746 \200 a m u a r t d n a s c i d e a p o h t r O Bright clasp of her whole hand around my \201 nger My daughter, as we walk together now. All my life I \200\231ll feel a ring invisibly Circle this bone with shining \200 Stephen S pender To My Daughter 747 Limb surgery in bloodless \201 elds This can be achieved with pneumatic tourniquets, whic h must have adequate width and curve, and be applied for as brief a time as possible.278 \200\230Bruner \200\231s rules \200\231: These minimize risk of ischaemic limb changes. \200 Width of tourniquet: 10cm for the arm; 15cm for legs. \200 Apply to the upper arm, or mid/upper thigh. \200 Use \211 2 layers of orthopedic wool to provide adequate paddin g (make sure it does not get wet with the skin preparation \202 uid, which should be aque ous, so that if wetting happens inadvertently, \200\230chemical burns \200\231 do not occu r). \200 In \202 ation \200\224arm: 50 \200\223100mmHg above systolic BP; leg: double sy stolic BP. \200 De \202 ation \200\224must be within 2h. \200 Re-application after onl y brief reperfusion is inadvisable.279 \200 Avoid heating the limb (cooling is better, if feasible).280 \200 Apply only with the utmost caution to an unhealthy limb. \200 Ensur e the apparatus is calibrated weekly, and is well maintained. \200 Document duration and pressure of tourniquet use. a m u a r t d n a s c i d e a p o h t r O Fig 1. Procedure for the evacuation of a subungual haematoma. Hand incisions \200\224 \201 g 2 A: pulp space drainage; B & B1: lavage of \202 exor ten dons; C: drainage of radial bursa; D: drainage of the ulnar bursa; E & E1: for the mid-palm ar space; F: drainage of the thenar space. Fig 2. Fractures in the hand Metacarpal fractures The base of the 2nd and 3rd metacarpals (MCs) fo rm the functional center of the hand around which the movement of the hand is centered. Thu s, whilst malalignment and imperfect reduction may be tolerated in the 5th MC (<40o volar a ngulation), far less is permitted in the 2nd MC (<10o). The 5th metacarpal is most commonly involved, often from a punching injury. Managment may vary depending on whether the fractu re is in the head/neck/ shaft or base of the MC, however, stable closed fractures can be ma naged in a splint/cast for 2 weeks, with the wrist in partial extension (20 \200\22330 ), MCP joints in 70 \200\22390o \202 exion with \201 ngers in extension. Unstable fract ures may re- quire K-wires/ORIF.281 Longer periods of splinting in plaster or \200\230boxi ng glove \200\231 bandage can cause a stiff hand, eg from joint adhesions/contracture, \202 exor tendon \201 brosis and collateral ligament shortening. 748 \200 a m u a r t d n a Refer any fractures with obvious rotational deformity (a clinical, not a radio- logical dec ision), as this can be disabling. Rotational fractures disclose them- selves by producing a rotation of the \201 ngers \200\224see BOX; they usually require operative \201 xation (plate & screws), as do fractures of \211 2 metacarpals. \200\207Beware wounds overlying metacarpophalangeal joints (often from the teeth of the pu nched victim, as they are contaminated, and may communicate with the joint). Fractures of t he proximal phalanx Spiral or oblique fractures occurring at this site are likely to be ass ociated with a rotation deformity \200\224and this must be corrected (see BOX). Often, the only way to do this accurately is by open reduction and \201 xation, eg with a single com pression screw.282 Middle phalanx fractures Manipulate these; splint in \202 exion over a malleable metal splint, strapping the \201 nger to its neighbor ( \200\230neighbor strap ping \200\231). The aim is to control rotation, which interferes with later \201 nger \202 exion. Distal phalanx fractures may be caused by crush injuries and are often open. If closed, symptoms may be relieved by trephining the nail to reduce swelling. Rarely, split skin grafts from the thenar eminence may be needed for partial amputations of the \201 ng er tip.1 283 Mallet \201 nger The tip of the \201 nger droops because of avulsion of th e extensor tendon \200\231s attachment to the terminal phalanx or rupture of the terminal p art of the tendon. If the avulsed tendon includes a piece of bone, union is made easier \200\224using a special splint, eg with 0 of extension. Use for 6 weeks.284 Sur- gical in tervention may be indicated if the fracture fragment is >30% of the joint surface.285 Poore r outcome is associated with delay in splinting. Gamekeeper \200\231s thumb This is so-call ed because of the laxity of the ulnar col- lateral ligament of the metacarpophalangeal join t of the thumb during the forced thumb abduction that occurs when wringing a pheasant \200 \231s neck. The same injury is described in dry ski slope participants who fall and catch t heir thumb in the matting ( \200\230skier s thumb \200\231). Diagnosis