)
RED FLAG:
Irrigation of ocular burns should
commence before detailed history
or examination:
Chemical burns:
• Alkali burns (bleach, chemical detergents, plaster/concrete) are true ocular
emergencies
• All chemical burns should be managed initially by copious irrigation
• Cycloplegic agents provide considerable pain relief in ultraviolet keratitis
Thermal burns:
• Commonly affect the lids because of the protective blink reflex
• Rarely affect the eyes
• Silver Sulphadiazine (SSD) should not be used on the eyelids in thermal burns
Complications
Thermal:
• Scarring
• Contractures
Chemical:
• Perforation of globe
• Corneal scarring
• Adhesion of lids to globe
• Glaucoma
• Cataracts
• Retinal damage
History
• First aid administered
• Co-morbidities eg diabetes/immunocompromise
• Current medications and allergies
Examination
• Initial focus on airway, breathing, circulation and neurological state as
appropriate
After irrigation (or cooling of thermal burns) assess:
Visual acuity
Nature, depth, area of burn
Ophthalmoscopy with fluorescein to assess corneal epithelial damage
• Other causes of keratitis for UV burns
Investigation
• Nil appropriate if isolated eye/adnexal burn
Burn Eye & Adnexa SHo..
Burn Eye & Adnexa
Treatment
Chemical burns:
• Topical anaesthetic, then irrigate with saline through an IV giving set for
15-20 mins. Tap water if saline is not immediately available. Check
fornices/double evert upper lid to detect and remove particulate matter
with moist cotton bud
• Continue irrigation until pH of tear film is 7.0-7.4. Recheck pH after 10 mins
• Urgent referral of all alkali burns
If uncertainty about pH in alkali burn continue irrigation throughout
transfer to hospital
• Non-alkali burns – after irrigation – stain with fluorescein to assess damage
to corneal epithelium but note widespread epithelia destruction causes
poor uptake of fluorescein, which may be confusing
• Apply chlormycetin ointment and double pad eye
• Analgesia – oral/IV depending on severity
Thermal burns of lids:
• Superficial (no blistering): apply antibiotic ointment eg Chloramphenicol based
• Partial thickness/full thickness: as above and referral
• Appropriate analgesia
UV burns:
• Topical antibiotic
• Cycloplegic agent – Cyclopentolate 1% TDS
• Analgesia
• Pad
• Reassess at 24 hours
• Chemical burns: urgent referral to ophthalmologist alkali burn or evidence
of corneal damage
• Thermal burns: partial/full thickness – refer to ophthalmologist if localised
to eyelids, otherwise to plastic surgeon
• Ultraviolet keratitis: refer to ophthalmologist if not settled within 48 hours
Burn Eye & Adnexa SHo..
Read Code: SH1..
KEY POINTS
• Resuscitate if appropriate
• Patients with history/examination findings suggestive of inhalation injury
should be transferred to hospital urgently
• Adequate cooling for all burns – 15 mins under running water or
saline/water soaked dressings
• Analgesia as appropriate
• Oral and perioral burns are the most common electrical injury in children
and result from chewing on a live cable. An apparently trivial burn may
later cause severe haemorrhage from the labial artery
Complications
• Airway compromise
• Respiratory embarrassment
• Scarring/Contractures
• Perioral electrical burns:
Delayed haemorrhage
Scarring
Impaired jaw growth
Abnormal speech development
• Infection
History
• Risk factors for inhalation injury
• Co-morbidities especially asthma/respiratory disease/diabetes/
immunocompromise
Examination
• Initial focus on airway, breathing, circulation and neurological state as
appropriate
• Signs suggestive of inhalation injury:
Oral/pharyngeal burns
Stridor/hoarseness/dysphonia
Respiratory distress
Carbonaceous sputum
Singed nasal hair
Reduced level of consciousness
• After cooling assess nature, depth and area of burn
Investigation
• Nil initially if isolated thermal burn to face, head or neck
• Burn swab and culture may be required later if infection develops
• Electrical burn – see Overview
Treatment
• Resuscitation as necessary – see Overview
• Rapid cooling for 15mins
• Superficial (erythema only): no treatment other than moisturising ointment
or film dressings
Burn Face, Head, Neck SH1..
• Superficial partial thickness (small blisters only):
Blister management
Face:
Liquid paraffin 2-4 hourly to keep moist
Eyelids – Chlormycetin ointment
Ears – Chlormycetin ointment
Neck – tulle gras/SSD – see Overview
• Deep partial thickness (larger blisters)/full thickness: tulle gras and discuss
with plastic surgeon
• Actual or potential inhalation injury – refer urgently to local emergency
department
• All partial thickness/full thickness burns to face or ears – discuss with
plastic surgeon to determine need for immediate referral or to agree further
management
• Other indications – see Overview
Burn Face, Head, Neck SH1..
Burn Trunk/Arm (excluding
wrist, hand)/Lower Limbs
Read Code: SH2../SH3../SH5..
KEY POINTS
• Resuscitate if appropriate (see Overview)
• Adequate cooling: 15 mins under running tap water or saline/water soaked
dressings
• Assessment of burn, documenting area involved, depth and location
Complications
• Shock (requirement for IV fluid therapy if body surfaces are burnt >20%
in adult or >15% in child or clinical signs of shock)
• Hypothermia (care with cooling large area involved and/or child)
• Infection
• Scarring/Contractures
History
• Nature of exposure:
Flame
Chemical
Hot fluid
Superheated gas
Electrical
• Contamination of burn
• Current medications/allergies
Examination
• Initial focus on airway, breathing, circulation and neurological state
• Assess area, depth, location of burn
• Note circumferential burns
• Check neurovascular status of limb
• Examine for injury to deeper structures
Investigation
• Nil initially if isolated thermal burn to face, head or neck
• Burn swab and culture may be required later if infection develops
• Electrical burn – see Overview
Treatment
• Resuscitation as necessary
• Rapid cooling for 15 mins
• Dressings – see Overview
• Advise elevation of limb burns
Burn Trunk/Arm/Lower Limbs SH2../SH3../SH5..
Burn Trunk/Arm (excluding wrist,
hand)/Lower Limbs
Immediate:
• Actual or potential inhalation injury, refer urgently to local emergency
department
• Burns associated with other serious injuries
• Partial thickness burns:
>15% BSA all ages
>10% BSA <10 or >50 years
• Smaller burns if significant co-morbidities
• Possibility of non-accidental injury in children
• Full thickness burns >3% BSA in any age groups
• Burns involving feet (unless trivial), genitalia, perineum
• Any heavily contaminated burn
• Persisting requirement for IV analgesia after dressing completed
• High voltage electrical burns
Delayed:
• Individuals with minor electrical burns should be discussed with a
specialist – follow-up as agreed
• Infection
Other Referral
• Refer burns affecting joint mobility to a physiotherapist
Burn Trunk/Arm/Lower Limbs SH2../SH3../SH5..
Burn Wrist & Hand
Read Code: SH4..
KEY POINTS
• Resuscitate if appropriate (see Overview)
• Adequate cooling: 15 mins under running tap water, longer if alkali
chemical burn
• Assessment of burn. Emphasis on nature of exposure, depth and
impairment of hand function
Complications
• Scarring/contractures
• Loss of function
History
• Nature of exposure:
Flame
Chemical (particularly hydrofluoric acid)
Hot fluid
Superheated gas
Electrical
• Contamination of burn
• Current medications/allergies
Examination
• Assess area, depth of burn
• Note circumferential burns
• Identify entry/exit burns in electrical injuries
• Identify injury to deeper structures, particularly neurovascular status in
electrical burns
• Note blister formation around joints
Investigations
• Electrical burns – ECG
Treatment
• Rapid cooling for 15 mins
• Remove jewellery
• Dressings – see Overview:
Small blisters should be left intact
Large blisters should be aspirated. An alternative dressing for the hand
and/or fingers is SSD inside a loose fitting thin plastic glove or bag,
changed daily
Ensure hand is elevated in a high-elevation sling to minimise
dependant oedema
Hydrofluoric acid burns – see Overview
Burn Wrist & Hand SH4..
Burn Wrist & Hand
Immediate:
• Full thickness burns
• Circumferential burns
• Burns with restriction of joint function due to pain or depth of burn
• Some electrical burns eg high voltage
• Hydrofluoric acid burns
Delayed:
• Individuals with minor electrical burns should be discussed with specialist
follow-up as agreed
• Infection
Other Referral
• Specialist hand physiotherapy is recommended if hand function is impaired
Burn Wrist & Hand SH4..
Section 4 Gradual Onset
Read Code
Carpal Tunnel
F340.
N211.
Medial Epicondylitis – Elbow/Lateral Epicondylitis – Elbow
N2131/N2132
Prepatellar Bursitis
N2165
Achilles Tendonitis/Sprain Tendocalcaneus (Achilles Tendon)
N2174/S5504
Synovitis/Tenosynovitis
N220.
4 gradual onset
CONTENTS
Carpal Tunnel
Read Code: F340.
KEY POINTS
• Modify/avoid precipitating factors
• Consider associated conditions such as myxoedema, pregnancy, rheumatoid
arthritis, diabetes, gout
Complications
• Chronic pain
• Paraesthesia
• Muscle wasting
• Occupational problems
History
• Nature of the pain – night pain or tingling in the hand, may radiate to
forearm and arm
• Loss of sensation or paraesthesia in median nerve distribution
• Onset insidious
• Pain aggravated by excessive, prolonged or repetitive movements/activity
• Weakness of grip
• Cervical spine symptoms
• Other medical conditions
• Occupation
Examination
• Phalens test may be positive
• Tinels test may be positive
• Sensory changes in median nerve distribution
• Thenar muscle wasting
• Muscle strength – weakness thumb abduction
• Cervical spine
• Cervical spine dysfunction
• Thoracic outlet syndrome
• Previous fracture/trauma to wrist
• Connective tissue disorders
• Overuse syndrome
• Tendonitis wrist and elbow
Investigation
• Nerve conduction studies
• FBC, rheumatology screen, TFT, uric acid, glucose
Treatment
• Identify and modify precipitating factors
• Wrist splint
• Steroid injection if failure to settle with conservative management
• Workplace assessment
• Physiotherapy – ultrasound may help
• Failure to settle
Carpal Tunnel F34o.
Read Code: N211.
KEY POINTS
• Defined as shoulder pain associated with any of the following:
Overuse
Repetitive movement
Following a poorly rehabilitated acute injury
Movement associated with biomechanical or anatomical abnormalities
• This is a progressive pathological process
• Pain is the most common symptom in all gradual onset injuries
• May be caused by, or lead to tendonitis
• Rotator cuff tendonitis and sub-acromial bursitis both present with
impingement or painful arc syndrome
• Impingement – occurs when the space between the underside of the
acromion and the top of the glenohumeral joint effectively narrows due
to any, or combinations of, the following:
Osteophytes from above
Inflamed subacromial bursa
Inflamed/swollen rotator cuff
Excessive elevation of the humeral head
• Impingement classically occurs between 60° and 120°
• Instability –usually occurs following an acute injury to the shoulder
causing a dislocation or subluxation. The ball and socket joint becomes
unstable and displays excessive movement. This can also lead to irritation
and inflammation of the surrounding structures resulting in impingement
• Age considerations – tendon degeneration from gradual onset damage
to the rotator cuff is age related:
Oedema and haemorrhage, age <25 years
Fibrosis and tendonitis, age 25-40 years
Tears of cuff, age >50 years
Neer stages:
Stage 1
Dull ache in deltoid region after
strenuous exercise
Stage 2
Persistent pain (through the night)
associated with tendonitis and fibrosis
Stage 3
Prolonged history with tendon
degeneration and/or rupture
Complications
• Subscapularis or biceps tendon rupture
• Chronic pain and shoulder dysfunction
• Failure of conservative treatment will require surgical intervention
• Decreased range of motion
• Frozen shoulder
History
• Age of patient
• Site of pain
• Duration of pain
• Determine any predisposing factors eg history of an acute injury, repetitive
movements
• Any night pain
• Severity of pain
• Position of shoulder which exacerbates or relieves pain
• Strenuous or repetitive activity especially overhead
• Chronic osteoarthritis of GH or AC joint
Examination
• Compare with the other shoulder
• Local tenderness
• Muscle strength and wasting
• Assess neuromuscular function
• Assess cervical spine
• Active movements
Rotator Cuff N211.
• Passive movements/painful arc
• Resisted movements
• Special tests
Impingement
Instability
• Crepitus
• Swelling
• Arthritis of acromio-clavicular and glenohumeral joints
• Calcific tendonitis
• Traumatic anterior subluxation of humerus
• Traumatic rotator cuff tear/rupture
• Subscapularis or biceps tendon rupture
• Instability
• Avascular necrosis of the humeral head
• Capsulitis
Investigation
• X-ray
• Ultrasound
• Arthrogram if chronic
Treatment
Stages 1 and 2:
Rest initially
Maintain range of movement with physio
NSAIDs
Activity modification
Sub-acromial steroid should only be used if not settling
Stage 3:
Maintain range of motion
Modification of activity
Referral
Identify causative factors and advise the patient to change behaviour
Modify workstation or technique
Modify sporting technique
Physiotherapy rehabilitation to stabilise and strengthen the GH joint
May require surgical intervention
Stages 1 and 2:
• No active movement
• If no improvement after 2-3 weeks
Stage 3:
• Refer all
• Elderly patients in danger of developing frozen shoulder
• If unsure of diagnosis
Other Referral
• Physiotherapy
• Home help for elderly
Rotator Cuff N211.
Medial Epicondylitis-Elbow/
Lateral Epicondylitis-Elbow
Read Code: N2131/N2132
KEY POINTS
• Extremely common presentation of sports people and manual workers
• For lateral epicondylitis the most common cause is an overuse syndrome
related to excessive wrist extension
• For medial epicondylitis pain is associated with excessive activity of the
wrist flexors
• Mostly due to gradual process
• Review, reduce or remove stressors
• Steroid injections can be effective but have potential side effects, are not
an instant cure and should be limited to a maximum of 3 injections
• Beware diagnosis <18 years of age
Complications
• Fat atrophy from steroid injections
• Psychological decompensation
History
Pain:
Diffuse radiating from lateral or medial epicondyles into proximal
forearm muscle masses
Occasionally may be more localised
Onset acute or insidious
Pain may arise from recent changes in training or technique, or
equipment used in sport or at work.
Severity of pain can range from minor to debilitating that can keep the
patient awake at night
The pain may be aggravated by simple tasks or by repetitive activities
If pain is related to activity it is more likely to be mechanical in origin
whereas if pain is persistent and unpredictable it may be referred pain
and/or related to posture
• Blow to elbow
• Past injury
• Other upper limb symptoms
Determine if:
Gradual process or acute injury
Excess repetitive forceful activity
New work processes
Occupational/sports associated
Examination
• Include observation/active movements/passive movements/resisted
movements/palpation
• Note local tenderness
• Note pain with stressing/stretching wrist/extensors or flexors
• Examine cervicothoracic spine
• Examine wrist, hand and shoulder joints as appropriate
• Crepitus (tendon)
Epicondylitis N2131/N2132
Lateral elbow pain:
• Extensor tendinosis
• Referred pain – from cervical spine, upper thoracic spine
• Synovitis of the radiohumeral joint
• Radiohumeral bursitis
• Posterior interosseous nerve entrapment
• Osteochondritis dissecans – Capitellum, radius (in adolescents)
Medial elbow pain:
• Flexor/pronator tendinosis
• Medial Collateral Ligament sprain
• Ulnar nerve compression
• Avulsion fracture of the medial epicondyle
• Apophysitis
• Referred pain
• Bone injury
• Neck or shoulder pathology
• Nerve entrapment
• Tendon rupture
• Osteoarthritis
• Forearm muscle strain
Investigation
• X-ray if no response to treatment or atypical features
• CBC/Alkaline phosphatase
• May require soft tissue ultrasound
Treatment
• No single treatment has proven to be totally effective
• Because the condition is of gradual onset, advise the patient that there
is no quick fix
• The aim of treatment is to eliminate pain, identify and change the causative
factors and to normalise function
• Conservative treatment initially
• Remove/reduce stressors
• Graduated return to activity
• Splint for tenosynovitis with crepitus
• Refer if no change after 3 months or if unable to work after 2 weeks
• The following may be considered:
NSAIDs
Steroid injection (Triamcinolone preferred) only after failure of
rehabilitation and after 3 months of localised pain. Beware of performing
repeated injections
• Acupuncture
• Physiotherapy
• OT for ADL/workplace assessment/sports technique assessment
• Features of nerve entrapment
• Tendon rupture
• Suspected sepsis
• Unable to work after 2 weeks
• 3 months failed conservative treatment
• Surgery is rarely indicated
Other Referral
• Physiotherapy
• OT for ADL/workplace assessment
• Possibly home help
Prepatellar Bursitis
Read Code: N2165
KEY POINTS
• Avoid kneeling
• Never incise, rarely aspirate
• Consider infection
• Consider risk of DVT if immobilised – teach quadriceps exercises
Complications
• Infection/septic bursitis
• Muscle wasting
• Chronic bursitis
• Recurrent fluid accumulation
• Progressive enlargement of bursa
History
• Swelling after kneeling
• Blow/pressure to patella
• Penetration of skin over patella
• Previous history of crystal arthritis
• Occupation
Examination
• Well-defined prepatellar swelling
• Knee joint to exclude other pathology, compare to other side
• Local tenderness
• Evidence of penetration/foreign body
• Toxicity/febrile
• Inflammation of knee joint, patella tendon
• Effusion knee joint
• Septic bursitis
• Crystal arthritis
• Injury to patella
• Reiter’s disease
Investigation
• Aspirate for crystals and culture if suspected sepsis
• X-ray/USS if diagnostic doubt
Treatment
• Rest
• Restriction of precipitating activity
• Consider NSAIDs, analgesia
• Pressure dressing (tubigrip)
• Splint if severe (remember quad exercises and beware DVT)
• Antibiotics if indicated
• Aspiration and steroid injection may be helpful if recurrent
• Febrile/suspected sepsis
• Not resolving
• Recurrent fluid accumulations
• Knee joint involvement
Prepatellar Bursitis N2165
Achilles Tendonitis/Sprain,
Tendocalcaneus (Achilles Tendon)
Read Code: N2174/S5504
KEY POINTS
• If injecting steroid ensure it is into the sheath and not the tendon
• Differentiate acute from gradual process
• Prolonged recovery common
• Heel raise important
• Ultrasound is a useful diagnostic tool
Complications
• Recurrence
• Rupture, particularly after steroid injection
• Steroid depositions
• POP effects
History
• May be slow onset (weeks)
• Niggling pain
• Severe pain while running
• Tightness
• Often a trigger event such as change in footwear
• Excessive morning stiffness
• Previous injury or injection
• Gout
Examination
• Compare with other side
• Swelling of tendon
• Pain on dorsiflexion
• Crepitus
• Tight calf
• Tendon tenderness
• Calf squeeze to exclude tendon rupture (negative Thompson test)
• Bursitis (retro calcaneal)
• DVT
• Rupture of Achilles tendon
• Gout
• Bruising
• Osteo or rheumatoid arthritis
• Inflammatory arthropathy
• Sever’s disease
Investigation
• Ultrasound if not settling or if uncertain of tendon integrity
• Consider rheumatological screen, uric acid
• X-ray if considering Sever’s disease
Treatment
• Moderation of activity
• Heel raise
• Calf stretching once pain reducing
Achilles Tendonitis N2174/S55o4
Achilles Tendonitis/Sprain, Tendocalcaneus
(Achilles Tendon)
Other options include:
• Physiotherapy
• Calf stretching
• Icing
• NSAIDs
• Crutches
• Possibly steroid injection to sheath
• Some may require equinus POP for 7-10 days if severe
• Podiatry for biomechanical assessment +/- orthotics
• Suspected or complete rupture
• Suspected DVT
• No improvement over 2 months
• Failed steroid injection
• Previous rupture
Achilles Tendonitis N2174/S55o4
Read Code: N220.
KEY POINTS
• Tenosynovitis involves inflammation of the tendon and tendon sheath
• Examples include De Quervain’s tenosynovitis and trigger finger
• Overuse (repetitive stress), poor technique or following on from an acute
injury are all causes of tenosynovitis
• Beware infection (joint or sheath)
• Rest is very important
• Consider conditions such as myxoedema or pregnancy
• Diagnosis <18 years of age rare
• Identify and modify any precipitating activity
Complications
• Chronic pain state
• Partial tear or rupture of the tendon (especially following steroid injection)
• Occupational problems
History
• Repetitive injury or function
• Pain and/or swelling in or around tendon
• Pain in forearm/wrist
• Pain brought on by prolonged activity or repetitive movements
• Work, sports, hobbies
Examination
• Local tenderness and swelling especially along tendon sheath
• Local heat
• Crepitus (tendons)
• Tendon/joint function
• Mental status (vague or non-specific pains)
De Quervain’s Tenosynovitis:
Pain on palpation along the radial aspect of the wrist
Pain with passive range of motion of the thumb
Finkelstein’s test
Trigger Finger:
Tenderness at the proximal end of the tendon sheath, in the distal palm
Palpable tendon thickening and nodularity may be present
Crepitation and catching of the tendon may be observed when the
finger is flexed
• Carpal tunnel syndrome
• Myxoedema/pregnancy
• Inflammatory arthritis
• Joint sprain/fracture
• Nerve entrapment local/distant
• Old carpal injury
• Ganglion
• Gout/pseudogout
• Soft tissue infections
Tenosynovitis N22o.
Investigation
• X-ray
• Nerve conduction tests
• Microscopy and culture of joint aspirate
• FBC and ESR (possibly rheumatological screening)
Treatment
• Reduce stressors
• Rest in splint (1 week)
Other options include:
• NSAIDs
• Physiotherapy
• Joint aspiration
• Local anaesthetic and steroid injection if not settling after 1 month of
conservative treatment (not into tendon)
• OT to assess workplace
• Occupation advice
• Not settling with conservative management
• Associated medical problems or inflammatory condition
Other Referral
• Physiotherapy
• Occupational therapist to assess workplace
• Occupation advice
Tenosynovitis N22o.
Section 5 Sprains
CONTENTS
Read Code
Low Back Pain, Acute Back Pain – Lumbar,
Lumbago/Lumbar Sprain/Sciatica
N142./S572./N143.
Cervicalgia – Neck Pain/Neck Sprain
N131./S570.
Sprain Rib
S5y3.
Sprain Acromio-Clavicular Ligament
S500.
Rupture of Supraspinatus/Biceps Tendon
S5Q2./S5Q4.
Shoulder/Rotator Cuff Sprains Tendon Tears
(Includes Infraspinatus and Supraspinatus Tear/Sprain)
S503./S504./
S507./S502.
S51..
Sprain Wrist or Hand (Carpal Ligament and Metacarpal
Ligament Sprains)/Sprain Tendon Wrist or Hand
S52../S524.
Hand/Wrist Flexor Tendon Rupture
N2264
Sprain Radial Collateral Ligament (Thumb)
S5204
Sprain Thumb
S522.
Sprain Finger
S523./S5513
Sprain Hip/Thigh
S53..
Sprain/Strain Quadriceps Tendon
S533.
Meniscal Tear (Medial/Lateral)
S460./S461.
Sprain Collateral Ligament Knee
S5400/S541.
S542.
Sprain Ankle (Lateral Ligaments)
S550.
Sprain of Metatarso-Phalangeal Joint/Interphalangeal Joint
S5512/S5513
5 sprains
Overview
Sprains/Strains Overview
ACC/National Health Committee
Red Flags for potentially serious conditions:
Features of cauda equina syndrome (especially urinary retention,
bilateral neurological symptoms and signs, saddle anaesthesia)
- this requires very urgent referral
Significant trauma
Weight loss
History of cancer
Fever
Intravenous drug use
Steroid use
Patient aged over 50 years
Severe, unremitting night-time pain
Pain that gets worse when patient is lying down
Yellow Flags: Psychosocial factors that increase the risk of developing
or perpetuating long-term disability and work loss associated with
low back pain:
Attitudes and beliefs about back pain
Behaviours
Compensation issues
Diagnostic and treatment issues
Emotions
Family
Work
Muscle Strains
Grade 1
• Clinical features: localised pain but no loss of strength.
