Cosmetic considerations These are very important. The \201 nal appearance of a scar depen ds partly upon the orientation of the wound and its relation to natural skin lines (modi \201 ed from Langer \200\231s description), but also upon initial management. Cleaning is c rucial, but do not debride with tissue excision in the ED. Consider suturing facial dog bit es ( b p.414) and non-contaminated facial wounds up to 24hr after injury (get senior advice \201 rst). Close facial wounds in layers, using 5/0 Dexon or Vicryl for deeper layers, w ith knots tied on the deep aspect. Aim to remove skin sutures (interrupted 6/0 non-absorbab le mono \201 lament) at 3 days and replace with Steri-Strips \204 to minimize scarring. C onsider GA to treat facial wounds in children. Damage to parotid duct/gland and facial nerve This is particularly likely with incised woun ds in the pre-auricular area. The facial nerve emerges through the parotid gland to supply the muscles of facial expression: unrepaired injury results in permanent dis \201 gurement . The parotid duct runs transversely forwards from the anterior portion of the gland, paral lel and inferior to the zygomatic arch, before entering the mouth opposite the second upper molar (look for blood here, as this implies proximal duct injury). Refer for exploration i n theater if there is clinical suspicion of involvement of any of these structures. Associated head injury Consider the possibility of signi \201 cant head or neck injury in all patients with a facial wound. Speci \201 c wounds Lip wounds Oppose the vermilion border accurately (it is often easiest to do this \201 rst). Remember that even a 1mm mismatch will result in a permanent visib le abnormality. Close in layers if the wound extends into subcutaneous or muscle layers. Tongue and oral wounds Check the teeth: if any are broken or missing, consider obtaining so ft tissue lateral X-rays of the lips in a search for embedded fragments. Small super \201 cial lacerations need not be closed, but close deeper ones in layers, using absorbable sutu res (eg 4/0 or 5/0 Vicryl/ Dexon for mucosal surfaces). Close through and through oral lace rations in layers (mucosa, muscle, and subcutaneous tissue, skin). Eyebrow wounds Do not shave the eyebrows. Exclude an underlying fracture by palpation (and X-rays, as appropriate). Eyelid wounds Many may be sutured with 6/0 non-absorbable mono \201 la- ment. Full eye exa mination, excluding a FB, is necessary. Refer wounds if there is involvement of lid margin, loss of tissue, or if lacrimal duct (medial canthus) or gland (superolateral) injury is su spected. Ears Involvement of cartilage requires suture with \201 ne absorbable material (by an Ear , Nose and Throat (ENT) specialist) prior to skin closure. Give prophylactic antibiotic cov er (eg co-amoxiclav) if there is any contamination. 465 FACIAL WOUNDS Langer \200\231s lines (Fig. 9.33 ) Fig. 9.33 Langer \200\231s lines. 466 CHAPTER 9 Wounds, fractures, orthopedics Pelvic fractures Major pelvic fractures result from very high energy trauma and are true or thopedic emergencies. Associated thoracic or abdominal injuries occur in 10 \200\22320 % \200\224 the principal immediate risk is massive hemorrhage and exsanguination. Compound fr actures of the pelvis have a mortality of > 50 % . Associated bladder or urethral damage is common. Rectal and vaginal injuries occur occasionally. Assessment \200 Resuscitate as for any severely traumatized patient ( b Major trauma: treatment principles, p.320). Obtain a pelvic X-ray on all patients with multisystem injury ( b p.322). Look carefully for evidence of hypovolaemia and treat appropriately. \200 Examine pubis, iliac bones, hips, and sacrum for tenderness, bruising, swelling, or crepitus. Do not try t o \200\230spring the pelvis \200\231 to assess stability \200\224 this is unreliable, unn ecessary, and may cause additional hemorrhage/damage. Similarly, avoid log rolling patients with obvious pelvis fractures \200\224 enlist a number of helpers and perform a straight lift. Look carefully for wounds especially in the perineum. \200 Perform a rectal examination f or anal tone, palpable fractures and to detect bleeding, rectal tears, and urethral damage (high riding, boggy prostate). Test urine for blood, but do not catheterize