Scratches These may comprise either a \200\230very super \201 cial incision \200\231 or a \200\230long, thin abrasion \200\231 \200\224 leave the distinction to an expert. Interpersonal violence \200\224 medicolegal implications Victims of violence frequently at tend ED for treatment of their injuries. Some patients (particularly those who have suffere d domestic violence) may not provide an accurate account of how the injuries occurred and m ay not seek involvement of the police. Classical defense wounds include: \200 Isolated ul na shaft fracture as the arm is raised to protect against blunt injury. Incised wounds on the palmar aspects of the palms and \201 ngers sustained in attempts to protect against knife attack. In cases where the police are involved and where injuries are serious or extensive, the pol ice may arrange to obtain photographs and a forensic physician (police surgeon) may be invo lved in the role of documenting injuries. Most ED patients who have suffered violence do no t see a forensic physician (police surgeon). Therefore, ED staff have a dual role of treati ng injuries and recording them accurately for medicolegal purposes. 404 CHAPTER 9 Wounds, fractures, orthopedics Further assessment of skin wounds Investigation X-ray if there is suspicion of fracture, in volvement of joint, penetration of body cavity or FB. Specify on request forms that a FB is being sought, to allow appropriate views and exposure. Most metal (except aluminum) and gl ass objects > 1mm in diameter will show up on X-ray. Some objects (eg wood) may not: USS ma y demonstrate these. CT or MRI are also occasionally helpful. Note: X-ray all wounds from glass that fully penetrate the skin During X-ray, use radio-opa que markers (eg paper clip) taped to the skin to identify the area of concern. Wound swabs for bacteriology are unhelpful in fresh wounds, but obtain them from older wounds showing s igns of infection. By far the most important investigation is: Wound exploration under appr opriate anesthesia Allows full assessment and thorough cleaning of wounds that extend fully through the skin. Do not explore the following wounds in the ED: \200 Stab wounds to the neck, chest, abdomen, or perineum. \200 Compound fracture wounds requiring surgery in th eater. \200 Wounds over suspected septic joints or infected tendon sheaths. \200 Most w ounds with obvious neurovascular/tendon injury needing repair. \200 Other wounds requirin g special expertise (eg eyelids). Obtain relevant X-rays beforehand. Adequate anesthesia is essential \200\224 in adults LA (eg 1 % plain lidocaine) is often suitable ( b p.282), bu t document any sensory loss \201 rst (if there is altered sensation, presume nerve injury and refer for formal exploration in theater). Do not inject LA into the edges of an infect ed wound: it will not work in that acidic environment and it may spread the infection. GA m ay be the preferred option for treating some wounds in young children. Inspect wounds for F Bs and damage to underlying structures. Most problems with wound exploration relate to blee ding. If it proves dif \201 cult to obtain a good view: \200 Obtain a good light and an assistant. The assistant retracting on a stitch placed on either side of the middle of the wound allows full exposure. \200 Press on any bleeding point for \211 1min, then look a gain. Lidocaine with adrenaline ( b p.283) is useful in scalp wounds which are bleeding pro fusely. If bleeding continues, consider a tourniquet for up to 15min. Consider a sphygmomanometer B P cuff in \202 ated above systolic pressure (after limb elevation for 1min) on the limbs, or a \200\230 \201 nger \200\231 of a sterile rubber glove may be used on \201 ngers or toes. Never leave a patient alone with a tourniquet on, lest it is forgotten. Ensure remov al of the tourniquet afterwards. Record the time of application and removal. If these measures fail, refer for specialist exploration in theater. Do not blindly \200 \230clip \200\231 bleeding points with artery forceps, for fear of causing iatrogenic neuro vascular injury. Sometimes, small blood vessels in the subcutaneous tissues can be safely l igated using an appropriate absorbable suture (eg 4/0 or 6/0 Vicryl (braided polyglactin) o r Dexon). 