• Maybe small amount of bruising
• Pathology: small numbers of muscle fibres torn
Grade 2
• Clinical features: pain, swelling, bruising.
• Strength is reduced and movement is limited by pain
• Pathology: tear of significant number of muscle fibres
Grade 3
• Clinical features: significant loss of movement/strength.
• May be no pain
• Pathology: complete tear of muscle. Seen most frequently at
musculotendinous junction
Predisposing Factors in Development of Muscle Strains:
• Insufficient flexibility
• Excessive muscle tightness
• Fatigue, overuse, inadequate recovery
• Muscle imbalance
• Inadequate warm-up
Overview
Sprains/Strains Overview
Ligament Sprains
Grade 1
• Ligament sprain with no laxity (pain only on stressing)
Grade 2
• Ligament sprain with laxity but definite end point
Grade 3
• Ligament sprain with laxity but NO definite end point (rupture)
Additional Points to Consider:
• Children <12 years rarely sprain ligaments
• Elderly patients are much more likely to fracture bones than sprain
ligaments
• Elderly patients are prone to suffer stiffening of their joints eg frozen
shoulder even in more peripheral injuries and need early mobilisation
• RICE therapy is useful early (first 24 hours, possibly 48) for most strains
• Watch for tendon ruptures in older patients
X-ray Rules
Ottawa Ankle Rules
X-ray if:
Unable to bear weight (take four steps) at time of injury and at
examination
Bone tenderness at posterior edge or tip of either malleolus
Bone tenderness over the naviculus or base of fifth metatarsal
Ottawa Knee Rules
X-ray if:
Patient older than 55 years
Tenderness present at head of fibula
Isolated tenderness over patella
Inability to flex knee to 90 degrees
Inability to transfer weight for four steps both immediately after
injury and at examination
Exclusion criteria:
Age less than 18 years
Isolated superficial injuries being re-evaluated
Patients with altered levels of consciousness, paraplegia,
or multiple injuries
Pittsburgh Knee Rules
Indicate radiography if the mechanism of injury is blunt trauma or a fall,
and either:
The patient is younger than 12 or older than 50 years of age; or
The injury causes an inability to walk four weight-bearing steps at
examination
Exclusion criteria:
Knee injuries that occur over six days before presentation
Patients with only superficial lacerations and abrasions
Those with a history of previous surgeries or fractures on the
affected knee
Reassessments of the same injury
Overview
Low Back Pain, Acute Back Pain–Lumbar,
Read Code: N142./S572./N143.
KEY POINTS
• An adequate clinical history and examination should be sufficient to
identify the need for investigation and specific therapy
• Psychosocial factors are better predictors of chronicity than physical
factors. Evaluate and address in the context of discussing reasonable
expectations for recovery
• Unless specifically targeted with appropriate preventive interventions
about 7-10% of patients with acute LBP remain disabled and become
chronic
• The mechanism of injury and patient age are important in the severity
of injury
• The majority of all clinically significant lower limb radiculopathy due
to disc herniation involves the L5 or S1 nerve root at the L4/5 or L5/S1
disc level
• Primary care practitioners have a critical role in preventing the development
of chronic pain-related disability
• For further information refer to the New Zealand Acute Low Back Pain
(LBP) Guide* (nzgg.org.nz)
The essential components of managing acute LBP are:
Identify or exclude major pathology – Red Flags
Use appropriate symptom control
Return to usual activities as soon as possible
Engage the patient in self-help. Note this usually requires a second
consultation
Complications
• Chronic LBP (CLBP) causes extensive suffering to individuals and their
families. The restoration of function and return to usual activity and work
is an essential part of preventing long-term disability
• Recovery from chronic LBP is difficult and demands high levels of resources.
Prevention of chronicity requires a high priority. Note that the best
opportunity for preventing chronicity occurs within the first few weeks
• Chronic LBP should not be treated as if it were acute or recurrent LBP,
since this leads to serial investigations and ineffective therapy
• Presence of underlying pathology eg Spondylolysis, Spondylolisthesis
RED FLAG:
For potentially serious conditions:
Features of cauda equina syndrome
(especially urinary retention,
bilateral neurological symptoms and
signs, saddle anaesthesia) - this
requires very urgent referral
Significant trauma
Weight loss
History of cancer
Fever
Intravenous drug use
Steroid use
Patient aged over 50 years
Severe, unremitting night-time pain
Pain that gets worse when patient is
lying down
YELLOW FLAG:
Psychosocial factors that increase the
risk of developing or perpetuating longterm disability and work loss
associated with low back pain:
Attitudes and beliefs about back pain
Behaviours
Compensation issues
Diagnostic and treatment issues
Emotions
Family
Work
History
• Circumstances of injury: mechanism and timing of injury related to
symptom development
• Occupation
• Other diseases eg osteoporosis, neoplasms
Back Pain N142./S572./N143.
Examination
• Area/level of dysfunction
• Neurological signs: nerve root and cauda equina
• Check for Red and Yellow Flags
Goals for the examination:
• Obtain a baseline for the level of function and activity
• Alleviate uncertainty about the regional nature of back pain
• Exclude neurological catastrophe
Conducting the examination:
• Diagnostic triage
• Psychosocial barriers to recovery (questionnaire in LBP guidelines)
• Non-specific back pain
• Nerve root pain
• Red Flags (refer Investigation)
• Cauda Equina syndrome
• Chronic LBP (requires different management)
Investigation
X-ray, full blood count and ESR/CRP if Red Flags present
Treatment
Initial treatment and management:
If no Red Flags:
• Provide (or refer to appropriately qualified provider):
Explanation
Reassurance
Advice on staying active
Directive to use short-term alteration for everyday and work activities
• Encourage and educate the patient to mobilise early, once Red Flags have
been excluded. Explain that no more harm will occur from early
mobilisation
Explore opportunities for demedicalising LBP:
Encourage directed self-management
Provide information
Distribute a copy of the Patient Guide: Acute Low Back Pain
Management, published by the National Health Committee and ACC.
• Note, this nearly always requires a second consultation
• Symptom control
May require rest, but no longer than 24-48 hours
Analgesics (such as paracetamol and NSAIDs)
Manipulation – (refer to a provider with a demonstrated record in
providing symptom control as an adjunct to increasing function, and
stipulate a time period (preferably less than 4-6 weeks) for reviewing
the patient and ceasing the course of therapy. Review and monitor
progress, within 1 week
Medical certification:
• Short-term depending on occupation: 1-2 days preferably, at least less
than 1 week
• Certificate for temporary alternative work with clear indication of functional
capacity
Ongoing treatment and management:
• Review and monitor progress regularly 1-2 days following the initial
consultation (issue the initial certificate for only 1-2 days)
• Where possible discuss with employer
• Conduct a comprehensive reassessment including the patient's pain and
disability (activity limitation), and response to treatment
• Recheck for Red and Yellow Flags
• Repeat initial management options
• Referral to an allied health professional
Reactivation, or reduction of activity intolerance:
• Patients who have not returned to usual activities or work, and failed to
respond to treatment may require reactivation
• Consider referral to a goal-oriented multidisciplinary team who will:
Reactivate the patient
Provide symptom control
Enhance coping and self-management
Deal with psychosocial barriers to returning to work or normal
activity level
• Cauda Equina syndrome (immediate referral)
• Serious spinal pathology (prompt referral acted on within 4 weeks)
• Nerve root pain that has failed to settle (referral not generally required
within first 4 weeks)
• Neurological deficit which is progressive and worsening eg foot drop –
discuss with specialist at the time of consultation
• Persistent back pain <20 years of age
Other Referral
• Case management if no RTW after 2 weeks, consider reactivation
• Chiropractors
• Home help
• Occupational therapy
• Osteopath
• Physiotherapy
• Psychologist or vocational management consultant if significant
psychosocial barriers to recovery and return to work
* New Zealand Acute Low Back Pain Guide, Jan 1997, ACC and National
Health Committee
Read Code: N131./S570.
KEY POINTS
• Take a clinical history including circumstances surrounding onset and
conduct an examination to identify the need for investigation and specific
therapy
• Clinical localisation of the pain source is sometimes possible. There are
fewer disc lesions. Manual techniques such as manipulation are easier,
but potentially more dangerous. The possibility of adverse effects is hard
to predict
• The mechanism of injury is important in the severity of injury eg Motor
Vehicle Accident (MVA), scrum collapse
• Compared with the lumbar spine, the cervical spine is significantly more
flexible and:
Prone to acceleration/deceleration injury (whiplash)
Disc lesions are less common
Manipulation is easier but potentially more dangerous
• Beware of:
Vertebral artery spasm (do not manipulate)
Fractures especially with underlying disease
Rheumatoid arthritis
Neurological signs
Complications
• Chronic neck pain is a serious clinical development, and prevention of
chronicity requires a high priority. The best opportunity for preventing
chronicity occurs within the first few weeks
• Chronic neck pain should not be treated as if it were acute or recurrent
neck pain, since this leads to serial investigations and ineffective therapy
• Vertebral artery spasm. Beware patients with symptoms of vertebral artery
insufficiency (syncope/light-headedness with turning, looking up or
sustained position).
• Neurological sequelae
• Acute nerve root compression syndrome
History
• Time relationship of symptoms to injury
• The mechanism of injury is important in assessing likely severity of injury
eg MVA, scrum collapse
• Past history – associated diseases eg rheumatoid arthritis, polymyalgia
rheumatica, cerebrovascular
Examination
• Diagnostic triage
• Neurological exam mandatory if pain/related symptoms present below
shoulder level
• CVS examination may be needed
• Psychosocial barriers to recovery (Refer to Yellow Flags)
Goals for the examination:
• Obtain a baseline for the level of function and activity
• Alleviate uncertainty about the regional nature of neck pain
• Exclude neurological/CVS catastrophe:
• Vertebral artery insufficiency: syncope/light-headedness with turning,
looking up or sustained position
Cervicalgia–Neck Pain/Neck Sprain N131./S57o.
• Soft-tissue injury, non-specific neck pain
• Myelopathy, occlusion of vertebral artery, fracture
• Chronic neck pain (requires different management)
• Non-injury neck pain, eg RA, polymyalgia rheumatica
• Myelopathy, occlusion of vertebral artery, fracture
• Rheumatoid arthritis
• Polymyalgia rheumatica
Investigation
X-ray, full blood count and ESR/CRP if signs or symptoms of serious disease
are present (Red Flags):
• The majority of cervical spine injuries do not need radiological imaging
unless Red Flags are present
Treatment
Contraindications to manipulation include:
Severe osteoporosis
Metastases
Vertebral artery insufficiency
Rheumatoid disease of neck
Acute nerve root compression
Children/infants
Last trimester pregnancy
Bleeding disorder
Initial treatment and management:
• If no Red Flags, or fracture
Provide (or refer to appropriately qualified provider):
• Explanation and reassurance (stress the importance of rest for 48 hours
only if possible)
• Advice on staying active
Directive to use short-term alteration for everyday and work activities
Explore opportunities for demedicalising neck pain
Encourage directed self-management approach
Symptom control:
Adequate analgesia – paracetamol/NSAIDs
Manipulation from experienced/qualified provider for first 4-6 weeks
maximum. Note contraindications to manipulation
• Review and monitor progress, within 1 week
Medical certification:
• Short-term depending on occupation: 1-2 days preferably, at least less
than 1 week
• Certificate for temporary alternative work with clear indication of functional
capacity
Ongoing treatment and management:
• Review the patient's pain and disability (activity limitation) and response
to treatment early at 1-2 days
• Review the patient's pain and disability (activity limitation) and response
to treatment at 1 week, then 3-6 weeks (if required)
• Check for signs and symptoms of serious disease (Red Flags) and
psychosocial barriers to recovery (Yellow Flags). Consider referral or
further diagnostic work-up – see Investigation
• Repeat initial management options
• Conduct a comprehensive reassessment
Reassessment and reactivation, or reduction of activity intolerance (at 3-6 weeks):
• Patients who have not returned to usual activities or work, and failed to
respond to treatment may require reactivation
• Consider referral to a goal-oriented multi-disciplinary team who will:
Reactivate the patient
Provide symptom control
Enhance coping and self-management
Deal with psychosocial barriers to returning to work or normal activity level
• Where possible discuss with employer
• Nerve root pain that fails to settle
• Serious spinal pathology
• Presence of Red Flags
Other Referral (note flags for manipulation)
• Chiropractor
• Osteopath
• Physiotherapy
• Psychologist or vocational management consultant only if significant
psychological barriers to recovery and return to work
• Home help
Sprain Rib
Read Code: S5y3.
KEY POINTS
• This code includes costo-vertebral, costo-chondral and chondro-sternal sprains
• Good history and examination of the whole patient are essential
• Review the patient and analgesia
• Beware children – less fracture chance after major trauma = higher risk
of intrathoracic damage
• Rib sprains are unlikely to have significant associated pathology
• Pain relief is the mainstay of treatment
• Investigation is usually not needed
Complications
• Respiratory – pneumothorax, haemothorax, pneumonia (hypoxia,
hypotension, pain)
• Heart (cardiac contusion, haemopericardium, tamponade)
• Skeleton – flail chest, fractures, dislocations (especially ribs, sternal joints)
• Abdomen – perforated viscus, splenic contusion, renal contusion, liver
• Neurological – subclavian, spinal, intercostal nerves
• Vascular – intercostal, subclavian vessels, haemoperitoneum
• Infection – fever, sepsis
History
• Mechanism of injury – direct blow/A-P crush/fall from height – may be
a good indicator of more severe pathology
• Pleuritic chest pain, often localised
• Pain – location, nature, radiation, aggravating/relieving factors
• Full functional enquiry
• Check for aggravating factors in past history: COPD, neoplasias, smoker,
past trauma, asthma
• Check for important symptoms eg haemoptysis
• Exclude other causes eg DVT
• 1st rib sprain may be associated with brachial plexus symptoms
Examination
• Pain – location, nature etc
• Examine whole patient before individual ribs:
Assess the chest: examine heart and lungs (stigmata of respiratory
distress including oxygen saturation, trachea midline, lung integrity,
auscultate heart +/- ECG, distal circulation)
Assess the abdomen: examine diaphragm, viscera, liver, spleen, kidneys
Assess the bony skeleton: examine spine, ribs, sternum, clavicles, check
for flail segment, limb function
Assess the neurological status: check Cspine, Tspine, brachial plexus,
intercostals, subclavian
Assess vascular status: general circulation, subclavian, intercostals
• Check for complications
• Exclude rib fracture
• Check thoracic/cervical spine for associated dysfunctions especially first rib
• Contusion
• Respiratory – infection/pleurisy/pulmonary embolus (see complications)
• Cardiac – beware MI, pericarditis
• Fracture – stress (rowers), sternum, ribs especially 1st ribs, spine
• Musculoskeletal – chronic conditions eg OA, costochondritis, ankylosing
spondylitis
Sprain Rib S5y3.
Sprain Rib
•
•
•
•
G.I. – GORD, PUD, hepatitis, biliary
Dislocation: costo-vert or costo-sternal/costo-costal
DVT, pulmonary embolus
Costochondritis
Investigation
• Usually not necessary
• Oxygen saturation
• X-ray Chest – expiratory and oblique (if severe fracture suspected)
Abdomen – erect, supine, lateral decubitusCspine, Tspine, Sternum
• May need CT views if 1st rib involved
Treatment
• Pain relief
• Consider I/C nerve block (beware iatrogenic pneumothorax)
• Depot intra-articular steroid with LA
• Musculo-skeletal manipulation (only if trained in technique)
• Physiotherapy
• Resuscitation – ABCD, primary and secondary surveys
• Mobilisation/manipulation
• Not needed unless significant underlying disease/injury
• Impaired ventilation – pneumothorax (discuss all), flail chest
• Impaired perfusion – haemothorax, haemopericardium, cardiac contusion,
arterial injury
• Impaired nerve function – Cspine, Tspine, brachial plexus
• Impaired skeletal integrity – first rib fracture, multiple rib fractures,
sternal dislocation, discuss spinal fractures
• Significant complication – viscus perforation, splenic contusion, liver
contusion, pneumonia, discuss renal contusions
Other Referral
• Physiotherapy
• Osteopath
• Chiropractor
• Acupuncture
Sprain Rib S5y3.
Read Code: S500.
KEY POINTS
• See Sprain/Strain introduction
• Always X-ray, including weight bearing
• Early physio to mobilise the synovial AC joint and supervise return
to sport
• Elderly patients more likely to fracture than sprain
• Elderly more prone to stiffening eg frozen shoulder
• Rest Ice Compression Elevation (RICE) therapy early
• Watch tendon rupture in elderly
Complications
• Non-healing/non-union
• Chronic recurrent injury
• Unstable joints if Grade 3 not referred
• Delayed rupture of major sprains
• Development of tendonitis in partial tendon tear
• Damage to underlying structures (neurovascular, tendon, lung)
• Frozen shoulder in elderly
History
• Blow or fall on to shoulder
• Contact sport
• Repetitive action
• Previous shoulder dislocation
• Associated fracture
Examination
• Tender AC joint
• Local deformity/swelling
• Step or instability in AC joint
• Grade 2 sprains may be difficult (have only a step deformity + too tender
to elicit laxity)
• Full flexion
• Pain on horizontal adduction and weight bearing
• Weakness
• Screen neck movement
• Fractured clavicle, humeral neck
• Dislocated shoulder
• Bruising
• Congenital
• Cervical spine injury
• Supraspinatus/acromial bursa injury
Investigation
• X-ray for all AC joint injuries to determine grade in association with
clinical findings
• Consider X-ray weight bearing
Sprain, Acromio-Clavicular S5oo.
Treatment
• All grades should have physiotherapy to mobilise the joint early and
supervise return to sport
• RICE 24-48 hours
• Pain relief as required
• Rest (avoid sport and lifting)
• Sling
Grade 1-2
• Rest 2-3 weeks – as pain allows
Grade 3
• Rest up to 6 weeks
• Refer if no improvement after 2 weeks
Education:
• Early referral to physiotherapy
• Diagnostic uncertainty
• Grade 3 ligament injuries
• Chronic ligamentous or tendinous inflammation
• Full tear in elite athlete
• A/C joint dislocations
Other Referral
Physiotherapy for all grades as above
Sprain, Acromio-Clavicular S5oo.
Rupture of Supraspinatus/Biceps Tendon
Read Code: S5Q2./S5Q4.
KEY POINTS
• Occasionally due to inappropriate use of steroids (abuse or injection)
• Refer distal rupture early to specialist
• Functional impairment variable
• Always examine shoulder and elbow as well
• Often misdiagnosed as rotator cuff strain
Complications
• Loss of function and/or power
• Deformity
History
• Mechanism of injury – trauma or repetitive strain (weights)
• Corticosteroid injection
• Steroid abuse (eg weight lifters)
Examination
• Deformity
• Moved muscle belly accentuated by contraction (pain may be absent)
• Ecchymosis
• Range of motion especially weakness of biceps power
• Palpate bicipital groove proximally near attachment to glenoid
• Shoulder sprain or contusion
• Subacromial bursitis/impingement
• Rotator cuff strain/tear
• Fracture humerus
• Pectoralis Major tear/strain
• Subluxation/dislocation/fracture of shoulder
• Glenoid labrum tear
Investigation
• X-ray
Treatment
Dependent on diagnosis:
Tendonitis – RICE, NSAIDs, physiotherapy
Rupture (proximal) – RICE, NSAIDs, high-arm sling 1-2 weeks,
physiotherapy, specialist referral at 1 week if age >50 years
Rupture (distal) – specialist referral stat
• Confirm no fracture
• Proximal biceps tendon >50 years at 1 week
• Significant loss of function/uncertain diagnosis
• Distal biceps tendon – refer all
• Persisting tendonitis
Other Referral
• Physiotherapy
• Consider home help in elderly
Biceps Tendon Rupture S5Q2./S5Q4.
Shoulder/Rotator Cuff Sprains &
Tendon Tears (Includes Infraspinatus)
Read Code: S507./S504./S503./S502.
KEY POINTS
• The rotator cuff (R/C) is a thin sheet of tissue made up from tendons
arising from scapular muscles including infraspinatus, teres minor,
subscapularis and supraspinatus. The function of the R/C is to stabilise
the glenohumeral joint during power movements performed by the prime
mover muscles (eg pectoralis major, latissimus dorsi and deltoid). The
secondary function of the R/C is rotation and abduction of the glenohumeral
joint and this is used as the clinical method of testing the R/C to ascertain
which of the R/C muscles/tendons is predominantly injured
• Patients >40 with a significant shoulder injury are more likely to have
a tear of their R/C
• 50% of patients >40 years, with a dislocated shoulder, will have a R/C tear
• Significant R/C tears do NOT heal (due to poor blood supply) and require
surgical repair
• Referral to a specialist should be made early if a significant R/C tear is
suspected
• Ultrasound is a good investigation (always request comparison of both
sides) for establishing the degree of R/C tear (can be operator dependent)
• Early mobilisation
RED FLAG:
If patient cannot push hand away
from lumbar region, this indicates
a major tear of R/C
Elderly patients (more likely to
fracture and develop stiff joint)
Complications
• Chronic pain and inflammation/tendonitis
• Permanent loss of function. The ability to repair surgically an R/C tear
diminishes with time (window of opportunity to surgically repair is
optimally in the first 3 weeks)
• Instability
• Impingement
History
• Mechanism of injury
• Sports injury eg direct blow, throwing injury, fall
• Trauma. Refer early significant shoulder trauma in patients >40 years
• Occupational history
Examination
• Observe – deformity/swelling. Compare both shoulders
• Active range of motion:
Abduction. Note painful arc if present
Internal rotation.
External rotation. Inability to actively externally rotate can indicate
significant R/C tear – early referral indicated
Shoulder Sprains, Tendon Tears S5o7./S5o4./S5o3./S5o2.
Shoulder/Rotator Cuff Sprains &
Tendon Tears (Includes Infraspinatus)
•
•
•
•
•
Passive range of motion
Resisted movements. Note pain/decreased power
Special tests. Impingement and instability tests
Neurovascular status
Cervical spine
• Rotator cuff sprain, sprain shoulder joint = painful arc, decreased active
abduction, pain on abduction and rotational active movements
• Infraspinatus sprain = pain external rotation and minor active and resisted
weakness of external rotation
• Supraspinatus tear/rotator cuff tear = painful arc, significant reduction of
active and resisted movements eg abduction, ext rotation, int rotation
• Instability
• Fracture
• Impingement
• Subluxation, dislocation
• Subacromial bursitis
• Ruptured biceps
• Calcific tendonitis
Investigation
• X-ray
• Consider ultrasound – operator dependent
Treatment
• Broad arm sling if necessary (beware stiffness in elderly)
• RICE 24-48 hours
• NSAIDs
• Pain relief
• Refer Red Flags early:
Suspicion of major tear of R/C (from history or clinical or investigations)
Elderly patient
• Physiotherapy/rehabilitation – mobilise, strengthen and monitor progress
• Review at 1 week – if no improvement, refer
• Education
• Steroid injection if not settling and can rule out significant tear
• If unable to exclude rupture
• Patient >40 years with significant trauma and symptoms/signs
• If no active movement – stat
• If no improvement after 1 week
Other Referral
• Physiotherapy
• Consider home help in the elderly
Shoulder Sprains, Tendon Tears S5o7./S5o4./S5o3./S5o2.
Read Code: S51..
KEY POINTS
• Children <12 years rarely sprain ligaments, therefore need X-ray
ligaments, therefore need X-ray
• RICE therapy is useful early (first 24 hours, possibly 48) for most sprains
Complications
• Chronic, recurrent injury, tendonitis
• Unstable joints if Grade 3 sprains are not referred
• Development of tendonitis in partial tendon tear
• Chronic pain and loss of function
History
• Fall
• Trip
• Sports injury
• Twisting injury with hand fixed
Examination
• Decreased range of motion. Unable to fully extend or flex when compared
to normal side. Record range of motion
• Pain and/or instability when stressing specific ligament or tendon
• Function to exclude fracture
• Specific ligament stability and function. Check collateral ligaments, can
be graded 1, 2 or 3
• Bone tenderness
• Joint effusion
• Fracture – radial head, supracondylar
• Dislocation
• Infection
• Tendon rupture. Biceps or triceps
• Tennis elbow
• Golfer’s elbow
• Triceps tendonitis
• Olecranon bursitis
Investigation
• X-ray (to exclude fracture). Check lateral for fat pad (sail sign)
• In children a comparison view of the normal side is often helpful to
determine bone/joint pathology
Treatment
• RICE in first 24-48 hours
• NSAIDs may have a place but may delay healing
• Splintage as required for pain relief (broad arm sling or collar and cuff)
• Early mobilisation especially in elderly
• Isometric exercise training as prevention of muscle wasting
Sprain Elbow/Forearm S51..