if urethral injury is suspected. Look at X-rays carefully for disruption of normal pelvic contours (Shenton \200\231s lines) , asymmetry and widening of the pubic symphysis or sacroiliac joints. Classi \201 cation of pelvic fractures (Table 9.3 ) Table 9.3 Tile classi \201 cation of pelvic injuries (see Fig. 9.34) Type A (Stable injuries) include avulsion fractures, isolated pubic ramus fractures, iliac wing fr actures, or single stable fractures elsewhere in pelvic ring Type B Rotationally unstable but vertically stable B1 \200\230Open book \200\231 antero-posterior compression fractures, causing separation of t he pubic symphysis and widening of one or both sacroiliac joints B2 Ipsilateral compression causing the pubic bones to fracture and override B3 Contralateral compression injury resulting in pubic rami fractures on one side and compress ion sacroiliac injury on the other Type C (Rotationally unstable and vertically unstable) The pelvic ring is completely disrupted or displaced at 2 or more points. Associated with massive blood loss and very high mortality. Subdivided into C1 (unilateral), C2 (bilateral) and C3 (involving acetabular fracture) 467 PELVIC FRACTURES Treatment Stable type A injuries require analgesia and bed rest until able to mobi- lize (u sually 3 \200\2236weeks). Isolated pubic ramus fractures are common and often missed in the elderly (particularly when the focus is on a potential fractured neck of femur). Refer to orthopedics for analgesia, initial bed rest, then mobilization. Unstable type B and C fractures are an orthopedic emergency Resuscitate as for any major tr auma ( b p.320). Correct hypovolaemia, anticipate coagulopathy and ensure blood is rapidly available as massive transfusion may be required. If DPL ( b p.347) is employed, use a supr a- umbilical approach, as pelvic haematoma may track up the abdominal wall. Minimize moveme nt, but support an obviously unstable pelvis frac- ture associated with severe hemorrhage u sing a pelvic binder or splint (eg SAM sling). Consider reduction and immobilization using an external \201 xator applied either in the resuscitation room or operating theater to h alt hemorrhage. If this fails, angiography and selective embolization are indicated. Type B1 fracture Type C1 fracture Fig. 9.34 Examples of pelvic fractures. Avulsion fractures around the pelvis Avulsion fractures occur at attachments of various mus cles as follows: \200 Anterior inferior iliac spine \200\224 rectus femoris (typically r esults from a miskick into the turf). Anterior superior iliac spine \200\224 sartorius. \200 Ischial tuberosity \200\224 hams trings. In most instances, symptomatic treatment based upon rest (consider crutches) and an algesia suf \201 ces. Larger avulsions (particularly of the ischial tuberosity) may requir e internal \201 xation (to avoid complications such as non-union). 468 CHAPTER 9 Wounds, fractures, orthopedics Hip dislocations and acetabular fractures Acetabular fractures Often accompany traumatic hi p dislocation following violent injury such as falls or blows to the hip. Posterior rim fra ctures are the most common. Complications include massive hemorrhage, sciatic nerve damage, myositis ossi \201 cans, and secondary OA. Resuscitate, give analgesia and deal with prio rities \201 rst. Additional X-rays (eg 45 oblique \200\230Judet \200\231 views) or CT are often required to make an exact diagnosis. Refer to orthopedics for traction, protecte d weight-bearing, or in some cases internal \201 xation. Central dislocation of the hip This injury is essentially a serious pelvic fracture, which involves the head of the femur being driven through the (fractured) acetabular \202 oor f ollowing a fall or force directed along the length of the femur (eg car dashboard). The dia gnosis is usually obvious on an AP pelvis X-ray. Treat associated injuries and for shock, a nd give analgesia. Contact the ortho- paedic surgeon immediately. Traumatic posterior dislocation of the hip Implies major trauma, often with other critical injuries (eg dashboard knee injury in a car crash) or fractured posterior acetabulum. Limb is short- ened, internally rotated with hip \202 exed and adducted. This appearance may b e absent if there is also a femoral shaft fracture. Check for sciatic nerve damage \200 \224 