Some patients may have been lying on the floor all night and have become hypoglycaemic and dehydrated. A blood glucose assessment is necessary. If there is a prolonged journey time t o hospital, fluid replace- ment should be considered for correction of dehydration. Similar ly, the elderly patient is at risk of developing pressure sores. Particular care should be taken to handle them carefully, especially when the patient has been lying still for any le ngth of time, avoiding hard surfaces such as scoop stretchers or spinal boards if possible. Otherwise, the time on one of these must be kept to a minimum. A vacuum mattress, if avail able, should be considered in this group of vulnerable patients. Any patient with hip pain should be transported to hospital to exclude femoral neck fractur e \200\224in those patients with no leg deformity, there may be fractures of the adjacent p ubic rami. The proximal femur is not an uncommon site of pathological femoral neck or intertrochanteric fractures due to malignancy. CHAPTER 3 Trauma 256 Fractures of the shaft of the femur Cause Fractures of the shaft of the femur are common fo llowing road traffic collisions, falls from significant heights, and crush injury (for exam ple, under falling masonry). A fracture that occurs spontaneously or after minimal trauma suggests that it is a patholog ical fracture, for example, secondary to carcinoma or myeloma. Signs and symptoms - Extreme pain - Deformity and swelling of the thigh - External rotation of the leg Palpation may reveal crepitus and mobility at the fracture site. Many high- vel ocity injuries are compound, some associated with extensive soft tissue injuries and blood loss. Treatment The initial assessment and treatment should follow the ABCDE system. High-flow ox ygen should be administered. Obvious external bleeding should be controlled, usually by dir ect pressure using a dressing and bandage. Very rarely, control may only be achieved using the windlass technique or a tourniquet. Vascular access should be obtained and intravenous fluid should be given if there is signif icant external blood loss or a delay in transporta- tion. Intravenous morphine titrated to the patient \200\231s clinical need should be given with an antiemetic. Femoral nerve block (see pp.393 \200\2234) can be considered in entrapments or prolonged transfer times. In patients with grossly contaminated wounds, obvious contaminating material should be wipe d or washed away and a sterile moist dressing applied. Externalized bone should be relocate d by traction if possible. The fracture should be realigned and approximated to the intact femur. This is achieved by a combination of longitudinal traction and rotation and should b e performed in a controlled way with an assistant or bystander gripping the proximal femur. The neurovascular status of the limb should be assessed and recorded before and after any manipulation. Should the peripheral pulse be lost as a result of a manipulation, the leg sh ould be re-positioned such that the pulse is restored. An appropriately applied traction sp lint will stabilize and immobilize the femur for transportation. Potential problems With an increasing number of patients undergoing hip replacements, peri- prosthetic fractures are common. These often present with a history of fairly minor trauma. However, the physical signs are similar to uncom- plicated femoral shaft fractures. Should the distal pulses be absent both before and after realigning the femur, this should be regarded as a time-critical emergency. Rapid transfer to hospital is necessary. REGIONAL INJURIES: LOWER LIMB1 257 Fig. 3.17 Using the windlass technique to control bleeding. Reprinted with permission from Greaves I et al. (2005). Emergency care: a textbook for paramedics, 2nd edn. W.B. Saunders Co. Ltd. CHAPTER 3 Trauma 258 Supracondylar fractures of the femur Cause Supracondylar fractures are commonly seen in the osteoporotic elderly female population, usually following a fall. The presence of a total knee replacement produces a stress interface at the proximal end, making this area particul arly vulnerable to fracture. Signs and symptoms - Pain - Swelling - Tenderness and deformity just above the knee, associ ated with loss of function. Treatment Treatment should follow the same principles as for fractures of the shaft of the femur. However, the pull of the gastrocnemius muscle tends to pull the distal fragment post eriorly. Attempting to straighten the leg worsens this problem and may compromise the circu lation. This fracture, which is relatively easy to recognize, should be treated by support under the knee, padding between the legs, and broad bandages to maintain the position. The distal vascular status should be assessed before and after the application of splintage. Fe moral nerve block is ineffective in supra- condylar fracture and traction splintage is cont raindicated as it allows the distal femoral fragment