405 FURTHER ASSESSMENT OF SKIN WOUNDS The approach to foreign bodies FBs within soft tissues can cause pain, act as a focus for i nfection, or migrate and cause problems elsewhere. Therefore, remove FBs from recent wounds where possible, particularly if lying near a joint (but if FB is within a joint, refer to the orthopedic team for formal exploration and removal). FBs which can be seen or felt or a re causing infection are usually best removed. Finding FBs is frequently dif \201 cult wit hout a bloodless \201 eld and good light. It may be appropriate to leave some FBs, such a s gunshot deeply embedded in buttock soft tissues (antibiotic cover advised). However, most FBs of any size not removed in the ED warrant specialist consideration. Patients not infrequently present with symptoms relating to (suspected) FBs under old heale d wounds. In these circumstances, refer to an expert for exploration under appropriate cond itions. Fishhooks The barbs on some \201 shhooks can make removal dif \201 cult. In some cases, it may be necessary to push a \201 shhook onwards (under LA) and thus out through the ski n \200\224 wire cutters can then cut through the hook below the barb and allow release. We ar eye protection when doing this. There are alternative methods for removing \201 shhooks. Smaller \201 shhooks that are relatively super \201 cially embedded can sometimes be pulled back and removed through the entry wound once a hollow needle has been advanced alongside the hook to cover the barb. 406 CHAPTER 9 Wounds, fractures, orthopedics Wound management Wound cleaning Thoroughly clean all wounds irrespective of whether closure is contemplated, to d risk of infection. The standard agent used for wound cleaning is 0.9 % (normal) saline, possibly preceded by washing using tap water. Aqueous chlorhexidine or 1 % cetrimide solutions are sometimes used. Do not use hydrogen peroxide or strong povidone iodine solutions. Wounds ingrained with dirt may respond to pressure saline irrigation (19 G needle attached to 20mL syringe), or may require to be scrubbed with a toothbrush (use go ggles to d chance of conjunctival \200\230splashback \200\231). Devitalized or grossly con taminated wound edges usually need to be trimmed back (debrided), except on the hand or fac e. If dirt or other foreign material is visible despite these measures, refer to a speciali st, who may choose to leave the wound open. Wound closure There are three recognized types of wound closure: Primary closure Surgical closure (by whatever physical means) soon after injury. Secondary closure No intervention: heals by granulation (secondary intention). Delayed primary closure Surgical closure 3 \200\2235 days after injury. If there is no underlying injury or FB, treat fresh wounds by primary closure as soon as po ssible. Accurate opposition of wound edges and obliteration of dead space provides the best cosmetic outcome with least infection risk. Wounds not usually suitable for primary closure in the ED include: \200 Stab wounds to th e trunk and neck. \200 Wounds with associated tendon, joint or neurovascular involvement. \200 Wounds with associated crush injury or signi \201 cant devitalized tissue/ skin loss. Other heavily contaminated or infected wounds. \200 Most wounds > 12hr old (except clean facial wounds). Methods of closure If in doubt, sutures are usually the best option (see opposite). Steri-Strips \204 Adhesive skin closure strips allow skin edges to be opposed with even di stribution of forces. They are inappropriate over joints, but useful for pretibial lacerati ons, where skin is notoriously thin and sutures are likely to \200\230cut out \200\231. Be fore application, make Steri-Strips \204 stickier by applying tincture of benzoin to dry s kin around the wound. Leave 3 \200\2235mm gaps between Steri-Strips \204 . See also b Preti bial lacerations, p.481. Skin tissue glue Particularly useful in children with super \201 cial wounds and scalp wounds. After securing haemostasis, oppose the dried skin edges befor e applying glue to the wound. Hold the skin edges together for 30 \200\22360sec to allow th e glue to set. Ensure that glue does not enter the wound. Do not use tissue glue near the e yes or to close wounds over joints. 407 WOUND MANAGEMENT Staples Quick and easy to apply, particularly suited to scalp wounds. Staple-removers are r equired for removal. Sutures ( \200\230stitches \200\231 or \200\230ties \200\231) Traditional and most commonl y used method to achieve primary closure. Oppose the skin aiming for slight eversion of wou nd edges, using strong non-absorbable inert mono \201 lament suture material attached to c urved cutting needles (eg prolene, polypropylene or nylon) with knots tied on the outside. Interrupted simple surgical knots tied using instruments are relatively easy, economical of thread and have a low risk of needlestick injuries. Specialized continuous sutures (eg sub cuticular) are not appropriate for wounds in the ED. The size of thread used and time to re moval vary according to the site. Use absorbable sutures (eg Vicryl) on the lips and inside the mouth. Absorbable sutures may also be used to close subcutaneous tissues to d chance o f haematoma and infection. Suture choice and time to removal are given in Table 9.1 . Table 9.1 Suture choice and time to removal Part of body Suture and size Time to removal 2/0 or 3/0 non-absorbable \200 glue or staples 7 days Scalp 3/0 non-absorbable \200 10 days Trunk 4/0 non-absorbable \200 10 days Limbs Hands 5/0 non-absorbable 10 days Face 5/0 or 6/0 non-absorbable 