• Fracture
• Grade 3 ligament injuries
• Ligamentous or tendinous inflammation has become chronic
• Rapid haemarthrosis
• Significant decreased range of motion of elbow persists 2 weeks after injury
Other Referral
• Physiotherapy
Sprain Elbow/Forearm S51..
Sprain Wrist or Hand (Carpal Ligament & Metacarpal
Read Code: S52../S524.
KEY POINTS
• See Sprain/strain introduction
• Children <12 years rarely sprain ligaments – X-ray
• Elderly require early mobilisation
• Elderly patient at risk of frozen shoulder with prolonged immobilisation
• Beware scaphoid fracture in adults
• Beware tendon rupture in elderly
Complications
• Chronic recurrent tendonitis
• Unstable joints
• Osteoarthritis
• Chronic pain
• Weakness of grip
• Permanent disability
History
• Mechanism of injury (acute cause and effect) – fall, trauma,
implement, twisting injury while gripping fixed object
• Duration of symptoms
• Activity
• Pre-existing pathology
• Hand dominance
• Occupation
Examination
• Deformity
• Tenderness
• Swelling
• Ability to grip
• Special tests eg Watson’s test
• Range of movement (active/passive)
• Exclude fracture
• Crepitus
• Lateral stability
• Triangular fibro-cartilage injuries
• Tendonitis
• Fracture, especially scaphoid, Colles, Bennett’s, growth plate # (tender
anatomical snuffbox)
• Dislocation of inferior radio-ulnar joint or carpal bones (carpal dislocations
require urgent referral)
• Scapho-lunate disassociation (tenderness in fossa distal to Lister’s tubercle)
• Ligamentous instability
Sprain Wrist or Hand, Tendon, Wrist or Hand S52../S524.
Sprain Wrist or Hand (Carpal Ligament & Metacarpal
Investigation
• X-ray to exclude fracture/dislocation and consider repeat at 2 weeks if
suspicion remains
• Pain distal to Lister’s Tubercle +/- pain on gripping ask for bilateral AP
clenched fist views to exclude scapho-lunate disassociation
Treatment
• RICE
• Pain relief
• Immobilisation by splinting in position of function (early mobilisation
in the elderly)
• Crepe bandage and broad arm sling
• If strong clinical suspicion of scaphoid fracture, apply POP and treat
according to Scaphoid Fracture Profile
• Fracture according to relevant Fracture Profile
• Dislocation (refer urgently if unable to rule out carpal dislocation)
• Gross instability
• Neurovascular impairment
• No improvement after 2 weeks
• Suspected carpal instability
Other Referral
• Physiotherapy if persistent
Sprain Wrist or Hand, Tendon, Wrist or Hand S52../S524.
Hand/Wrist Flexor Tendon Rupture
Read Code: N2264
KEY POINTS
• Can be secondary to rheumatoid or osteoarthritis
• Occasionally due to inappropriate use of corticosteroids
• Can be secondary to laceration proximal to hand and wrist
Complications
• Osteoarthritis
• Joint subluxation
• Chronic pain
History
• Rheumatoid or osteoarthritis
• Trauma
• Corticosteroid injection(s)
• Localised pain and decreased function
Examination
• Swelling
• Pain on movement
Specific examination for hand/finger flexor tendon rupture:
Profundus tendon of finger:
• Hold PIP joint of examining finger in full extension, ask patient to flex
at DIP joint
Sublimis/superficialis tendon of finger:
• Extend and hold all fingers (DIP and PIP joints of all fingers not being
tested) then ask patient to flex at PIP joint of the finger being tested
Wrist tendons:
• Resist palmar flexion. Look and feel for Palmaris Longus (not always
present), Flexor Carpi Ulnaris (test with resisted ulnar deviation and
palmar flexion), Flexor Carpi Radialis (test with resisted radial deviation
and palmar flexion)
• Spain/strain
• Fracture
• Infection
• Carpal ligament injury
Investigation
• X-ray
• Check for scapholunate instability with bilateral AP clenched fist views
Treatment
• Confirm no fracture
• Splint with a position of function splint (DIP and PIP joints extended,
MCP 90˚, wrist dorsiflexed 45˚)
• Referral for repair acutely if suspect rupture of any flexor tendon
• To plastic, hand, or orthopaedic specialist for consideration of repair acutely
Hand/Wrist Flexor Tendon Rupture N2264
Read Code: S5204
KEY POINTS
• Less common than UCL sprains
• Measure instability in extension by comparison with uninjured side
• Complete tears as disabling as complete UCL tears – need referral <7 days
• >30° movement on stressing RCL implies rupture and must be referred
• Mobilisation with physiotherapy must start by 7-10 days
• X-ray all but most trivial injuries
• Look carefully for associated injuries eg dislocation reduced previously,
tendon rupture in elderly
Complications
• Dysfunctional grip from instability
• Stiffness
• Degeneration of joint surfaces
History
• Mechanism of injury – force, degree and direction
• Past injury/arthritis
• Occupation/hobby
• Hand dominance
Examination
• Determine degree of sprain (Grade 1, 2 or 3)
• Measure instability in extension
• >30° movement on stressing RCL implies rupture
• Tenderness over joint
• Joint stability – passive and active
• Tendons
• Full rupture
• Dislocation reduced elsewhere
• Fracture
• Tendon injury
• 1st MCP joint sprain
Investigation
• X-ray
Treatment
Ruptured RCL:
Grade 1
• RICE
• Thumb spica/elastoplast
• Physiotherapy
Sprain Radial Collateral Ligament (Thumb) S52o4
Grade 2
• Thumb spica
• Physiotherapy
Grade 3
• Refer (urgent)
• Radial collateral ligament rupture (Grade 3 strain)
• Associated fractures (qv)
Sprain Radial Collateral Ligament (Thumb) S52o4
Sprain Thumb
Read Code: S522. (Most important is Ulna Collateral ligament sprain)
KEY POINTS
Diagnoses include:
Ulna collateral ligament sprain (Skier’s, Gamekeeper’s thumb)
Capsular strain of 1st MCP joint
IP joint strain
Radial collateral ligament strain (see S5204)
• Measure instability in extension using comparison with non-injured side
• Unstable injuries need referral
• Collateral ligament tear (complete) needs referral <7 days
• >30° movement on stressing UCL implies rupture and must be referred
• Mobilisation with physiotherapy must start by 7-10 days
• RICE therapy early
• Look carefully for associated injuries eg dislocation reduced previously,
tendon rupture in elderly
Complications
• Dysfunctional grip from instability
• Stiffness
• Degeneration of joint surfaces
History
• Mechanism of injury – force, degree and direction
• Capsular sprain of 1st MCP joint: common mechanism is hyperextension
or axial compression
• Past injury/arthritis
• Occupation/hobby
• Hand dominance
Examination
• Determine degree of sprain (Grade 1, 2 or 3)
• Measure instability in extension
• >30° movement on stressing UCL implies rupture
• Tenderness over joint
• Joint stability – passive and active
• Collaterals especially UCL and IP joint sprains
• Volar Plate
• Tendons
• Weakness of pinch grip (Grade 2 or 3 UCL injury)
• Degree of strain
• Dislocation reduced elsewhere
• Fracture
• Tendon injury
Sprain Thumb S522.
Sprain Thumb
Investigation
• X-ray
• Stress X-ray (under nerve block) if thumb UCL injury
Treatment
Ruptured UCL:
Grade 1
• RICE
• Thumb spica/elastoplast
• Physiotherapy
Grade 2
• Thumb spica splint/plaster for 4-6 weeks
• Physiotherapy
Grade 3
• Refer <7 days as ligaments become degraded very quickly making acute
repair difficult
• Chronic UCL injuries with residual instability, pain, and weakness of
pinch grip need referral for surgery
Capsular MCP joint sprain:
• Brace/splint 7-10 days to prevent hyperextension
• Prone to recurrence
• Referral not usually needed
IP joint sprains:
• Partial tear – buddy strap 7-10 days, physio
• Volar plate – splint for 5-10/7 at 10-15° flexion
• Complete rupture – refer
• Ulna collateral ligament rupture
• Unstable volar plate injuries
• Rupture of central extensor slip
• Grade 3 ligament damage
• Associated fracture (qv)
Other Referral
• Physiotherapy (hand specialist if available)
UCL Grade 1
• If no improvement in 1 week
UCL Grade 2
• Stable volar plate injury
Sprain Thumb S522.
Sprain Finger
Read Code: S523./S5513
KEY POINTS
• The key is to maintain mobility while keeping stability, sensation and analgesia
• Early mobilisation requires early review usually at 7-10 days
• These codes include:
MCP joint strains
PIP joint strains especially volar plate tears (often missed)
DIP joint strains
• Children <12 years rarely sprain ligaments (probably likely to fracture
growth plates or suffer greenstick injury)
Complications
• Chronic recurrent tendonitis
• Unstable joints
• Boutonnière Deformity (after volar plate injury – usually develops after
initial injury)
• Chronic mallet deformity
• Chronic swelling
History
• Direct impact
• Traction
• Torsional forces
• Acute or chronic event
• Site of pain
• Recurrence
• Occupational
• Hand dominance
• History of dislocation
Examination
• Tenderness
• Swelling
• Deformity
• Stability
• Range of movement, passive and active checking, also tendon function
• Determine grade of sprain
• PIP joint exam – often best done under digital block if significant injury:
can assess active range of motion and passive stability. Assess true collateral
ligaments in flexion when accessory collaterals lax
• Early volar plate injuries often indicated by PIP joint swelling, tenderness
at dorsum of middle phalanx base and mild flexion deformity
• Fracture (fractures involving avulsions of <30% of joint surface from the
volar plate can be treated as per sprains)
• Dislocation
• Tendon injuries (note FDP avulsions often missed)
• Arthropathies
• Neurovascular injuries
Sprain Finger S523./S5513
Sprain Finger
Investigation
Treatment
• RICE
• Pain relief
• Immobilisation/strapping – buddy strapping
• Volar plate injuries: actual or suspected – extension block splint
• Review 7-10 days
• Early mobilisation in elderly
• Exercises
• Grade 3 injury
• Discuss volar plate injuries or suspected injuries with hand specialist
Other Referral
• Physiotherapy – Grade 1 and 2
Sprain Finger S523./S5513
Sprain Hip/Thigh
Read Code: S53..
KEY POINTS
• Children <12 years rarely sprain ligaments. Consider infection, irritable
hip, SUFE, Perthes and traction apophysitis (avulsion fractures)
ligaments
• Elderly patients are prone to suffer stiffening of their joints and need
early mobilisation
RED FLAG:
Children and elderly - a careful
assessment is required where the
history is not consistent with the
severity of symptoms. Seek
advice early
Complications
• Osteoarthritis
• Osteomyelitis
• Pain/loss of function if inadequately rehabilitated
History
• Site of pain
Examination
• Temperature, pulse, BP
• Active and passive range of motion of hip joint and resisted movements
• Record capsular irritation (pain and reduced internal and external rotation
with a flexed hip and knee at 90˚)
• Palpate for bony and muscular tenderness
• Resting position of leg externally rotated
• Exclude hernia
• Examination of lower back may be indicated
• Fracture/Dislocation
• Infection
• Tendon rupture/strain – hip flexors, hip extensors, hip rotators
• Arthritis
• Children – Perthes, SUFE, septic arthritis, irritable hip, osteomyelitis
• Pain radiating from lower back, SI joint
• Hernias
• Greater trochanteric bursitis
Investigation
• X-ray (to exclude fracture)
• Consider FBC, ESR, blood cultures
• Consider ultrasound
Treatment
• RICE in first 24-48 hours
• NSAIDs
• Crutches or wheelchair if required
• Isometric exercise training as prevention of muscle wasting
• Discuss with specialist if unsure of diagnosis in children
Sprain Hip/Thigh S53..
Sprain Hip/Thigh
• Fracture
• Red Flags: children and elderly
• Unstable hip joint, non-weight-bearing, progressive and worsening antalgic gait
Other Referral
• Physiotherapy rehabilitation and to monitor progress
• Children do not need physiotherapy
Sprain Hip/Thigh S53..
Read Code: S533.
KEY POINTS
• In children consider irritable hip, infection, Perthes, slipped upper femoral
epiphysis
ligaments
• RICE therapy is useful early (first 24 hours, possibly 48) for most sprains
• One of the quadriceps muscles (rectus femoris) covers both the hip and
the knee, thus it is important to consider both joints when examining
Complications
• Muscle wasting
• Quadriceps haematoma
• Myositis Ossificans
History
• Over stretching
• Direct blow – contusion
• Running/kicking – strain
• Site of pain
Examination
• Pain and/or instability when stressing tendon
• Function to exclude fracture
• Gap in tendon
• Site of tenderness
• Ability to actively straight leg raise
• Passive, active, resisted movements of knee joint
• Fracture
• Tendon rupture
• Muscle tear
• Infection/abscess
• Traction apophysitis (avulsion fractures in children)
• Lumbar spine strain
• SI joint strain
• Contusions/corked thigh/haematoma
• Hernias
• Traumatic osteitis pubic symphysis
• Children – consider Perthes, slipped upper femoral epiphysis, infection,
cancer, irritable hip
Investigation
• X-ray (to exclude fracture), especially children and the elderly
• Consider FBC, ESR in children
• Consider ultrasound
Sprain/Strain Quadriceps Tendon S533.
Treatment
• Control of haemorrhage – RICE in first 24-48 hours
• Early referral to physiotherapy
• Restoration of pain free range of motion (physiotherapy)
• Functional rehabilitation (physiotherapy and education)
• Graduated return to activity (education and monitoring)
• NSAIDs may have a place, but may also delay healing
• Splintage or knee brace as required for pain (only for a short period, up
to 1 week)
• Isometric exercise training as prevention of muscle wasting, especially
for all knee injuries
• Fracture
• Grade 3 muscle strains (refer to grades of muscle strains in introduction)
• Large haematoma
• Associated knee effusion
Other Referral
• Physiotherapy
Sprain/Strain Quadriceps Tendon S533.
KEY POINTS
• History important – especially in sports person
• Exclude meniscal tear if persistent symptoms in "sprained" knee
• Aspiration if tense effusion or to exclude haemarthrosis (fracture, ruptured
ACL, dislocated patella, intra-articular fracture)
• Check for additional injuries to knee structures eg ACL
• Some tears require referral and possible arthroscopy
• Haemarthrosis uncommon – aspiration if tense effusion
• Early rehab (physio) mandatory to reduce effusion ASAP. Maximises range
of motion, allowing early strengthening and proprioceptive retraining
and return to work/sport
• Advice to patient about avoiding re-injury and further effusion is essential
• May present as chronic knee pain in older people
• Lateral tears are rarer than medial and can be associated with ACL injury.
Also often require more rehabilitation
Complications
• Wasting of quadriceps muscles, especially VMO
• Long-term degenerative osteoarthritis
• Other underlying abnormalities present eg spasticity, congenital
deformities, valgus/varus deformity
• Chronic pain
History
• Usually a twist injury with flexed knee with a fixed foot
• Sudden onset of painful knee while running, jumping, twisting or
even kneeling
• Swelling usually >4 hours or next day
• Degree of force
• Mobility since injury
• Locking/giving way
• Consistent localised pain (especially joint line)
Examination
• Effusion – haemarthrosis not always present
• Pain variable
• Check range of motion – may have "springy" resistance to extension
• Tenderness on joint line
• Ligamentous instability especially ACL
• Special tests – McMurray's, Tibial Torsion
• Pain with tibial rotation at 90( flexion
• Pain on flexion/extension with foot rotated, medially or laterally
(McMurrray’s test)
• Torn cruciate ligament
• Torn medial/collateral ligaments
• Osteochondral fracture
• Patella dislocation/subluxation
• Degenerative joint disease
• Other abnormalities eg spasticity, congential deformities, valgus/varus
deformity
Meniscal Tear (Medial/Lateral) S46o./S461.
Investigation
X-ray if :
Suspected fracture
Child/adolescent
High speed injury
Loose body
Haemarthrosis present
• Refer Ottawa/Pittsburgh knee rules
Treatment
• RICE/Rehab (physio) early
• Padded crepe bandage or tubigrip and knee brace
• Gradual mobilisation
• Aspiration if tense effusion or to exclude haemarthrosis
• Crutches
• Passive quadriceps exercises
• Analgesia as necessary/NSAIDs
• Physiotherapy for muscle balance assessment and strengthening programme
• At 1-2 weeks post-injury if:
Not full range of motion (active/passive)
Effusion still present
Pain still present
Giving way still present
Locking present NB: Locked knee = either loss of end-range extension
or loss of all range of motion:
Loss of end-range extension >5,(refer at 1-3 weeks)
Loss of all active/passive range of motion, refer acutely
• +ve McMurray test after 2 weeks
• Haemarthrosis detected
Other Referral
Physiotherapy for muscle balance assessment and strengthening programme
Meniscal Tear (Medial/Lateral) S46o./S461.
Read Code: S5400/S541.
KEY POINTS
• See Sprain/Strain Introduction and Pittsburgh/Ottawa rules for X-raying knee
• Use removable splints and physio rather than casts
• Majority achieve functional recovery if uncomplicated
• Large knee effusions can cause loss of range of motion and muscle wasting
thus early rehabilitation is essential
• Medial collateral ligament injury much more common than lateral ligament
Complications
• Patello-femoral syndrome
• Unstable knee
• Wasting of quadriceps
• Meniscal injuries
• Osteoarthritis if not rehabilitated appropriately
Ottawa Knee Rules
X-ray if:
Inability to transfer weight for four steps
both immediately after injury and at
examination
Exclusion criteria:
Isolated superficial injuries being
re-evaluated
Patients with altered levels of
consciousness, paraplegia,
History
• Determine mechanism of injury – direct, indirect blow
• Location of pain/tenderness
• Valgus injury on a weight-bearing flexed knee causes stress and injury to
the MCL
• Varus injury on a weight-bearing flexed knee causes stress and injury to
the LCL
Examination
• Observe gait, swelling, range of motion
• Ligament laxity/resistance
• Stress the ligaments with the knee in a slightly flexed position to determine
the grade
• Cruciate ligament injury
• Meniscal injury
• Fracture
• Patella subluxation/dislocation/#
Indicate radiography if the mechanism of injury
is blunt trauma or a fall, and either:
The patient is younger than 12 or older
than 50 years of age; or
The injury causes an inability to walk
four weight-bearing steps at
examination
Exclusion criteria:
Knee injuries that occur over six days
before presentation
Patients with only superficial lacerations
and abrasions
Those with a history of previous
surgeries or fractures on the
affected knee
Investigation
• X-ray if swollen, possible fracture, severe trauma (see Ottawa and
Pittsburgh rules)
Treatment
Grades 1 and 2
• RICE
• Analgesia
• Tubigrip and crutches. Mobilise with partial weight-bearing flexion
extension only
• May require or benefit from hinged knee brace
• Physiotherapy for range of motion and strengthening of the dynamic
stabilisers of the knee
RED FLAG:
If the knee opens to valgus/varus
stress while fully extended this
implies a posterior capsular tear of
the knee and should be referred
Sprain Collateral Ligament Knee S54oo/S541.
• Advise on preventing further injury, especially from weight-bearing and
twisting on a flexed knee (eg getting in and out of vehicles)
Grade 3
• Refer
• Probable associated meniscal tear
• May also have associated cruciate rupture
• Grade 3
• Recurrent strains
• Instability
• Significant trauma
• Fracture
Other Referral
• Physiotherapy
Sprain Collateral Ligament Knee S54oo/S541.
Read Code: S542.
KEY POINTS
• See Sprain/strain Overview
• Start static muscle exercises early to prevent muscle wasting
• Knee should not be immobilised for more than 2 days
• Ottawa or Pittsburgh rules for X-raying knee
• Use removable splints and physiotherapy rather than casts
• Meniscal injury should be estimated
• Monitor every few days if unsure of diagnosis and refer early
• Segond # pathognomonic of ACL rupture
• ACL ruptures associated with early haemarthrosis
• PCL ruptures are extracapsular and not always associated with knee
joint effusion
• PCL ruptures rarely require surgical repair
Ottawa Knee Rules
X-ray if:
Inability to transfer weight for four steps
both immediately after injury and at
examination
Exclusion criteria:
Isolated superficial injuries being
re-evaluated
Patients with altered levels of
consciousness, paraplegia,
Complications
• Patello-femoral syndrome
• Unstable knee
• Muscle wasting causing worsening instability
• Rupture of quadriceps mechanism
• Meniscal injuries
• Osteoarthritis
History
Landing from a jump, sudden deceleration
Twisting injury on a weight-bearing flexed knee
Forced hyper extension against resistance
Forced flexion
Pivoting on the knee
• Audible pop at time of injury
Indicate radiography if the mechanism of injury
is blunt trauma or a fall, and either:
The patient is younger than 12 or older
than 50 years of age; or
The injury causes an inability to walk
four weight-bearing steps at
examination
Exclusion criteria:
Knee injuries that occur over six days
before presentation
Patients with only superficial lacerations
and abrasions
Those with a history of previous
Unresolved previous injury:
Loss of function eg knee giving way
• Rapid swelling (usually in first 4 hours) implies ACL/PCL rupture or
fracture
• Complete tears – athletes are unable to keep playing immediately following
the injury
surgeries or fractures on the
affected knee
Examination
• Difficult to examine with large effusion present
• Check quadriceps mechanism
• Swelling, gait
• Joint stability
• Stress test
• Define end point and resistance
• Lachman/pivot shift test for ACL rupture
• Sag sign for PCL
Sprain Cruciate Ligament Knee S542.
• Collateral ligament injury
• Fracture/dislocation eg Tibial plateau
• Other cruciate: partial/complete tear
• Association with meniscus/patella/fractures/articular cartilage
• Rupture of quadriceps mechanism
Investigation
• X-ray – see Ottawa and Pittsburgh rules (see Sprain/strain introduction)
Treatment
• RICE
• Splint/crutches
• Aspirate tense knee effusions for pain relief and mobilisation
• Reassess early (48 hours)
• Start static muscle exercises early to prevent muscle wasting
• Early referral to physiotherapy for prehab (preparing knee for surgery)
and rehab
• Reassess 1 week and refer if appropriate (see Referral to Specialist)
• Rehabilitation should begin on day 1 and should be a team approach
(doctor, specialist, physiotherapist). Patient should be educated that
rehabilitation is a long, slow process. Compliance with the rehabilitation
programme is crucial for satisfactory outcome and to avoid long-term
complications
• The ACL has a major proprioception function. Any rehabilitation
programme must include ongoing balance retraining
• No improvement after 1 week
• Fracture
• Functional instability
• Knee giving way
• Combined ACL/MCL tear
Rupture:
ACL/PCL
ACL with bone attached
• Meniscal injury
• Rupture quadriceps mechanism
Other Referral
• Physiotherapy
• Possibly podiatry
Sprain Cruciate Ligament Knee S542.
Read Code: S550.
KEY POINTS
• Ottawa rules for X-raying ankle injury (plus Red Flags)
• Inversion injury – exclude fracture of 5th metatarsal
• Medial ligament sprain is rarely isolated, review for other sprain or fracture
• Rupture of tibio-fibular ligaments
• Rupture tibialis posterior tendon especially if >45 years
• Foot needs to be maintained at 90˚ to appose ligament ends for
perfect healing
Complications
• Instability
• Swelling
• Arthritis
• Pain syndrome
• Osteochondral defects
• Capsulitis
History
• Injury mechanism usually inversion with rotation (for lateral ligament injury)
• Record whether weight-bearing
• Location of pain will indicate which ligament has been injured
• Swelling
• Pain elsewhere in the limb
• Previous injury – type and residual dysfunction
• Eversion injury more suggestive of medial ligament damage or fracture
• Compressive type of injury suggestive of osteochondral injury
Ottawa Ankle Rules
X-ray if:
Unable to bear weight (take four steps)
at time of injury and at examination
Bone tenderness at posterior edge or
tip of either malleolus
Bone tenderness over the naviculus or
base of fifth metatarsal
RED FLAG:
Prolonged symptoms >6 weeks of
appropriate rehabilitation (pain,
swelling, antalgia, decreased range
of motion) suggestive of
osteochondral injury/capsulitis.