can be diffi cult as the thumb is so painful to examine, but to miss this injury may condemn the patient to a w eak pincer grip \200\224inject 1 \200\2232mL 1% plain lidocaine around the ligament to faci litate examination. Diff erentiation of complete vs partial tears of the liga- ment is cruc ial because the treatment for complete tears is surgical. Radio- graphic evaluation will de tect a bony avulsion fragment. s c i d e a p o h t r O Partial tears (clinically stable), or those associated with undisplaced avul- sion fracture s of the proximal phalanx, can be adequately treated using simple short-arm thumb spica cas ting. 1 For \201 ngertip injuries in general, loss of <1cm2 \201 nger pulp skin should be abl e to heal by secondary intention. Fig 1. Nail avulsion. \200 If the nail margins are all intact, this is usually not needed . Look carefully at the dorsal nail fold, the nail root may have been avulsed then slipped back. \200 Warn the patient the nail may not re- grow (or may regrow improperly). Get con sent. 749 a m u a r t d n a s c i d e a p o h t r O Ring block the \201 nger and test it is numb. Push one jaw of a small straight clamp down one side of the nail at its edge. \200 Close clamp \201 rmly. Warn the patient to look away. Turn the clamp on its long axis as if opening a sardine can. The nail will wrap round the c lamp and peel off its nail bed. Having repaired the nailbed, replace the nail to serve as a splint. Ensure the nail \201 ts into the nail fold, to minimize scarring along it. The old nail will drop out as the new one grows. Assessing rotational deformity Assessing for rotational deformity in \201 nger and metaca rpal fractures is essential, as last- ing deformity can be disabling. It cannot be accurate ly assessed with the \201 ngers extended, so ask the patient to \202 ex their \201 ng ers: they should all point to the scaphoid. Alternatively, look at and assess the nails end on in this posi- tion. Refer to a specialist if rotation is detect- ed, as manipulation ma y be required; function and perhaps livelihood are at stake. Fig 2. Salter Harris II fracture of base of 5th proximal phalanx. The \201 nger can be ap preciated to be angulat- ed, but the degree of rotation must still be assessed clinically. Image courtesy of Norfolk and Norwich University Hospital (NNUH) Radiology Department. Pelvic fractures Rang \200\231s aphorism: The pelvis is like a suit of armor: after damage there is much more concern about its contents than about the structure itself. Owing to the ring structure of the pelvis, single fractures are often stable (see BOX) and just need a few weeks \200\231 rest. In contrast, \211 2 fractures in the pelvis (with one above the l evel of the hip) renders the ring unstable and is a serious injury, with internal injuries in 25%. The force producing the fracture may be anteroposterior (AP), lateral compression ( LC), vertical shear or a combination and is correlated with the pattern of organ injury and overall outcome.286 Signs to look for include leg length discrepancy, abdominal distention , bruising, per- ineal or scrotal haematoma, and blood at the urethral meatus. For some exa m- ples of pelvic fractures, see the BOX \200\230Stability of pelvic fractures \200\231 an d \201 gs 1 to 3. Malgaigne \200\231s fracture (20% of all pelvic fractures, 60% of unsta ble ones) There is disruption of the pelvis anteriorly and posteriorly with displacement of a fragment containing the hip joint. Acetabular fractures Common sites: posterior lip or t ransverse. CT scans are needed to de \201 ne injuries exactly287 (easy to miss on x-ray as the acetabular columns are diffi cult to trace). Treatment: open reduction and reconstruct ion of the articular surface \200\224to delay the onset of secondary osteoarthritis.1 Exami ning patients with suspected pelvic fracture \200\207Gentle palpation of the iliac crests, pubic symphysis, sacrum/coccyx and posterior SI joints is re- quired. The pelvis may be ge ntly compressed (once) to assess stability but rocking the pelvis is no longer recommende d, as it is painful and may disturb the retroperitoneal haematoma, so exacerbating hemorrha ge. The diagnosis is principally made from the pelvis radiograph/CT scan. Complications \200\207 Hemorrhage (see BOX \200\230Shock with pelvic fracture \200\231, eg internal ilia c artery). Check foot pulses, BP, CVP, and urine output often. Transfusion often needed. \200\207 Bladder rupture \200\224may be intraperitoneal or extraperitoneal (more com- 750 \200 a m u a r t d n a s c i d e a p o h t r O mon). \200\207 Urethral rupture \200\224often at the junction of the prostatic and membranous pa rts in males. The appearance of a drop of blood at the end of the urethra is suggestive. He may be unable to pass urine (avoid repeated tries). On rectal examination, the prostate ma y be high riding