3 \200\2235 days * Lips, tongue, mouth Absorbable eg 6/0 Vicryl/Dexon \200\223 \200 One size smaller may be appropriate for children. * Sutures may be replaced with Ste ristrips at 3 days. Key points when suturing The technique of a basic instrument tie is shown in Figs 9.1 \200 \223 9.6 . \200 Tie sutures just tight enough for the edges to meet. \200 Do not close a wound under tension. \200 Handle the skin edges with toothed forceps only. \200 Avoid too many deep absorbable sutures. \200 Mattress sutures are useful on some deep wounds, but avoid on hands and face. Dispose of sharps as you use them \200\224 do not make a collection. \200 Use strategic initial sutures to match up obvious points in irregular wounds. If a suture does not look right \200\224 take it out and try again. \200 If it still doe s not look right \200\224 get help! 408 CHAPTER 9 Wounds, fractures, orthopedics Fig. 9.1 Fig. 9.2 Fig. 9.3 409 WOUND MANAGEMENT Fig. 9.4 Fig. 9.5 Fig. 9.6 410 CHAPTER 9 Wounds, fractures, orthopedics Tetanus prophylaxis Tetanus causes many deaths in the developing world. Occasional cases st ill occur in the UK. Injecting drug users are at risk (particularly if using SC or IM route s). The exotoxin tetanospasmin produced by the anaerobic, spore-forming Gram + ve bacillus Clostridium tetani interferes with neuro- transmission ( b p.236). Spore proliferation and toxin production is likely in heavily contaminated wounds with devitalized tissue. However, any wound (including a burn) is a potential risk: always ensure tetanus prevention. Tetanu s immunization program Standard active immunization involves an initial course of 3 IM or d eep SC doses of 0.5mL tetanus toxoid (formalin inactivated toxin) given at monthly interval s starting at 2months of age, followed by booster doses at 4 and 14years. A full course of 5 doses is considered to result in lifelong immu- nity. From 2006 in the UK, combined tetan us/diphtheria/inactivated polio vaccine replaced previous tetanus/diphtheria vaccine for ad ults and adoles- cents. Immunization required after injury depends upon immunization status of the patient and the injury. Inadequate immunity against tetanus is particu- larly likel y in immigrants, the elderly, patients with d immunity and those who have refused vaccinati on. Anti-tetanus prophylaxis The need for tetanus immunization after injury depends upon a patient \200\231s tetanus immunity status and whether the wound is \200\230clean \200\231 or \200\230tetanus prone. \200\231 The following are regarded as \200\230tetanus prone \200\231: \200 Heavy contamination (especially with soil or feces). \200 Devitalized ti ssue. \200 Infection or wounds > 6hr old. \200 Puncture wounds and animal bites. Follow Department of Health guidelines. See www.dh.gov.uk Do not give tetanus vaccine if there is a past history of a severe reaction: give HATI. Pregnancy is not a contraindication to giv ing tetanus prophylaxis. Patient is already fully immunized If the patient has received a f ull 5-dose course of tetanus vaccines, do not give further vaccines. Consider human anti-te tanus immunoglob- ulin ( \200\230HATI \200\231 250 \200\223500units IM) only if the risk is especially high (eg wound contaminated with stable manure). Initial course complete, boost ers up-to-date, but not yet complete Vaccine is not required, but do give it if the next do se is due soon and it is convenient to give it now. Consider human anti-tetanus immunoglob- ulin ( \200\230HATI \200\231 250 \200\223500units IM) in tetanus prone wounds only if the risk is especially high (eg wound contaminated with stable manure). Initial course incomple te or boosters not up-to-date Give a reinforcing dose of combined tetanus/diphtheria/polio vaccine and refer to the GP for further doses as required to complete the schedule. For tet anus- prone wounds, also give one dose of HATI at a different site. The dose of HATI is 250 units IM for most tetanus prone wounds, but give 500units if > 24hr have elapsed since inju ry or if there is heavy contamination or following burns. Not immunized or immunization sta tus unknown or uncertain Give a dose of combined tetanus/diphtheria/polio vaccine and refer to the GP for further doses as required. For tetanus-prone wounds, also give one dose of H ATI (250 \200\223500units IM) at a different site. 411 ANTIBIOTIC PROPHYLAXIS Antibiotic prophylaxis Antibiotics are not required for most wounds. Thorough cleaning is t he best way of preventing infection. After cleaning and closure, consider oral antibiotic p rophylaxis (eg penicillin + \202 ucloxacillin) for certain wounds: compound \201 ngerti p fractures and wounds in those at extra risk (eg valvular heart disease, post-splenectomy) . Co-amoxiclav has activity against anaerobes, and is appropriate for bites and heavily con taminated or infected wounds: leave these wounds open. Antibiotics are indicated for penetr ating injuries which cannot be properly cleaned ( b Puncture wounds, p.419). Although a sci enti \201 c basis is lacking, antibiotics are frequently used for wounds > 6hr old, comple x intra-oral wounds and in workers at high risk (gardeners, farmers, \201 shermen). 