to angulate posteriorly. Potential problems Regular circulatory assessment is necessary as this fracture is commonly associated with vascular trauma. REGIONAL INJURIES: LOWER LIMB1 259 Patella fractures Cause Patellar fracture most commonly follows a direct injury, for exampl e, on the dashboard of a car or a fall onto a hard surface. An occasional cause is crush, f or example, falling masonry. Uncommonly, patellar fracture may follow a resisted extension force, for example, when catc hing a shoe on the sidewalk whilst extending the leg, or a blocked, tackle playing football . Signs and symptoms - The patient is often unable to walk or stand unaided. - The knee is sw ollen and after some time may become bruised. Associated wounds make the injury compound, f or example, dashboard injuries may be associated with transverse skin wounds, whereas falls to the ground are associated with abrasions, local contusions, and ragged lacerations. Treatment Wounds should be covered with a sterile dressing, the leg should be straightened, and position maintained in a long leg box splint. Potential problems In significant front end road traffic accidents producing femoral shaft fractures, there is often an associated knee injury, the differential diagnosis of which in cludes patella fracture. A patient suffering a simple undisplaced patella fracture with intact medial and lateral pa tella retinaculae may be able to perform a straight leg raise. However, there is usually an associated extensor lag. Resisted extension forces may also produce rupture of the quadriceps tendon at its insertio n, rupture of the patella tendon, or avulsion of the tibial tubercle. In the presence of sw elling, it may be difficult to differentiate these from a patella fracture. CHAPTER 3 Trauma 260 Patella dislocations Cause Patellar dislocation commonly follows a muscular contraction, as sociated with sudden twisting or changes in direction, in \200\230at risk \200\231 individ uals, usually women. It generally occurs when the knee is close to full extension. Predispo sing causes include a narrow femoral sulcus and genu valgum (an exaggeration of the normal tibiofemoral valgus which produces a lateral vector and, therefore, a tendency to lateral s ubluxation or dislocation of the patella). Often, there is a history of recurrent dislocati ons. Patella dislocations may also follow direct blows to the knee, with lateral dislocation being more common than medial. Signs and symptoms - Pain - Reluctance to permit examination of the knee. The misplaced pat ella is invariably lateral and fairly obvious on examina- tion. The patient will not active ly move their leg. Treatment With appropriate analgesia (for example, Entonox) , in a co-operative patient \200\231 the patella can be reduced by simply extending the knee. A click following relocat ion is usually followed by an expression of relief both visual and otherwise on behalf of t he patient. Many patients will not tolerate this without considerable analgesia and multipl e attempts, whilst the patient becomes increasingly distressed, should be avoided. Reductio n can take place in hospital. The knee should be immobilized in flexion with a blanket under the knee and FRAC Straps o r triangular bandages, and the patient transported to hospital. REGIONAL INJURIES: LOWER LIMB1 261 Dislocations of the knee Cause Although associated with major trauma, for example, a dashbo ard injury, some dislocations occur after seemingly innocuous trauma. Patients with a gross ly normal knee who say \200\230I dislocated my knee but it went back \200\231 have usually suffered a dislocated patella. Signs and symptoms Depending on the mechanism of injury, the dislocation (as described by t he position of the tibia relative to the femur) can be in any direction, anterior and poste rior being the most common. The dislocation pro- duces major ligamentous disruption, menisc al displacement, and, in some cases, neurovascular injury (injuries to the popliteal vein, popliteal artery, and the common peroneal nerve being the most uaual). Treatment The knee should be supported and splinted in the position in which it is found. B ecause of the dislocation, the knee will not straighten, therefore it should be splinted to the normal leg using pads and broad triangular bandages. This is a time-critical problem r equiring urgent transfer to hospital for manipulative reduction. Potential problems Frequent observations for distal vascular compromise should be undertake n. CHAPTER 3 Trauma 262 Fractures of the tibial plateau Cause These fractures commonly occur due to significant var us or valgus forces, when the femoral condyle impacts with the tibial plateau producing a f racture of the plateau. The degree of damage depends on the force involved. As the displacement is increased, there may be rupture of the collat- eral ligament (on the side of contact), cruciate ligament rupture, and meniscal damage. These injuries