i.e. elevated out of reach. NB: CT is the image of choice in trauma pati ents with haematuria. \200\207 Vaginal and rectal perforation \200\224look for bleeding. Both are rare. \200 \207 Paralytic ileus \200\224this may occur with or without operative \201 xation. \200 \207 Trapping of the sciatic nerve \200\224there is persistent pain. Treatment Relieve pain and replace blood (BOX 1). If urethral rupture is sus- pected, ATLS guidelines suggest per forming a retrograde cystourethrogram (RUG) before catheterizing; a suprapubic catheter may be needed. However, be aware that this may interfere with interpretation of pelvic angiogr ams. One study suggests a single, blind, gentle attempt at urethral catheterization will no t worsen urethral injuries.288 Get urological help. A small volume of urine suggests bladde r rupture. A cystogram or CT is needed. If no pelvic \202 uid is seen on CT, bladder rupt ure is unlikely.289,290 Reassuring signs on a pelvis radiograph: \200 Symphysis pubis sep aration <1cm \200 Integrity of superior & inferior rami \200 Integrity of the acetabula & femoral necks \200 Symmetry of ilium & sacroiliac joints \200 Symmetry of the sacral foramina, eg by evaluating the arcuate lines \200 No fracture of transverse process of L 5. 1 See \201 g 4, OHCM p719, for a surface rendered 3D reconstruction of a superior acetabu lar fracture. 751 Shock with pelvic fracture This carries a mortality of 14 \200\22355% (towards the higher e nd if base excess on arterial blood gas analysis is \211 \200\2235).291,292 \200 Is the patient pregnant? This poses big problems, eg \200\200pelvic blood \202 ow. Maternal he morrhage is probably more important than direct uterine trauma in determining fetal outcome .293 a m u a r t d n a s c i d e a p o h t r O \200 Resuscitate vigorously and meticulously: see p725. \200 Ways to reduce blood loss: A void manipulations of the pelvis. Internally ro- tate both lower legs to close an \200\230 open-book \200\231 fracture. Apply a pelvic binder. Compression may help reduce blood loss in AP fractures, but excessive compression, especially in lateral compression fractures may exacerbate it. Traction applied to the legs may help. Surgical reconstruction may then be undertaken. NB: pneumatic antishock garments (PASGs) are not designed for speci \201 cally for the stabilization of pelvic fractures. \200 Alternatives: External \201 xation frame.294 \200 Is there associated abdominal an d pelvic injury? Look and think hard. In one series of pelvic fractures there were splenic lesions (37%), diaphragm (21%) and bladder ruptures (24%), liver lacerations (19%), urethra l lesions (17%), intestinal lesions (17%), and kidney rupture (9%).295 \200 Imaging: Sometimes diagnosis is hard. Prompt spiral CT identi \201 es those needing a special procedure, such as angiographic embolization.296 \200 Ordering of interventions matters \200\224eg laparotomy with surgical packing of retr operitoneum and mechanical stabilization of fracture will control ve- nous bleeing. Angiogr aphy with embolization will target arterial bleeding. In practice it can be hard to decide if bleeding is arterial or venous in origin. The majority of patients will have venous blee ding \200\224however, hypotensive, \202 uid unresponsive patients may be more likely to h ave arterial bleeding.297 \200 Inter-disciplinary co-operation is vital \200\224and must be practiced. The stability of pelvic fractures When assessing the stability of a pelvic ring fracture, t wo important vectors need to be considered: vertical stability and rotational stability. Th e presence of vertical stability may mean that operative \201 xation is not required, dep end- ing on factors such as concomitant visceral injury, haemodynamic instability or inadeq uate mobilization. Pelvic ring fractures can therefore be categorized as one of the followi ng: 1 Vertically stable, rotationally stable: eg isolated pubic rami ( \201 g 1) or iliac wing fractures 2 Vertically stable, rotationally unstable: eg ispi- or contralateral ( \200\230bucket hand le \200\231 type \200\224 \201 g 2) lateral compression fractures; \200\230open book \200 \231 fracture (look for widening at the SI joints from rupture of the otherwise strong SI l igaments and diastasis (=separation) of the pubic symphysis). 3 Vertically unstable, rotationally unstable: eg fracture through the ipsilateral SI joint and pubic rami ( \201 g 3). NB: a clue to the presence of vertical instability is superior migration of the pelvic fragment. Fig 1. A vertically and rota- tionally stable pelvic frac- ture. Fig 2. A vertically stable, rotationally unstable pelvic fracture \200\224contralateral lat - eral compression type. Fig 3. A vertically and rota- tionally unstable pelvic frac- ture. \200 Expert help is nee ded here. Injury to the hip and femur \200\207Currently there are 75,000 patients with hip fracture s annually in the uk. This number is set to rise to >100,000 by 2020. 