412 CHAPTER 9 Wounds, fractures, orthopedics Wound aftercare Dressings A large variety of dressings are available, with little scienti \201 c evidence to help choose between them: choice depends upon personal preference/ preju dice and local departmental policy. A dry non-adherent dressing will protect most wounds fr om inadvertent contamination in the \201 rst few days. Dressings are not usually necessar y for facial and scalp wounds. Beware circulatory problems resulting from encircling dressi ngs/bandages applied too tightly to digits or other parts of limbs. Burns dressings are con sidered in b p.396. General advice Advise to keep wounds clean and dry for the \201 rst few days. Limb wounds require rest and elevation for the \201 rst 24hr. After this, restrict movements to avoi d undue stress causing the suture line to open up (especially where the wound is over a joi nt). Warn all patients to return if features of infec- tion develop (redness, i pain, swell ing, fever, red streaks up the limb). Approximate times to suture removal are shown on Tabl e 9.1 \200\224 these need to be adjusted to meet the occasion. For example, sutures over j oints are sensibly left 14 days to avoid dehiscence. Similarly, sutures may need to be left in for longer where wound healing may be delayed (eg DM, the elderly, malnourished, and th ose on steroids). Local policy will dictate where suture removal occurs (GP surgery or ED). If available, discharge with illustrated instructions about wound care and suture removal. This may particularly help patients with memory impairment or under the in \202 uence of alcohol. Speci \201 c advice Patients often ask when to return to work. If a question of personal s afety or safety of the public or work colleagues is involved, advise to return to usual dut ies only once the wound has healed and sutures are out. This particularly applies to food h andlers and some workers with machinery. Provide a sickness certi \201 cate for the patien t \200\231s employer as appropriate. Review and delayed primary closure Arrange review of heavily contaminated wounds, infected wounds not requiring admission, and other wounds at particular risk of infection at \211 \210 36hr. Check T * and look for wound discharge and erythema, ascending lymphangitis, and regional lymphadenopathy. Systemic symptoms or evi- dence of spreading infection despite o ral antibiotics are indications for admission for wound toilet, rest, elevation, and IV ant ibiotics. Treat other wounds deemed initially to be at less risk of infection, but not suit able for primary closure, with cleaning, light packing/dressing, and review at 3 \200\2235 days. Ideal dressings keep wounds moist, so consider the need for dressing changes prior to closure. If the wound is clean, employ delayed primary closure after wound cleaning and de bridement under appropriate anesthesia. If despite further cleaning and debridement, foreig n material remains ingrained, consider if the patient requires admis- sion. If there is muc h exudate and evidence of local infection, take wound swabs for culture, consider removing the sutures, clean and redress the wound, give oral antibiotics, and arrange further review . Do not use \200\230loose closure \200\231 in contaminated wounds. The technique has all the risks of infection combined with a poor cosmetic result. 413 INFECTED WOUNDS AND CELLULITIS Infected wounds and cellulitis Wound infection after injury Although prompt treatment with cleaning and primary closure will d risk, any wound may become infected. The risk of infect ion is i by: \200 Contamination (eg bites) and foreign material (including excess sutures ). \200 Haematoma. \200 Devitalized tissue. \200 Poor nutrition and d immunity (eg st eroid therapy). Pain is usually the \201 rst clue to wound infection. Note that many soft tissue infections (cellulitis, erysipelas) occur in the absence of an obvious wound (see b Cellulitis and erysipelas, p.528). Examination Indicates the extent of the infection. Eryt hema and tenderness limited to the area around the wound suggest localized infection. Swell ing and \202 uctuation are evidence of a collection of pus. Remove all sutures, together with pus and devitalized tissue, under appropriate anesthetic. Send wound swabs for culture . Consider the possibility of a retained FB \200\224 X-ray/explore as appropriate. After t horough cleaning, leave the wound open, cover with a dressing and arrange review with a dre ssing change in 36hr. Consider the need for antibiotics (eg co-amoxiclav) particularly for cellulitis, for the immunocompromised and for patients at particular risk (eg those with pr ostheses