are commonly seen when the bumper of a car strikes a pedestrian or when the bindings fail to release in a skiing accident. Signs and symptoms - Knee swelling due to the presence of a haemarthrosis - Bruising (may t ake some time to develop) - Deformity and instability depending on the extent of damage (not always present - Inability to weight bear. Treatment Analgesia. The leg should be positioned as straight as possible and immo- bilized in a box splint. Some supplementary padding may be necessary. The neurovascular status sho uld be checked before and after splinting. Potential problems Injuries to the medial tibial plateau following varus force may be assoc iated with a common peroneal nerve injury. REGIONAL INJURIES: LOWER LIMB1 263 Tibial and fibula shaft fractures Cause Tibial and fibula shaft fractures commonly follow d irect and indirect trauma. Direct injury produces transverse fractures, for example, follow ing a blow to the shin as in a kick in football or from a heavy weight falling on the leg. Isolated single bone fractures may occur. Fractures following indirect force produce tortional/rotatory injuries with oblique or spir al fractures usually affecting both bones. This pattern of injury is commonly seen in assoc iation with sporting injuries, falls from a height, and road traffic collision. Signs and symptoms - Pain - Swelling - Deformity - Loss of function. In displaced fractures , there may be obvious shortening and deformity producing angulation and rotation due to th e pull of the non-opposed intact muscles. The fracture may be compound, particularly when due to direct trauma or in relation to the subcutaneous border of the tibia where there is very little soft tissue coverage. Neurovascular damage is more common in open fractures, particularly where there has been a penetrating injury. Less commonly, vascular injury may follow proximal tibial fractures in close proximity to the pop- liteal artery trifurcation. Treatment Following appropriate analgesia, any gross contamination should be removed from t he compound wound and exposed bone should be relo- cated beneath the skin and the limb real igned. A clean sterile dressing should be applied to any wounds present. If possible, a pol aroid picture should be taken to accompany the patient to hospital. A long leg box splint, to immobilize the joint above and below the fracture, should be applied. The neurovascular status should be assessed before and after any manipulative procedure. Potential problems It is not uncommon for fractures of the tibia and fibula to be accompa- nied by an ipsilateral femoral shaft fracture. Immobilization using a traction splint, with supporting padding and broad bandages above and below the respective fractures, is one way of managing this injury. An acute compartmental syndrome may complicate closed tibial and fibular fractures, particu larly following moderate to severe energy trans- fer. It occurs because of swelling within a closed fascial space and is characterized by increasing pain beyond normal, excruciating pain on passively extending the toes (stretching ischaemic muscle), and, later, pallor, par asthesia, and, ultimately, pulselesness. CHAPTER 3 Trauma 264 Acute compartment syndrome commonly takes several hours to develop but due to delay in acce ss to the patient, protracted entrapment, or journey times, this could become a problem for the pre-hospital carer. Treatment is by surgical decompression, and this should be regarde d as a time-critical emergency. It is important to remember that the presence of a distal p ulse does not guarantee that the limb is adequately perfused. In the unconscious patient, v ascular compromise may initially go unnoticed. REGIONAL INJURIES: LOWER LIMB1 265 Ankle fractures Cause Ankle fractures commonly occur due to rotatory forces. The talus is n ormally sited between the fibula and tibia (like a mortis and tenon joint) and is stabilize d by the medial (deltoid) ligament, the lateral ligament complex, and the tibio-fibular lig ament (syndesmotic ligament). Depending on the forces involved, trauma will produce ligamen tous injuries and fractures of the malleoli (medial, lateral, and posterior) which may prog ress to a clinical picture of fracture dislocation. Direct injuries may occur at the site of contact, due to compression as in falls from a hei ght, or following forced dorsiflexion as in brake pedal injuries. These high-energy injurie s commonly produce comminuted fractures of the tibial articular surface. Signs and symptoms The most common ankle injury is a lateral ligament sprain (partial injur y) which presents with: - Pain - Swelling and tenderness - Difficulty with weight bearing. Bony tenderness over the fibular is usually pathomnemonic of an underlying fracture. Bimall eolar swelling and tenderness is suggestive of an underlying bony injury. The differentiati on between a soft tissue injury and bony fracture should be made in