10% will die within 1 month of this fracture; >30% will die within 1 year.298 Intracapsular fractures occur just below the femoral head (see \201 gs 1 & 2). This often causes external rotation, adducti on and shortening.1 The injuring force can be trivial and the patient may be able to walk ( but with diffi culty). As the me- dial femoral circum \202 ex artery supplies the head via the neck, ischaemic necrosis of the head may occur, particularly if there is much displace ment. Treatment: \200 Assess vital signs. Treat shock with crystalloid, but beware incipi ent heart failure. If central ve- nous access is present, monitor CVP. 752 \200 a m u a r t d n a Fig 1. AP radiograph of the left hip showing a sub-capital frac- ture of the femoral neck. This may be easily appreciated on this view, but a lateral is vital for less obvious injuri es. Courtesy of Norfolk and Norwich University Hospital (NNUH) Radiol- ogy Department. s c i d e a p o h t r O Relieve pain (eg morphine 0.1mg/kg IV + femoral nerve block + an antiemetic). Images: a good quality lateral is essential (see \201 g 1). 5% of fractures can be missed unless CT is used. Prepare for theater: FBC, U&E, CXR, ECG, crossmatch 2U, consent. \200 Sort out medical pr oblems pre-op: \200\207get help from an ortho-geriatrician. \200 If displacement is mini mal, multiple screw \201 xation in situ is appropriate, as the risk of avascular necrosis is much less. In displaced fractures the head is excised and a prosthesis inserted.299 Int ertrochanteric-extracapsular fractures (between greater & lesser tro- chanters \200\224see \201 g 2). They occur in an older age grOUP and, as blood supply is adequate, non-union i s rarer. \201\227: Dynamic hip screw (DHS) \201 xation. The principle of the DHS is to s tabilize the fracture but allow compression by sliding. Surgery is associated with \200 \201length of hospital stay and improved rehab.300,301 Femoral shaft fracture \200\207Requ ire considerable force \200\224think of injuries elsewhere and manage ABCs. 500 \200\223150 0mL of blood may be lost in a sim- ple fracture \200\224look for swelling and check distal pulses (possible femo- ral artery injury). Sciatic nerve injury may also occur. The proxima l bone fragment is \202 exed by iliopsoas, abducted by gluteus medius, and later- ally ro tated by gluteus maximus. The lower fragment is pulled up by the hamstrings and adducted (w ith external rotation) by the adductors. Treatment: Stabilize patient in ED with resuscitat ion and traction. De \201 nitive treatment is typically with a locked intramedullary nail introduced proximally over a guide wire that is manipulated across the fracture under \202 uoroscopic control. This allows early mobilization. Condylar fractures and tibial plat eau fractures Being intra-articular, these demand accurate joint reconstruction to minimize later OA. Hinged cast braces can be used for tibial plateau fractures. Posterior hip dislo cation (eg to front-seat passengers if the knee strikes the dashboard). Feel for the femora l head in the buttock. The leg is \202 exed, inter- nally rotated, adducted, and shortene d. \200\207The sciatic nerve may be lacerated, stretched, or compressed; early MRI diagnos is may prevent later equinus foot deformity. Treatment: Reduction under GA, by lifting the femoral head back into the joint. Traction for 3 weeks promotes joint capsule healing.302 1 This is opposed to the internal rotation found in hip dislocation. These positionings are explained by the changes in the fulcrum for the force applied by iliopsoas to the proximal femur in either condition. \200\207NB: pathological fractures are discussed on p709. 753 Types of proximal femoral fractures The same principles apply for describing proxi- mal fem oral fractures as for any other (p734). Here are pattern-speci \201 c descriptive terms th at are useful to remember ( \201 g 2): \200\225303 \200 Intra-itn and extraext-capsular fractures:304 1 Subcapital itn 2 Transcervical itn 3 Basicervical itn 4 Intertrochanteric/p ertrochanteric ext 5 Reverse oblique/transtrochanteric ext 6 Subtrochanteric ext a m u a r t d n a s c i d e a p o h t r O Determining the type and site of fracture is im- portant, to determine management. Eg: \200 Undisplaced intracapsular (1 or 2) \200\203 AO screw \201 xation/conservative (AO = Arbeitsgemeinschaft \200 Displaced intracapsular (1 or 2) \200\203 (hemi)ar- throplast y.305 \200 Basicervical (3)/intertrochanteric (4) \200\203 DHS \201 xation (p752). \200 Transtrochanteric (5)/subtrochanteric (6) \200\203 DHS \201 xation can be used, bu t an intramedullary hip screw (IMHS) is usually preferred. Fig 2. The fracture pattern in the proximal femur will deter- mine the treatment. ). Osteosynthesefragen Courtesy of Norfolk and Nor- wich University