Local tenderness with minor/moderate laxity, but with a de \201 nite end- point implies a grade II injury. Provide analgesia, crutches, instruction on quadriceps exercises and refer for orthopedic follow-up. Major laxity (ie the joint opening up > 1cm) with no end-point implies complete rupture. Co nsider a POP cylinder (or splint), and provide crutches, analgesia, quadriceps exercises, a nd orthopedic follow-up. Ruptured quadriceps Complete rupture of the distal quadriceps insertion can result from a d irect injury or from sudden, violent contraction of the quadriceps muscle. Examination reve als complete inability to straight leg raise \200\224 never assume this is just due to pai n. There may be a palpable defect in the muscle inser- tion. Refer to the orthopedic surgeo n for repair. Ruptured patellar tendon Examine for complete inability to straight leg raise , a high-riding patella, a palpable defect in the patellar tendon. There is frequently an a ssociated avulsion of the tibial tuberosity. Refer to orthopedics for repair. 479 OTHER KNEE PROBLEMS Other knee problems Acutely locked knee A springy block to full extension (which varies fro m just a few degrees to much more) in the knee indicates an underlying meniscal injury or o ther loose body in the knee joint. Obtain knee X-rays (including a tunnel view), which may show a loose body. Do not attempt to unlock the knee by manipulation as this is usually pai nful and futile. Give analgesia and refer for arthroscopy. Prepatellar and infrapatellar bursitis This results from in \202 ammation of the \202 ui d- \201 lled bursa in front of or just below the patella, respectively, typically from una ccustomed kneeling. Treat with rest (which may involve the use of crutches), a short course of NSAID, and avoidance of the causative activity. Persistent symptoms may necessitate ele ctive excision of the bursa. Infective bursitis may occur ( i T and cellulitis are clues to this): aspirate \202 uid for culture and sensitivity, and start antibiotics (eg co-am oxiclav). Other causes of knee pain Patients present not infrequently with knee pain of variable dura tion and no history of trauma. In adults, causes include Baker \200\231s cyst, osteoarthritis (especially in the elderly), and acute arthritic conditions, including septic arthritis (rare but important). Also rare , but worthy of consideration is osteosarcoma, which typically affects teenagers or young a dults, producing pain and swelling. In children, causes include sepsis (including both septic arthritis and osteomyelitis ( b T he limping child, p.704), Osgood \200\223Schlatter \200\231s disease, osteochondritis disse cans, Johansson \200\223Larsen \200\231s disease (all in b Osteochondritis, p.708), chondro malacia patellae, referred pain from the hip, malignancy (eg leukaemic deposits). 480 CHAPTER 9 Wounds, fractures, orthopedics Tibial and \201 bular shaft fractures Adult tibial fractures are usually a result of dire ct blows or falls onto the tibial shaft. Spiral fractures of the tibia or \201 bula follo w violent twisting injuries, usually from sports (eg soccer, rugby, skiing). Displaced frac tures typically involve both the tibia and the \201 bula. A large portion of the tibia ha s relatively little soft tissue covering \200\224 compound injuries are common. Displaced tibial shaft fractures may be complicated by injury to the popliteal artery and compartment syndromes ( b Crush syndrome, p.398). Fractures of the proximal \201 bula may be associa ted with injury to the common pero- neal nerve. Check (repeatedly) for distal pulses and se nsation. Diagnosis is usually easy. Look for deformity, localized swelling, or tenderness. Regard all wounds near the fracture site as potential compound injuries. X-rays Ensure X-ra ys show the whole length of tibia and \201 bula. Examine closely for the presence of othe r injuries (eg around the knee or ankle). Undisplaced stress fractures can occur, particula rly in adults involved in sports, and may not be visible on initial plain X-rays. Persistin g symptoms suggestive of stress fracture require orthopedic follow-up (and may eventually r equire speci \201 c coned X-rays or even bone scanning). Tibial shaft fractures Treat undisplaced transverse tibial shaft fractures with analgesia a nd long leg POP backslab. Spiral and oblique fractures also need immobilization, but are po