examine foot dorsi \202 exion and below knee sensation. Complications: sciatic nerve injury, avascular necrosis of femoral head (risk i the longer the hip is dislocated), and s econdary OA. Diagnosis is usually obvious on AP X-ray, but lateral views may be needed to e xclude dislocation. Treat as follows: \200 Resuscitate the patient and deal with A, B, C priorities \201 rst. \200 Give analgesia \200\224 posterior dislocation causes severe pain. \200 Refer for reduction under GA. In unconscious, multiply injured patients, consider an early attempt to reduce the dislocation. Reduction technique for posterior dislocation ( \200\230Allis technique \200\231) \200 It is easiest and safest to reduce the dislocation if the anesthetized patient is placed on t he \202 oor. If this is not possible, stand on the trolley. An assistant presses down on the patient \200\231s anterior superior iliac spines to hold down the pelvis. Flex hip and knee both to 90 , and correct adduction and internal rotation deformities. Grip the patient \200\231s lower leg between your knees and grasp patient \200\231s knee with both hands. Lean back and lever the knee up pulling the patients hip upwards. A \200\230clunk \200\231 con \201 rms successful reduction. X-ray to con \201 rm reduction. Dislocated hip prostheses Relatively common, follows minor trauma. Con \201 rm posterior d islocation of hip prosthesis by X-ray. Treat with IV opioid and refer to orthopedics for MU A (and assessment of prosthesis stability) under GA. Anterior dislocation of the hip Less common. The leg is held abducted and externally rotate d. Complications include damage to the femoral nerve, artery, and vein. Give analgesia and refer for reduction under GA. 469 SACRAL AND COCCYGEAL FRACTURES Sacral and coccygeal fractures Fractures of the sacrum Usually occur from violent direct tr auma such as falls. Damage to sacral nerve roots may occur. Check carefully for saddle anes thesia, d anal tone, lower limb weakness, or bladder dysfunction. Refer to the orthopedic t eam. Fracture of the coccyx Follows a fall onto the bottom. Do not X-ray routinely \200\224 the diagnosis is clinical. Perform a rectal examination and check for local coccygeal tenderne ss, palpable fractures, or evidence of rectal damage. Refer patients with rectal tears to t he general surgeon. Refer to the orthopedic team if the coccyx is grossly displaced, as it may require manipulation under LA or even excision. Treat the remainder symptomatically (eg suggest a ring cushion and provide analgesia). 470 CHAPTER 9 Wounds, fractures, orthopedics Hip fractures Intracapsular fractures of the neck of femur Can follow relatively minor trau ma. Risk i in the elderly, because of osteoporosis, osteomalacia, and i rate of falls. Thes e fractures can disrupt the blood supply to the femoral head, causing avascular necrosis. Fractures around the hip in younger patients imply high energy injury: the incidence of non -union or avascular necrosis may be as high as 20 % . Diagnosis Usually follows a fall onto the hip or bottom. Pain may radiate down towards the knee. The affected leg may be shortened and externally rotated. Check for hypothermia and d ehydration (the patient may have been lying for hours). Look for tenderness over the hip or greater trochanter, particularly on rotation. Suspect hip fracture in an elderly person wh o: \200 Exhibits sudden inability to WB. There may be no history of injury, particularly in the presence of confusion or dementia. Is unable to WB and has pain in the knee (the hip may not be painful). \200 Has \200\230 Gone off her feet \200\231. X-rays Look closely for disrupted trabeculae/cortices and abnor mal pelvic contours (Shenton \200\231s lines). Fractures of the femoral neck are not always visible on initial X-rays. Repeat X-rays, bone scanning, or MRI may be required if symptom s continue. Intracapsular femoral neck fractures may be graded according to the Garden clas si \201 cation. Treatment \200 Obtain IV access and draw blood for U&E, glucose, FBC, and cross-match. Start IV infusion if indicated (eg dehydration or shock). \200 Give IV analgesia plus an anti-emetic. Provide all analgesia IV in small increments every few minutes until pain is controlled. Obtain an ECG to look for arrhythmias/MI and consider need for CXR. \200 Arrange other in vestigations as indicated by history/examination. \200 Admit to orthopedic ward. Intertrochanteric fracture These affect the base of the femoral neck and the intertrochante ric region. Initial management is identical to neck of femur fractures outlined above. Isolated trochanteric avulsion fracture Sudden force may avulse insertions of gluteus mediu s (greater trochanter) or iliopsoas (lesser trochanter). Give analgesia and refer for follo w-up for gradual mobilization and symptomatic treatment. 