hospital. Treatment The injured ankle should be immobilized in a box splint or an appropriate alterna tive. Dislocations, depending on the skill base of the pre-hospital care practitioner, may be reduced by simple traction and manipulation to restore normal alignment after the admini stration of analgesia. The limb should then be immobilized as above. Potential problems Fracture dislocations may be associated with distal vascular compromise and major pressure on the skin, risking necrosis. This is a time-critical injury and if man ipulation and reduction is not possible at the scene due to lack of experience or appropria te skills, urgent transfer to hospital is necessary. Some rotational injuries result in disruption of the interosseous membrane between the tibi a and fibula with a proximal fibular fracture, which will account for proximal fibular pain and tenderness in the presence of an ankle fracture (Maisonneuve fracture). CHAPTER 3 Trauma 266 (a) (b) Fig. 3.18 (a) Inversion and (b) eversion of the ankle. Reprinted with permission from Greav es I et al. (2005). Emergency care: a textbook for paramedics, 2nd edn. W.B. Saunders Co. L td. REGIONAL INJURIES: LOWER LIMB1 267 Fractures of the talus and calcaneum Cause Talar fractures commonly follow forced dorsiflex ion such as may occur in road traffic collisions, where the break pedal forces the talar ne ck onto the front of the tibia. This injury was first described as \200\230aviator \200 \231s astraga- lus \200\231 from violent dorsiflexion due to impact with the rudder pedals at the time of an aircraft crash. This injury may also occur following falls from a height. Calcaneal fractures commonly follow falls from a height, landing on the heel. They can be b ilateral, depending on the first point of contact with the ground. Signs and symptoms - Pain - Inability to weight bear - The heel will appear swollen, broade r, and, in some cases, displaced into a valgus position Characteristic bruising tracking to the sole of the foot will occur (late). Treatment The limb should be immobilized in a below-knee padded box splint and the patient transported to hospital. Potential problems Patients sustaining injuries following falls from a height not uncommonl y have other injuries including tibial plateau injuries, hip and pelvis injuries, and fract ures to the thoracolumbar spine. Injuries to the various processes of the talus and calcaneum can occur as well as more majo r peritalar dislocations. These injuries should be treated as above. CHAPTER 3 Trauma 268 Midtarsal injuries Cause Midtarsal dislocations (between the talus and the calcaneus proxim ally and the navicular and cuboid distally) commonly result from forced abduction or adduct ion. Signs and symptoms - Pain - Deformity may be masked by considerable swelling except in the early period following injury. Treatment The foot and ankle should be immobilized in an appropriate box splint. Potential problems The distal neurovascular status should be assessed and reassessed becaus e of the risk of associated vascular injury or compartment syn- drome. Lesser injuries in t his region also occur, for example, navicular avulsions. All of these injuries should be tr eated in a similar way in the pre-hospital environment. REGIONAL INJURIES: LOWER LIMB1 269 Tarsometatarsal dislocations Cause These injuries may follow a fall on the plantar-flexed f oot or complicate road traffic collisions. Signs and symptoms - Pain - Swelling - Inability to weight bear. Treatment The treatment is simple splintage, analgesia, and transfer to ho spital. Potential problems Occasionally, there may be vascular compromise due to a compartm en- tal syndrome, particularly where there has been significant trauma, for example, when t he foot has been run over. CHAPTER 3 Trauma 270 Metatarsal fractures Cause These commonly follow direct injuries (for example, when a weigh t falls onto the foot) or are indirect, as part of a forced inversion or eversion to the fo re foot. Signs and symptoms Pain, swelling, local tenderness, and an inability to weight be ar are sug- gestive of an underlying bony injury. Treatment No specific treatment may be ne cessary at the pre-hospital scene. Potential problems Metatarsal fractures may occur as par t of more significant foot fractures, In particular, it is imperative not to miss the Lisfr anc injury which commonly involves an anterior subluxation/dislocation of the second metata rsal in association with other metatarsal injuries. Inversion injuries to the ankle may also be associated with fractures to the proximal shaft or base of the fifth metatarsal. Stress fractures (most often affecting the second metatar sal) are common and can present with acute pain. REGIONAL INJURIES: LOWER LIMB1 271 Phalangeal fractures Cause These commonly follow crush injuries, (for example as a result o f a heavy weight falling on the foot) but they may also result from kicking a solid object or catching