tentially unstable, so refer to orthopedic team for admission. Immobilize displaced fractur es in a long leg POP backslab following IV analgesia and refer (to consider MUA or closed i ntramedullary nailing). Badly com- minuted or segmental fractures may require ORIF. Contact orthopedics immediately if suspected vascular injury, sensory de \201 cit or gross swelli ng. Treat compound fractures initially as on b p.422 and refer to the orthopedic surgeon fo r urgent wound toilet, debridement, and \201 xation \200\224see www.boa.ac.uk/en/publicat ions/boast Fibular shaft fractures These can occur in combination with a tibial fracture, as a result of a direct blow (eg from a car bumper) or from twisting injuries. The common peroneal nerv e may be damaged in proximal \201 bular injuries. Examine speci \201 cally for weakness of ankle dorsi \202 exion and d sensation of the lateral aspect of the forefoot. Treat und isplaced proximal or \201 bular shaft fractures with analgesia and elevation. Support in a tubigrip or padded bandage. If unable to WB, use a below knee POP for comfort with crutch es until WB is possible. Arrange follow-up in all cases. Refer displaced or comminuted frac tures to the orthopedic team. Stress fractures of the \201 bula are relatively common, ty pically affecting the \201 bular neck of military recruits and athletes following vigorou s training. Treat symptomatically with rest and analgesia. Maisonneuve fracture ( b p.501) Transmitted forces may fracture the proximal \201 bula following an ankle injury. This us ually involves fracture of the medial malleolus, fracture of the proximal \201 bula or \201 bular shaft, and implies damage to the distal tibio- \201 bular syndesmosis. Examine the proximal \201 bula in all ankle injuries and X-ray if locally tender. 481 PRETIBIAL LACERATIONS Pretibial lacerations Common in the elderly following relatively minor trauma. Most pretibi al lacerations can be satisfactorily treated in the ED with adhesive strips ( \200\230Steri -Strips \204 \200\231). Clean and irrigate to remove clot, and close using Steri-Strips \204 under appropriate anesthesia. Aim to leave gaps of \211\210 0.5cm between the Steri- Strips \204 . Apply a non-adherent dressing and light compression bandage. Instruct the pat ient to elevate the limb whenever possible (Fig. 9.36 ). Arrange follow-up (ED or GP) for 5 days \200\231 time for wound inspection and dressing change (but leave underlying Steri-St rips \204 until the wound is healed). Consider admission for patients with poor social sup port. Note Suturing pretibial wounds is not usually recommended as the pretibial skin is friable and undue tension compromises wound healing. Complications are likely in patients with large, distally based and poorly viable skin \202 aps, and patients on steroids or anticoagulants (check clotting control). Refer to pla stic surgeons large lacerations where skin edges cannot be opposed, or where complications are likely. Fig. 9.36 Application of Steristrips. 482 CHAPTER 9 Wounds, fractures, orthopedics Calf and Achilles tendon injuries Calf muscle tears Acute tears of the gastrocnemius muscle often occur during sports. They can also occur simply from stepping from a bus or kerb, or from a sudden jump. Sharp or burning pain in the calf is followed by i stiffness or pain o n weight- bearing. Examine for localized tenderness and/or swelling over the calf muscle be llies. The medial head of gastrocnemius is more commonly injured. Carefully check the Achil les tendon for signs of rupture (see below). Differential diagnosis includes DVT ( b p.118) or rupture of a Baker \200\231s cyst. Treat with analgesia, NSAID, and initial ice applica tion. Raising the heel with a pad may also help. Advise elevation of the leg and progressiv e weight-bearing as guided by symptoms. Use of crutches may be required if symptoms are sev ere (in this case, arrange follow-up and early physiotherapy). Calf muscle bruising Direct blunt calf trauma can result in haematoma formation and conside rable swelling. Be alert to the possibility of compartment syndrome, particularly where the re is a signi \201 cant mechanism of injury (eg b p.398). Achilles tendon rupture Achilles tendon rupture can occur without prior symptoms during sud den forceful contraction of the calf. Usually this occurs during sports (notori- ously badm inton). It also