471 HIP FRACTURES The Garden classi \201 cation (Fig. 9.35 ) Garden I Garden II Garden III Garden IV Fig. 9.35 The Garden classi \201 cation. Garden I: trabeculae angulated, but inferior cort ex intact. No signi \201 cant displacement. Garden II: trabeculae in line, but a fracture line visible from superior to inferior cortex. No signi \201 cant displacement. Garden III : obvious complete fracture line with slight displacement and/or rotation of the femoral he ad. Garden IV: gross, often complete, displacement of the femoral head. Hip pain after injury, but no fracture Elderly patients who report hip pain and struggle to walk after a fall, but yet have no fracture of hip or pubic rami on X-ray may need assessm ent by an occupational therapist or physiotherapist before deciding if they can be safely d ischarged home with analgesia and appropriate walking aid. A small, but signi \201 cant, p roportion of such patients will turn out to have a hip fracture. Therefore, arrange for all patients to return for further imaging (eg MRI or CT) if pain continues for more than 1 we ek. In some patients with very signi \201 cant symptoms, consider requesting MRI or CT sca n at the time of initial presentation to show up a hip fracture not identi \201 ed on plai n X-rays. 472 CHAPTER 9 Wounds, fractures, orthopedics Shaft of femur fractures Enormous force is required to break an undiseased adult femoral sh aft. Fractures are frequently associated with multisystem trauma. Treatment of immediately life-threatening injuries takes priority. Transverse, spiral, or segmental shaft fractures usually result from falls, crushing injuries, or high-speed road traf \201 c collisions. T here is often associated dislocation of the hip or other serious injury to the pelvis, hip, and knee. Complications Closed fractures of the femoral shaft, even without obvious vascular injury, may be associated with marked blood loss. Up to 1.5L of blood may be lost without visible t high swelling. Rarely, gross blood loss may occur from compound femoral fractures. Later co mplications include fat embolism/ARDS. The incidence of complications is d by early splinta ge and early de \201 nitive treatment (usually closed intramedullary nailing). Diagnosis The diagnosis is usually clear on examination with deformity, shortening, externa l rotation and abduction at the hip on the affected side. The frac- ture may be felt or eve n heard on movement of the lower limb. Carefully check for associated pelvic, knee, or dist al limb injuries or for the presence of associated wounds. Document sensation and pulses in the limb and re-check frequently. Treatment Before X-rays, resuscitate, exclude life-threatening injuries, replace IV \202 uids, give adequate analgesia, and splint fractures as follows: \200 Assess ABCs, establi sh priorities, and resuscitate. \200 Start \202 uid replacement via 2 large-bore IV can nulae. \200 Obtain blood for cross-matching. \200 Administer IV analgesia \200\224 giv e small increments of opioid (with an anti-emetic) until pain is controlled, Strongly consider femoral nerve block (b p.304). As this starts to take effect ( \211\210 5 \200\22310min), prepare splintage and immobilize in Thomas or other traction splint. Arrange X-rays of the femur and contact the orthopedic team. Subtrochanteric fractures Involve the most proximal part of the femoral shaft, at or just d istal to the trochanters. Typically involve high-energy trauma in younger patients and are often associated with other serious injuries. They can also occur as iso- lated injuries fo llowing relatively minor trauma in those with osteoporosis or metastatic disease. Treat as for femoral shaft fractures. Supracondylar fractures Fractures of the distal third of the femur usually follow violent d irect force. They are frequently comminuted and often intra-articular with associated damag e to the knee joint. In adults, the distal femoral fragment tends to rotate due to pull fro m gastrocnemius. Treat as for femoral shaft frac- tures, but note that femoral nerve block may not be as effective. 