and valvular heart disease). Consider admission (for rest, elevation, analgesia, wound/blood cultures, and IV antibiotic s) in patients with one or more of the following: \200 A red line spreading proximally (a scending lymphangitis). \200 Regional (sometimes tender) lymphadenopathy. \200 Pyrexia > 38 * C. \200 Systemic upset. Soft tissue crepitus is ominous, suggesting gas-forming or ganisms ( b p.237). Infected hand wounds A particularly common problem is an infected wound on the dorsum of th e hand over a MCPJ after a punch injury. These are often bite wounds, presenting late with infection in the region of the joint. Refer for explora- tion/washout in theater and antibi otics ( b p.416). Infected facial wounds Take infected wounds of the cheek very seriously. They pose a signi \201 cant threat of sepsis spreading intracranially, resulting in papilloedema and ophthal moplegia due to cavernous sinus thrombosis. Adopt a low threshold for referring for admissi on and IV antibiotics. Infected surgical wounds Infection of a recent surgical wound after a planned procedure is a rel- atively common complication. In addition to the possible threat to life, wound infec tion can have disastrous implications as far as the success of the preceding operation is c oncerned (eg hernias may recur). Contact the team which performed the surgery as soon as po ssible, to allow the surgeon to treat the complication. 414 CHAPTER 9 Wounds, fractures, orthopedics Bite wounds Bites and infection Bites cause contaminated puncture wounds, contaminated crus h injuries, or both. All carry a high risk of bacterial infection, some also a risk of vira l or other infections (eg rabies). Bacterial infection is particularly likely in: \200 Puncture wounds (cat/human bites). \200 Hand wounds, wounds > 24hr old. \200 Wounds in alcoholics, diabetics, or the immuno compromised. Bacteria responsible include: streptococci, Staphylococcus aureus , Clostridiu m tetani , Pasteurella multocida (cat bites/scratches), Bacteroides , Eikenella corrodens ( human bites). Approach Establish what the biting animal was, how long ago and where the bite occurred. Ob tain X-rays if fracture, joint involvement (look for air) or radio-opaque foreign body (FB) (tooth) is suspected. Management of bite wounds Cleaning Explore fresh bite wounds under appropriate anesthetic, debride and clean thoroughly with \200\230normal \200\231 saline (or by washing using tap water). Refer sig- ni \201 cant facial wounds and wounds involving tendons or joints to a specialist. Closure Cosmetic considerations usually outweigh risks of infection for most facial wounds, so aim for primary closure. Elsewhere, choose between primary or delayed primary closure \200\224 the latter is usually preferred in bite wounds affecting limbs, due to the increas ed risk of infection. Do not close puncture bite wounds that cannot be satisfactorily irrig ated. Antibiotic prophylaxis Deciding whether or not to employ prophylactic antibiotics for bite wounds can be dif \201 cult and is controversial. Many departments advocate prophylactic a ntibiotics for all bite wounds. One approach is to give antibiotics for patients with any o f the following: \200 Puncture bites. \200 Crush injuries with devitalized tissues. \200 Bites to the hand, wrist, or genitals. \200 Bites that are primarily closed. \200 Bites from humans, cats, and rats. \200 Bitten individuals who are immunocompromised (eg immunosuppressed, diabetes, post-splenectomy, rheumatoid arthritis, those with prosthetic joints). Co-amoxiclav is an appropriate broad spectrum agent, effective against Strep , Staph , Past eurella , and Eikenella . Alternatives for patients allergic to penicillin/amoxicillin incl ude doxycycline + metronidazole or (especially if pregnant) ceftriaxone alone. Do not use erythromycin or \202 ucloxacillin alone as prophylaxis. 415 BITE WOUNDS Tetanus Bite wounds are tetanus-prone. Give prophylaxis accordingly (b p.410). Rabies (cove red fully in b p.249) Rabies results after the \200\230bullet-shaped \200\231 RNA rhabdovi rus present in saliva of infected animals is transmitted to humans via a mucous membrane or skin break. After thorough cleaning, refer all patients who might have been in contact wit h a rabid animal to an Infectious Diseases specialist. Obtain further help from the Virus R eference Laboratory, London (020 8200 4400). The long incubation period of the rabies virus (14 \200\22390 days) allows successful post-exposure prophylaxis at even a relatively late stage, according to agreed guidelines. Hepatitis, HIV Consider possible risks of hepatitis B, C, and HIV in anyone who presents fo llowing a human bite and treat accordingly (see under b Needlestick injury, p.418). Quantif ying risks can be dif \201 cult, particularly for example, in \200\230reverse \201 ght bites \200\231 ( b p.416) where the other person involved may be unknown. If in