occurs in other situations (eg running for a bus or missing a step and land ing heavily). Patients on cipro \202 oxacin, oral ster- oids or with a history of steroid injection of the Achilles tendon area are at i risk. The patient often describes a sudden s harp pain behind the ankle like a \200\230bang \200\231 or similar description. Patients o ften mistakenly initially believe that they have sustained a blow to the back of the ankle. Examination may reveal swelling, pain, bruising, and often a (diagnostic) palpable defect (gap) in the tendon \211\210 5cm above the calcaneal insertion. Plantar \202 exion again st resistance will be weaker than on the normal (uninjured) side, but do not rely on this w hen making a diagnosis. Beware plantar \202 exion (even standing on tip-toes) may still b e possible due to action of the tibialis posterior, peroneal, and toe \202 exor muscles. Calf squeeze test (Simmonds/Thompson \200\231s test) Kneel patient on a chair, facing the b ack, with feet hanging free over the edge. Alternatively, position the patient to lie prone on a trolley with ankles over the end. Gently squeeze mid-calf and look for normal plantar \202 exion of the ankle (Fig. 9.37 ). To avoid confusion do not describe the result as + ve or \200\223ve, just state \200\230calf squeeze test normal \200\231 or \200\230abnor mal \200\231. Treatment Remains controversial, so follow local policy. Treatment options ar e: \200 Conservative management : many ruptures are managed with crutches, analgesia, and immobilization for 6weeks in a long leg plaster with the ankle in plantar \202 exion and knee \202 exed to \211\210 45 . This is followed by careful rehabilitation under the care of the orthopedic team and physi- otherapist. Primary surgical repair is often employed in young patients and athletes. Refer to the orthopedic team to consider this. 483 CALF AND ACHILLES TENDON INJURIES Note Sometimes a \200\230partial \200\231 Achilles tendon rupture is suspected. In this in stance, the safest initial treatment is immobilization in a non-weight-bearing BKPOP with a nkle \202 exion, crutches, and orthopedic follow-up. USS can help to determine the state of the tendon. Tendon rupture Tendon intact Foot plantar flexes No/reduced movement Fig. 9.37 Calf squeeze test to check integrity of Achilles tendon. Achilles tendonitis/paratendonitis This frequently follows unaccustomed activity or overuse (eg dancing, jumping, running, or even walking) and may be associated with familial hyperc holesterolaemia. There is usually a history of i pain, aggravated by ankle movements. Exami ne for localized pain, swelling, and palpable crep- itus over the Achilles tendon (the most common site is \211\210 5cm from its insertion). The calf squeeze (Simmonds) test is norm al. Check lipid pro \201 le. Treat with analgesia, NSAID, and a brief period of rest (eg 1 \200\2232 days) before gradually returning to normal activities as guided by symptoms. Occ asionally, 1 \200\2232 weeks in a BKWPOP may be useful. A heel pad inserted into footwear m ay help. Athletes may bene \201 t from removal of heel tabs from training shoes if implica ted. Avoid local steroid injection, which may i risk of tendon rupture by impeding healing or by allowing premature resumption of activity. Calf/leg pain with no history of trauma A variety of conditions may be implicated, including: \200 Shin splints : a variety of path ophysiological processes have been sug- gested, including tibial periostitis. This conditio n is characterized by pain over the anterior distal tibial shaft after running on hard surf aces. Advise rest and NSAID. Stress fractures : can affect the tibia (as well as the \201 bula \200\224 see b p.480). Treat with analgesia and POP with orthopedic follow-up. Bursitis : in \202 ammation of the bursae around the insertion of the Achilles tendon responds to conservative measures. DVT: see b p.118. \200 Cellulitis : see b p.413. \200 Ischaemia : see b p.531. \200 R uptured Baker \200\231s cyst. 484 CHAPTER 9 Wounds, fractures, orthopedics Approach to ankle injuries Ankle injuries are among the most common problems presenting to the ED. Adopt a logical, consistent approach to identify which patients are likely to have a fracture and to avoid unnecessary X-rays in patients with uncomplicated sprains. History Establish the exact mechanism of injury. Most are inversion