473 SHAFT OF FEMUR FRACTURES Splints for fractured femoral shaft The Thomas splint is traditional, but other forms of te lescopic, metal, or pneumatic traction splints are increasingly being used. These are conve n- ient, and particularly suitable for temporary immobilization in patients going directly to theater or in transit to hospital. Ensure adequate padding around the groin and the ankl e to avoid pressure necrosis of the skin. Application of a Thomas splint \200 Measure circumference of the uppermost part of the un injured thigh in cm. Select splint of appropriate ring size (also have sizes above and below ready). Prepare splintage \200\224 wrap ring in wool roll. \200 Slide sleeve of tubigrip over sp lint to support leg from ring to distal calf. Secure tubigrip by tying to ring or taping al ong sides of splint. If the ring has a buckle this should be on the upper half of the ring. Prepare the limb for skin traction \200\224 gently. If time permits, shave hair from medial and lateral aspects of limb. Apply splint (if using femoral nerve block wait until this is effective). Start with adhesi ve skin traction, making sure the foam part adequately covers the malleoli. Remove backing and apply adhesive tape along sides up limb, extending as far up the limb as possible. Trim off the remaining tape. Wrap the leg from ankle to mid-thigh with gauze bandage. \200 Apply traction to the leg. Gently pull the ankle with one hand and support the knee with the other. Correct the abduct ion and external rotation while pulling steadily. Slide the Thomas splint over the leg until it is against the perineum. Take care not to sna g the skin or genitalia. If the splint does not \201 t, replace it while maintaining trac tion. Tie the cords from the heel end of the skin traction to the end of the splint while maintai ning traction. Insert 2 tongue depressors between the cords and twist them until the cords are reasonably taut. Place wool roll padding under the thigh and if necessary, add more padding around the groin. Bandage around the whole splint from thigh to lower calf with a broad bandage. Support and elevate the leg on a pillow. \200 Check distal pulses. \200 Arrange X-rays. 474 CHAPTER 9 Wounds, fractures, orthopedics Approach to knee injuries History Many knee injuries seen in the ED result from sports, par ticularly foot- ball and rugby. Carefully document the exact mechanism of injury as it prov ides clues to the diagnosis. Valgus or varus stresses can damage the medial and lateral col lateral ligaments, respectively. Flexed, twisting knee injuries are frequently associated w ith meniscal injuries. The anterior cru- ciate ligament (isolated or associated with medial collateral and/or medial meniscal injuries) may tear during forced \202 exion or hyperex tension. Posterior cruciate ligament injuries may follow falls or dashboard impact where th e tibia is forced backwards violently (often associated with medial or lateral ligament inj uries). Rapid onset tense swelling in a knee is usually an acute haemarthrosis . Swelling developin g more gradually over several days is more likely to represent a reactive effusion. Ask abo ut previous knee problems: swelling, clicking, locking, or giving way (the last two suggest underlying meniscal pathology). Document any previous knee surgery or the presence of othe r joint problems. In a hot, swollen, painful, and stiff knee without a history of signi \201 cant trauma consider and exclude septic arthritis. Examination Always examine both legs with the patient suitably undressed and lying supine. If there is much discomfort, consider giving oral analgesia and re-examine in 10 \200\22315 min. Reassure him/her that you will not suddenly pull or move the leg without warning. Look for bruising, swelling, redness, abrasions, or other wounds. Feel for warmth, crepitation, or the presence of a knee effusion (patellar tap or ballottab le \202 uid). Ask the patient to straight leg raise The ability to do this against resistance virtually