the little toe on a static object whilst walking bare foot. Signs and symptoms - Pain - Tenderness - Swelling - Deformity (sometimes). Very occasionally, these may be com pound injuries. Treatment Wounds should be dressed and simple realignment and companion strapping applied i f the patient will tolerate it. Potential problems It is often impossible to distinguish between toe dislocations and fract ures. If a dislocation is obvious, simple longitudinal traction may reduce it. CHAPTER 3 Trauma 272 The complications of fractures Actions in the pre-hospital care phase may influence the com plications that occur in the immediate, early, and late phases of patient treatment. Immediate A closed fracture may be converted into an open fracture by inappropriate handlin g, thereby increasing the risk of complications, particularly infec- tion. In addition, del ays in realigning fractures may lead to undue pressure on the skin, risking subsequent necr osis, and may delay relief of pressure on nerves and arteries. In cases of prolonged entrapment or in long transportation times, a compartmental syndrome may develop, particularly in high-energy closed long bone fractures such as of the tibia an d fibula. Removal of any gross contamination from compound fractures, although no substitute for surg ical toilet and debridement, may influence the early development of infection, particularly if there is a delay in surgical treatment. Early Delayed or inappropriate immobilization of major long bone fractures will increase th e risk of the development of fat embolism syndrome particularly in patients who have uncorr ected hypoxia and hypovolaemia. As stated above, early problems include compartmental syndrome and mishandling which could convert a fracture into an open injury. Late complications Late complications usually relate to delays in union or to non-union, a situation which can be linked to associated sepsis in compound injuries. Unrecognized compa rtmental syndromes have devastating consequences. Failure to recognize and relieve pressure on nerves has a significant morbidity. This page intentionally left blank CHAPTER 3 Trauma 274 Soft tissue injuries Types of injury A large number of injuries, particularly sports injuri es, are soft tissue injuries. They occur most commonly in the lower limbs. Many are minor a nd self-limiting (for example, simple bruises to the skin and underlying tissues) but they can range from this to major skin, ligament, muscle, and tendon injuries. The immediate care practitioner must decide whether the patient requires medical interventi on or, as in the case of minor bruises and sprains, can be readily treated with rest, ice, compression, and elevation (RICE). The more serious injuries may be obvious, although perip heral nerve and tendon injuries can be difficult to recognize and require a high index of s uspicion based on the mechanism of injury and a safeguard referral pattern to the emergency department. Soft tissue injuries may follow blunt or penetrating trauma. Penetrating trauma usually pro duces a localized anatomical injury whereas blunt trauma may produce more diffuse injuries often associated with crush. Patient assessment Assessment should follow the ABCDE system of the primary survey. Soft ti ssues injuries may, for example, be recognized under breathing assess- ment where there is bruising to the chest wall or under circulation where there is an obvious major wound assoc iated with bleeding. Other injuries may be apparent when the patient is appropriately expos ed, or found during the secondary survey. In relation to the limbs, the secondary survey includes an inspection for swelling, wounds, and deformity and an assessment of motor function (M), sensation (S), and circulation (C). The latter can be summarized by the mnemonic MSC x 4: - Motor response \200\224test for ac tive movements - Sensation \200\224response to touch - Circulation \200\224pulse, pallor, a nd skin temperature - x 4 \200\224all four limbs. SOFT TISSUE INJURIES1 275 Injuries to specific tissues Skin Wounds may be classified as open or closed. Open wounds i nclude: - Incised wounds \200\224for example, wounds sustained with glass or knives. - Lace rated wounds \200\224where the skin is irregularly torn, for example, following a blow to the face. Puncture wounds \200\224for example, from a needle or garden fork. - Graze or abrasions \200\224partial thickness injuries to the skin. - Contused wounds \200\224following a fall or direct blow which splits the skin and bruises the soft tissues. Gunshot wounds \200\224often associated with entry and exit wounds with significant internal disruption. Closed wounds Closed wounds include: - Crush injuries \200\224where the skin integrity is n ot compromised. - Bruising \200\224swelling and later discolouration associated with contained bleeding within the underlying tissues. Open wounds External hemorrhage control should follow stepwise