injuries (where the sol e of the foot turns to face medially as the ankle is plantar \202 exed) causing damage to structures around the lateral malleolus (most notably, the anterior talo \201 bular ligam ent). Eversion injuries occur less com- monly and damage the structures around the medial m alleolus. Hyper- dorsi \202 exion and plantar \202 exion injuries occur less frequently. The following are relevant in the initial assessment of ankle injuries: \200 A fracture i s more likely in patients who are unable to weight bear (WB) immediately following the injury. A \200\230crack \200\231 or \200\230snap \200\231 may be heard and is not indicative by i tself of a fracture. Ice, analgesia, and elevation may in \202 uence the appearance of an ankle injury. Examination Examine from the knee down for tenderness over: \200 Proximal \201 bula. \200 Lateral malleolus and ligaments. \200 Medial malleolus and ligaments. \200 Navicu lar. \200 Calcaneum. \200 Achilles tendon. \200 Base of 5th metatarsal (MT). Is an X- ray required 1 ? Follow the Ottawa ankle rules (Fig. 9.38 ) for adults and X-ray ankles if patients: \200 Were unable to WB for 4 steps both immediately after the injury and at the time of examination. Have tenderness over the posterior surface of the distal 6cm (or tip) of the lateral or medial malleolus. Note that tenderness over the navicular, calcaneum, base of 5th MT or proximal \201 bula require speci \201 c X-rays to exclude fractures. Adopt a lower threshold for X-ray in the very young, the elderly, and in patients who are d if \201 cult to assess (eg intoxicated). 1 Adapted from Stiell IG ( 1993 ) Decision rules for the use of radiography in acute ankle injuries. Re \201 nement and prospective validation . J Am Med Ass 269 : 1127 \200\223 32 . 485 APPROACH TO ANKLE INJURIES Fig. 9.38 The Ottawa ankle rules. Guidelines for X-ray in a simple ankle injury. Bony tende rness over the points indicated requires an X-ray. X-ray is also required if the patient is unable to weight-bear immediately after the injury or to walk 4 steps in the ED. X-ray the ankle for malleolar tenderness and the foot for metatarsal/tarsal tenderness. If the patie nt is not X-rayed then they are given instructions to return after 5 days if they have trou ble weight- bearing. Adapted from Stiell IG (1993) Decision rules for the use of radiograph y in acute ankle injuries. Re \201 nement and prospective validation. J Am Med Ass 269: 11 27 \200\22332. 486 CHAPTER 9 Wounds, fractures, orthopedics Ankle fractures and dislocations Clinical assessment and imaging after ankle injury is outl ined in b p.484. Ankle fractures Fractures around the ankle most commonly involve the malle oli \200\224 medial, lateral, and what is commonly referred to as the \200\230posterior m alleolus \200\231 (the posterior part of the distal tibia). The mortice joint formed by the talus and the distal tibia, \201 bula, ligaments, and the distal tibio- \201 bular synd esmosis allows very little rotation or angulation at the ankle joint. As a consequence, for ced twisting or angulation of the ankle joint causes fractures associated with ligamentous injuries and in severe cases, disruption of the distal tibio- \201 bular syndesmosis. Trea tment depends upon a combination of clinical \201 ndings and X-ray appearances. Look care fully for talar shift. \200 Small avulsion fractures essentially re \202 ect ligament/jo int capsule damage. Treat with rest, elevation, analgesia, and early mobilization as for sp rains. \200 Larger avulsion fractures may require initial immobilization in BKPOP with crutches and orthopedic follow-up. Undisplaced, isolated medial or lateral malleolar fractures are usually stable and do well with conservative measures. Provide analgesia, crutches, and immobilize in a well-padded BK POP cast. Advise limb elevation and arrange orthopedic follow-up. Note that an isolated \200\230high \200\231 lateral malleolus fracture may only be apparent on the lateral X-ray and may be associated with deltoid (medial) ligament injury with instability \200\224 some require ORIF. Displaced fractures of the medial or lateral malleolus require ORIF. Give analgesia and, as appropriate, IV sedation to allow reduction of talar shift. Immobilize the limb in a BKPOP slab and refer to the orthopedic team. \200 Bimalleolar or trimalleolar fractures are un stable. Having attempted