e xcludes quadriceps, patellar tendon rupture, or transverse patellar fractures. If unable (p ossibly due to pain), ask the patient to kick forwards whilst sitting with the affected leg dangling free. Assess tone and bulk of quadriceps muscle and compare with the other side. Assess knee movement Gentle encouragement or supporting the limb may be required, but do no t use any force. Assess the cruciate ligaments Try to bring the knee to 90 \202 exion, sit on the patie nt \200\231s foot and hold the leg with both hands around the upper tibia. Ensure the quadr iceps and hamstring muscles are relaxed. Using body weight, gently rock backwards and forwa rds looking for anterior glide (draw) of the tibia (indicating rupture of the anterior cruc iate ligament) or posterior glide of the tibia (indicating rupture of the posterior cruciat e ligament). Up to 5mm movement is normal \200\224 always compare both legs. If unable to \202 ex to 90 , assess with slight \202 exion \211\210 10 . Repeat the procedure with the tibia slightly internally rotated. 475 APPROACH TO KNEE INJURIES Assess the collateral ligaments With the leg straight, gently apply a valgus stress to the knee joint (ie move the lower leg laterally) examining for laxity or pain in the medial col lateral ligament. Next apply a varus stress (ie move the lower leg medially) examining for laxity or pain in the lateral collateral ligament complex. Repeat the procedure with the kn ee in \211\210 20 \202 exion as this will relax the cruciate ligaments. Compare both sides. Palpate around the knee joint examining all the structures around the knee for tenderness, swelling, warmth, or crepitus (eg bony landmarks, ligament insertions, and over the joint l ine medially and laterally). X-rays for knee injuries X-rays form the mainstay of initial imaging for knee trauma: other imaging (eg CT, MRI) may be indicated after specialist consultation. Obtain X-rays followi ng knee injuries where there is suspected fracture or other signi \201 - cant injury. Use the Ottawa knee rules to assist the decision (in those aged between 18 and 55 years) as to whether or not to X-ray: X-rays are only required if any of the following are present: \200 There is isolated bony tenderness of the patella. \200 There is bony tenderness over the \201 bula head. \200 The patient cannot \202 ex the knee to 90 . \200 The patient could not weight- bear (take at least 4 steps) both immedi- ately after the injury and at the time of examination. Adopt a lower threshold for obtaining X-rays in those aged <18 or > 55years, patients intox icated with alcohol, those suffering from bone disease (eg RA, documented osteoporosis), an d for those who reattend the ED with the same injury (having not been X-rayed initially). 476 CHAPTER 9 Wounds, fractures, orthopedics Knee fractures and dislocations Patellar fracture This may follow a direct blow or fall ont o the patella or sudden violent knee \202 exion or contraction of the quadriceps muscle. Look for pain, swelling, crepitus, and dif \201 culty extending the knee. Displaced, trans verse fractures result in an inability to straight leg raise (this is also a feature of rup ture of the quadriceps tendon or patellar tendon \200\224 b Soft tissue knee injuries, p.4 78). There may be an associated haemarthrosis. X-rays may be dif \201 cult to interpret as the patella overlies the distal femur on the A P view and can obscure subtle fractures. Do not routinely order \200\230skyline \200\231 v iews of the patella. Take care not to mistake a bipartite patella for a fracture (the acces sory bone is typically in the upper, lateral part of the patella). Treatment \200 Treat vertical fractures with analgesia, immobilize in a non-weight- beari ng cylinder POP, supply crutches, and arrange orthopedic follow-up. Transverse fractures tend to displace due to the pull of quadriceps. Treat with analgesia, immobilization in a POP backslab, and refer to the orthopedic team for probable ORIF (occas ionally, the orthopedic team may decide to treat an undisplaced transverse fracture conserv a- tively). Dislocation of the patella The patella typically dislocates laterally. This often follows m edial stress to the knee \200\224 the dislocation may reduce spontaneously. There may be a history of recurrent dislocation. The