Re-X-ray and refer
All children <12 years
Elderly patients
Examination
• Determine degree of ligament damage
• Perform anterior draw and talar tilt tests to determine laxity of joint,
compare with uninjured ankle
• Check function and ability to weight bear
• Site of tenderness
• Swelling and bruising
• Check full length of fibula
• Check 5th metatarsal (base)
• Check proprioception (1 leg standing)
Sprain Ankle (Lateral Ligaments) S55o.
• Fracture
• Lateral/Medial ankle strain
• Anterior inferior tibio-fibular ligament tear
Investigation
• X-ray – use Ottawa rules
• Full length of fibula
• Consider stress views if instability
• Consider bone scan if indicated
Treatment
The management of lateral ligament injuries of all 3 grades follows the same
principles:
Initial management RICE
Reduction of pain and swelling (NSAIDs at 2-3 days)
Muscle conditioning
Proprioceptive exercises
Functional exercises
Return to activity (taping)
Grade 1
• RICE
• Education/physiotherapy
• Crepe or tubigrip strapping
• Review in 1 week if no improvement
Grade 2
• RICE
• Simple analgesia
• Consider NSAIDs
• Physiotherapy
• Consider cast/splint for 1 week
• Review 1 week if no improvement
Grade 3
• Do not refer acutely
• Stabilise in cast/backslab (non-weight-bearing) 7-21 days with weekly
clinical review
• Physiotherapy/taping
• Mobilise with partial weight bearing (at 1-3 weeks) and crutches
• 3rd degree sprains
• Tendon injuries
• Medial ligament sprain
• Tibialis posterior rupture
• Fibula fracture
• Rupture of inferior tibia/fibula ligament
Other Referral
• Physiotherapy – Grades 1 and 2
Sprain Ankle (Lateral Ligaments) S55o.
Sprain of Metatarso-Phalangeal Joint/
Read Code: S5512/S5513
KEY POINTS
• Includes strains of all MTP and IP joints of the foot and toes eg
haemarthrosis of MTP joint, sesamoiditis
• Good history and examination are important especially of the whole foot;
MTP joint strains may reflect whole foot pathology especially in runners
• Plantar displacement best seen on lateral X-ray
• If persistent pain after 7-10 days need to re-X-ray for occult fracture
• Toes must heal in normal shape to fit shoes and avoid pressure areas
• Gout may be triggered by trauma, presenting 2-5 days after injury
• MTP joints must heal with normal mobility to maintain normal gait
Complications
• Gout
• Chronic metatarsalgia
History
• Twisting injury
• Hyper extension
• Occupation eg dancer, athlete,
• Level of exercise
Examination
• Examine whole foot, especially arches, skin
• Tendons and ligaments: passive and active range of movement
• Deformity
• Ecchymosis
• Swelling, erythema
• Point tenderness
• Pain on stressing ligaments
• Gait
• Fracture of MT neck with/without plantar tilt of MT head
• Stress fractures of metatarsal neck
• Dislocation
• Infection
• Tendon rupture
• Metatarsalgia due to hallux rigidus or hallux valgus
• Gout
• Intra-articular fracture
• Plantar fasciitis
• Interdigital neuroma (Morton’s neuroma)
Investigation
• X-ray toe and foot if fracture suspected
• Aspirate joint +/- uric acid if gout suspected
Treatment
• RICE
• Buddy strap
• Analgesia
• Hard-soled shoes
• Orthotics
Foot Joint Sprain S5512/S5513
Sprain of Metatarso-Phalangeal Joint/
• Fracture of the MT neck with tilt on MT head
• Displaced intra-articular fracture
• Tendon rupture
• Discuss possible stress fractures with specialist
Other Referral
• Physiotherapy for gait assistance and joint mobilisation if restriction present
• Podiatry
Foot Joint Sprain S5512/S5513
Section 6 Lacerations/Abrasions
CONTENTS
Read Code
Abrasion Face
SD000
Abrasion Shoulder/Upper Arm/Lower Arm/ Knee/Leg
SD2../SD3../ /SD6..
Abrasion Trunk
SD10.
Avulsion of Nail/Open Wound Fingernail
7G321/S935.
Open Wound Head/Neck/Trunk
S8...
Open Wound Ear
S82..
Open Wound Scalp/Open Wound Forehead
S830./S8342
Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth
S832./S8341/S8343/
S8344/S8345/S836
Open Wound Elbow /Forearm,Wrist/Hand,Finger/ Thumb
S91../S92../S93..
Open Wound Buttock/Ext Genitalia
S87../S88..
Open Wound Upper Limb/Shoulder,Knee/Leg/Ankle,Foot/Toe
S9../S90../SA10./
SA2../SA3..
Amputation of Finger(s)
S96..
6 lacerations/
abrasions
Overview
Lacerations/Abrasions Overview
Timely and appropriate management of wounds can greatly reduce subsequent
morbidity.
History
Mechanism of injury:
• Type of injury – wounding agent, crush/shear/stab
• Potential contaminants and foreign bodies – note Luge injuries
• Species of animal if bite wound
Circumstances of injury:
• Work-related
• Assault (possible domestic violence)
• Self-inflicted wound
Age of wound
Associated symptoms:
• Pain, paraesthesia, anaesthesia, weakness, loss of function
Tetanus immunisation status
Current medications and allergies
Prior medical history:
• Previous injury/illness with residual disability in the wounded area
• Immunosuppression/corticosteroid use
• Diabetes mellitus
• Heart disease requiring endocarditis prophylaxis
• Previous keloid or hypertrophic scar formation
• Asplenia
• Peripheral vascular disease/venous hypertension
• Bleeding disorders
• Implanted prosthesis
Social history:
• Occupation/hobbies
• Handedness if upper limb injury
• Carers available if required
Examination
• Airways, breathing, circulation
• Vital signs recorded
• Secondary survey if required
• Weight for children for calculating drug dosage
Wound inspection:
Document:
• Length, width, depth
• Location
• Shape of wound
Overview
• Direction of wound related to skin surface – perpendicular/oblique eg
flap wound on cheek requires special consideration
• Vascular integrity
• Distal nerve and tendon function
• Evidence of obvious contamination – note Luge injuries may be
contaminated with minute rubber particles which must be removed
• Viability of tissues
• Signs of infection
Explore:
• Throughout full range of motion, both active and passive, of adjacent
joints if possible tendon injury
Imaging:
• Imaging is essential if there is suspicion of an associated fracture or
foreign body
• Radio-opaque objects are easily visualised on plain radiographs. They
include metallic objects other than aluminium, almost all types of glass,
some plastics and gravel
• Radiolucent objects such as wood, thorns and some plastics may best be
visualised with ultrasound
• Occasionally MRI scanning may be necessary to identify plastic
foreign bodies
Anaesthesia and Analgesia
• Adequate pain relief is essential if wounds are to be cleaned, inspected
and repaired under optimal conditions
• Anaesthesia of the affected area may need to be supplemented by:
Sedation in anxious and paediatric patients
Systemic analgesic agents if injuries are extensive or associated with
underlying fractures
• An assistant may be useful when suturing children
• A variety of anaesthetic techniques are available:
Local anaesthesia – topical or by infiltration
Regional
General
Local anaesthesia:
• Topical agents eg Amethocaine/Lignocaine/Adrenaline solutions (eg Emla,
Ametop gel) are particularly suited to use in children and provide excellent
levels of local anaesthesia without discomfort
• Infiltration agents – several are available:
Agent
Onset of Action
Duration of Action
Max Dose
Lignocaine
1 minute
30-60 minutes
4mg/kg
Lignocaine/Adrenaline
1 minute
60-120 minutes
7mg/kg
Bupivicaine
5 - 10 minutes
90-180 minutes
3mg/kg
The discomfort of local anaesthetic infiltration has been shown to be
minimised by:
Slow infiltration (facilitated by use of small gauge needles)
Infiltration into subcutaneous fat
Infiltration as the needle is withdrawn
Warming of anaesthetic solution to 37˚ to 40˚ C
Overview
Buffering with Bicarbonate (1 ml of 8.4% Sodium Bicarbonate/9mls of
1% Lignocaine). As well as reducing discomfort this technique increases
the intensity of the blockade
Side effects of local anaesthetic agents:
Allergic reactions
Systemic toxicity
• Allergic reactions are very uncommon and are normally to the preservative
in the solution rather than the anaesthetic agent
• Systemic toxicity is manifested by
Tachycardia
Perioral tingling or numbness
Nausea
Vomiting
Seizures
CVS collapse
It is related either to administration of an excessive amount of the agent or
to its inadvertent intravenous injection. Management involves:
Discontinuing administration
Attention to airway, breathing and circulation
Seizure activity can be terminated by administration of Benzodiazepines
Cardiovascular collapse is treated with intravenous fluid administration
and if necessary a vasopressor such as Adrenaline
Contraindications to use of Adrenaline:
Proximity to arterial supply eg digits
Extremities eg nose, ear, penis
Contaminated wounds (increases infection rate)
Regional anaesthesia:
• Digital block – ring block of fingers or toes. It is essential to deposit
anaesthetic in the vicinity of both dorsal and palmar digital nerves if full
anaesthesia of a digit is to be secured
• Sole of the foot. Local infiltration here is particularly painful. Regional
blockade of the sural and tibial nerve is much less painful to the patient
and provides excellent anaesthesia
Sedation:
• Whenever conscious sedation is used the patient should be monitored
continuously. Children may take 2-3 hours to recover. Monitor:
02 saturation
Respiratory rate
Heart rate
Blood pressure
• Midazolam is particularly useful because it is easy to administer and
because it is easily reversed if deleterious side effects develop. It also
provides anterograde amnesia.
Midazolam Dosage
Recommended Dose
Admin Route
0.5mg/kg
Oral
Onset of Action
20-30 min (may be mixed with juice)
0.2-0.5mg/kg
Intranasal
5-15 min
Reversal agent Flumazenil – dose
O.Olmg/kg
IV
Overview
Systemic Analgesia:
• Morphine – given IV (for speed and predictability of onset). Boluses of
1-2.5mg until pain adequately controlled. (Max dose 0.1mg/kg in children)
– orally for children (0.1mg/kg)
General Anaesthesia:
• Referral for General Anaesthesia may be appropriate for:
Young children if unco-operative, even with relatively minor wounds
Adults with more extensive wounds
Wound preparation
Careful wound preparation optimises conditions for wound healing without
infection.
Cleaning:
• N/Saline or dilute aqueous Chlorhexidine for wound irrigation in all cases
• Severely contaminated wounds – aqueous Povidone-Iodine can be used
as its ability to reduce pathogen load outweighs the disadvantage of tissue
damage associated with its use
• Wounds should be irrigated under pressure
• If it is necessary to remove hair in the course of wound repair it should
be trimmed rather than shaved
• Scrubbing of wounds may be necessary. Luge wounds impregnated with
rubber (which may not be obvious) require thorough cleaning by scrubbing
to avoid infection
Debridement:
• Devitalised tissue should be carefully debrided
• Irregular wound edges, other than on the face, should be trimmed
Antibiotic prophylaxis and Tetanus prophylaxis
Tetanus vaccination schedule for acute wound management
Hx of
Time Since
Type of
DTP/
Tet
Vaccination
Last Dose
Wound
DT/TT
Immunoglobulin
3 doses or more
<5 years
All
No
No
5-10 years
Clean/minor
No
No
>10 years
Unknown/less than
All wounds
Yes
No
Clean/minor
Yes
No
Yes
Yes
3 doses
Others
DTP for children
<8 yrs
ADT for patients
>8 yrs
Allergic reactions to Tetanus toxoid are extremely rare, although local
reactions are common. If the possibility has been raised, the patient can be
treated with Tetanus immune globulin if considered appropriate and they
can then be referred for allergen testing to confirm or refute the possibility
of allergy.
Overview
Antibiotic prophylaxis has been shown to reduce wound infection rates in
a number of situations:
• Wounds caused by a crush injury
• Wounds contaminated with soil, vegetation or faeces
• Late presentation (hand/foot wounds more than 8 hours after injury, other
areas more than 12 hours after injury)
• High-risk bite wounds (see section 8)
• Circulatory impairment – peripheral vascular disease or lymphoedema
• Impaired host defence – immunosuppression, diabetes mellitus
• Wounds affecting cartilage (ear/nose), tendon, bone and joint
RED FLAG:
Choice of antibiotic agent:
Single agent prophylaxis is preferred – encourages compliance
Animal bites/faecal contamination – Amoxycillin/clavulanate
Puncture wounds to foot through sole of shoe – Ciprofloxacin (gives cover
for Pseudomonas) All other wounds requiring prophylaxis – Flucloxacillin/
Dicloxacillin/Amoxycillinclavulanate/Doxycycline/metronidazole/clindam
ycin/ciprofloxacin (Recommendations vary)
• Optimal duration of therapy is unclear – 5 days is commonly recommended
near joints. They cannot be used to
Patients at risk of endocarditis or with
orthopaedic implants DO NOT require
antibiotic prophylaxis for clean,
uncomplicated wounds.
RED FLAG:
Tape closure is not appropriate in areas
where skin is moist, on the scalp or
close wounds that are actively
bleeding. They should not be placed
circumferentially on fingers. Friar's
Balsam may improve tape adhesion.
Wound closure
Several different techniques of wound closure are available:
• Tape
• Adhesives
• Staples
• Sutures
Tape:
Wound taping has several advantages over suturing in the closure of certain
wounds:
• Simplicity of application
• Reduced need for anaesthesia
• Elimination of need for suture removal
• Lower infection rate than sutured wounds
Wounds suitable for taping:
• Superficial straight lacerations under little tension
• Lacerations and bite wounds with a high potential for infection
• Lacerations in which skin edges are thin (the elderly, steroid dependent
patients and in flaps where sutures might compromise perfusion of the
wound edges)
• Tapes may also be used to support lacerations after suture removal to
minimise widening of the scar
Adhesives:
• Tissue adhesives give a cosmetic result equal to suturing under certain
circumstances. Characteristics of suitable wounds:
Lacerations with sharp edges and under little tension where no deep
sutures are required
Laceration 5cm or less in length
• If used on the face, steps must be taken to prevent the adhesive from
accidentally reaching the eye
• Adhesives are not suitable for
Lacerations subject to deforming stresses such as near joints
Lacerations that are actively bleeding
Overview
Staples:
Stapling gives as good a cosmetic result as suture closure and is very much
quicker. Cost of disposable stapling devices may be offset by time saved in
wound closure and by the reduced need for wound closure instruments.
Wounds suitable for stapling:
Linear lacerations of the scalp, trunk and extremities
Staples should be avoided for facial and hand lacerations
Sutures:
• Interrupted sutures most commonly used
• Monofilament sutures are preferred
• Silk/absorbable sutures may be more comfortable in the mouth
• Use absorbable sutures for deep tissue planes
Guide to appropriate suture size and time for removal according to location
of wound
Body region
Suture size
Time for removal
Scalp
3/0-4/0
7 days
Face
6/0
5 days
Trunk
3/0-4/0
Front 7 days
Arm/Leg
4/0
10 days
Hand/Foot
4/0-5/0
12 days
Back 10 days
• Add 2-3 days for wounds crossing extensor surfaces and subtract 2-3 days
in young children
Dressings:
• Many different dressings are available commercially and recommendations
are contentious
• Heavily contaminated wounds should be reviewed and redressed after 2 days
• Dressings for abraded wounds are detailed in the relevant profiles
• Sutured wounds should be kept dry – dressings should wick away any
fluid oozing from the wound and should only be changed when their
absorptive capacity is exceeded or if there are concerns regarding
possible infection
Overview
Abrasion Face
Read Code: SD000
KEY POINTS
• Exclude serious underlying injury
• Clean wounds meticulously to avoid subsequent tattooing by retained
foreign bodies
• Clinical examination of facial skeleton is superior to X-ray in detecting fractures
• Abraded skin is prone to hyperpigmentation – advise use of sunblock for
6 months post injury
Complications
• Infection
• Scarring
• Tattooing
• Missed underlying injury
History
• Time of injury
• Associated injuries
• If associated head injury:
Loss of consciousness/duration
Clinical course following injury
• Co-morbidities
• Allergies
• Symptoms suggestive of blow out fracture of orbit:
Diplopia/pain on upward or lateral gaze
• Symptoms suggestive of mandibular/maxillary fracture:
Malocclusion/pain on biting
Examination
• Initial focus on airway, breathing and circulation followed by neurological
examination if associated head injury
• Check stability of maxilla if possible mid-facial fractures
• Note area, depth, shape, location of wounds
• Note extent of contamination/devitalised tissue
• Note presence of retained foreign bodies
• Periorbital injuries
Full eye examination including visual acuity
• Underlying facial fractures
• Ocular trauma
Investigation
• X-ray facial bones if possible fractures
• Wound culture if late presentation and wound infection apparent
Treatment
• Analgesia to allow thorough cleaning:
Local anaesthetic if small area
For larger areas nerve blocks, IV opiates or Entonox may be appropriate
• Clean with warm N/Saline
• Remove all foreign material (use scrubbing brush/sterile soft toothbrush
if necessary)
Abrasion Face SDooo
Abrasion Face
• Dress with hydrocolloid/Tegaderm or leave open and keep moist with
Bacitracin or Chlomycetin ointment
• Inspect at 5 days unless signs of infection develop earlier
• Provide tetanus prophylaxis as necessary – see Overview
To plastic surgeon:
• If patient’s age or extent of abrasions precludes adequate cleaning
• Management of facial fractures
To maxillo-facial surgeon:
• Mandibular/maxillary fractures – according to local practice
Abrasion Face SDooo
Abrasion Shoulder/Upper Arm (No Infection), Abrasion/
Friction Burn Lower Arm, Abrasion Knee/Leg
Read Code: SD20./SD30./SD602/SD60.
KEY POINTS
• Exclude serious underlying injury
• Clean wounds thoroughly to avoid subsequent tattooing by retained
foreign bodies
• Soft tissue injury alone or in combination with an underlying fracture
may cause a compartment syndrome
Complications
• Infection
• Scarring
• Tattooing
• Ischaemic contractures from compartment syndromes
History
• Time of injury
• Co-morbidities
• Symptoms of compartment syndrome:
Disproportionately severe, poorly localised pain
Severe swelling
Hyperaesthesia/paraesthesia in distribution of nerves crossing
compartment
Examination
• Deformity/limitation of movement of limb suggesting underlying fracture,
dislocation or closed tendon injury
• Signs of compartment syndrome
Pain on passive stretching or active flexion of affected muscle groups
Distal sensory abnormalities
• NB Normal distal pulses, skin colour and capillary return do not exclude
compartment syndrome
• Underlying fracture
Investigation
• X-ray if possible underlying fracture/dislocation
Treatment
For larger areas IV opiates or Entonox may be appropriate
Abrasion Arm, Leg SD20./SD30./SD602/SD60.
Abrasion Shoulder/Upper Arm (No Infection),
Abrasion/Friction Burn Lower Arm, Abrasion
Knee/Leg
• Remove all foreign material (use scrubbing brush if necessary)
• Dress with tulle gras
• Inspect at 2 days unless signs of infection develop earlier. Redress with
tulle gras/hydrocolloid
• Provide tetanus prophylaxis as necessary -see Overview
To plastic/orthopaedic surgeon:
• Patient’s age or extent of abrasions precludes adequate cleaning
To orthopaedic surgeon:
• Underlying fracture/dislocation or potential/actual compartment syndrome
Abrasion Arm, Leg SD20./SD30./SD602/SD60.
Abrasion Trunk
Read Code: SD10.
KEY POINTS
• Exclude serious underlying injury. NB: In children the highly compliant
rib cage may allow serious intra-thoracic or abdominal injury to occur
with relatively minor evidence of injury externally
• Clean wounds thoroughly to avoid subsequent tattooing by retained
foreign bodies
Complications
• Infection
• Scarring
• Tattooing
• Co-existent intra-thoracic and abdominal injuries
History
• Time of injury
• Co-morbidities
Examination
• Initial assessment of airway, breathing, circulation and neurological state
• Secondary survey of chest and abdomen if appropriate
• Underlying fracture
• Intra-thoracic/intra-abdominal injury
Investigation
• Chest X-ray and ECG if significant chest trauma
• Urinalysis if significant abdominal trauma
Treatment
For larger areas IV opiates or Entonox may be appropriate
• Remove all foreign material (use scrubbing brush if necessary)
• Dress with tulle gras
• Inspect at 2 days unless signs of infection develop earlier
• Redress with tulle gras/hydrocolloid
To local emergency department:
• Evidence of actual or potential internal injury
To plastic/orthopaedic surgeon:
• Patient’s age or extent of abrasions precludes adequate cleaning
Abrasion Trunk SD10.
Avulsion of Nail/Open Wound
Fingernail
Read Code: 7G321/S935.
KEY POINTS
• See Overview
• Inadequate repair of damage to nail bed or matrix may lead to long-term
nail deformity
• Subsequent revision surgery is disappointing
• Associated mallet finger deformity in children is an epiphyseal injury
requiring reduction and possible internal fixation
Complications
• Nail deformity
• Non-adherence of new nail
• Persistent mallet finger
• Osteomyelitis
History
• Time of injury
• Age
• Occupation
• Leisure activities
• Hand dominance
• Co-morbidities
Examination
• If nail remains attached and nail bed/matrix laceration apparent or >50%
subungual haematoma present – remove nail to allow full assessment and
appropriate treatment
Assess for:
Nail bed/matrix laceration or tissue loss
Exposed bone/compound fracture
Associated mallet finger deformity
If late presentation signs of infection
Investigation
• X-ray if mechanism of injury/clinical examination suggests fracture or if
mallet finger deformity
• Wound culture if late presentation and signs of infection present
Treatment
• Provide analgesia with digital nerve block (never with adrenaline)
• Remove nail if remains attached
• Clean
• Suture nail bed laceration with 6/0 absorbable (preferable) suture
• Trim sides of nail and replace to prevent formation of adhesions within
nail fold. NB Also greatly reduces pain of dressing changes
• If nail unavailable use sterile Silastic sheet or part of suture packet
• Prophylactic antibiotics if exposed bone/compound fracture – see Overview
• Mallet finger deformity
Adults – splint in full extension – refer if >25% of articular surface of
distal phalanx is involved
Children – refer
• Provide tetanus prophylaxis (see Overview)
Avulsion Nail 7G321/S935.
Avulsion of Nail/Open Wound Fingernail
Referral to Specialist:
• Complex or extensive nail bed laceration
• Nail matrix laceration
• Partial nail bed avulsion – refer with (appropriately chilled) avulsed tissue
if possible
• Mallet finger deformity in adults – refer if >25% of articular surface of
distal phalanx is involved
• All mallet finger deformities in children
• Unstable distal phalanx fracture (unusual)
• Inadvertent ring block with adrenaline – refer urgently
Avulsion Nail 7G321/S935.
Open Wound Trunk
Read Code: S8...
KEY POINTS
• See Overview
• History of injury and events following is critical
• If conscious level impaired never attribute to alcohol/drugs even if such
ingestions are known to have occurred
• Seemingly trivial penetrating wounds of the abdomen may also involve
intra-thoracic structures and vice versa
Complications
• Infection
• Co-existent intra-thoracic and abdominal injuries
• Scarring
• Tattooing
• Pneumo/haemothorax – other intra-thoracic/abdominal organ damage
History
• Time of injury
• Clinical course following injury
• Associated symptoms/injuries
• Co-morbidities
• Medication especially Warfarin
• Allergies
• History from a witness
Examination
• Vital signs
• Examination of chest and abdomen, to exclude associated injuries
• Note length, depth, shape, location of wound
• After instillation of local anaesthetic assess depth of wound on trunk
Investigation
• Chest X-ray and ECG if significant chest trauma
• Urinalysis if significant abdominal trauma
• Soft tissue X-ray if possible retained foreign body
Treatment
• Anaesthesia to allow adequate cleaning and examination of wound – local
infiltration Lignocaine with Adrenaline or topical anaesthetic in children
• Clean wound and remove devitalised tissue
• Oversew bleeding vessels
• Suture/staple/glue skin – see Overview
• Evidence of actual or potential internal injury
• Stab wounds to chest or abdomen unless trivial
• To plastic surgeon if patient’s age or extent of wounds precludes adequate
treatment
Open Wound Trunk S8...