to reduce any signi \201 cant talar shift (with appropriate sedat ion), place in a BKPOP, obtain fresh X-rays, and refer to the orthopedic team. Ankle dislocation Dislocation of the ankle is an orthopedic emergency. Treat promptly on di agnosis. Examination shows gross deformity of the ankle, severe stretching of the skin (res ulting in fracture blisters, skin necrosis, or even converting the injury to a compound fra cture), and often de \201 cits in peripheral pulses or sensation. The ankle can dislocate in the absence of associated fractures, but this is uncommon. Treatment Prompt closed reduc tion and immobilization in POP usually has to precede X-ray (unless available immediately). \200\230Prompt treatment \200\231 does not justify reduction without considering analgesi a or sedation. \200 Give Entonox , IV analgesia, or sedation as appropriate with full precautions. Warn the patient there may be a brief i in discomfort as the ankle reduces. With the knee \202 exed and supported, gently grasp the heel with one hand and support the patient \200\231s calf with the other. Pull smoothly on the heel \200\224 it may be necessary to slightly exag- gerate the deform ity in order to obtain reduction. Success is indicated by return of normal ankle contours, relief of skin tension, and often dramatic relief of pain. Once reduced, re-check pulses and sensation, immobilize in a POP slab, and arrange check X-rays. Refer the patient to the orthopedic team immediately. 487 ANKLE SPRAINS Ankle sprains Clinical assessment and imaging after ankle injury is outlined in b p.484. Th e structures most frequently injured in inversion injuries are the lateral joint capsule an d the anterior talo \201 bular ligament. Increasing injury causes additional damage to the calcaneo \201 bular ligament and posterior talo \201 bular ligament. Treatment Historically, treatment of sprained ankles has been based upon \200\230RICE \200 \231 (rest, ice, compression, elevation), but the scienti \201 c basis for all the element s of this is distinctly lacking! Advise initial rest, elevating the ankle above hip level, and to consider applying ice inte rmittently during the \201 rst 2 days for periods of 10 \200\22315min. Begin to WB as soo n as symptoms allow, but elevate at all other times. An elastic support from toes to knee i s traditional, but of no proven value (and may be harmful by i pain without speeding recove ry). If used, ensure that it is not worn in bed. Advise the patient to gently exercise the ankle in all directions and to use simple analgesia regularly until symptoms improve. Most patients with minor sprains can expect full recovery in \211\210 4weeks. It may be possibl e to resume sports gradually within 2weeks, depending on progress. The inability to WB implies more severe injury. Provide crutches to those completely unable to WB despite analgesia, with advice to elevate the ankle. Arrange review at 2 \200\2234da ys \200\224 if still unable to WB, consider 10days \200\231 immobilization in a below-knee cast, with subsequent outpatient follow-up. Other approaches include the use of adhesive s trapping or pre- formed ankle braces. These may be useful in selected cases. Patients can u sually expect good functional recovery and should not regard the ankle as \200\230weak \200\231. Long-term problems (eg weakness/instability whilst walking over rough ground) are often related to d ankle proprioception following immobilization, so aim to mobilize as so on as possible. Long-term complications Do not regard ankle sprains simply as trivial injuries: patients ma y suffer long-term morbidity (which often causes them to return to the ED): \200 Instabil ity often manifests itself by recurrent ankle sprains. Refer to physiotherapy (to include isometric exercises). Peroneal tendon subluxation re \202 ects a torn peroneal retinaculum, allowing the peronea l tendons to slip anteriorly. The clinical presenta- tion includes clicking and a sensation of something slipping. Movement of the foot/ankle (especially eversion) reproduces the sub luxation. Refer for orthopedic follow-up \200\224 surgery is an option. Peroneal nerve injury is relatively common, but not frequently sought for. Neurapraxia resu lts from stretching of branches of the peroneal nerve at the time of injury, with subsequen t d sensation over part of the dorsum of the foot and d proprioception at the ankle joint ( re \202 ecting injury to the articular branches). 