doubt, take a baseline blood sample for storage (to allow later testing if necessary) and provide cove r against hepatitis B. Treatment of infected bites Most bacterial infections occur > 24hr after injury and are due to staphylococci or anaerobes. Pain, in \202 ammation, swelling regional lymphadenopat hy within 24hr suggests P. multocida infection. Take wound swabs of all infected wounds, th en treat with cleaning, elevation, analgesia, and antibiotics. Oral co-amoxiclav and outpat ient review at \211\210 36hr is appropriate for localized wound infection with no systemic symptoms and no suspected underlying joint involvement. Refer patients with spreading infe ction for IV antibiotics and admission. Septicaemia is uncommon after bite injury, but has been reported with the Gram \200\223ve bacillus Capnocytophaga canimorsus , previously known as Dysgonic Fermenter 2 (DF-2). Infec tion produces a severe illness with septicaemia and DIC, often in immunocompromised (splene ctomized individuals, diabetics, or alcoholics). Take wound swabs and blood cultures, then give IV antibiotics and refer. Prevention of dog bites Injury prevention measures aimed at preventing children from being bitten includes legislation relating to \200\230dangerous dogs \200\231 and education. Chi ldren may be taught the following: \200 To treat dogs with respect. \200 To avoid distu rbing a dog that is sleeping, eating, or feeding puppies. \200 To avoid shouting or runni ng in the presence of a dog. \200 Not to approach or play with unfamiliar dogs. 416 CHAPTER 9 Wounds, fractures, orthopedics Speci \201 c bites and stings Human bites and \200\230 \201 ght bites \200\231 Many huma n bites occur \200\230in reverse \200\231, when an individual punches another in the mouth , causing wounds on the dorsum of the hand over the MCPJs. Underlying joint involvement is common and may progress to septic arthritis unless treated aggressively with exploration, i rrigation and anti- biotics. Refer all patients for this. Consider hepatitis B, C, and HIV, give appropriate prophylaxis ( b Needlestick injuries, p.418) and arrange counseling. Tick bites Ticks are recognized vectors of a number of exotic diseases worldwide. In the UK , patients often present with embedded sheep ticks. Remove ticks by gentle traction with bl unt forceps applied as close to the skin as possible. Avoid traditional folklore methods of removal, which may cause the tick to regurgitate, promoting infection. In areas where Lyme disease is endemic (see b p.231), some physicians provide antibiotic prophylaxis with amox icillin. Insect bites Minor local reactions are common. Treat with ice packs, rest, elevation, analg esia and antihistamines (eg chlorphenamine PO 4mg tds or a non- sedating alternative such a s loratadine PO 10mg od). Occasionally, insect bites may be complicated by cellulitis and a scending lymphangitis requiring antibiotics ( b Infected wounds and cellulitis, p.413). Wasps and honey bee stings May cause local reactions or anaphylaxis \200\224treat promptly (b p.42). Flick out bee stings left in the skin. Treat local reactions as for insect bites. Jelly \201 sh stings and \201 sh spines Most jelly \201 sh in UK coastal waters are har mless. Wash the bitten part in sea water then pour vinegar (5 % acetic acid) over it to neu tralize the toxin. Fish spines (typically Weever \201 sh) produce a heat labile toxin, which may be neutrali zed by immersion in hot water for 30min. Occasionally, tiny parts of the \201 sh spines b ecome embedded and cause long-term irritation. Localizing and removing these tiny FBs is di f \201 cult, so refer to an appropriate expert. Contact with other wild animals Contact with rats \200\231 urine may cause leptospirosis (W eil \200\231s disease) \200\224 see b p.239. Provide prophylactic doxycycline to anyone wh o presents following an episode of signi \201 cant exposure (eg immersion in river water o r sewage). Unusual bites may pose speci \201 c threats, which infectious disease specialis ts will advise about (eg monkey bites may cause herpes simplex infection: give prophylactic oral aciclovir). Bats may carry rabies ( b p.249). 417 SPECIFIC BITES AND STINGS Snake bites The European adder is the only native venomous snake in the UK. It is gray/brow n, with a V-shaped marking behind the head and dark zig-zag markings on the back. Most bite s occur in summer. Venom is injected by a pair of fangs. The venom contains enzymes, polype ptides, and other low molecular weight substances. Only 50 % of bites cause envenomation. Features Envenomation causes pain and swelling: look for 2 puncture marks 1cm apart. Vomiti ng, abdominal pain, diarrhea, and hypotension may follow. Investigation Check urine, perform an ECG, and take blood for: FBC, U&E, LFTs, coagulation screen, and D-dimer. Treatment \200 Prehospital : rest (and avoid interference with) the bitten part. \200 C lean and expose