Open Wound Ear
Read Code: S82..
KEY POINTS
• See Overview
• Exclude associated head injury
• Auricular haematoma/tympanic membrane perforations (from slapping)
may represent non-accidental injury
• Minimal debridement of lacerations to avoid distortion of cartilage
• Lacerations involving auricular cartilage merit antibiotic prophylaxis
• Acute vertigo/deafness implies inner/middle ear damage
• Avulsions – if avulsed tissue available transfer with patient to plastic surgeon
Complications
• Chronic TM perforations
• Cosmetic deformity
• External auditory canal stenoses
• Auricular cartilage necrosis secondary to infection
• Auricular cartilage overgrowth secondary to auricular haematoma
History
• Time of injury
• If associated head injury:
Loss of consciousness/duration
Clinical course following injury
• Acute vertigo/deafness
• Co-morbidities
• Allergies
Examination
• Length, depth, shape, location of wound
• Evidence of retained foreign body
• Extent of contamination/devitalised tissue/cartilage involvement
• Tympanic membrane/external auditory canal trauma
• Check for hearing loss, test with tuning fork
Investigation
• Audiogram if hearing impaired
Treatment
Laceration:
Local anaesthesia with field block around base of ear, no adrenaline
Clean wounds
Minimal debridement
Approximate skin with 6/0 sutures but minimal/no suturing to cartilage
Well padded and shaped pressure dressing to reduce risk of auricular
haematoma
• TM Perforation – see Section 8
Specialist Referral
• Full thickness skin loss +/- perichondral loss
• Partial/complete avulsions
• Auricular haematoma (discuss to agree plan for follow-up)
• Acute vertigo/deafness
• Chronic perforation
Open Wound Ear S82..
OpenWound Scalp/OpenWound Forehead
Read Code: S830./S8342
KEY POINTS
• See Overview
• Assume cervical spine injury until such injury can be confidently excluded
• History of injury and events following is critical
• If conscious level impaired never attribute to alcohol/drugs even if such
are known to have occurred
• Fatal air embolism may occur through apparently trivial wounds of the
neck which involve the great veins
RED FLAG:
CLEARING THE CERVICAL SPINE
If high risk injury:
High speed MVA
Fall from height
Altered level of consciousness
Intoxicated
Complications
• Infection
• Associated head/cervical spine injury
• Concussion
• Skull fracture
• Intracranial haemorrhage
• Dural tear with CSF leak
• Scarring
• Tattooing
History
• Time of injury
• Loss of consciousness/duration
• Co-morbidities
• Medication especially Warfarin
• Allergies
• History from a witness
Focal neurological signs
Neck pain/midline cervical
tenderness
Major distracting injuries
Then X-ray.
If none of the above, no X-ray
required and cervical spine can be
cleared if full range of motion is
painless
If in doubt refer
Examination
examination if head injury:
Pupils
Glasgow Coma Scale
Cranial nerves
Focal neurological signs in limbs
• Assess cervical spine:
Tenderness
Steps/deformity
Crepitus
Maintain protective measures until injury excluded
• After instillation of local anaesthetic palpate for underlying skull fracture
• If anterior neck wounds have penetrated the superficial fascia – do not
examine further – refer (see further details under Treatment)
Investigation
• Skull X-ray/CT scan as discussed in Section 8, Concussion
• Soft tissue X-ray if possible retained foreign body
Open Wound Scalp, Forehead S83o./S8342
OpenWound Scalp/OpenWound Forehead
Treatment
• Cervical spine protection until injury excluded
• Anaesthesia to allow adequate cleaning and examination of wound:
Local infiltration Lignocaine with Adrenaline or topical anaesthetic
in children
Forehead laceration – consider supraorbital nerve block
• Clean wound (N/Saline) and remove devitalised tissue
• Oversew bleeding vessels
• Suture/staple/glue skin – see Overview
• Scalp laceration – if galea aponeurotica involved close with absorbable
3/0 sutures
• Forehead laceration – transverse wrinkles of forehead act as landmarks
for accurate apposition of skin edges. Young patients can raise eyebrows
to create wrinkles
• In penetrating neck trauma do not allow patient to sit/stand until airtight
dressing covering wound to prevent air embolism
• Evidence of actual or potential internal injury or skull fracture
• Lacerations associated with head injury if SXR/CT required
• If possible cervical spine injury
• To ENT/general/cardiothoracic surgeons (according to nature of injury
and local practices)
• Neck wounds penetrating superficial fascia
• If patient’s age or extent of wounds precludes adequate treatment,
children requiring GA
• Complex forehead laceration or significant tissue loss
• Degloving/scalping wounds – send avulsed tissue with patient
Open Wound Scalp, Forehead S83o./S8342
Open Wound Nose/Cheek/Eyebrow
Lip/Jaw/Mouth
Read Code: S832./S8341/S8343/S8344/S8345/S836.
KEY POINTS
• See Overview
• For ears refer Open Wound Ear
• Aim to repair wounds with optimal recovery of function and restoration
of appearance
• When closing wounds use key sutures first to approximate landmarks
• Never shave eyebrows – regrowth is unpredictable
• Bite wounds to the face should be closed after thorough cleaning and
debridement
Complications
• Nerve, vessel, muscle, eye injury
• Facial fracture
• Infection – potentially fatal if mid-facial and leads to cavernous sinus
thrombosis
• Facial palsy
• Epiphora/Corneal exposure if tissue loss/contracture of scar of eyelids
• Salivary fistula
• Associated head/cervical spine injury
History
• Time of injury
• Loss of consciousness/duration
• Symptoms suggestive of blow out fracture of orbit:
Diplopia/pain on upward or lateral gaze
• Symptoms suggestive of mandibular/maxillary fracture:
Malocclusion/pain on biting
• Co-morbidities
• Allergies
Examination
examination if associated head injury
• Check stability of maxilla if possible mid-facial fractures
• Note length, depth, shape, location of wound and check for intra-oral
involvement
• Periorbital injuries:
Full eye examination including visual acuity. Assess integrity of canthal
ligaments/lacrimal apparatus
• Cheek injuries – between tragus of ear and mid-pupillary line:
Check facial nerve function and look for evidence of Parotid
duct damage
Open Wound Face S832./S8341/S8343/S8344/S8345/S836.
Open Wound Nose/Cheek/EyebrowLip/Jaw/Mouth
Investigation
• X-ray facial bones if possible fracture or if possible retained foreign body
• SXR/CT scan as discussed under Concussion
Treatment
• Local infiltration Lignocaine with Adrenaline – except nose, contaminated
wounds – or topical anaesthetic in children
• Use regional block for lips to minimise distortion
• Clean wound and remove devitalised tissue
• Oversew bleeding vessels and repair muscle layer
• Align landmarks
• Suture/glue/steristrip skin
• Tetanus prophylaxis – see Overview
Specialist Referral – dependent on local resources
• Lacerations associated with head injury if SXR/CT required
• Eyelids – avulsion/canthal ligament damage/lacrimal duct damage
• Evidence of facial nerve damage
• Complex/extensive wounds including flap lacerations of face
• Tissue loss – avulsion/devitalisation
• Full thickness nose/lip lacerations
• Facial fractures (may be plastic surgeon or maxillofacial surgeon according
to local protocols)
• Mandibular fractures/significant intra-oral wounds
• Complications
Open Wound Face S832./S8341/S8343/S8344/S8345/S836.
OpenWound Elbow/Forearm/Wrist/Hand
(+Tendon Involved)/Finger(s)/Thumb
Read Code: S922./S93..
KEY POINTS
• See Overview
• Thorough initial examination will delineate full extent of injuries. This
allows early definitive treatment and minimises morbidity
• Tendon sheath, web space and palmar space infection require urgent
hospital treatment
• High pressure injection injuries may present with minor symptoms and
signs but over a few hours may cause irreversible ischaemic injury unless
decompressed
• Punch injuries (lacerations from opponent’s teeth over MC heads) are at
very high risk of infection
• Physiotherapy may speed recovery
Complications
• Infection
• Scarring
• Missed neurological/tendon injury
• Stiffness
History
• Time of injury
• Posture of hand at time of injury
• Age
• Occupation
• Hand dominance
• Previous injury/disability
• Co-morbidities
Examination
Assess neurologic function before using local anaesthesia
• Position at rest
• Vascular:
Colour/warmth
Pulses
Capillary refill
• Neurologic:
Motor:
Ulnar n – finger ab/adduction
Radial n – wrist extension
Median n – function of Ab Pollicis Brevis/thumb opposition to fingers
• Sensory:
Ulnar n – tip of little finger
Radial n – dorsal 1st web space
Median n – tip of index finger
Digital nerves – 2 point discrimination on ulnar/radial borders of all
finger pulps
• Bone and joint:
Deformity
Local tenderness
Pain with axial compression
Joint range of motion
Ligamentous stability: DIP, PIP, MCP joints
Open Wound Arm, Hand S922./S93..
OpenWound Elbow/Forearm/Wrist/Hand
(+Tendon Involved)/Finger(s)/Thumb
• Musculotendinous:
Function of each muscle-tendon group
Strength against resistance
Pain with motion
• Explore wound with hand/finger in position in which injury occurred
and then through full range of active and passive movement to maximise
chance of identifying divided/partially divided structures
• If presentation is delayed by more than a few hours exclude infection:
Tendon sheath infection causes tenderness along tendon affected,
symmetric swelling of finger, pain on passive extension and the affected
finger is held flexed
Deep fascial space infections may present with swelling over the dorsum
or palmar aspect of the hand or over the thenar eminence. Passive
movement of adjacent digits causes pain
• Remove rings if severe finger injuries
Investigation
X-ray to check for:
Associated fracture
Retained foreign body
Penetration of joint capsule (air within joint)
Fight bites – for tooth fragments/compound fracture 5th MC neck
• Ultrasound if possible non-radio-opaque retained foreign body
• Wound culture if late presentation and signs of infection apparent
Treatment
• Provide anaesthesia/analgesia by local/regional block
• Clean wounds
• Debride as necessary
• Suture with absorbable sutures to subcutaneous layers, monofilament
non-absorbable to skin
• Consider steristrips for hands if appropriate
• Non-adherent dressing
• Provide tetanus prophylaxis as necessary
• Antibiotic prophylaxis for high-risk wounds:
More than 8 hours old
Heavily contaminated
Compromised patient
• All tendon and joint injuries should be discussed with local orthopaedic
surgeon. Some extensor tendon repairs may be done in the community
by experienced practitioners
• Physiotherapy if problems with mobility apparent or anticipated
• Evidence of vascular compromise of digit or hand (urgent)
• High-pressure injection injury (urgent)
• Tendon sheath, web space and palmar space infection (urgent)
• Any tendon injury – for discussion – see Treatment
• Nerve injury proximal to DIP joint
• All human bite wounds for exploration and antibiotics unless definitely
no deep structures involved
Open Wound Arm, Hand S922./S93..
Read Code: S87../S88..
KEY POINTS
• See Overview
• Anogenital trauma in children and adults may represent sexual abuse/assault
• Consider trauma to rectum/vagina/urethra/testes even in apparently
superficial wounds
• Obtain patient consent and assistance of a chaperone before conducting
examination
• If assault/possible abuse refer to or discuss with appropriate agency prior
to examination, other than exclusion of life-threatening injury. Particularly
for children, it is preferable that only 1 examination is done
• If forensic examination required referral to appropriately trained
practitioners and use of Police examination kit required
• Prophylactic antibiotics for perineal wounds – see Overview
• Ensure victims of sexual assault are going to a place of safety with
appropriate follow-up
Complications
• Infection
• Scarring
• Secondary to injury to rectum/anal canal/genito-urinary system
History
• Time of injury
• Mechanism of injury – if paediatric patient document child’s account
verbatim as well as that of caregiver
• Age
• Blood loss PR/PV/PU
• Past medical history and co-morbidities
• Medications and allergies
• Features suggestive of child abuse
Examination
• If assault excluded:
Rectal examination/proctoscopy for blood if possible rectal trauma –
NOT in children
Speculum examination if possible vaginal/cervical injury – NOT in
children
• If assault possible/confirmed, refer to appropriate agency
• Bowel injury
• Genito-urinary tract injury
• Sciatic nerve injury
Investigation
• Urinalysis for occult haematuria
• Ultrasound of testes if traumatic hydrocoele or possible rupture
Open Wound Buttock, Genitalia S87../S88..
Treatment
• Analgesia/local anaesthesia
• Clean wounds with N/Saline and debride as necessary
• Suture – absorbable suture to subcutaneous layers if wound gaping
• Monofilament suture to skin
• Apply occlusive dressing, if possible otherwise encourage washing BD
• Prophylactic antibiotics for perineal wounds – see Overview
• Review/redress wounds at 48 hours
• General surgeon/gynaecologist/urologist as appropriate if assault not
suspected and evidence of trauma affecting rectum/anal canal/genitourinary system
• Paediatrician if possible child sexual abuse – see Section 8
• Appropriate local agencies if sexual assault – see Section 8
Open Wound Buttock, Genitalia S87../S88..
Open Wound Upper Limb/Shoulder/
Lower Limb/Leg/Knee/Foot/Toe
Read Code: S87../SA101/SA100/SA2../SA3..
KEY POINTS
• See Overview
• Exclude serious underlying injury including significant haemorrhage
• Assess distal neurovascular and musculotendinous function
• Soft tissue injury alone or in combination with an underlying fracture
may cause a compartment syndrome
• Forefoot lacerations and puncture wounds are prone to infection.
Pseudomonas common infecting organism
RED FLAG:
Normal distal pulses, skin colour and
capillary return do not exclude
compartment syndrome
Complications
• Infection
• Scarring
• Missed neurovascular injury
• Ischaemic contracture secondary to compartment syndrome
History
• Time of injury
• Co-morbidities
• Symptoms of compartment syndrome
Disproportionately severe, poorly localised pain
Hyperaesthesia/paraesthesia in distribution of nerves crossing
compartment
Examination
• Note length, depth, shape and location of wound
• Deformity/limitation of movement of limb suggesting underlying fracture,
dislocation or closed tendon injury
• Signs of compartment syndrome:
Disproportionate pain increasing in severity
Pain on passive stretching or active flexion of affected muscle groups
Distal sensory abnormalities
Severe swelling
Investigation
• X-ray if possible underlying fracture/dislocation
• Consider wound culture if late presentation and wound infection apparent
Treatment
• Analgesia/local anaesthesia
• Clean wounds with and debride as necessary
• Suture – vicryl to subcutaneous layers if wound gaping
• Monofilament suture to skin
• Apply non-adherent dressing
• Prophylactic antibiotics for foot or otherwise infection prone wounds
• Review/redress wounds at 48 hours
Open Wound Shoulder, Leg S87../SA101/SA100/SA2../SA3..
Open Wound Upper Limb/Shoulder/
Lower Limb/Leg/Knee/Foot/Toe
Specialist Referral
• Orthopaedic surgeon:
Extensive/complex lacerations
Evidence nerve or significant muscle damage
Possible compartment syndrome
• Vascular surgeon – possible major vessel injury
Open Wound Shoulder, Leg S87../SA101/SA100/SA2../SA3..
Read Code: S96..
KEY POINTS
• See Overview
• Wherever possible:
Ensure early functional recovery
Maintain good tissue coverage
Maintain normal/near normal sensation
Maintain finger length
• Skin grafting for fingertip injuries often results in decreased sensitivity
and tenderness
• Physiotherapy may speed recovery
Complications
• Decreased sensitivity
• Cold intolerance
• Cosmetic disability
• Osteomyelitis
History
• Time of injury
• Age
• Occupation
• Hand dominance
• Co-morbidities
Examination
• Exclude associated injuries
• Establish extent of tissue loss:
Bone
Soft tissues
Nail bed/matrix
Finger pulp
• If late presentation signs of infection
• If amputated tissue is available assess for possible reimplantation:
Extent of crushing/tissue distortion
Degree of contamination
Level of amputation
Amputated tissue should never be discarded as it may be used as a
source of full thickness skin for grafting even if replantation is
not possible
Investigation
• X-ray if possible fracture and to define level of bony amputation
• Wound culture if late presentation and signs of infection apparent
Treatment
Fingertip injuries:
Most can be dealt with conservatively:
Provide analgesia with digital nerve block. Preferably Bupivicaine 0.5%
(Marcaine 0.5%) to maximise duration of anaesthesia – especially if
for referral (never with Adrenaline)
Clean
If bone exposed trim to below level of soft tissues
Amputation Finger S96..
Cover with non-adherent dressing
Review at 2-3 days unless earlier signs of infection and then at 5-7
day intervals
Prophylactic antibiotics if exposed bone – see Overview
• If more than 50% of nail bed or terminal phalanx involved refer to
plastic/hand surgeon
More proximal injuries:
• Use systemic analgesics as local infiltration causes tissue distortion, which
may interfere with re-implantation
• Sterile saline soaked dressing to stump
• Wrap amputated tissue in saline-soaked gauze squeezed dry, seal in plastic
bag and immerse in ice for transfer with patient
• Provide tetanus prophylaxis – see Overview
• Referral to physiotherapy if problems with mobility anticipated or apparent
• If more than 50% of nail bed or terminal phalanx involved
• If resection of prominent bone is necessary and facilities unavailable
• Proximal amputations
• Inadvertent ring block with Adrenaline – urgent referral to local emergency
department
Amputation Finger S96..
Section 7 Contusions/
Crush Injuries
Read Code
Contusion (Bruise) Face, Scalp, Neck/Trunk/
Upper Limb/Lower Limb
SE0../SE2../SE3../SE4..
Compartment Syndrome
Sk0y.
Crush Injury Upper Arm
SF203
Crush Injury Wrist or Hand
SF22.
Crush Injury Finger(s)
SF23.
Crush Injury Finger/Thumb (Open and Closed)
SF231/SF233
Closed Crush Injury Foot
SF322
7 contusions/
crush injuries
CONTENTS
Contusion (Bruise) Face, Scalp, Neck/
Trunk/Upper Limb/Lower Limb
Read Code: SE0../SE2../SE3../SE4..
KEY POINTS
• Assessment for compartment syndrome risk in limbs. Most sensitive
indicator is severe pain/disproportionate pain for injury
• All urethral injuries should be referred. Do not catheterise. Always
consider urethral injury if perineal bruising
• Always ask if history of bleeding disorders or concurrent Warfarin use
• Aspiration of haematomata generally discouraged unless infected
Complications
• Compartment syndrome/ischaemic contracture(s) if not recognised
• Excessive bleeding and haematoma formation
• Calcification of haematoma in muscle belly (myosotis ossificans)
• Infection
• Risk of avascular/septic necrosis of nasal and aural cartilage
• Chronic pain
History
Fall
Direct blow (with implement or fist)
Vehicular/cycle injury
• Location of pain and severity
• Co-morbidities
• Anticoagulants (especially Warfarin, aspirin) or bleeding disorders
Examination
• Assess for associated injuries
• Palpate bony landmarks and assess function to exclude fracture
• Assess size, site of haematomata
• Assess severity of swelling in limbs
• Presence of bruising in perineum +/- blood at external urethral meatus
suggests urethral injury
• Examine nasal septum in all nasal injuries to exclude haematoma
• Examine ears for aural haematoma
• Muscle compartment contusion
• Circulation
• Haematuria in back injury or multi-trauma
• Nerve injury
• Fracture
• Compartment syndrome present or risk
• Impaired circulation
• Abrasion
• Fracture
Investigation
• Consider:
X-ray (to exclude fracture in specific areas)
Contusions SEo../SE2../SE3../SE4..
Contusion (Bruise) Face, Scalp, Neck/
Trunk/Upper Limb/Lower Limb
Coagulation studies if on anticoagulants or history of bleeding disorder
Urinalysis if back or trunk injury or multi-trauma
Treatment
• Ice packs applied to area to reduce pain and swelling for 20 minutes
every 2-3 hours for first 24 hours
• Simple analgesia (avoid aspirin)
• Rest/elevate (in sling if forearm or hand)/compression
• Reassess next day if significant haematoma forming or patient on anticoagulants
• Presence or significant risk of compartment syndrome
• Aural haematoma
• Nasal septal haematoma/dislocation
• Significant genital haematoma or urethral injury
• Large haematoma when on anticoagulants or has bleeding disorder
• Haematuria
To orthopaedic surgeon:
• Suspicion of compartment syndrome
• Gross haematoma of any large muscle group eg quadriceps
To ENT surgeon:
• Aural haematoma
• Nasal septum haematoma
To urologist:
• Testicular haematoma
To gynaecologist:
• Significant genital haematoma (female)
Other Referral
• Physiotherapy to optimise joint function if required
• Home help for elderly or disabled may be required
Contusions SEo../SE2../SE3../SE4..
Compartment Syndrome (acute)
Read Code: Sk0y.
KEY POINTS
• Acute compartment syndrome can occur to a limb following fractures or
soft tissue injuries; it requires prompt diagnosis and urgent treatment.
Following injury, increased interstitial pressure can lead to obstruction
of the microcirculation with resulting tissue necrosis. The commonest
site to be affected is the anterior compartment of the lower leg
Clinical features include:
Progressive swelling of limb
Persistent pain (greater than one would normally expect for a given
injury)
Erythema
Increased tissue tension
Extreme pain on passive stretch of involved muscles
Progressive loss of sensory and motor function
The loss of capillary return and peripheral pulses are unreliable indicators
of the severity of the condition
• Following diagnosis, urgent referral is required for immediate
decompression, usually by fasciotomy
Compartment Syndrome Skoy.
Read Code: SF203
KEY POINTS
• Careful assessment to detect compartment syndrome early; if suspicious
refer for compartment pressure studies
• Meticulous wound management
• Assess and document neurovascular status
Complications
• Compartment syndrome with ischaemic contractures if unrecognised
• Nerve injury
• Infection
History
Industrial machinery (rollers)
Vehicular accident
• Time of injury
• Current medications especially Warfarin and allergies
• Co-morbidities especially diabetes and immunocompromise
• Tetanus immunisation prophylaxis
Examination
• Assess each muscle compartment for swelling and impending compartment
syndrome
• Skin laceration/abrasion
• Assess for presence of foreign bodies
• Crepitus suggesting bony injury
• Laceration
• Fracture
• Nerve injury
• Major vessel injury
Investigation
• X-ray to exclude fracture if indicated
Treatment
• Treat associated injuries as indicated
• Analgesia as required
• Tetanus prophylaxis if indicated – see Lacerations/Abrasions section
Open wound:
• Document neurovascular status
• Refer immediately to hospital if suspicion of compartment syndrome
• Infiltrate local anaesthetic for irrigation and meticulous debridement
• Close wounds if appropriate
• Simple dressing to keep covered and protected
• Rest in broad arm sling
• Review wounds 24-48 hours
• Prophylactic antibiotics if high risk wound – see Lacerations/Abrasions section
Crush Injury Upper Arm SF2o3
Closed injury:
• Refer immediately to hospital if suspicion of compartment syndrome
• Rest in broad arm sling
• Review as indicated
To orthopaedic surgeon if:
• Signs/symptoms suggestive of (or significant risk of) compartment
syndrome
Severe pain especially on passive extension (earliest and most sensitive sign)
Severe swelling
Neurological impairment
Diminished pulses or perfusion (late sign)
• Extensive wounds requiring general anaesthetic for debridement
• Nerve/tendon injury
• Fracture
To plastic surgeon if:
• Significant tissue loss/de-gloving
Other Referral
• Consider home help for elderly or disabled
• May require physiotherapy to restore normal function
Crush Injury Upper Arm SF2o3
Read Code: SF22.