progression, noting that mos t external bleeding can be controlled by simple measures. Tech- niques include: - Direct pr essure - Elevation - Wound packing - Windlass technique (See p.257) - Indirect pressure - T ourniquet. In the event of blood soaking through applied dressings, further added dressings are unlikely to arrest hemorrhage. An appropriate wound dressing should be placed within t he wound and effective pressure achieved by securing this firmly in place. It may be necess ary to use the windlass technique (See p.257) to control the hemorrhage. For extensive wounds, where direct pressure would be futile, hemorrhage control may be effe cted by indirect pressure over a proximal artery (for example, the femoral artery or the br achial artery). Alternatively, a tourniquet can be applied. Vessels Bleeding from major blood vessels is usually obvious if there is an external wound and control should be effected by following the guidelines above. Contained vessel damage m ay produce significant limb swelling, com- partment syndrome, or overt signs of distal vasc ular insufficiency. The features of ischaemia include: - Pain - Pallor - Pulselessness - Pa rathesaea - Paralysis. The five Ps CHAPTER 3 Trauma 276 Muscles Most significant muscle injuries complicate open wounds such as lacera- tions, inci sed wounds, and wounds associated with open fractures. Less frequently, closed muscle injur ies, such as ruptures of the long head of the biceps or the quadriceps muscle close to its insertion into the patella, may occur. Sportsmen may sustain a \200\230pulled muscle \200\231 (for example, the hamstring). These are normally small intramuscular tears. Treatment should be symptomatic. Where there is significant loss of function (for example, a quadriceps rupture), appropriate splintage is necessary and the patient should be referre d to hospital. Simple muscle sprains can be managed initially following the RICE regimen. Tendons Tendon injuries, particularly to the hand, are often not recognized in the pre-hosp ital scene. A high index of suspicion is necessary, noting the mechanism of injury (for exa mple, a glass or knife injury) and the ana- tomical site of an injury (for example, the vol ar aspect of the wrist or the palmar aspect of a finger). There may be visible tendons with in a wound or obvious loss of function but, in many cases, the only clue to a significant i njury is the location of the laceration. It is inappropriate to probe a wound to determine the presence of any tendon injury. Since any tendon injury present will be found on that part of the tendon which was under the woun d at the time of injury, it may not be apparent in a position of rest. The wound should be managed by control of hemorrhage and application of a sterile dressing and referral to hospital. In the majority of cases, careful surgical exploration under opti mal conditions will be necessary to exclude tendon or nerve injury. Rarely, spontaneous rupture of tendons occurs following trivial trauma, for example, of the patella tendon producing an inability to straighten the leg, or the extensor tendon as in a mallet finger deformity. Nerves Nerve injuries may be open or closed injuries, the former associated with wounds com monly due to glass or knives. As in tendon injuries, a high index of suspicion is necessary . Treatment involves the management of the wound and referral to hospital. Closed nerve inj uries may be seen, for example, in supracondylar fractures of the humerus in children and s ciatic nerve injuries associated with posterior hip dislocations. Neurological injuries ass ociated with fractures and dislocations require urgent transporta- tion to hospital to opti mize the chances of neurological recovery. Ligaments Partial injuries to ligaments, for example, in soft tissue sprains to the ankle, are extremely painful. Complete ligament ruptures are often surprisingly pain free and, the refore, the injury may not be recognized. The mecha- nism of injury is the clue to diagnosi s. In both instances, the pre-hospital treatment is symptomatic. It is usual to refer these patients to hospital to exclude significant ligament injury or associated bony trauma. SOFT TISSUE INJURIES1 277 Regional injuries The wrist Soft tissue injuries to the wrist are common, although differen tiation from a bony injury is difficult since both present with swelling, pain, and some lo ss of function. Pre-hospital management is symptomatic with ice, analgesia, and a broad arm sling. Referral to hospital is appropriate. The knee Common features of knee injuries include pain, swelling, difficulty in, or inabili ty to weight bear and a loss of function. The mechanism of injury may give a clue to the li kely injury. Quadriceps tendon rupture This may follow resisted extension or occur spontaneously. The cl inical features include: - Localized pain, tenderness, and swelling - Inability to extend t he knee - A palpable defect above the