wound, give analgesia and IV \202 uids for hypotension. \200 Treat anap hylaxis urgently according to standard guidelines ( b Anaphylaxis, p.42). Give prophylactic antibiotics (eg co-amoxiclav) and ensure tetanus cover. Antivenom has its own risk of anaphylaxis, but may be given for signs of systemic envenomin g, hypotension, WCC > 20 \227 10 9 /L, ECG changes, elevated cardiac enzymes, metabolic ac idosis or signi \201 cant limb swelling (eg past the wrist for bites on the hand, or past the ankle for bites on the foot, within 4 hr). Obtain speci \201 c advice from a Poisons Information Center ( b p.181). \200 Observe fo r least 24hr, all patients who have any symptoms after snake bite. 418 CHAPTER 9 Wounds, fractures, orthopedics Needlestick injury A needlestick injury is a specialized puncture wound. In a clinical sett ing, it may represent failure to follow universal precautions ( b p.32) and should provoke a review of policy and procedure. Many infective agents have been transferred by needlestic k: Blastomycosis, Brucellosis, Cryptococcosis, Diphtheria, Ebola fever, Gonorrhea, Hepatiti s B, Hepatitis C, Herpes zoster, HIV, Leptospirosis, Malaria, Mycobacteriosis, Mycoplasmosi s, Rocky Mountain spotted fever, Scrub typhus, Sporotrichosis, Staph aureus , Strep pyogene s , Syphilis, Toxoplasmosis, TB. In practice, the principal risks are hepatitis B and C and HIV. The risk of acquiring hepatitis B following a needlestick from a carrier has been est imated at 2 \200\22340 % . All hospital workers should be immunized against hepatitis B and have regular checks of their antibody status. The risk of hepatitis C is believed to be 3 \200\22310 % . In contrast, the risk of acquiring HIV after needlestick with HIV + ve sourc e is much less (estimated at 0.2 \200\2230.5 % , but may be higher if signi \201 - cant vo lumes are injected). There is a small ( \211\210 0.03 % ) risk of HIV transmis- sion after mucocutaneous exposure (ie exposure of cuts, abrasions, mucous membranes including the eye ). The (small) risk of acquiring HIV following needlestick injury from a person with known HIV may be reduced further by post-exposure prophylaxis, but time is of the essence (see be low). No proven post-exposure prophylaxis currently exists for hepatitis C. Preventing need lestick injuries and exposure to these viruses is therefore crucial. Management \200 Wash the wound with soap and water. \200 Ensure tetanus cover. \200 Ensure hepatitis B cove r: if not previously immunized, give hepatitis B immunoglobulin and start an active immuniz ation course (give \201 rst vaccine in the ED and arrange subsequent doses). If previousl y immunized, check antibody titres. If satisfactory, take no further action. If low, give b ooster vaccine. If very low give both immunoglobulin and start vaccine course. Many local n eedlestick policies advise obtaining informed consent from the source patient, prior to tak ing blood to check hepatitis and HIV status. In practice, the identity of the source patien t is not always clear: do not withhold hepatitis B prophylaxis if there is any doubt. If the source patient is known to be (or suspected of being) HIV + ve, follow local guideli nes and/or refer immediately to an infectious dis- eases specialist to discuss post-exposur e prophylaxis and follow-up. Follow Department of Health guidance on www.dh.gov.uk Combined prophylaxis therapy (eg 1 Truvada tablet od and 2 Kaletra tablets bd \200\223 ie 24 5mg tenofovir od + 200mg emtricitabine od + 400mg lopinavir bd + 100mg ritonavir bd) is mos t effective if started within an hour of exposure, but may be worth considering up to 72hr. However, prophylaxis has side effects, especially diarrhea. Involve both healthcare worker and a local expert in deciding whether or not to start prophylaxis. Either way, advise the patient to use barrier contraception and not to give blood as a donor until subsequent HIV seroconversion has been ruled out. Take baseline blood for storing (serology for possible future testing), and in the case of a possible HIV source patient, also take FBC, U&E, LFTs, and amylase). If the incident occurred in hospital, report it to Occupational Health. 419 PUNCTURE WOUNDS Puncture wounds Puncture wounds are small skin wounds with possible deep penetration. Stab wounds to the trunk and neck are considered elsewhere ( b Penetrating chest injury, p. 340). Puncture wounds often involve the sole of the foot, patients having trodden on a nail . Examine to exclude neurovascular injury, then obtain an X-ray looking for FB. If signi \201 cant foreign material is present radiologically, or the patient has associated fractur e, tendon injury, or neurovascular de \201 cit, refer for formal exploration and cleaning in theater under a bloodless \201 eld. Otherwise: \200 Irrigate and clean other wounds under local anesthetic (LA) where possible (consider nerve blocks). For wounds to the sole of the foot this may be impractical. As a compromise, immerse foot in warm anti- septic (eg povidone iodine solution) for 15min. Apply a dressing and advise review/follow-up with GP as appropriate. \200 Ensure adequate tetanus cover ( b Tetanus prophylaxis, p.410). \200 Prescribe simple analgesia. \200 S trongly consider prophylactic oral antibiotic cover (eg co-amoxiclav). Some puncture wounds may become infected despite treatment. This may be due to retained foreign material in the wound. Pseudomonas osteitis is an uncommon, but recognized complication of puncture wounds to the foot, particularly where a nail has gone through training shoes to cause the wound. Refer infected wounds for formal exploration and irrigation. 