KEY POINTS
• Assess compartment syndrome risk
• Assessment of neurovascular and tendon function important in open wounds
• Refer de-gloving injuries
• Meticulous wound management
Complications
• Compartment syndrome/ischaemic contracture(s) if not recognised
• Nerve injury
• Fracture and tendon rupture
• Reflex sympathetic dystrophy syndrome – complex regional pain syndrome
• Infection
History
Crush
Machinery (rollers)
Wringer
• Site of pain
• Time of injury
• Hand dominance
• Occupation
Examination
• De-vitalised tissue
• Assess each muscle compartment for swelling and impending compartment
syndrome
• Skin laceration/abrasion
• Assess for presence of foreign bodies
Motor function:
Motor
Ulnar n – finger ab/adduction
Radial n – wrist extension
Median n – function of Abd Pollicis Brevis/Thumb opposition to fingers
Sensory:
Ulnar n – tip of little finger
Radial n – dorsal 1st web space
Median n – tip of index finger
Digital nerves – two point discrimination on ulnar/radial borders of all
finger pulps
• Assess tendon function
• Crepitus for bony injury
Crush Injury Wrist or Hand SF22.
• Cellulitis
• Laceration
• Fracture
• Nerve injury
• Major vessel injury
Investigation
• X-ray as appropriate (to exclude fracture or foreign body if risk)
• Ultrasound may be indicated if suspicious of non-radio-opaque foreign body
Treatment
• Tetanus prophylaxis if indicated – see Lacerations/Abrasions Overview
Open wounds:
• Refer immediately to hospital if suspicious of compartment syndrome
• Infiltrate local anaesthetic for irrigation and meticulous debridement
• Close wounds if appropriate
• Simple dressings to keep covered and protected
• Splinting of limb in appropriate position if extensive wound or over joint
• Elevate in sling
• Review wounds in 24-48 hours
• Prophylactic antibiotics if high risk – see Lacerations/Abrasions Overview
Closed injury:
• Refer immediately to hospital if suspicious of compartment syndrome
• Elevate in sling
• Review in 24-48 hours
• Signs/symptoms suggestive of (or significant risk of) compartment
syndrome:
Severe pain especially on passive extension (earliest and most sensitive sign)
Severe swelling
Neurological impairment
Diminished pulses or perfusion (late sign)
• Extensive wound/s for debridement and management
• Nerve/tendon injury
• Fracture (depending on type)
To plastic surgeon if:
• Significant tissue loss/de-gloving
Other Referral
• Consider home help for elderly or disabled
• May require specialist hand physiotherapy
Crush Injury Wrist or Hand SF22.
Read Code: SF23.
KEY POINTS
• Meticulous assessment of tendon and nerve function important
• A subungal haematoma causing pain should be drained to provide relief
• Trephining a subungal haematoma in the presence of a fracture constitutes
a compound fracture
• Consider referral for nail removal and nail bed repair if subungal
haematoma >50%
Complications
• Nail deformity if injury to nail matrix
• Infection (including osteomyelitis)
History
Blow with implement eg hammer
Crush in door
Machinery
• Time of injury
• Hand dominance
• Occupation
Examination
• Distal capillary return (circulation)
• Presence of subungal haematoma and size
• Presence of mallet finger deformity (avulsion extensor tendon)
• Clinical likelihood of fracture
• Degree of swelling
• Joint injury – limitation of movement
• Sensation in finger – digital nerve injury
• Cellulitis
Investigation
• X-ray to exclude fracture if indicated
Treatment
• Tetanus prophylaxis as indicated – see Lacerations/Abrasions Overview
No fracture (and no nerve, tendon injury):
• Elevate in high sling
• If significant subungal haematoma causing pain, trephine with heated
paper clip or sterile needle
• Consider referral for nail removal and nail bed repair if subungal
haematoma >50%
• Mobilise early
Crush Injury Finger(s) SF23.
Tendon injury:
• Mallet finger injury
X-ray to ensure minor bony avulsion only (if >25% articular surface, refer)
Manage in appropriate splint (if not available, refer acutely)
Need 6 weeks in splint
All children with mallet deformity/injury should be referred acutely.
• Flexor tendon injuries
Refer acutely
Nerve injury:
• Digital nerve injuries may be repaired acutely
• Generally not considered if injury distal to DIP joint
• If doubt about appropriateness of referral seek telephone advice
• Otherwise refer acutely
Circulatory impairment:
• Gross swelling, pain, poor capillary return:
Elevate
Refer acutely
To plastic/hand/orthopaedic specialist according to local practices:
• Digital nerve injury
• Fracture of phalanx if:
Significant involvement of articular surface
Mal-rotation
Mal-alignment
Unstable fracture
• Flexor tendon injury and some mallet finger injuries
• Collateral ligament rupture and instability
• Nail bed injury/sub-ungual haematoma >50%
Other Referral
• Consider home help for disabled or elderly
Crush Injury Finger(s) SF23.
Read Code: SF231
KEY POINTS
• Prompt drainage of sub-ungual haematoma relieves pain
• Fracture plus broken skin or drilling sub-ungual haematoma = compound
fracture
• Consider tendon rupture/division
• Avoid sutures where possible
• Avoid tourniquet or digital vessel clamps
• Meticulous assessment of tendon and nerve function important
• Consider referral for nail removal and nail bed repair if sub-ungual
haematoma >50%
Complications
If open wound:
• Osteomyelitis from unrecognised compound fracture
• Wound infection
All crush injuries:
• Separation of new nail from nail bed if significant nail bed injury
• Nail deformity if nail matrix injury
• Extensor tendon damage
• Collateral ligament rupture
• Finger/thumb pulp ischaemia
• Loss of mobility
History
Mechanism of injury:
Blow with implement eg hammer
Crush in door
Machinery
• Time of injury
• Hand dominance
• Occupation
Examination
• Distal capillary return (circulation)
• Presence of sub-ungual haematoma and size
• Presence of mallet deformity
• Clinical likelihood of fracture
• Joint injury – limitation of movement
• Sensation in thumb – digital nerve injury
• Stability of ligaments especially ulnar collateral ligament of MCP joint
• Cellulitis
Investigation
• X-ray
• Swab for C and S if infected
Crush Injury Thumb (Open and Closed) SF231
Treatment
No fracture (and no nerve, tendon, ligament injury):
• Elevate in high sling
• If significant sub-ungual haematoma causing pain, trephine with heated
paper clip or sterile needle
• Consider referral for removal of nail and repair of nail bed if sub-ungual
haematoma >50%
• Mobilise early
Ulnar collateral ligament rupture:
• See Sprains section
Tendon injury:
Mallet deformity/injury:
X-ray to ensure minor bony avulsion only (if >25% articular surface, refer)
Manage in appropriate splint (if not available refer acutely)
Need 6 weeks in splint
All children with mallet deformity/injury should be referred acutely
Flexor tendon injuries:
Refer acutely
Nerve injury:
• Digital nerve injuries may be repaired acutely
• Generally not repaired if distal to DIP joint
• If uncertain about appropriateness of referral, seek telephone advice
• Otherwise refer acutely
Circulatory impairment:
• Gross swelling, pain, poor capillary return
• Refer acutely
To plastic/hand/orthopaedic specialist according to local practices
• Digital nerve injury
• Fracture of phalanx if:
Significant involvement of articular surface
Mal-rotation
Mal-alignment
Unstable fractures
Essentially all fractures except tuft fractures
• Flexor tendon injury, some mallet injuries in adults and all in children
• Collateral ligament rupture and instability especially ulnar collateral
• Nail bed injury/sub-ungual haematoma >50%
Other Referral
• Consider home help for disabled or elderly
Crush Injury Thumb (Open and Closed) SF231
Closed Crush Injury Foot
Read Code: SF322
KEY POINTS
• Meticulous assessment of X-rays as Lis-Franc (tarsometatarsal) fractures
of the mid-foot are difficult to diagnose and have serious consequences
• If unable to weight bear, ensure early follow-up
Complications
• Osteoarthritis
• Chronic pain
• Reflex sympathetic dystrophy – complex regional pain syndrome
• Unrecognised fractures of mid-foot with mal-union
History
Crush injury
Road trauma
Foot run over
• Time of injury
• Co-morbidities especially diabetes, immunocompromise and peripheral
vascular disease
• Social support
Examination
• Active and passive range of movement toes and foot
• Circulatory impairment
• Presence of wounds or abrasions
• Deformity
• Presence of bony tenderness suggesting fracture
• Sensory deficit suggesting nerve injury
• Ability to bear weight
• Gout
• Cellulitis
Investigation
• X-ray if indicated to exclude fracture
Treatment
• Analgesia if required
• Regular application of ice compresses in first 24 hours
• Elevate as much as possible
• Support if severe in form of bandaging or splinting
• Review at 2 days if severe and unable to weight bear
• Circulatory impairment
• Nerve injury
• Unable to weight bear after 2 days
Other Referral
• May require physiotherapy if delay in return to function
Closed Crush Injury Foot SF322
Section 8 Miscellaneous
CONTENTS
Read Code
Anaphylaxis Treatment Protocol
Concussion
S60..
Head Injury Risk Groups
Post-Concussion Syndrome
E2A2.
F542.
Loss of Teeth (Accident)/Broken Teeth
JO510/S8363
Foreign Body in Skin or Subcutaneous Tissue
M2y5.
Corneal Abrasion/Corneal Foreign Body
SD810/SG00.
Foreign Body in Ear/Foreign Body in Nose
SG1../SG2..
Ingested Foreign Body
SG5..
Toxic Ingestion (Activated Charcoal)
SL...
TE532
Dog Bite/Human Bite (Also Cat)
TE60./U120.
Electrical Injury
TL01.
Management of Sexual Assault/Abuse
SN571
Management of Child Sexual Abuse
SN571
8 miscellaneous
Glasgow Coma Score
KEY POINTS
• There is no place for conservative management of anaphylaxis
• Early administration of adrenaline in association with fluid replacement
is the mainstay of treatment
• In general, the more severe the reaction, the more rapid the onset. Most
life-threatening reactions begin within 10 minutes of immunisation. The
intensity usually peaks at around 1 hour after onset. Symptoms limited
to only one system can occur, leading to delay in diagnosis
• Biphasic reactions where symptoms recur 8-12 hours after the onset of
the original attack and prolonged attacks lasting up to 48 hours have
been described
AETIOLOGY AND RECOGNITION OF ANAPHYLAXIS
• Parenteral penicillin, hymenopteran (bees and wasps) stings and foods
are the commonest causes of anaphylactic fatalities
• Radiocontrast media, aspirin or other NSAIDs are the most common cause
of anaphylactoid fatalities (same range of clinical features though not
requiring previous exposure)
• Characteristically occurs in otherwise fit patients
• The speed of onset reflects the severity of the reaction
• Most symptoms occur within 30 minutes although symptoms can be
delayed for some hours especially with topical or oral exposure
• The clinical features described below may occur in combination or as
isolated features. The diagnosis may be simple in the classic presentation,
however, a presentation with isolated hypotension may be more difficult
• Late deterioration may occur in around 5% of individuals; therefore
patients in whom adrenaline is used should be hospitalised for a period
of 6-8 hours
• In severe cases, up to 50% of the circulating volume can be lost from the
vascular compartment
Signs and Symptoms
Timelines
Signs and Symptoms
Severity
Early Warning Signs
Dizziness, tingling,warmth, pruritus
Mild
Flushing, urticaria, nasal congestion,
Mild to Moderate
sneezing, lacrimation, angioedema,
erythema (especially weals)
Hoarseness, nausea, vomiting,
Moderate to Severe
Laryngeal oedema, dyspnoea,
abdominal pain/cramps
Bronchospasm, stridor, syncope,
Late, Life-Threatening
hypotension, dysrhythmias, coma,
Symptoms
confusion
Life-Threatening
Treatment
First line treatment:
• Oxygen by face mask 10-15 l/min – can be discontinued if cutaneous
manifestation only
Adrenaline:
Adults
0.5mg IM ie 0.5mls of 1:1000
repeated at 5-10 minute intervals according to response
Children – dose dependent on weight/age
EITHER
Age (yrs)
Dose(mg)
<2
0.0625
2-5
0.125
6-11
0.25
>11
0.5
OR
0.01 mg/kg (IM ie 0.1 mls/kg of 1:10,000)
Repeated at 5-10 minute intervals according to response
• Fluids: 10-20 mls/kg colloid or crystalloid IV repeated according to
haemodynamic parameters
Second line treatment:
• Nebulised Beta-agonists:
Adrenaline if predominant stridor 1mg diluted to 4ml with saline and
repeat as necessary
Salbutamol if predominant bronchospasm 5mg
• Antihistamines:
H1 blocker (promethazine or diphenhydramine) are of most value
when the allergic condition is mild-moderate, progressing slowly and
dominated by cutaneous manifestations
They may be used in combination with H2 blockers ie ranitidine
Both may be initially given IV, later orally for 2-3 days
Steroids:
Role in reducing protracted symptoms especially bronchospasm
Discharge medication to reduce likelihood of relapse of symptoms
2-3 day course
Aminophylline:
Severe bronchospasm resistant to adrenaline
5mg/kg over 30 minutes with cardiac monitoring
Glucagon:
Consider in patients on beta-blockers who may have more symptoms
that are difficult to treat; 1mg IV repeated every 5 minutes if necessary.
• Beta–blocked patients may require additional doses of adrenaline.
Concussion
Read Code: S60..
KEY POINTS
• History of injury is critical, particularly reports from other people/bystanders
• Frequent neurological assessment necessary to recognise progressive
deterioration. Record observations serially
• May need neurophysiological assessment for reaction to safety issues
related to machinery at work
• Neurological status is the most important indicator of risk
• X-rays/CT scans do not always identify damage or complications
• Intracranial haemorrhage can safely be ruled out only by CT/MRI scan
• Patients should only be discharged:
When fully alert
With competent observer who can arrange prompt reassessment
With written advice sheet
Head-injured individuals should be warned that post-concussion
symptoms are to be expected
• Athletes will need clear advice about length of time off. Guidelines based
on neurological assessment have been published (available on ACC’s
Injury Prevention website www.sportsmart.org.nz)
• Concussion may be missed in patients with other life-threatening conditions
RED FLAG:
High-risk patients:
>40 years of age
Students, professionals with jobs
involving complex cognitive demands
Skilled persons
Individuals with psychiatric histories
and/or personality types
Alcohol/drug dependence
Previous concussion or head injury
Complications
• Post-concussion syndrome (decreased concentration, headaches, sleepiness,
fatigue, irritability, dizziness)
• Cerebral contusion
• Intracranial haemorrhage – operable (subdural, extradural, some
intracerebral haematomata)
• Intracranial haemorrhage–inoperable (traumatic subarachnoid haemorrhage)
• Post-traumatic epilepsy
• Persistent hearing loss/sensory problems
• Risk of Second Impact Syndrome (a second blow to the head, while still
suffering the effects of a prior concussion, can cause serious cerebral
oedema out of proportion to the energy of the second injury)
History
Force of impact
Distance of fall
Vehicular speed
• Pattern of patient’s clinical course from time of injury
• Current clinical and neurological status
• Loss of consciousness
Patient’s recollection of events:
Retrograde/anterograde amnesia
• Associated injuries especially cervical spine
• Recreational drug use (including alcohol)
Concussion S6o..
Concussion
• Co-morbidities, including psychiatric history
• Presence of associated symptoms:
Lightheadedness
Vertigo
Tinnitus
Blurred vision/diplopia
Headache
Nausea/vomiting
Photophobia
Balance disturbance
• Duration of symptoms if post-concussion
Examination
• Initial focus on airway, breathing (respiratory rate, O2 sats) and circulation
(blood pressure and pulse rate)
• Neurological state:
Glasgow Coma Scale score
Pupils
Focal neurological signs in limbs
Assessment of II, III, IV, VI, VII, VIII cranial nerves
Assessment of cerebellar function
• Head and neck examination:
Nose (CSF rhinorrhoea)
Ears (haemotympanum)
Cervical tenderness
• Mental status:
Orientation
Immediate memory
Concentration
Delayed recall
• Look for basal skull fracture signs:
Bilateral periorbital bruising (Raccoon’s eyes)
Blood or CSF from nose, ear, or blood behind ear drum
Bruised mastoid area (Battle’s sign)
• Exclude other injury
• Test speech, vision, co-ordination
• Drug/alcohol intoxication
• Intracranial haemorrhage:
Extradural
Subdural
Intracerebral
• Stroke (CVA)
• Drug and/or alcohol intoxication
• Psychiatric disorder
• Post-ictal
• Metabolic disturbance eg hypoglycaemia
• Other medical causes eg infection
Concussion S6o..
Concussion
Investigation
Referral for CT head scan if:
• Focal neurological signs
• Deteriorating level of consciousness (as assessed by GCS score)
• All patients with GCS <13
• All patients GCS 14 (drowsy, confused) with failure to improve at 3-4
hours (NB these patients will need admission for close observation anyway)
• Suspected or proven penetrating head injury
• Patients in whom neurological assessment is difficult (due to alcohol or
other drug use, language difficulties)
• Persistent associated symptoms
Severe headache
Vomiting
• Compound head injury
RED FLAG:
The decision to refer for urgent CT head
scan must be strongly influenced by
multiple factors. If any doubt exists the
patient should be discussed with local
emergency physician or neurosurgeon.
RED FLAG:
If intracranial injury is suspected,
CT is the examination of choice.
Skull X-ray:
• Possibility of depressed skull fracture in otherwise well patient (impact
with sharp objects or objects with small surface area)
• Young children with normal conscious state and clinical suspicion of
fracture
• Suspicion of compound skull fracture where conscious level normal and
CT scan unavailable (due to distance)
• Cervical spine X-ray if indicated
• Audiogram if hearing loss
Treatment
Resuscitation:
Assess airway, breathing and circulation and treat as appropriate
Prevent hypoxia and hypotension
Attention to other injuries
• Stabilise cervical spine if indicated
• Urgent referral if indicated for CT head scan +/- admission
High risk:
• Protect and X-ray cervical spine if drowsy
• Stabilise ABC
• Urgent head CT
• Refer to neurosurgeons promptly
Moderate risk:
• CT is the optimum investigation
• Consider skull X-ray only if CT unavailable
• Fracture – discuss with neurosurgeon
• No fracture – observe for 4 hours then reassess
• Ongoing observation for deterioration
Concussion S6o..
Concussion
Low risk:
• Check thoroughly, observe
• No need for X-ray or CT
• Discharge with advice sheet
• Must have observer to check frequently“The Grey Zone”
A senior MO should review the case.
• Neurological observation if history of recent loss of consciousness, with
regular reviews and documentation
• Mild analgesia (avoid aspirin)
• Admission if deterioration
• IV line if signs of deterioration
If not hospitalised:
Education and explanation to patient and carer
Discharge to competent/responsible caregiver
Simple analgesia (regular paracetamol, avoid aspirin)
Regular reviews
Avoid driving of motor vehicle until review at 24-48 hours
• All high-risk patients
Requirement for urgent CT head scan:
To local emergency department/neurosurgeon
• Requirement for close observation (will be influenced by time of day/night,
presence or absence of responsible carers, nature of injury, age and social
situation of patient):
Hospitalise (inpatient speciality according to local practices)
• Refer or discuss if:
Skull fracture
Not fully recovered after 4 hours (including presumed intoxication)
Inadequate support and observation at home for next 20 hours
Lives too far from hospital ((45mins) for prompt return
Abnormal CT scan
Neurological observations show a decline in consciousness/
responsiveness
• Neurologist or psychologist referral if:
Persistent neuropsychological issues (emotional, sleep, stress disorders)
Children with behavioural or educational issues
Other Referral
•
Audiology as indicated
Concussion S6o..
Head Injury Risk Group
KEY POINTS
HIGH RISK
• 2% of all head injuries, 30% have intracranial injury
• Drowsy/confused (GCS<14)
• Focal neurological signs
• Delayed convulsion
• Deteriorating recordings or symptoms eg GCS fall by 2 pts
• Penetrating skull injury or palpable depressed fracture
• Basal skull fracture signs:
Bilateral periorbital bruising (Raccoon's eyes)
Blood or CSF from nose, ear or blood behind ear drum
Bruised mastoid area (Battle's sign)
MODERATE RISK
• 23% of all head injuries, 4% have intracranial injury
• GCS 14
• Severe or worsening headache especially if accompanied by vomiting
• Serious facial injury
Suspected impingement on to brain tissue:
Scalp injury/assault with firm, pointed object
Gunshot, missile, shrapnel
Possible depressed skull fracture
• Bleeding disorder or anticoagulation
• Unreliable history of injury (eg language difficulties)
MINOR RISK
• 75% of head injuries, minimal risk of intracranial injury
• None of the above criteria
• Mild headache
• Dizzy
• Scalp haematoma/laceration/contusion/abrasion ONLY
"THE GREY ZONE"
Any history of:
Loss of consciousness (KO'd, amnesia)
Recurrent vomiting
Head Injury Risk
Glasgow Coma Score
Eye Opening
Points
Spontaneous
4
To speech
3
To pain
2
Nil
1
Best Motor Response
Obeys commands
6
Localises to pain
5
Withdraws to pain
4
Abnormal flexion
3
Extensor response
2
Nil
1
Verbal Response
Oriented
5
Confused conversation
4
Inappropriate words
3
Incomprehensible sounds
2
Nil
1
Maximum possible score
15
Minimum possible score
3
Glasgow Coma Score
Post-Concussion Syndrome
Read Code: E2A2.
KEY POINTS
• May occur even after relatively minor head injury
• Recovery may be slow (1-3 months)
• 5% may still be impaired at 2 years
Complications
• Psychosocial problems
• Work difficulties
History
• Head injury
• Headache
• Decreased concentration, memory difficulties
• Sleep disorder
• Easily fatigued
• Irritability/aggression
• Anxiety/depression/affective disorder
• Dizziness, tinnitus, vertigo
• Photophobia, blurred vision
• Social, relationship dysfunction
• Occupational difficulties
• Previous psychiatric history
• Symptoms worse after work/exercise
• Onset/worsening of symptoms after head injury
Examination
• Rule out intracerebral pathology
• Psychiatric conditions
• Chronic fatigue syndrome
Investigation
• Consider CT scan
• Referral for psychometric testing
Treatment
• Education of family and caregivers
• Assessment of work safety
Referral
• For psychometric testing – attention, memory difficulty
• Psychiatrist
• Neurologist if symptoms >21 days
• Head Injury Society
Post-Concussion Syndrome E2A2.
Read Code: F542.
KEY POINTS
• Tympanic membrane heals best if kept clean and dry (water raises risk
of infection)
• Baro-trauma from diving should be discussed with dive medicine
personnel/ENT specialist
• SCUBA divers with abrupt onset of balance disturbance while diving
should be referred urgently
• Most ruptures of the tympanic membrane heal spontaneously within 23 weeks; failure to heal is usually due to loss of tissue or infection
• Perforations due to welding sparks often fail to heal and should be referred
• Aural or oral antibiotics are not indicated unless presence of infection
(or perforation occurs in contaminated or tropical waters)
RED FLAG:
When direct trauma to the ear is
associated with sensori-neural
hearing loss and/or vertigo the
patient should be referred and
surgery may be required
Complications
• Chronic perforation with hearing loss
• Infection
• Ossicular injury
• Permanent hearing loss
• Cholesteatoma formation
History
Blow to ear (especially open hand)
Welding sparks
Foreign body insertion
Baro-trauma
Syringing
• Concurrent ear infection
• Previous ear disease/hearing impairment
• Tinnitus/vertigo
Examination
External ear:
Signs of blood or mucous discharge
External ear canal:
Lacerations
• Tympanic membrane (site and extent of rupture)
• Temperature
• Assessment of hearing
• Nystagmus
• Tuning fork tests – Rinne and Weber
• Fractured floor of skull with bleeding from behind tympanic membrane
• Tympanic membrane rupture associated with otitis media
• Pulsatile discharge in external auditory canal
• Laceration to ear/canal
• Bleeding from behind tympanic membrane (haemotympanum)
Tympanic Membrane Perforation F542.
Investigation
• Usually none
• If concerns of inner ear damage or persistent impairment of hearing after
perforation healed–audiogram
Treatment
• Keep ear clean and dry:
Use cotton wool plugs with vaseline if necessary or cup over ear when
showering
• Aural/oral antibiotics not indicated unless infection present (or
perforation occurs in contaminated or tropical waters)
• Avoid immersion of head until healed (most heal within 2-3 weeks)
• Review until healed, initially 2 weekly then monthly
• Audiology when healed – expect healing in 4 weeks
• Tetanus prophylaxis as indicated – see Lacerations/Abrasions Overview
Urgent referral to Dive Medicine/ENT if:
• Significant history of baro-trauma especially if associated with balance
disturbance or other history of decompression illness or sensori-neural
hearing loss.