488 CHAPTER 9 Wounds, fractures, orthopedics Foot fractures and dislocations Crushing or other violent injuries to the foot can result i n signi \201 cant long-term disability. Multiple fractures or dislocation of the tarsals o r MTs are often overlooked in the presence of other severe injuries. Delayed or inadequate treatment result in high rates of post-traumatic OA. Compartment syndromes ( b p.398) or va scular injuries may occur. Amputations or severe mangling injuries of the foot are rarely s uitable for reconstruction/re-implantation due to poor long-term functional results. Talar injuries Falls onto the feet or violent dorsi \202 exion of the ankle (eg against ca r pedals in a crash) can result in fractures to the anterior body or articular dome of the talus. Displaced fractures and dislocations frequently result in avascular necrosis. Treat with analgesia, immobilization in a backslab POP, and refer promptly for orthopedic t reatment (may require MUA and/or ORIF). Dislocations of the talus require prompt reduction under GA. Upper/midfoot dislocations These injuries follow violent twisting, inverting or everting in juries of the foot. Peritalar/subtalar dislocations involve the articulation between the ta lus and the calcaneum. Give adequate analgesia and refer to ortho- paedics for prompt reduc tion under GA. Mid-tarsal dislocations involve the mid-tarsal joint (comprising the calcane um and talus posteriorly and the navicular and cuboid anteriorly) and are treated similarly . Isolated dislocation of the talus is rare and requires prompt reduction under GA. Calcaneal fracture Calcaneal fractures most often follow a fall from height directly onto t he heels. Always exclude associated injuries of the cervical and lumbar spine, pelvis, hips , or knees. Examine for swelling, bruising, and tenderness over the calcaneum, particularly over the sides. Examine both calcanei for com- parison, remembering that fractures are com monly bilateral. Examine the Achilles tendon for injury ( b p.482). Request speci \201 c c alcaneal X-rays and scrutinize carefully breaks in the cortices, trabeculae or subtle signs of com- pression (reduction in Bohler \200\231s angle \200\224 see Fig. 9.39 ). Refer all fractures to orthopedic staff. The majority will require admission for elevation, analgesi a and in selected cases, ORIF following CT scanning. Tibia Talus 35 \200\22340 Calcaneum Fig. 9.39 Bohler \200\231s angle (normally 35 \200\22345 ). 489 FOOT FRACTURES AND DISLOCATIONS Clinically suspected calcaneal fracture, but X-rays normal Sometimes, clinical suspicion of a calcaneal fracture is not con \201 rmed by X-rays at the time of initial presentation. It is possible that X-rays may initially fail to identify a calcaneal fracture. Therefore, treat clinically with analgesia, rest, elevation, crutches and arrange review at 7 \200\223 10days, when consideration can be given to further imaging if symptoms persist (eg more X-r ays and/or CT scan). Metatarsal fractures and dislocations Multiple MT fractures may follow heavy objects fallin g onto the feet or more commonly, after being run over by a vehicle tire or wheel. In all such cases, consider the possibility of tarso-metatarsal (Lisfranc) dislo- cation. This can be easily missed on standard foot X-rays, which do not usually include a true lateral view \200\224 look to check that the medial side of the second MT is correctly aligned with th e medial side of the middle cuneiform. Check for presence of the dorsalis pedis pulse. Mult iple, dis- placed, or dislocated MT fractures require urgent orthopedic treatment. Support in a POP backslab following analgesia and refer for MUA, K-wire \201 xation, or occasiona lly, ORIF. MT stress fractures are discussed below. Isolated avulsion fractures of the 5th MT base These follow inversion injuries of the ankle , the base of the 5th MT being avulsed by the tendon of peroneus brevis. Always examine thi s area in ankle injuries and request foot X-rays if tender. Do not mistake accessory bones or the epiphysis (which runs parallel, not transverse to the 5th MT base). Treat with analg esia, elevation, and support in a padded crepe bandage or temporarily, in a BKPOP if sympto ms are severe. Arrange orthopedic follow-up. Jones fracture (of the 5th MT) This is a transverse