Hospital (NNUH) Radiology Department. NB: diff erent surgeons may favor one \201 xation method over another. Garden classi \201 cation (not commonly used, as it is based purely on the AP radiograph \201 ndings) T his classi \201 es intracapsular femoral neck fractures \200\224it correlates with prognos is, IV being the worst. Incomplete undisplaced fracture with the inferior cortex intact; look for trabecular disrup tion I II Complete undisplaced fracture through the neck III Complete neck fracture with displacem ent; there is abduction and internal rotation of the proximal fragment in the acetabulum IV Fully displaced fracture with the proximal fragment in the neutral position Preventing hip fractures \200 Prevent falls: eg good lighting, less sedation, & keep- \201 t programs.1 \200 Teach exercise and balance training, eg with tai chi1 classes for the elderly. This lessens fear of falling, and can halve rates of multiple falls.306 \200 Prevent osteoporosis: eg exercise, bisphosphonates (see p709). \200 Ensure good vitamin D intake (plasma levels \211 30nmol/L; esp. in northern climes). A lack of vitamin D and c alcium is associated with hip fracture whether or not patients are osteoporotic. Follow-up meta-analyzes have cast doubt over whether hip protectors de- crease risk of hip fracture in the elderly. Acceptability by users remains a problem, because of discomfort an d practicality.307 The following may prevent complications after hip injury \200 Early mobilization to preve nt thromboembolism. \200 Co-ordinated multidisciplinary inpatient rehabilitation. \200 Good nutrition \200\224but meta-analyzes do not provide much support for spe- ci \201 c multi-nutritional commercial food supplements. 1 The Chinese characters for tai chi chuan can be translated as the \200\230supreme ultima te force \200\231 \200\224an odd concept, one might think, to \201 nd in village halls \200\224until one combines this with the Chinese concept of yin-yang \200\224the dynamic d uality (male/female, active/passive, dark/light, forceful/yielding, etc.) seen in all thing s. Think of tai chi as meditation combined with mobile yoga sequenced into sets of movement s inspired by the animal kingdom and martial arts traditions. In Chinese philosophy and med icine there ex- ists the concept of \200\230chi \200\231, a vital force that animates the body. One aim of tai chi is to circulate \200\230chi \200\231 within the body to promote h ealth and vitality. Another aim of tai chi is to foster a calm and tranquil mind, focused o n the precise execution of movements. Injuries to the lower leg The patella Dislocation: Is typically lateral \200\224often as th e result of a twisting motion of the lower leg, combined with contraction of the quadriceps . The knee is \202 exed with a lateral deformity. Reduction is achieved with gentle me- d ial pressure, combined with extension of the knee. Radiographs should be ob- tained post re duction to ensure no fracture to the patella. Check the extensor mechanism of the knee post reduction. Ensure a period of immobilization in cast/posterior splint or brace. Rehabilita tion will require quadriceps strength- ening exercises. Recurrent dislocation may be relate d to developmental abnor- malities around the knee and may warrant surgery to strengthen th e medial expansion. Patella fracture usually results from a fall onto a \202 exed knee or due to dashboard injury in motor vehicle collision. Non-displaced fractures with an intact extensor mechanism may be managed conservatively. Displaced frac- tures are likely to requ ire operative \201 xation. The knee Injury to a collateral ligament is common in sport. M echanism: The medial ligament is most commonly injured by a blow to the lateral aspect of t he knee whilst the foot is \201 xed (putting valgus stress on the knee); vise versa for t he lateral ligament. Signs: Eff usion tenderness over aff ected ligaments. Rest is neede d, then \201 rm support. See p686 for examination techniques. NB: surgery is rarely neede d for isolated medial collateral ligament injury.308 In lat- eral injury, surgery is requir ed if there is instability; also look for associated common peroneal nerve injury. Anterior cruciate ligament (ACL) tear: Typically follows a twisting injury to the knee with the foo t \201 xed to the ground. Signs: Eff usion; haemarthrosis; +ve \200\230draw \200\231 sig n (immobilize the patient \200\231s leg by sitting on his foot, and then with the knee in 9 0 \202 exion, grip the upper tibia and try to draw it towards you, away from the femur; the reverse \200\230set back \200\231 suggests a posterior cruciate tear \200\224eg in ca r crashes as the knee strikes the dashboard). Do a \200\230pivot shift test \200\231 (p686 ). Examination under GA may be needed. Treatment: This is problematic. 