Urgent referral to otorhinolaryngologist (ENT specialist):
• Tympanic membrane perforation and evidence of ossicular disruption
(vertigo, persistent nystagmus, tinnitus)
• If perforated when syringing
• If the edges of the perforation are ragged and hang into the middle ear
referral is necessary because of the late complication of cholesteatoma
formation. The referral needs to be within the first few days following injury
• Sensori-neural hearing loss and vertigo suggesting perilymphatic fistula
Delayed referral to otorhinolaryngologist (ENT specialist):
• Persistent hearing impairment after perforation healed
• Failure of perforation to heal by 1 month
• Perforation due to welding injury as failure to heal is common
• If perforation related to diving, careful assessment for evidence of
decompression illness and referral to Hyperbaric Medicine Unit as
appropriate
Other Referral
•
Audiologist
Tympanic Membrane Perforation F542.
Read Code JO510/S8363
KEY POINTS
• Prevention is preferable to repair – encourage sports players to wear
mouthguards
• Avulsed permanent teeth should be replanted as soon as possible
• Intact avulsed teeth have excellent chance of reimplantation if within
4 hours
• Attempt to find all avulsed teeth and tooth fragments
• Keep avulsed teeth moist in buccal cavity or milk, but preferably replant tooth
• Never handle avulsed teeth by the root
• Do not discard teeth or remove loose teeth
• Consider associated mandibular or maxillary fracture plus other injuries
• Check teeth if there is an injury to the mucosal aspect of lip and ensure
careful oral examination
• All dento-alveolar injuries require referral to a dentist
Complications
• Loss of dentition
• Infection of gum or pulp/root infection in tooth fractures
• Painful TMJ, headaches
• Death and/or discolouration of re-implanted tooth
History
Fall
Direct blow
• Time of injury
• Initial first aid
• Facial or mouth injury
Examination
• Oral cavity – especially tongue and upper and lower labial sulci (stripping
lacerations often contain FBs)
• Lips – examine under anaesthesia for tooth fragments
• Alignment of teeth and bite
• Loose/missing teeth – beware apparent avulsed/lost tooth – check inside
socket for impaction or backward displacement
• Bleeding socket – check for impaction
• Examine for mandibular and maxillary fracture
• Facial nerve function
• Pulpitis
• Dento-alveolar abscess
• Gingival inflammation
• Alveolar osteitis (dry socket post extraction)
• Erupting teeth
• Chipped teeth
• Fractures of maxilla/mandible
• Dental caries, loss of filling
Loss of Teeth (Accident) JO510/S8363
Investigation
• Chest X-ray if concern about possible tooth or tooth fragment aspiration
• Dento-alveolar injuries – intra-oral X-rays (ordered by dentist)
• Mandibular injury – OPG, PA and lateral X-rays +/- occlusal views
• Maxillary fractures – facial X-rays
Treatment
• Find and assess avulsed teeth – handle by crown NEVER by ROOT
• Gently wash off dirt with saline
• Transport tooth as appropriate – best location is in socket if tooth intact
– replace firmly, stabilise with aluminium foil. Next best is in saline, then
milk, or plastic wrap
• Apply pressure to bleeding tooth socket
• Simple analgesics as necessary
Avulsed teeth:
Do not attempt to replace if primary dentition
Permanent dentition:
Long-term prognosis depends on early reimplantation
Don’t allow to dry out
Gentle irrigation under running water/saline for 15 seconds
Replant tooth in socket
Refer immediately to dentist
• Broken teeth – may require temporary cover depending on extent of damage
• Do not reimplant fragments of tooth – refer, especially if red spot present
= pulp laceration
• Repair skin lacerations with 6/0 nylon and 5/0 absorbable suture to muscle
eg undyed polyglactin to muscle, prior to reimplantation
Referral to Specialist/Dentist
• Avulsion of secondary teeth where teeth are available should be referred
urgently
• Avulsion of primary teeth can be referred non-urgently
• Urgent referral if exposed pulp injury
• Dentine-only injuries can be referred non-urgently
• Refer urgently if infection present
• To faciomaxillary surgeon (or as per local referral practices) if mandibular
or maxillary fracture
Loss of Teeth (Accident) JO510/S8363
Read Code M2y5.
KEY POINTS
• Wounds should not be closed if foreign material not completely removed
• Most wounds contaminated by <100,000 bacteria/g of tissue heal
uneventfully following repair
• Good irrigation and a clean technique for repairing wound is essential
• Foreign matter greatly enhances the infectivity of a given bacterial
inoculation
• The procedure is nearly always more difficult than it first appears
• Use bony landmarks for identifying location of foreign body (seen on X-ray)
• Not all foreign bodies require removal
• Glass is nearly always radio-opaque
• Historical details are important so appropriate type of imaging is performed
if required
Complications
• Incomplete removal of foreign body(ies)
• Infection locally and via tissue planes
• Retained foreign bodies are a common complication of simple wound
repair and a frequent source of medical misadventure complaints against
emergency doctors
History
• Nature of foreign body:
Metal
Glass
Wood
Organic eg flax, grass
Plastic
• Timing of injury
• Velocity of foreign body entry
• Injury on glass, metal
• Penetrating injury eg wood/stick/thorn/palm
Examination
• Palpate for foreign body
• Localise tenderness
• Look for puncture wound
• Foreign body may be seen in the wound or on X-ray
• Neurovascular assessment before surgical exploration
• Presence of infection
• Assess for signs of injury to deeper structures:
Sensory deficits
Tendon injuries
Vascular compromise
• Laceration
• Abscess
• Tumour
• Infection
• Insect bite
• Cellulitis
Foreign Body in Skin M2y5.
Investigation
• If likely foreign body radio-opaque – X-ray area
• If likely foreign body non-radio-opaque – ultrasound area
• May require MRI for plastic foreign body as density similar to tissue
• Although radiographic studies will identify all retained metallic fragments
and more than 90% of glass foreign bodies, retained wood and plastic are
often detected only by wound exploration
Treatment
• Consider leaving open if foreign body not completely removed or wound
has been heavily contaminated
• Antibiotics are indicated for wounds with a high probability of becoming
infected(>10%). This includes wounds repaired more than 12 hours after
injury and involving body areas other than the head, for heavily
contaminated wounds, and for wounds in patients with
immunocompromising conditions or taking immunosuppressive drugs
• Referral as necessary if neurovascular compromise
Superficial or open wound:
• Explore under local anaesthetic, remove foreign body then treat as normal
open wound
• Factors to be considered in the decision to either close primarily or to
delay repair include host factors (age, general health, presence of
immunocompromising conditions and immunosuppresive drugs) and
wound factors (likelihood of significant bacterial infection, degree of
contamination by soil or other organic debris, time since injury, mechanism
of injury and site of wound)
Deeper foreign bodies:
• May need exploration under regional or field block with an ischaemic
field (tourniquet). This requires greater expertise and time and may justify referral
• If possible remove under local anaesthetic and then treat as normal open wound
• Daily/alt day dressings, monitor healing
• Check tetanus status and decide whether wound is tetanus prone
• Consider antibiotics for pseudomonas prone wounds (foreign
body/penetrating wound to the sole of the foot via rubber soled shoes)
• Soil contaminants are removed by copious irrigation which will significantly
help healing by decreasing the infection risk
• If the wound is not healing consider: infection, toxic substance, retained
foreign body or neoplasm
To orthopaedic/general/paediatric surgeon as per local practice:
• Deep foreign body needing removal
• Child requiring GA
• Beyond competence to remove
• Significant neurovascular injury
• Inappropriate to remove foreign body due to:
Lack of equipment
Time required
Complexity of procedure due to site involved and expertise
• Involvement of deeper structures:
Major vessel
Nerve
Tendon
Joint/bone
Foreign Body in Skin M2y5.
Read Code: SD810/SG00.
KEY POINTS
• Always assess and record visual acuity before intervention
• If blunt or penetrating injury check deeper ocular structures
• Do not remove a protruding intraocular foreign body
• 24-hour follow-up required and daily review until healed
• History of metal vs metal and eye symptoms requires X-ray to exclude
intraocular foreign body
• Check under lids and double evert upper lid
• Always examine after staining with fluorescein
• Advise patient of need to wear eyepad or shield eye until anaesthetic
drops have worn off – 1-2 hours usually
• Photophobia may persist for several days after corneal injury (avoid bright
lights, direct sunlight, TV)
• Use of pad is contentious for corneal abrasion
• Driving is not permitted with a padded eye
• Low threshold for specialist referral if slit lamp biomicroscope not available
or if not confident
• Continued use of local anaesthetic drops delays epithelialisation, decreases
protective reflexes, can cause keratitis – do not give to patients to use
Complications
• Missed metallic intraocular foreign body leading to siderosis
• Infection
• Cataract
• Corneal instability – recurrent corneal abrasion at site of original abrasion
• Loss of vision
• Scarring of cornea reducing visual acuity
• Secondary opthalmoplegia, glaucoma
• Persisting rust ring
• Prolapsed iris and risk of intraocular infection with persisting eye wounds
History
• Nature of foreign body in eye
• Mechanism of injury to eye – blow, gardening, fighting, dust, debris,
chemical burns
• Time of injury
• Site of pain – beware unilateral painful red eye
• Watering and photophobia
• Metal on metal or welding
• Use of protective eyewear
• Occupational history
• Contact lenses
• Tetanus status
• Foreign body sensation (irritation, watering/photophobia)
• Previous eye problems
• Co-morbidities
Examination
• Visual acuity (bilateral with pin hole/glasses)
• Inspect under lids by eversion
• Pupil regularity and reactions bilaterally
Corneal Abrasion/Foreign Body SD81o/SGoo.
• Inspect conjunctiva, cornea with magnification, stain with fluorescein,
blue light, slit lamp if available
• Circumcorneal injection – may indicate more severe pathology eg iritis
• Iris, anterior chamber (check for cells, flare, macroscopic/microscopic
hyphaema/hypopion)
• Fundoscopy – lens, vitreous, retina
• Cold compress may reduce blepharospasm
• Local anaesthetic drops may facilitate examination
• Periorbital/other facial structures
• Conjunctivitis
• Corneal ulcer – herpetic, marginal
• Corneal burn
• Iritis
• Keratitis – actinic, punctate
• Trichiasis
• Entropion
• Contact lens trauma
• Acute glaucoma
Investigation
• X-ray if intraocular foreign body suspected (specify up/down gaze views)
• Swab – if infection
Treatment
• Instil topical anaesthetic drops to facilitate adequate examination and
treatment
• Eye should be double padded until anaesthetic wears off (1-2 hours)
• Eye padding for longer remains somewhat controversial but tendency is
not to pad
• Regular systemic (oral) analgesia will usually be required
• Tetanus prophylaxis as indicated – see Lacerations/Abrasions section
• Follow up until healed
Abrasion:
• Irrigate with saline if indicated
• Confirm size and location by fluorescein staining
• Remove foreign material if necessary
• Larger abrasions with ciliary muscle spasm – short acting mydriatics
(cyclopentolate 1% tds) will provide some relief of discomfort
• If abrasion >30% cornea or over visual axis, refer to ophthalmologist for
follow-up
• Otherwise daily follow-up until healed (usually 24-48 hours)
• Caution with abrasions involving organic material (eg while gardening)
as fungal infection may develop
• Instil A/B ointment, continue qid 48 hours
• Pain relief
Corneal Abrasion/Foreign Body SD81o/SGoo.
Corneal foreign body:
• Irrigate with saline
• Instil topical anaesthetic drops
• Stabilise head (preferably seat patient at slit lamp)
• Excellent magnification and lighting required
• Short acting mydriatic eg Cyclopentolate 1% tds for ciliary spasm
• Remove foreign body using cotton bud, hypodermic needle or dental burr
• Inspect for rust ring, remove following day
• A/B ointment, continue qid 48 hours
• Pain relief
• Daily follow-up until healed
Chemical agent:
• Instil LA drops
• Irrigate with water/saline for 15-20 minutes, using >1000ml then refer
immediately (as per eye specialist). Continue irrigation until pH 7.0-7.4,
recheck after 10 mins. If uncertainty about pH in alkali burn continue
irrigation during transfer to hospital
Intraorbital foreign body:
If obvious – refer immediately. Do not examine further. Prevent further
injury – stabilise head, apply eyeshield – commercial or styrofoam cup
• DO NOT REMOVE protruding FB
• Pain relief (consider narcotics)
• Anti-emetic to prevent raised IOP
Urgent referral to ophthalmologist:
• Impaired VA not corrected with pin hole or persisting corneal defect after
48 hours
• All full thickness abrasions/lacerations
• Significant infection
• Intraocular foreign body
• Penetrating eye injury
• Hyphaema
• Corneal abrasion >30% cornea or over visual axis
• Central visual axis abrasion or foreign body
• Unable to completely remove foreign body
• Vitreous haemorrhage suspected
Delayed referral to ophthalmologist:
• No improvement in size of corneal abrasion at 24 hours
Corneal Abrasion/ Foreign Body SD81o/SGoo.
Read Code: SG1../SG2..
KEY POINTS
• Try to ascertain nature of foreign body
• In nose/ear attempt to get probe/hook behind foreign body. Do not use forceps
• The procedure is nearly always more difficult than it first appears
• Good lighting, correct instruments and possibly additional staff member
to reassure person during procedure
• Avoid repeated attempts
• Wounds should not be closed if foreign material not completely removed
Ear:
Mostly children
Most hard, round objects (eg beads)
Rarely cause problems until unskilled removal is attempted
Can cause permanent damage if child jumps suddenly
Nose:
Mostly children
Most present with unilateral offensive-smelling discharge
Foam plastic, beads, calculator batteries, peanuts
• Disc (button) batteries should be removed within 2 hours; caustic leakage
can cause injury to epithelium and cartilage
• Avoid use of sharp instruments
Complications
• Inhalation of foreign body (nose)
• Incomplete removal of foreign body
• Infection
• Damage to tympanic membrane/external auditory canal/ossicular damage
• Damage to nasal turbinates/nasal mucosa
• Hearing loss
History
• Time/date/place of injury
• Nature of foreign body
• Foul smelling discharge ear/nose
• Child placing foreign body up nose or in ear
• Insect in ear
• Hearing loss/blocked ear
• Previous nasal or ear disease
Examination
• Direct visualisation using headlamp and nasal or aural speculum
• Check both sides
• Check for damage to ear drum/canal
• Tuning fork tests
Foreign Body in Ear/Nose SG1../SG2..
• Aural cerumen
• Sinusitis
• Otitis externa
• Intranasal tumour
• Cholesteatoma
Investigation
• Usually none
• X-ray, inspiratory and expiratory views if any suspicion that a nasal foreign
body may have been aspirated
Treatment
• Do not use sharp hook as may increase damage
• Only one person should try removing foreign body
• Attempt to get blunt angled probe behind foreign body
• Good light source (head lamp), right angled hook (eg paper clip) essential
• Tetanus toxoid immunisation if indicated (if abrasion to mucosa) – see
Nose:
• Administration of a few drops of 4% Lignocaine mixed with a decongestant
(eg Otrivine), 5 minutes before removal is helpful
• Strong exhalation through nose with contralateral nares occluded, if
person co-operative (sneeze)
• Use nasal speculum (Thuddicum) if available with good light source
(preferably head light)
• Remove using flat probe, hook (care as can push object deeper)
• Re-examine for signs of mucosal injury or residual foreign body
• Low threshold to refer to ENT specialist unless foreign body anterior,
good equipment and adequate expertise
• Disc (button) batteries remove ASAP – see Key Points
Ear:
• Require co-operative, motionless patient
• Remove foreign body using canal hook or suction
• Live insects can be killed with olive oil, Lignocaine or Ophthalmic
Amethocaine drops – useful to provide topical anaesthesia
• May need to irrigate ear with warm water
• Suction applied if available and by experienced operator (eg ENT Specialist)
• Direct visualisation with speculum and good light source
• Removal with flat angled probe or microalligator forceps if in lateral half
of auditory canal
• Do not use forceps unless close to meatus
• Syringing with warm water, directed at the posterior wall of the canal
may facilitate removal in some cases
• Disc (button) batteries remove ASAP – see Key Points
• Foreign body in medial half of external auditory canal usually requires
greater magnification to prevent damage to the tympanic membrane
• If in doubt, safer to refer
• Beyond competence
• Risk of damage to ear drum
• Failure of one person to remove foreign body
• If any suspicion that a nasal foreign body may have been aspirated
• Refer to otorhinolaryngologist (ENT specialist) if:
Most foreign bodies in young children (occasional GA required)
Foreign bodies in medial half of external auditory canal
In general, foreign bodies not easily removed
• NB Most foreign bodies are successfully removed without a general
anaesthetic by ENT specialist
Read Code: SG5..
KEY POINTS
• Oesphageal foreign bodies causing complete obstruction are usually caused
by meat bolus. There may be underlying oesophageal disease
• Distal oesophageal obstruction may present with only occasional
regurgitation of saliva
• Individuals with persistent symptoms of dysphagia despite normal X-ray
and indirect laryngoscopy should be discussed with ENT surgeon to
determine appropriate referral
• Most ingested foreign bodies in the paediatric age group do not require
repeat (serial) X-rays
• Children ingesting high risk foreign bodies (very long foreign bodies,
sharp foreign bodies, button batteries or heavy metals eg lead) should
have their care discussed with a specialist (paediatric surgeon if available)
and may require removal of the foreign body by gastroscopy
Complications
• Pharyngeal perforation and mediastinitis
• Bowel obstruction/perforation
History
• Time of ingestion
• Nature of agent ingested (if known):
Coin
Button battery
Pins
Food bolus
Chicken/fish bone
• Odynophagia (pain on swallowing)
• Dysphagia (difficulty swallowing)
• Previous history of same problem
• Prior stroke(CVA)
• Known oesphageal disease/abnormality
Examination
• Observe:
Drooling
Respiratory distress
Continuously spitting
Spitting up saliva every few minutes
• Level of discomfort:
Patient should point to source of pain
Helpful if above sternal notch
Poor accuracy of localisation if below sternal notch
• Palpate neck for tenderness or crepitus
• Inspect:
Tonsillar fossae
Tongue base
Piriform fossae (by indirect laryngoscopy)
• Auscultate chest if suggested by symptoms
Ingested Foreign Body SG5..
• Existing oesphageal stricture
• Other oesphageal disease
• Central cause eg stroke
• Pharyngeal/oesophageal mucosal abrasion/laceration
• Consider aspiration if respiratory symptoms
RED FLAG:
If it is likely that the food bolus
contains bone, glucagon and/or
carbonated beverage are not
recommended and the patient
should be referred for urgent
Investigation
Obstructed oesophagus in adult
• Nil
Paediatric ingestions
• X-ray chest, neck, abdomen as needed to localise foreign body if radioopaque
Pharyngeal foreign body in adult
• X-ray soft tissues neck
gastroscopy
RED FLAG:
Although the food bolus may pass into
the stomach with the above
treatments, the patient should still
have a gastroscopy performed (nonurgent) to exclude oesophageal
Treatment
Obstructed oesophagus in adult:
• A number of agents have been used to relax smooth muscle and allow
passage of the food bolus with variable success
Glucagon 1mg IV/IM
Carbonated beverage orally eg Coke
If unsuccessful, or unable to use these agents (see red flag), refer for
urgent gastroscopy
pathology
Paediatric ingestions:
• The majority of swallowed foreign bodies are asymptomatic and pass
through the gut without problems
• If symptoms of choking, or difficulty swallowing or drooling refer by
ambulance to hospital for urgent investigation and treatment
• Children who have ingested high-risk foreign bodies (very long foreign
bodies, sharp foreign bodies, button batteries, heavy metals eg lead) need
close follow-up and may need urgent gastroscopy. Their care should be
discussed with a paediatric surgeon or referral as per local practices.
Pharyngeal foreign body in adult:
• Often sharp – chicken/fish bone
• Occasionally may be seen on X-ray
• If no foreign body seen on X-ray or on indirect laryngoscopy but persistent
symptoms, telephone consultation with ENT specialist is recommended
and F/U as agreed (may be delayed a few days)
• If foreign body seen, referral to ENT specialist may be necessary for removal
Obstructed oesophagus in adult:
• To gastroenterology/ ENT specialist – as per local referral practices (usually
distal to gastroenterologist and proximal to ENT although referral practices vary)
Paediatric ingestions:
• All oesphageal foreign bodies – to ENT specialist or paediatric surgeon
as per local referral practice
• Some foreign bodies below diaphragm eg button battery, very long foreign
bodies, sharp foreign bodies, heavy metals (lead) – urgent specialist
referral (paediatric surgeon if available) for close observation/gastroscopy
Pharyngeal foreign body in adult
• To ENT specialist
Toxic Ingestions (Activated
Charcoal) – Treatment Protocol
Read Code: SL...
The Management of Toxic Ingestions with Activated Charcoal
• Identify the poison
• Contact National Poisons Centre - Telephone 03 474 7000
• If toxic dose taken, give activated charcoal as detailed below
Available as CARDSORB (see New Ethicals)
• If Activated Charcoal given, refer patient to local Emergency Department
• Don’t use Ipecacuana
Activated charcoal is the primary method for the gastrointestinal
decontamination of the majority of toxic ingestions. Chemical processes
increase its surface area and enable Activated Charcoal to adsorb a wide
range of toxic compounds preventing or reducing their absorption by the
gastrointestinal tract.
Activated Charcoal is effective for a wide range of compounds, and it is
easier to list those for which it is not effective. The following is a list of
compounds for which activated charcoal is not indicated:
• Acids/alkalis
• Hydrocarbon compounds (eg alcohols, glycols, petroleum distillates)
• Ionised compounds (eg iron, fluoride, potassium, lithium)
Activated charcoal is administered orally, and while it may be instilled via
a nasogastric tube, this should be performed following consultation with
the National Poisons Centre or a local Emergency Physician.
Contraindications
• Activated charcoal is contraindicated when:
Bowel sounds are absent
The toxic compound is not effectively bound by Activated Charcoal
It is recommended that the National Poisons Centre (NPC), or its guidelines,
be consulted prior to the use of Activated Charcoal to ensure its effectiveness
for the substance involved.
Dosage Recommendations for the Treatment of Toxic Ingestions
Dosage Guide:
• The usual recommendation for single-dose Activated Charcoal is:
Children – 1g/kg
Adults – 50g
Use of Activated Charcoal solutions with cathartics (eg sorbitol) is not
recommended.
Activated Charcoal is most effective if administered while a toxic ingestant
is still in the stomach. As liquids transit more quickly than solids, the
window of opportunity for administering Activated Charcoal is smaller for
liquids. It is therefore recommended that for:
Toxic Ingestions (Activated Charcoal) SL...
Toxic Ingestions (Activated Charcoal)
– Treatment Protocol
Liquids:
Activated Charcoal should be administered within half an hour of ingestion,
if indicated.
Solids:
Activated Charcoal may be administered up to 4 hours after ingestion, and
for some compounds, longer.
Method
Activated Charcoal is administered orally. Children may object to drinking
the black and gritty solution. It is therefore recommended:
• children be encouraged in a firm, friendly manner, preferably in the
presence of a caregiver
• use of a straw with an opaque, covered container to increase acceptance
As a last resort a flavouring agent (eg a flavoured drink) may be added to
increase palatability but this will decrease the effectiveness of the Activated
Charcoal.
If a child will not accept Activated Charcoal, nasogastric intubation to instil
Activated Charcoal should not be routinely attempted.
Nasogastric Intubation
Instillation of activated charcoal via nasogastric intubation is only
recommended for highly toxic compounds which meet all of the following
requirements:
• are readily absorbed to Activated Charcoal
• have no antidotes
• the time-frame is acceptable
• symptomatic and supportive care alone is unlikely to lead to a satisfactory
outcome
All cases should be discussed with the NPC or a local emergency physician
prior to attempting the procedure.
Adverse Effects
The major adverse effect of single-dose Activated Charcoal is inadvertent
aspiration of charcoal that may lead to asphyxia or bronchiolitis obliterans.
National Poisons Centre
The National Poisons Centre is available to give advice 24 hours a day, seven
days a week. Telephone 03 474 7000.