patella - An inability to weight bear - Swelling of t he knee due to an associated haemoarthrosis. Pre-hospital treatment includes splinting the knee in extension and refer- ral to hospital. Patella tendon rupture This may be caused by a direct blow to the front of the knee, a pene trat- ing knee injury, or a resisted extension injury. Clinical features include: - Infrapa tellar tenderness, swelling, and pain - A palpable defect in the tendon - An inability to e xtend the knee - An inability to weight bear. Pre-hospital treatment includes splinting the knee in extension, analgesia, and referral to hospital. Reduced lateral dislocation/subluxation of the patella The patient will usually give a hist ory of dislocation or subluxation. There will be an associated knee haemarthrosis and tende rness over the medial patella retinaculum. Weight bearing should be discouraged and the pat ient should be referred to hospital to exclude associated bony injuries and for ongoing man agement. Ice and splintage may be necessary. Meniscal tears Classically, these occur due to a rotational injury whilst weight bearing on a semi-flexed knee. They occur most commonly in males and as sporting injuries, in particu lar in football. Common clinical features include: - Pain - Swelling - Locking - Giving way of the knee. Locking implies a mechanical obstruction within the knee due to a displaced p art of the meniscus. Patients with locked knees require referral to hos- pital for definiti ve management. CHAPTER 3 Trauma 278 Ligament injuries These are particularly common in footballers and skiers. Injuries include partial and complete tears to the medial collateral ligament, the lateral collateral ligam ent, and the cruciate ligaments. As an example, a valgus force applied to the knee may prod uce, in sequence: - A partial tear to the medial collateral ligament - A complete tear of t he medial collateral ligament - A medial meniscal peripheral detachment - A rupture of the anterior cruciate ligament. Clinical features include pain, swelling, tenderness, decreased function, and instability. The magnitude of the injury is usually apparent from the mechan ism of injury as related by the patient. Treatment should be symptomatic including ice, spl intage, and referral to hospital. The ankle Lateral ligament inversion sprains are the most common soft tissue injury to the ankle and present with: - Swelling - Tenderness - Difficulty bearing weight. Differentiatio n from a fracture can be difficult. Complete absence of tenderness over both malleoli and t he fifth metatarsal makes a fracture very unlikely. Bony tenderness mandates referral to ho spital for an X-ray. Minor sprains can be treated by RICE. Achilles tendon ruptures Achilles tendon ruptures most commonly occur due to asymptomatic d egeneration in the tendon or as an acute event, often on the sports field or squash court. There may be an audible snap or the patient may feel as if they have been kicked or hit in the back of the leg, although no contact has occurred. Clinically, there is pain and tenderness in relation to the rupture with a palpable gap if examined early. Most commonly, there is an inability to bear weight and a major compromise of plantar flexion. Absence of plantar flexion, when the patient \200\231s calf is squeezed with the patient in the kneeling position, is diagnostic of Achilles tendon rupture. (Simmonds test). Pre-hospital treatment is symptomatic only. The patient should be taken to the emergency department for definitive management. This page intentionally left blank CHAPTER 3 Trauma 280 Spinal injuries Spinal injuries range from simple soft tissue sprains to fractures, stable or unstable, with the potential for spinal cord injury or the presence of established spina l cord injury. In general terms, all patients with an appropriate mechanism of injury shoul d be regarded as having a spinal injury until proven otherwise and should, therefore, be su bjected to spinal immobilization. Spinal injuries commonly follow: - Road traffic collision s - Falls - Gymnastics\trampolining - Rugby/football - Horseriding Road traffic collisions are the most common cause of injury and are responsible for 50% of patients suffering spina l cord injuries. Compres- sion/flexion and extension/rotation are the common forces involve d. Lesser injuries include whiplash injury due to rear end shunts producing flexion followe d by extension. Skiing - Hang-gliding - Aquatic activities - Weights falling onto the back. Whilst the majority of injuries are in the cervical spine, 10% of these patients have a second spinal injury. Falls, in particular, are associated with thoracolumbar fractures. Scrummage injuries in ru gby are commonly associated with cervical spine injury. Aquatic sports, particularly diving into a shallow pool, often produce a combination of head and cervical spine trauma. Histor ically, falls onto the back in coal miners produced major thoracic