420 CHAPTER 9 Wounds, fractures, orthopedics How to describe a fracture Clear, precise, complete descriptions of fractures aid accuracy and save time when referring patients. System for describing fractures \200 State the age of the patient and how the injury occu rred. \200 If the fracture is compound, state this \201 rst (and Gustilo type \200\224 b p.422). Name the bone (specify right or left, and for the hand, whether dominant). \200 Describe the position of the fracture (eg proximal, supracondylar). \200 Name the type of fracture (eg simple, spiral, comminuted, crush). \200 Mention any intra-articular involvement. \200 Describe deformity (eg displacement, angulation) from anatomical position. State grade or classi \201 cation of fracture (eg Garden IV). \200 State presence of any complications (eg pulse absent, paraesthesia, tissue loss). Other injuries and medical problems. Example using this system \200\23029 year old male mo torcyclist with a compound fracture of the left humerus. It is a transverse fracture of the humeral shaft and is Gustilo type I compound and minimally displaced with no neurovascular compromise \200 \200\231 Type of fracture Simple Single transverse fracture of bone with only 2 main fragments. Obli que Single oblique fracture with only 2 main fragments. Spiral Seen in long bones as a resu lt of twisting injuries, only 2 main fragments. Comminuted Complex fracture resulting in > 2 fragments. Crush Loss of bone volume due to compression. Wedge Compression to one area of bone resulting in wedge shape (eg vertebra). Burst Comminuted compression fracture with sc attering of fragments. Impacted Bone ends driven into each other. Avulsion Bony attachment of ligament or muscle is pulled off. Hairline Barely visible lucency with no discernible di splacement. Greenstick Incomplete fracture of immature bone follows angulatory force, with one side of the bone failing in compression, the other side in tension. Torus/buckle Kinkin g of the metaphyseal cortex follows axial compression. Plastic deformation Deformation beyo nd the elastic limit but below the fracture point results in bending of bone microfractu res (not apparent on X-ray). Pathological Fracture due to underlying disease (eg osteoporos is, metastasis, Paget \200\231s disease). 421 HOW TO DESCRIBE A FRACTURE Stress Certain bones are prone to fracture after repetitive minor injury. Fracture-dislocat ion Fracture adjacent to or in combination with a dislocated joint. Deformity Describe defo rmity using the terms displacement, angulation and rotation. Displacement ( \200\230transla tion \200\231) Describe the relative position of two bone ends to each other. Further descr ibe the direction that the distal fragment is displaced from the anatomical position (eg vo lar, lateral). Also estimate the degree of apposition of the bone ends (eg 50 % ). Angulati on This is usually described in terms of the position of the point of the angle (eg posteri or angulation means that the distal fragment is pointing anteriorly). This can sometimes be confusing. Although a little long-winded, one way to avoid confusion is to describe the di rection in which the distal part points, relative to the anatomical position (eg a Colles \200\231 fracture may be described as a \200\230fracture of the distal radius in which the distal fragment points dorsally \200\231). Try to measure the angle on X-ray. Rotation Des cribe the degree of rotation from the anatomical position, in terms of the direction (eg ex ternal or internal rotation) in which the distal part has moved. Fractures \200\224 the role of osteoporosis Osteoporosis is an important factor in a signi \201 cant proportion of fractures seen in the ED. The following fractures are frequently (but by no means exclusively) associated with osteoporosis: \200 Colles \200\231 fracture ( b p.444). \200 Fracture of surgical neck of humerus ( b p.459). \200 Lumbar spine ve rtebral fracture. \200 Fracture of neck of femur ( b p.470). \200 Pubic rami fracture ( b p.466). Patients with post-menopausal osteoporosis may be treated with a biphosphonate i n an attempt to d risk of future fractures, but do not commence this treatment in the ED.