Toxic Ingestions (Activated Charcoal) SL...
Read Code: TE532
KEY POINTS
• Reaction may be local, urticarial without systemic reaction or
generalised/systemic reaction
• Sting to cornea may cause more serious damage
• Oxygen, adrenaline, fluids for anaphylaxis
• Generalised toxic reaction – observe closely, usually admit to hospital
• Stings to throat or mouth may cause airway obstruction
Complications
Local:
• Erythema, infection
• Impaired circulation in distal extremity from secondary oedema
• Corneal ulceration (from corneal sting)
• Retained FB (stinger), granuloma, skin necrosis
Generalised:
• Serum sickness-like illness at 10-21 days
• Unusual complications include encephalopathy, neuritis, vasculitis,
nephrosis, coagulopathy, renal failure
• Anaphylaxis
History
• Time/number of stings (>30 stings more likely to be fatal)
• Past history of stings (most fatalities occur in patients with a history of
recent sting causing severe/generalised reaction)
• Identify insect
• Position of sting (face/body)
• Past history of anaphylaxis
• Current medication and allergies
• Symptoms of itching, sneezing, tongue swelling, shortness of breath
Examination
• Vital signs: pulse rate, blood pressure, respiratory rate and level of
consciousness
• Skin rash
• Presence of stings – number and site
• Site/s of sting/s for erythema and swelling, check if sting still in place
• Circulation distally
• Signs of shock: poor tissue perfusion, confusion, hypotension
• Signs of anaphylaxis: see treatment protocol in this section
If Generalised:
• Pharyngeal, facial, neck oedema
• Hypotension
• Airway obstruction
• Arrhythmias
• Abdominal signs
Toxic Reaction Bee Sting TE532
• Urticaria
• Other invertebrate bite especially ants, wasps, spiders
• Localised infection
• Other causes of anaphylaxis, circulatory collapse
• Corneal abrasion/laceration – if corneal sting
Investigation
If generalised reaction:
• Pulse oximetry
• Cardiac monitor
Treatment
• Remove stinger – don’t squeeze
• Resuscitation, treat as appropriate
Local:
• 20% aluminium sulphate cream/spray (Stingose) – denatures venom
• RICE and paracetamol
• Localised reaction:
Large local reaction may benefit from systemic steroids for 2-3 days
Sting to eye – refer for assessment
Sting to mouth or pharynx – observe closely for airway obstruction
Antihistamine
• Generalised toxic reaction (due to multiple stings):
Supportive care
May require adrenaline if features of anaphylaxis (bronchospasm or
hypotension)
Usually hospitalise for more prolonged observation as other organ
dysfunction may develop
Anaphylaxis (see Treatment Protocol this section):
• Adrenaline
• Oxygen, antihistamine, steroid, fluid resuscitation
Other:
• Mouth or throat sting be prepared for intubation
• If generalised symptoms continue for 2-4 hours refer
• Consider prescription of Anakit for subsequent emergency treatment
• Consider medicalert bracelet
• Consider emergency paediatric transfer if <14 years
• If anaphylaxis, generalised toxic reaction, or airway obstruction – to local
emergency department
• Sting to eye – discuss with ophthalmologist or refer directly
• Delayed referral to allergy specialist if severe – life-threatening anaphylaxis
for assessment
• Slow response to treatment or relapse (systemic reaction)
• Pregnant with systemic reaction
• Immunocompromised/other serious medical problems
Toxic Reaction Bee Sting TE532
Dog Bite/Human Bite/Cat Bite
Read Code: TE60./U120.
KEY POINTS
• Infection risk with all bites (cat bites 75%; human and dog bites 5-20%)
• Human bite risk factors
MCP joints => ascending tendon infection
Tooth vs head in child => subgaleal (scalp) infection
Finger => deep tendon infection
• Animal bite risk factors:
High risk:
Hand, wrist or foot
Scalp in infants (risk of skull penetration)
Over joint
Punctures and heavily crushed injuries
Age >50 years
Co-morbidities (asplenia, chronic alcoholic, diabetic,
immunocompromise, peripheral vascular disease)
Low risk:
Face
Large, minimally contaminated wound, easily irrigated
Superficial wounds and abrasions
•
•
•
•
•
•
•
Adrenaline in local anaesthetic and deep sutures increase infection rate
Critical treatment strategy is thorough wound cleansing
Teeth fragments may be in wounds
Erythromycin is not an appropriate antibiotic for bite wounds
Consider rabies exposure if bite occurs in rabies endemic country
Close follow-up at 24-48 hours advisable especially with cat bites
Check tetanus status
Complications
• Infection – fulminant sepsis, DIC, renal failure in those
immunocompromised
• Cat scratch fever (Bartonella henselae)
• Nerve, vessel, muscle, bone and joint injury
History
• Time since injury
• Age of patient
• Affected body part
• Medical history:
Asplenia or liver disease
Metabolic or circulatory problems
Immunocompromised
• Species of mammal
• History of possible exposure to rabies (bite in foreign country with
incidence of rabies)
• Consider child/domestic abuse
Dog Bite/Human Bite/Cat Bite TE6o./U12o.
Examination
• Site (check for multiple sites) – consider injuries to dorsum of MCP joint
as human bite wounds until proven otherwise
• Nature of wounds, depth, foreign body, tissue loss
• Explore wounds over nerve, bone, tendon, joint, artery
• Assess movement, circulation, nerve supply
• Palpate for evidence of gas in tissues
• Extent of bleeding
• Penetration/injury to joint
• Evidence of active infection
• Cellulitis or systemic toxicity if delayed presentation
• Other causes of lacerations/puncture wounds
• Cellulitis
Investigation
• Usually none
• If evidence of active infection – swab for culture and sensitivity
• If concern about bony involvement/penetration of joint or teeth in wound
– X-ray
• Blood culture if toxic
• Consider CT for skull bites in children
Treatment
• Stop bleeding
• Infiltrate local anaesthetic (plain) as needed to ensure well-anaesthetised area
• Remove foreign material and obviously necrotic material, NB meticulous
debridement with as much tissue preservation as possible
• Copious irrigation with saline or povidone-iodine 10% solution (diluted
with saline to 1 part povidone-iodine and 10-20 parts saline). Irrigation
through a 19-20 gauge needle, 50 ml syringe. The amount necessary –
100-250mls, or more depending on degree of contamination
• Closure (avoid deep sutures, may need delayed primary closure at 3-4
days if high-risk wound – see Key Points)
• Suspicion of exposure to rabies – discuss with infectious disease specialist
• Pressure bandage dressing
• Immobilise and elevate if appropriate
• Review daily for 3-5 days
• Treat associated injuries as appropriate
Dog bites:
• Usually primary closure unless:
>12 hours old
Puncture wounds
Hand lacerations
High-risk wound, see Key Points
Almost always close bites on face
• Antibiotic prophylaxis – controversial. Usually not necessary unless high
risk factors, see Key Points. Amoxycillin with clauvulanate. If penicillin
allergic, cotrimoxazole or doxycycline +/- metronidazole or clindamycin
3-5 day course
Human bites:
• Primary closure usually avoided unless cosmetic concerns (eg facial bite)
• Prophylactic antibiotics usually indicated except for the most superficial
human bite wounds – see above.
• The common punch injury with wound over dorsum of MCP joint is
notoriously prone to infection and septic arthritis – urgent specialist
referral advised
Cat bites:
• Usually puncture wounds with deep penetration
• Avoid closure
• High infection incidence
• Prophylactic antibiotics usually indicated unless minor scratch – see above
• Close follow-up
• Spreading cellulitis if not responding to treatment
• Nerve damage
• Penetration of joint
• Significant ear/nose damage
• Asplenia or liver disease if infected
• Hand and foot wounds if infected
• Facial bite wounds (especially children) where optimal cosmetic result
imperative – to plastic surgeon
• Extensive wound/s requiring considerable time/debridement/exploration
– orthopaedic or plastic surgeon
• Infected wound requiring extensive debridement
• Wound with significant tissue loss
• Many young children who may require sedation or general anaesthetic to
facilitate wound care
• Punch injuries to dorsum of MCP joint – to orthopaedic (hand) specialist.
• Concern about rabies exposure – to infectious disease specialist
Electrical Injury
Read Code TLO1.
KEY POINTS
• Electrical injuries can be divided into high voltage (>1000V) and low
voltage (<1000V)
• Lethal cardiac dysrhythmias occur at the time of exposure
• Exposure to electricity depolarises electrically active tissue (cardiovascular
and nervous systems) AND burns tissue due to heat generated
• Other injuries may result from subsequent trauma eg fall
• Individuals suffering high voltage electrical injury should be hospitalised
• Individuals suffering low voltage electrical injury may be safely managed
in the community providing certain criteria are met – see Treatment section
Complications
• Rhabdomyolysis and myoglobinuria
• Neurological impairment
• Scarring from burns
History
Domestic
Industrial
Activity involved
• Voltage exposure:
Low <1000v
High >1000v
• Time of injury
• Pattern of injury
• Co-morbidities especially ischaemic heart disease
Examination
• Initial focus on airway, breathing, circulation and neurological state if
appropriate
• Assess and record vital signs
• Assess associated injuries eg if subsequent fall
• Secondary survey:
Thermal burns (entry/exit wounds)
Muscle tenderness
Presence of fractures
Evidence of neurological impairment
Assess for evidence of compartment syndrome
• Other causes of thermal injury
Electrical Injury TLo1.
Electrical Injury
Investigation
• 12 lead ECG
Treatment
• Analgesia as indicated (opiates may be necessary)
• Tetanus prophylaxis as indicated – see Lacerations/Abrasions section
High voltage:
• Burns should be cooled for 15 minutes – see Burns section
• Then cover with sterile drape
• Refer to hospital for admission – close observation, cardiac monitoring
• Analgesia as above
Low voltage:
• If no loss of consciousness, no evidence of neurovascular or muscle injury,
a normal ECG and no history of ischaemic heart disease – patient can be
safely discharged
• If any of the following are present, the patient should be referred to
hospital for further assessment and observation:
History of loss of consciousness
Neurological injury (motor weakness/sensory deficit)
Muscle injury (muscle tenderness/pain/swelling)
Vascular injury (acute ischaemia or loss of pulses)
Abnormal ECG or history of ischaemic heart disease
• Associated injuries may necessitate admission to hospital
• Burns should be treated as per Burns section
To local Emergency Department:
• All high voltage electrical injuries
• Some low voltage injuries – see Treatment section
Electrical Injury TLo1.
Management of Sexual Assault/
Abuse in General Practice
Read Code: SN571
KEY POINTS
• Sexual assault/abuse is a crime
• A history of sexual assault/abuse is very common in general practice (up
to 30% of patients) and such patients are at more risk of both short and
long-term negative impact on physical and psychological health
• Management commonly (always with children) requires a multi-disciplinary
approach with involvement of judicial, child-protective and other social
agencies
• Management may be forensic as well as therapeutic
• Doctors should act within the limits of their training and experience and
refer appropriately, particularly if untrained in doing or assessing the need
for a forensic examination
• ACC has contracted with accredited DSAC doctors to provide free medical
assessment of sexual assault
• Document carefully – may have medico-legal significance. If first person
told of the assault – document verbatim questions and response
• Do not ask leading questions and do not seek information beyond that
required to attend to the immediate emotional and medical needs of the
patient ie do not attempt to take a full and detailed history of the assault
Therapeutic Role of GP
• Recognise and treat physical injury
• Attend to the emotional impact on patient and family/intimates with nonjudgmental supportive approach and provision of appropriate counselling
• In New Zealand under the Contraception, Sterilisation and Abortion Act
1977, it is a legal requirement to provide protection against pregnancy
after rape
• Screen for STDs and/or provide prophylaxis and/or treatment when indicated
• Attend to patient safety with appropriate referral to police/child protection
agencies/women's refuge/family and friends
• Arrange medical follow up to ensure adequate progress in all of the above
Forensic Considerations
• A forensic medical examination is a specialised examination undertaken
by a forensic medical examiner who is specially trained
• It involves taking a detailed history of the assault, a comprehensive
physical and genital examination, the collection of samples for a forensic
science laboratory and recording of all findings using the protocol and
kit supplied by the police
• The procedure may take up to 3 hours
• The examining doctor is required to give expert opinion for the police
and later to a court of law on the significance of any findings in relation
to allegations of sexual assault
Management of Sexual Assault/Abuse SN571
Management of Sexual Assault/
Abuse in General Practice
Practical Advice for Provision of Supportive Approach
• Allow patients to tell their story, acknowledge their trauma and that a
crime has been committed
• Reassure patients that what they are feeling is part of a post-traumatic
response. Immediate crisis reactions include numbness, shock, disbelief
and anxiety that may last for days to weeks. Subsequent emotional reactions
include continued feelings of helplessness, depression, sleep disturbances,
nightmares, flashbacks, guilt, self-blame and shame
• Patients often feel guilty for not struggling. Reinforce the fact that this
may have helped them survive the assault
Three statements that should be part of consultation:
YOU ARE SAFE NOW (but don't say this if it is not true)
I AM SORRY THIS HAPPENED TO YOU (or in your own words convey
empathy and your belief in the worth of this patient)
IT'S NOT YOUR FAULT (gently draw attention to how patient is
blaming her/himself eg "sounds as if you are blaming yourself for that?")
Management of Sexual Assault/Abuse SN571
Adult Survivors of Abuse or Previous
Undisclosed Assault Presentation
KEY POINTS
• Spontaneous disclosure by a patient
• Disclosure by patient in response to doctor asking “Has anyone ever made
you have sex that you didn’t want to and didn’t agree to?” in one of the
following situations:
A routine question as part of a sexual health history
ECP request following non-use of condom
Patient has strong negative reaction to genital examination
Some chronic or unexplained pain conditions – especially pelvic,
gastrointestinal.
Patients presenting with mental health problems
Significant behavioural, drug or alcohol problems, high grade CIN or
pregnancy in adolescent
Management Guidelines
• Affirm the patient for having told you. Do not push for full details of the
abuse or attempt to deal with all the issues
• Inform patient of widespread incidence of sexual abuse to reduce patient
feelings of isolation
• Ask the patient how the abuse has affected or still is affecting their life
and what they want to do about this (if anything). Respect the patient’s
decision
• Check if the patient (and other family members) is safe now – including
in current relationship
• Enquire whether a sexual health check – STD screen and/or smear etc –
has been done since the assault/abuse. Offer an examination to check
physical injuries, scars or medical conditions related to the abuse. Normal
findings may address the patient’s unspoken concerns and reassure
• When performing a physical examination request permission for even
minor procedures – be gentle, take time, give encouragement. Involve
the patient (eg to insert the speculum herself), ensure the patient
understands that consent to the examination is flexible (not final) and
can be withdrawn at any stage in the procedure
• On some occasions it may be appropriate to advise the patient on making
a complaint to the police, for instance if injuries, STI or concerns about
patient safety are present
Stress Symptoms
• For most patients a routine enquiry about past abuse does not precipitate
crisis. Some patients may require extra medical care following disclosure
because of the emergence of post-traumatic stress symptoms. Assess for
and advise about:
Anxiety or sleep disturbances (short-term medication may help)
Depression – SSRIs may be helpful for PTSD
Exercise and general stress management
Work/financial needs – patients previously employed and not coping
may need time off work (some occupations make recovery from sexual
abuse more difficult), or additional support.
Alcohol/eating problems
Problems in current relationship(s)
• For a minority of patients the issue of recovered memory may arise. These
cases are complex and referral to an appropriate expert (a mental health
professional who is a member of a recognised college or equivalent body
with clinical expertise in this area)is advised
Adult Survivors of Abuse SN571
Adult Survivors of Abuse or Previous
Undisclosed Assault Presentation
• Advise the patient that many people find it helpful to talk things over
with a trained sexual abuse counsellor.
• Be guided by the severity and nature of the patient’s symptoms, the patient’s
wishes and culture, in deciding where to refer.
• Refer to a therapist (psychologist, psychotherapist or counsellor) who
has a balanced, well-informed approach to sexual abuse, memories and
family dynamics.
• Fill out ACC 45 where appropriate.
• Know your own limits. If you have not had in-depth training in counselling
or psychotherapy, do not attempt to be a sexual abuse counsellor for your
patient
Adult Survivors of Abuse SN571
Adolescent Sexual Abuse
KEY POINTS
Certain issues are specific to adolescents. Always consider suicide risk after
disclosure of sexual assault in this age group.
Adolescent Development
• Adolescents are no longer children but do not have the independence or
full self-determination of adults. An adolescent is capable of varying
degrees of self-determination. Respect for their developing identity is
essential to recovery from abuse
Confidentiality and Legal Issues
• There is a dichotomy between the adolescent’s need for self-determination
and basic human rights and their requirements for protection as specified
in child protection and criminal laws. This poses difficulties for health
professionals in relation to confidentiality
• Clarify your position on confidentiality of information – don’t make
promises you cannot keep. The requirement to share information does
not necessarily preclude confidentiality about the adolescent's needs that
may or may not be related to the sexual abuse eg consenting intercourse
with peer, drug use etc
• The limits on confidentiality can be explained as “Everything you tell me
is confidential – except I will have to talk to someone else if I think you
may be at risk of serious harm” AND “I would not do this behind your
back. I would discuss it with you first”
Safety and Protection Issues
• Because adolescents are not yet independent adults, especially in aspects
of power, they may require intervention for protection, safety and education.
This may be needed regardless of what the adolescent and/or their
caregivers or family wish. Consider CYFS or Police referral for all young
people 14 and under, and consultation on all between 14 and 17 years
with a senior colleague or CYFS social worker
Sexual Health Needs
• For adolescents who are victims of sexual abuse it is essential to assist
in normalising their developing sexuality and present sexual behaviour.
They need help to identify themselves as sexually healthy individuals
separate from their sexual abuse. They need the usual adolescent
contraceptive and STI advice
General Health Care
• Any contact with an adolescent should be used opportunistically to attend
to wider aspects of health care including suicide prevention, and drug
and alcohol use
Adolescent Sexual AbuseSN571
Adolescent Sexual Abuse
Follow-up at 1 & 3 months
• Is victim safe?
• Check physical health/concerns
• Rule out /manage pregnancy
• Check STI symptoms/concerns
• Arrange STI blood tests @ 3/6 months – Hep.B. HIV, VDRL
• Assess psychological state
• Consider medication (SSRI?)
• Offer counselling referral again
• Review ACC entitlements–if cover has been granted
• Check progress if Police case
• Consider public safety.
• Request permission to report assault without identifying victim
• Counsel patient re police report
• Enlist crisis counsellor
• Refer for forensic medical examination (if within 7 days of assault) to
keep reporting options open
• Discuss informing police “for intelligence purposes with no view to
prosecution”
• Treat urgent medical conditions
• Document verbatim
• Preserve forensic evidence (no food /drink/cleansing/wiping/nail biting)
Adolescent Sexual AbuseSN571
GP Management of Child (or Adolescent
Under 17) Sexual Abuse
KEY POINTS
• Child sexual abuse (suspected or disclosed) requires specialist referral
and multi-disciplinary management.
Consider the possibility of the diagnosis if:
Disclosure by a child
Pregnancy in a young adolescent
Vaginal bleeding or other signs of injury
Vaginal discharge
Significant behavioural disturbance – running away, phobias, sexual
acting out etc
Do Not:
Attempt to manage or investigate a suspicion of sexual abuse on your own
Attempt to interview the child beyond a gentle inquiry about possibility
of abuse if indicated
Promise to keep what you are told a secret
Conduct a forensic medical examination unless you are adequately
trained. Perform only a limited external medical examination to ascertain
the urgency of a referral when there is acute trauma or vaginal bleeding
or if other conditions such as vulvitis are suspected
Show child you are shocked or angry by what they say
Criticise the alleged abuse in front of the child
Try to determine if abuse has occurred by confronting the parents
Management
Document:
The child’s history and clinical symptoms (note verbatim child’s words)
Explanation of symptoms and injuries given by either parents or child
• Consult
If in doubt about the basis of your concern or how you should proceed
consult:
A doctor experienced in management of sexual abuse (GP or
paediatrician) or
CYFS senior social worker
• Refer Promptly:
If there is reasonable suspicion that abuse has occurred and/or the child is
at risk of further abuse:
Refer to CYFS or Police
Section 16 of CYP and F Act protects a doctor who reports suspicion
of child abuse from any criminal or civil litigation provided the report
is made in good faith
Immediate specialist medical referral is indicated and admission should
be considered if:
Assault/rape within 7 days especially for young child, ill or unsafe
Obvious external physical trauma or suspected internal trauma
Systemic signs or symptoms of illness, local signs and symptoms –
especially significant genital discharge or bleeding or ano-genital pain
Child Sexual Abuse SN571
GP Management of Child (or Adolescent Under 17)
Sexual Abuse
• Follow Up – Maintain Liaison
The GP should provide support for the child, family/whanau.
Support family members who may disclose their own past abuse at this
time
Use community resources to refer for counselling both child and family
if appropriate
Provide continuing medical care and follow-up to ensure that the child
remains safe, injuries heal, STDs have been recognised and treated
appropriately and pregnancy recognised and assistance provided
Check that ACC documentation has been provide
Child Sexual Abuse SN571
Presentation of Recent Sexual Assault
• Treat urgent medical conditions
• Document verbatim
• Preserve forensic evidence (no food/drink/cleansing/wiping/nail biting)
Does patient want to make police
RED FLAG:
complaint?
Full medical management of an acute
YES
UNSURE:
sexual assault, whether or not police
• Counsel patient re police report
• Enlist crisis counsellor
are involved, requires time and
• Refer for forensic medical
examination (if within 7 days of
assault) to keep reporting options
open
• Discuss informing police “for
intelligence purposes with no
NB. If assault was within 7 days
experience. It is difficult to fit into a
URGENT report to Police required
general practice consultation.
Consider referral to DSAC accredited
doctor for ACC-funded management.
YES
view to prosecution”
DSAC Office (09) 376 1422
Consider public safety. Request
NO
Patient decides to make police
permission to report assault without
identifying victim
complaint
REPORT TO POLICE
Refer to Forensic Medical Examiner
to examine using accepted protocol
THERAPEUTIC MANAGEMENT
ALWAYS CONSIDER PATIENT'S SAFETY AND SECURITY
PHYSICAL INJURIES:
• Treat or refer as appropriate
• Offer vaginal examination if not done for forensic reasons
FOLLOW-UP AT 1 WEEK
Review therapeutic and
PSYCHOLOGICAL TRAUMA:
• Provide supportive approach
• Offer support person or counsellor
• Provide patient literature
• Refer for on-going counselling
counselling needs
PREGNANCY:
• Check pre-existing pregnancy, Hx and PT
• Discuss risk in relation to assault, menstrual cycle and other variables
• Offer prophylaxis –Postinor© 2, or Yuzpe (Nordiol© or Ovral© 2 + 2
and anti-emetic)
• Give written instructions
STI:
• Counsel re risk
• Offer baseline screening
• Offer prophylaxis
Chlamydia – Azithromycin 1Gm stat (fully subsidised for sexual
assault prophylaxis) – if contraindicated use erythromycin
ethylsuccinate 800mg qid 7 days
Gonorrhoea and incubating syphilis (with emerging resistance
regime changes, check with local STI specialist). Amoxicillin 3Gm
+ Probenecid 1Gm orally
Ciprofloxacin 500 mg orally stat (not pregnant, child, adolescent
– consult STI specialist)
Anti-fungal – Clotrimazole
Hepatitis B – Hyperimmune globulin up to 14 days + first Hep.B
vaccine.
HIV – consult local STI specialist
• Arrange return for screening
VICTIM COMPENSATION:
• Discuss role of ACC
• Complete ACC45 Referral if appropriate
FOLLOW-UP AT 1 & 3 MONTHS:
• Is victim safe?
• Check physical health/concerns
• Rule out/manage pregnancy
• Check STI symptoms/concerns
• Arrange STI blood tests @ 3/6
months–Hep.B. HIV, VDRL
• Assess psychological state
•
•
•
•
Consider medication (SSRI?)
Offer counselling referral again
Review ACC entitlements
Check progress if Police case
ISBN 0-478-11756-6
ACC 579
Printed December 2000
Treatment
Profiles
2001
Composite

ACC579 Treatment profiles 2001

Transcription

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