3 weeks \200\231 res t and physio may help. In the young, or \200\200knee instability, consider ligament recons truction (autograft).309,310 Meniscal (semilunar cartilage) tears: Medial meniscus tears (e g \200\230bucket- hadle \200\231) follow twists to a \202 exed knee (eg in football). Ad duction + internal ro- tation causes lateral meniscus tears. Extension is limited (knee loc king) as the displaced segment lodges between femoral and tibial condyles. The patient must stop what he is doing, and can only walk on tiptoe, if at all. The joint line is tender, a nd McMurray \200\231s test is +ve (p686). If the \200\230handle \200\231 of the \200\230b ucket \200\231 be- comes free at one end ( \200\230parrot beak \200\231 tear), the knee sud denly gives way, rather than locking. MRI gives tear location, morphology, length, depth, a nd stability, and helps predict tears requiring repair.311 Look for avulsions on x-ray. Man - agement is conservative when possible, though arthroscopy is usually needed for locked kn ees, cysts, or persisting symptoms after injury. Typical injury triad: ACL + medial collate ral ligament + medial meniscus. Occult bone injury: If MRI/x-rays are \200\223ve, don \200 \231t put everything down to \200\230minor problems with the meniscus \200\231. Detailed M RI (STIR1 + dynamic contrast to show periosteal oedema)312 may show: \200 Subchondral fra cture eg of the posterior margin of the medial tibial condyle.313 \200 Stress fracture (i ntramedullary and periosteal oedema with high signal intensity)314 \200 Tibial plateau oe dema. Tibia fracture Avulsion fractures of the intercondylar region often occur with anteri or cruciate injury. Arthroscopic reduction may be tried.315 Sliding traction, or surgery wi th open elevation of the joint surface may be needed. Open shaft fractures are common as th ere is little anterior covering tissue. Soft tissue stripping may devascularize the bone le ading to poor union in tibia fractures. With closed fractures, operative or non-operative m anagement can depend on patient variables (eg kneeling occupation), fracture (eg stability) factor, and surgeon \200\231s preference. Open fractures: See managing open fractures (p73 5). 754 \200 a m u a r t d n a s c i d e a p o h t r O Pretibial lacerations The shin (esp. if elderly) has poor blood supply. It is vulnerable to \202 ap wounds ( \201 g 1.). Treatment: Try hard to iron out all the \202 ap, reposit ioning it careful- ly: an ideal tool is the wrong end of a Vacutainer needle, sheathed in rub- ber. The important thing is to evacuate the haematoma to prevent tension (tension \200\203breakdown \200\203plastic surgery) \200\224so skin closure with adhesive strips (eg Steristrip ) is better than sutures, as they can be loosened if the tissues swell. Wound glue may be better still.316 Dress, and advise a support bandage, and leg elevation. Review to check for infection, wound tension, and necrosis. 755 a m u a r t d n a s c i d e a p o h t r O Fig 1. Flap wounds. Bone marrow contusions reveal the mechanism of injury Bone marrow contusions are often seen on knee trauma MRIs. These osseous injuries result from a direct blow, from compression im pact from adjacent bones, or from traction from avulsion injury. The distribution of oedema gives valuable clues to associated soft-tissue injuries. 5 contusion patterns are associat ed with soft-tissue knee injuries: 1 Pivot shift injury: Oedema involves the posterolateral tibial plateau and the midportion of the lateral femoral condyle. 2 Dashboard injury: Oedema is in the anterior aspect of the proximal tibia. 3 Hyperextensio n: Results in the \200\230kissing \200\231 contusion pattern involving the an- terior aspect of the proximal tibia and distal femur. 4 Clip injury: Results in a big area of oedema in the lateral femoral condyle and a small area of oedema involving the medial femoral condyle. 5 Lateral patellar dislocation: Causes oedema involving the inferomedial pa- tella and the lateral femoral condyle (anteriorly). So you can infer the mechanism of injury by patterns of oedema, and hence predict which spe ci \201 c soft-tissue abnormalities are present.317 Fig 2. Axial view fat-suppressed fast-spin echo MRI in patella dislocation injury. Full-thi ckness chondral fracture (arrow) of the medial patella facet is seen as an area of increase d signal in- tensity. Bone contusion oedema of the subjacent marrow (arrowhead) involving t he lateral femo- ral condyle was caused by impaction of the pa- tella against the epicondyl e.1 Courtesy of Hollis M. Fritss, MD. Some other leg fractures \200 Isolated \201 bular fracture: A supportive dressing may b e suffi cient. \200 Toddler \200\231s fracture: This is a spiral fracture of the distal t ibial shaft seen in toddlers. Treatment is supportive, eg analgesia and cr pe bandaging. \200 These should never occur in a child who is not yet walking, so you must think of NAI i n such cases and alert the pediatric team (p146). 