and thoracolumbar fractu res. Certain criteria must be fulfilled if the spine is to be cleared of any injury at scene (See box opposite). Assessment If there is a high index of suspicion of spinal injury based on the mecha- nism of injury, the spinal column should be protected, unless the patient \200\231s spine can be cleared following the criteria detailed in the box opposite. The patient should not be all owed to get up and, ideally, should be main- tained in the supine neutral position. In the case of road traffic collisions, the neck should be moved to a neutral position and inline spinal stabiliza- tion maintained prior to and during extrication. An inability to achieve a neutral position suggests the possibity of a fracture dislocation, in which case the neck should be maintained in as near neutral position as possible. No attempt should be made to forcibly restrain or fasten down an aggressive, unco-operative patient. Such patients may sometimes tolerate a cervical collar alone, which must be accep ted as \200\230better than nothing \200\231. Such aggression may be the result of hypoxia and, if present, this should be identified and treated. SPINAL INJURIES1 281 Criteria for cleaning spine of injury - There is no altered level of consciousness - The pa tient is not under the influence of alcohol or drugs - There is no midline spinal tendernes s - There are no neurological signs or symptoms - There are no other distracting painful in juries - There is no history of previous spinal injury - The patient does not suffer from a n inflammatory arthropathy such as rheumatoid arthritis or ankylosing spondylitis Segment Representative dematomes Representative myotomes Sensation over detoid Sensation over thumb Sensation over middle finger Sensation over litt le finger Sensation over inner aspect of elbow Sensation around nipple Sensation over xiphi sternum Sensation around umbilicus Sensation around symphysis Sensation in inguinal region Sensation anterior upper thigh Sensation anterior mid thigh Sensation on medial aspect leg Sensation between 1st and 2nd toes Sensation on lateral border of foot Sensation over ischi al tuberosity Sensation around perineum C5 C6 C7 C8 T1 T4 T8 T10 T12 L1 L2 L3 L4 L5 S1 S3 S4/5 Deltoid muscle Wrist extensors Elbow extensors Middle finger flexors Little finger abductio n \200\223 \200\223 \200\223 \200\223 \200\223 Hip flexors Knee exensors Ankle dorsifl exors Long toe extensors Ankle plantar flexors \200\223 \200\223 Fig. 3.19 Motor and sensory levels. Reprinted with permission from Greaves I et al., (2001) . Trauma Care Manual. Hodder Arnold. CHAPTER 3 Trauma 282 The conscious patient may complain of motor weakness or altered sensation, the extent of wh ich will depend on the level of injury. Important anatomical landmarks and their relevance are summarized below (and in Fig. 3.19): - Injuries from C1 \200\2232 \200\224the patient i s unable to breathe because of intercostal and diaphragmatic paralysis and will die unless they receive basic life support Injuries at C3 \200\223C5 \200\224depending on the extent of the injury, the diaphragm may be functional or non-functional due to paralysis of the phrenic nerves. Over a period of time, patients who may initially be able to cope are at risk of developing resp iratory failure due to exhaustion or progression of diaphragmatic deficiency due to spinal cord swelling. Injuries between C5 and C7 \200\224there is complete loss of intercostal function. However, the phrenic nerve and the diaphragm are functional. The patient displays a seesaw pattern of breathing. - Injuries between T1 and L2 \200\224there will be a variab le loss of intercostal muscle function and, therefore, respiratory compromise depending on the level o f cord injury. The higher the level of injury, the greater the deficit. Above the level of T6, there is sufficient loss of sympathetic outflow to produce neurogenic shock. This is ch aracterized by bradycardia, a low blood pressure (usually 70 \200\22380mmHg), and distal pe ripheral vasodilatation. Male patients have priaprism (sustained penile erection). The flaccid paralysis and areflexia associated with a spinal cord injury is commonly referr ed to as spinal shock. This is not \200\230shock \200\231 in the normal pathophysiological sense but a state of electrical interruption to the cord: spinal concussion. This should n ot be confused with neurogenic shock and the term spinal shock is best avoided. In the unconscious patient, there will be no specific complaint of pain and no verbal commu nication regarding motor or sensory deficit. The physical signs detailed above may suggest spinal cord injury. A high index of suspicion and mandatory full spinal immobilization are necessary. Management Primary survey Problems due to spinal injury may be detected during the primary survey. Examples include: - Inadequate breathing and ventilation due to intercostal or phre nic nerve compromise.