fracture of the 5th MT just distal to t he intermetatarsal joint. It is a signi \201 cant fracture as it is prone to non-union. Tr eat with analgesia, crutches, BKPOP, and orthopedic follow-up. Stress fractures of the MTs Fatigue fractures of the MTs are common. They typically follow prolonged or unusual exercise (hence the term \200\230march fracture \200\231), but often occur without an obvious cause. The commonest site is the 2nd MT shaft, but the 3rd MT or r arely the navicular or other MTs may be affected. Examine for swelling over the forefoot (t here may be none) and localized tender- ness over the MT shaft or on longitudinal compressi on of the MT shaft (do this by pressing on the MT head below the toe \200\224 pain will be felt along the MT shaft). X-rays are usually normal initially. Callus or periosteal reac- tion seen at \211\210 2 \200\2233weeks on X-ray will con \201 rm the diagnosis, but this is not required for treatment. Treat symptomatically with analgesia, elevation, rest, and modi \201 ed daily activity as required. A padded insole may help. Firm shoes or boots may be more comfortable than \202 exible trainers. Expect full recovery in 6 \200\2238 weeks. If unable to WB, consider a br ief period in a BKPOP (or \200\230Aircast \200\231 boot) until symptoms improve. 490 CHAPTER 9 Wounds, fractures, orthopedics Toe injuries Most toe injuries do not require X-ray The treatment of isolated closed fractu res of the toe phalanges without clinical deformity or other complicating factors is not al tered by X-rays. X-ray the following: \200 Obvious deformity, gross swelling or suspected dislocation. \200 Suspected compound injuries. \200 If any tenderness over the MT head or MTPJ. \200 Suspected FB. Toe fractures Treat uncomplicated phalangeal fractures with simple analgesia, elevation, an d support with padded buddy strapping. Advise the patient to resume normal activities as so on as possible, but explain that some discomfort may be present for up to 4 \200\2236weeks. Hospital follow-up is not normally required. Manipulate displaced fractures under LA digit al block (as des- cribed for \201 ngers on b p.294). Angulated toe phalangeal fractures c an be dif \201 cult to manipulate \200\224 a useful trick is to use a pen (or needle hold er) placed between the toes as a fulcrum. Once satisfactorily reduced, buddy strap and con \201 rm the position with X-rays. Dislocated toes Untreated, toe dislocations may cause troublesome, persistent symptoms. Red uce promptly under LA digital block and splint by buddy strapping. Always con \201 rm redu ction by X-ray, and discharge with analgesia and advice on elevation and gradual mobilizati on. Compound toe injuries Careful wound toilet, debridement, and repair is essential to ensure rapid healing and avoid infective complications. Ensure that there is adequate tetanus prop hylaxis. Always clean wounds thoroughly under adequate anesthesia (usually LA digital block ), provide antibiotics and analgesia. Advise the patient to elevate the injured foot and ar range follow-up according to local practice. More severe injuries will require exploration and repair under GA. Refer these cases to the orthopedic team. Mangled or amputated toes Functional results of attempted re-implantation of amputated toes or repair of badly mangled toes are often poor. Provide analgesia and refer to the orthope dic surgeon for wound management and amputation of unsalvageable toes. 491 SOFT TISSUE FOOT PROBLEMS Soft tissue foot problems Puncture wounds to the foot \200 \200\230Simple \200\231 punct ure wounds : see b p.419. \200 Weever \201 sh injuries : see b p.416. FBs embedded in the foot Searching for small FBs in the sole of the foot has been likened t o search - ing for a needle in a haystack. Follow the principles set out in b Further asses sment of skin wounds, p.428. Nerve blocks ( b p.306) can be useful to allow exploration of foot wounds. Morton \200\231s metatarsalgia A burning discomfort radiating to the toes may result from a n interdigital nerve neuroma at the level of the MT heads. The nerve between the 2nd and 3r d MT heads is frequently affected. There is localized tenderness, which is also reproduced on compression of MT heads together. Advise simple analgesia and GP follow-up to consider r eferral to a foot surgeon. Plantar fasciitis Plantar fasciitis can occur spontaneously or as