1 STIR = Short T1 Inversion Recovery MRI (has speci \201 c timing to suppress the signal f rom fat). Ankle and foot strains, and fractures Ankle ligament strains Twisting inversion accounts fo r the common strain to the anterior talo \201 bular part of the lateral ligament ( \201 g 2). Signs: Stiff ness, tenderness over the lateral ligament, pain on inversion. If there i s tender- ness at either malleolus or inability to walk (eg 4 steps) do radiographs to rule out fracture (see p778). Treatment: Consists of RICE (rest, ice, compres- sion, elevation) . Medial deltoid ligament strains ( \201 g 2), due to eversion, are rare. Supervized walki ng exercises and diapulse therapy relieve pain. NB: minor sprains may respond to rest and s imple analgesia topical NSAID (ibuprofen, ketoprofen, piroxicam). Prevention: Good footw ear may be more important than shoe-heel height. Proprioceptive training can \200\201incid ence of ankle sprains in athletes,318 but this may only hold for recurrence.319 For athlete s, consider trade-off between prevention of injury and performance restriction.320 Malleola r and metatarsal fractures \200 Either malleolus may be fractured by the above injuries. Rotation causes oblique lateral malleolar fracture (hard to see except on lateral radiograp hs), or a proximal fracture of the 5th metatarsal (avulsion by peroneus brevis). \201\227: In general stable fractures only involve one side of the ankle (AO/Weber A1/B1 fractures \200\224see \201 g 1). Stable or minimally displaced fractures maybe treated non-operativ ely in a cast. Unstable or displaced fractures require surgery. 756 \200 a m u a r t d n a s c i d e a p o h t r O Maisonneuve \200\231s fracture Proximal \201 bular fracture + syndesmosis rupture, and me dial malleolus fracture or deltoid ligament rupture. If 2 bones dislo- cate where no true j oint exists, the term diastasis ( \200\230standing apart \200\231) is used. \200\207Always examine the proximal \201 bula with \200\230ankle sprains \200\231. \201\227 is surgic al, with restoration of the ankle mortise and placement of 1 \200\2232 suprasyndesmotic scr ews.321 \200 Lisfranc fracture-dislocation at the 1st tarsometatarsal joint \200\207This is a com- monly missed fracture in multitrauma patients, but it can also occur by step- pi ng awkwardly off a kerb. It may cause compartment syndrome of the me- dial foot ( later a rthritis and persistent pain).322 Images: On plain x-ray look for widening of the gap betwe en the medial cuneiform and the base of the 2nd metatarsal. Because of the overlapping bone s, subluxations can be hard to see. CT helps.323 \201\227: Achieve precise anatomic reduct ion. Open reduction and temporary screw or K-wire \201 xation may be best.324 Other fract ures Fractured neck of talus can occur after forced dorsi \202 exion, and is a serious inj ury because interruption of vessels may lead to avascular necrosis of the body of the talus . \201\227: Displaced fractures require ORIF. Os calcis fractures Often bilateral, after s erious falls (which is associated with worse outcome).325 \200\207Always look for associat ed spinal fracture. Signs: Swell- ing; bruising; inability to weight bear. Check Bohler \200\231s angle on lateral X-ray: the angle between lines from the anterior process to the peak of the posterior articulating surface and from the same to the posterior calcaneal pro cess: <20 is abnormal. \201\227: \200\207Does the fracture enter the subtalar joint? So me only opt for conservative treatment in extra-articular fractures, or minor displaced int ra-articular fractures in nonambulatory patients. Others opt for surgery, but it is not cle ar that operative management has better outcomes, even for intra-articular fractures.326 Mi d-tarsal (eg calcaneocuboid) dislocation produces a painful, swollen foot. The navicula pro ximal articular surface may not articulate with the talus. \201\227: Early manipulation + plaster cast for, eg 7 weeks.327 2nd metatarsal march fracture: Shaft # may simply require rest. Several weeks of crutches may be useful. Severe pain may be better managed with a cas t. Fractures of the toes: Simple protective dressings usually suffi ce. NB: consider dedica ted bone algorithm CT for all complex fractures in this region. 