a chronic overuse injury. In \202 ammation develops in the plantar fascia, typically at its calcaneal insertion. Th is results in gradually increasing, burning pain in the sole of the foot and heel, which is worse on WB. Examine for localized tender- ness over the calcaneal insertion of the planta r fascia and heel pad. X-ray may reveal a calcaneal spur, but this is not a useful diagnost ic feature. Advise NSAID, rest and elevation for 1 \200\2232 days, with GP follow-up. A padded shoe ins ole or sorbothane heel pad may help. Severe, persistent cases are occasionally treated with local steroid injection or even surgical division of the plantar fascia. Osteochondritis d issecans ( b p.708) Osteochondritis of a MT head (usually the 2nd \200\224 Freiberg \200 \231s disease) causes gradual onset pain on WB. The cause is often unclear, but it may foll ow minor injury. Examination may reveal local tenderness but little else. X-ray for evidenc e of \202 attening, widening, or fragmentation of the MT head or narrowing of the MTPJ. Treat initially with simple analgesia. Refer persistent cases to orthopedics to consider ex cision of the MT head or osteotomy. In-growing toenails Refer back to the GP for elective treatment, unless there is evidence o f infection. In this case, consider oral antibiotics (eg \202 ucloxacillin or co-amoxicla v), or if there is an acute paronychia, incision, and drainage under LA. On occasion, it ma y be appropriate to excise a wedge of nail under LA. 492 CHAPTER 9 Wounds, fractures, orthopedics Low back pain Low back pain is the commonest cause of lost work days in the UK. The initial ED approach is to identify any patients who may have immediately life- threatening problem s (eg leaking aortic aneurysm) and sort the rest into: \200 Simple ( \200\230mechanical \200\231) back pain : no investigations or referral required. \200 Nerve root pain : refe rral and investigation needed if symptoms persistent or progressive. Possible serious spinal pathology : referral and investigation required. \200 Suspected c ord compression : immediate neurosurgical/orthopedic referral mandatory. Psychogenic back pain is not an ED diagnosis. If in doubt, refer. History General Document patient \200\231s age, sex and employment. Note onset and duration of symptoms, character, position and radiation of pain, exacerbating or relieving factors. Precipitants include injuries, falls, heavy lifting, or unaccustomed activity. Past history Detail any previous back problems or surgery, other medical conditions (eg rhe umatoid arthritis, OA, osteoporosis). Drug history Is the patient using analgesia (and has it helped?). Ask about corticosteroids and contraindications to NSAIDs. Social history Ask about home circumstances, work, and stress. Systemic enquiry Weakness, altered sensation, weight loss, anorexia, fever, rigors, cough, sputum, haemoptysis, bowel, or urinary symptoms. Examination \200\230Unwell \200\231 patient Immediately assess airway, breathing, and circ ulation. Look for shock and a pulsatile abdominal mass, peritonism, evidence of blood loss, radial-femoral pulse discrepancies or asymmetry. \200\230Well \200\231 patient Look for signs of weight loss, cachexia, anemia, clubbing, o r muscle wasting. Inspect the back for muscle spasm, scars, scoliosis, or other deformity. If possible, watch the patient walk, looking for spasm, abnormal posture or limping. Palpat e for tenderness over the spine, lower ribs and renal angles. With the patient supine on a trolley, look for muscle wasting in the legs. Examining both sides: \200 Straight leg rai se : note the angle which reproduces pain (lumbar nerve root irritation). Crossed straight leg raise : nerve root symptoms reproduced by lifting contralateral leg st rongly suggests lumbar disc prolapse and nerve root entrapment. Perform a neurological examination Check tone, power, sensation, and re \202 exes in the l ower limbs: \200 L4 covers sensation of medial lower leg; quadriceps power; knee jerk. \200 L5 covers sensation of lateral lower leg and great toe; extensor hallucis longus power; hamstrings jerk. S1 covers sensation of little toe and lateral foot; foot plantar \202 exors power; ankle jerk. Always check perineal and perianal sensation. Perform a rectal examination for anal tone, masses, or blood. Examine the abdomen for masse s. Document peripheral pulses and perfusion.