757 a m u a r t d n a s c i d e a p o h t r O Fig 1. A simpli \201 cation of the AO WEBER classi \201 cation of malleolar fractures.328 Images courtesy of Professor Peter Scally. a1 Transverse \201 bula fracture at or below the joint line with no medial injury a2/3 Tr ansverse \201 bula fracture below joint line + medial injury (ligament / fracture) b1-3 F ibula fracture at the joint line (B1) + medial injury (B2) + posterior injury (B3) c1/2 Obl ique \201 bula fracture above a ruptured tibio \201 bular ligament + medial injury c3 Ma isonneuve \200\231s fracture, i.e. proximal \201 bular fracture + medial injury Anterior talo \201bular ligament Interosseous taleocalcaneal ligament Anterior tibio \201bular ligament Dorsal taleonavicular ligament Dorsal cuneonavicular ligament Dorsal tarsometatarsal ligament Calcaneo- \201bular ligament Dorsal calcaneocuboid ligament Long plantar ligament Tibiocalcaneal part Posterior tibiotalar part Tibionavicular part Medial talocalcaneal ligament Posterior talocalcaneal ligament Dorsal talonavicular ligament Dorsal cuneonavicular ligament Long plantar ligament Plantar calcaneonavicular ligament Fig 2. Ligaments of the ankle and hind/midfoot: (top) lateral and (bottom) medial views. Th e medial view is dominated by the various parts of the deltoid ligament. \200 Injuries to the face and neck Assault is the commonest cause of facial trauma, with y oung men the most af- fected. Facial laceration and mandible fracture are the commonest inj uries.329 \200\207If there is airway obstruction, summon expert help promptly. Remove bloo d, loose/false teeth, and vomit from the mouth. Lie in the semi-prone position to prevent o bstruction (p799) from a swollen injured tongue, but always be- ware of cervical spine trau ma with injuries above the clavicle. If the pharynx is swelling or there is fracture of the larynx, try gentle intubation. If impossible, do cricothyrotomy (OHCM p786), then tracheos tomy. Blood aspiration is pre- vented by direct pressure to the bleeding site. Precautions with possible neck trauma Injury to the cervical spine should be considered in any trauma s ituation, especially if: high energy; patient com- plaining of neck pain; patient unconscio us. CT is the best method if high/mod- erate risk for cervical fracture.217 See p658 for as sessing neck injuries. Lacerations of the face Clean meticulously. Alignment of the tissues and anti- sepsis must be exact to produce a good cosmetic result. \200 Simple laceration s: Consider glue or steristrip closure (p730). \200 Complex lacerations: Is there a plast ic surgeon available? \200 Mammal bites: Give antibiotic cover: p782, eg co-amoxiclav 1 t ab/8h PO.231 \200 Rugby player \200\231s ( \200\230cauli \202 ower \200\231) ear: Aspira te/drain haematoma (repeat every 758 \200 a m u a r t d n a s c i d e a p o h t r O few days) and then strap pressure dressing against the head. Ruptured ear drum: NSAIDs for analgesia, and advise to keep ear dry. \200 Avulsed teeth m ay be replaced (p784). If inhaled, do expiratory CXR. Bleeding socket: bite on adrenaline-soaked pads, or use sutures. Eye injury, nose fractures, and nose bleeds: See p452, p560, & p562. Mandible injury Signs: Local tenderness and swelling; jaw malocclusion; a mobile fragment; bone may protrude into the mouth in open fractures; if com- minuted, the tongue may make airway management extrem ely diffi cult, so get expert help. Diagnosis: Orthopantogram (OPG) radiographs. Enlist exp ert den- tal help. Treating TMJ dislocations: Place (gloved) thumbs over the back teeth and press downwards, while at the same time levering the chin upwards with your \201 ngers ( both hands). Consider midazolam sedation: see p718. Blows to the chin may cause fracture at the impact site, or indirect fractures near the tem poromandibular joint. Fractures: Open reduction + internal \201 xa- tion with miniplates is better than wiring teeth together for 6 weeks. Try to get onto a daytime consultant list , rather than at night. Complicated fractures may bene \201 t from lag osteosynthesis. Com plications: infection; non-union.330 \200\230Whiplash \200\231 injury (a source of some co ntroversy) is cervical strain caused by sudden neck extension with rebound \202 exion. It is common, often in rear-end crashes. Hyperextension causes damage to the anterior musculo ligamentous structures. Subsequent protective muscle spasm causes pain and stiff ness, whic h may be severe. Treatment:331 Reassure physical injury is rare. Empha- size positive attit udes to prognosis and recovery are important. Encourage prompt return to usual activity and occupation. Suggest active mobilization (if tolerated), eg with gentle stretching and post ure control, as exercise enhances recovery. Aim to prevent chronicity and \200\230disuse s yndrome \200\231 through advocat- ing self-management with analgesia. Collars, rest and neg ative attitudes can contribute to delayed recovery and chronicity. If symptoms last for >1y r, they are likely to be permanent.332 Other car-crash neck sprains (Seen in \205\223 of c ar users soon after crashes.) Symptoms may be delayed and persist for years. The best treat ment may be to give NSAIDs, a cervical collar, and review in the next clinic, with referral for immediate physiotherapy if symptoms warrant this. Explain to the patient that head res traints are helpful \200\224the usual mistake is that they are adjusted too low. 759