patient has a painful knee, held in \202 exion wit h obvious lateral displacement of the patella. X-rays are not generally required prior to r eduction of the dislocation. Reduction can usually be achieved using Entonox \200\224 I V analgesia is seldom required. Stand on the lateral side of the affected limb and hold the affected knee gently. Using a thumb, lever the patella medially in one smooth, \201 rm m ovement whilst gently extending the knee at the same time. Successful reduction is obvious and should rapidly relieve symptoms. Once reduced, obtain X-rays, immobilize in a canvas ( \200\230cricket pad \200\231) back-splint or cylinder cast POP, provide analgesia and arran ge orthopedic follow-up. Surgery is not usually indicated for \201 rst time dislocations. Spontaneous reduction/patella subluxation The patient who has experienced spontaneous reduc tion and/or subluxation prior to arrival at hospital will typically have maximal tenderness over the medial aspect of the upper patella re \202 ecting damage to the attachment of va stus medialis. There may be \200\230apprehension \200\231 when gentle lateral pressure is applied to the patella. If clinical features are dramatic, rest in a splint (occasionally c ylinder POP may be needed), otherwise refer for physiotherapy and orthopedic follow-up. 477 KNEE FRACTURES AND DISLOCATIONS Dislocation of the knee Although rare, this injury indicates severe disruption of the ligam entous structures and soft tissues of the knee. Look carefully for associated injuries (eg femur or lower limb), and document distal pulses and sensation \200\224 the popliteal arte ry or nerve are often injured. Reduction requires adequate (IV opioid) analgesia, and usual ly GA or sedation with full precautions. Reduce by simple traction on the limb and correcti ng deformity. Check distal pulses and sensation after reduction, immobilize in a long leg P OP backslab, and arrange orthopedic admission. Check the circulation repeatedly, since popl iteal artery damage may not become apparent for some hours \200\224 angiography is usually required. Compartment syndrome is another recognized complication. Tibial plateau fractures Falls onto an extended leg can cause compression fractures of the proximal tibia. Valgus stresses crush or fracture the lateral tibial plateau. These injurie s are commonly seen in pedestrians injured following impact with car bumpers. Varus injurie s result in crushing or fracture of the medial tibial plateau and are usually associated wi th rupture of the opposite collateral ligaments. Examine for tenderness over the medial or lateral margins of the proximal tibia. Look for swelling, haemarthrosis, or ligamentous ins tability (also try to assess the cruciate ligaments \200\224 b Approach to knee injuries, p.474). Look carefully on X-rays for breaks in the articular surfaces of the proximal tibia , avulsions from the ligamentous attachments, or loss of height from the medial and lateral tibial plateaux, but beware, this may be subtle. Treat with immobilization in a long leg POP backslab following adequate analgesia and refer to orthopedic staff. Fractures of the tibial plateau often require elevation ORIF with bone grafting. Admit all patients with an acute haemarthrosis. Treat small, isolated avulsi ons without haemarthro- sis with immobilization, crutches, and analgesia, and arrange ortho pedic follow-up. Posterolateral corner injuries The posterolateral corner of the knee is comprised of a grou p of ligaments and muscles/tendons that add to the stability of the joint. Postero-lateral corner injuries often occur in association with other signi \201 cant knee trauma (eg disl ocations, rupture of anterior or posterior cruciate liga- ments, but isolated injuries can occur. Suspect this injury when signi \201 cant symptoms follow the application of varus f orce to the anteromedial aspect of the extended knee. Chronic instability can result. X-ray s may be normal or show subtle avulsions or widening of the lateral joint space. Urgent MRI and orthopedic referral will enable prompt treatment. 478 CHAPTER 9 Wounds, fractures, orthopedics Soft tissue knee injuries Acute haemarthrosis Rapid onset swelling following a knee injury, often warm, tense, and painful. Common causes include cruciate ligament rupture, tibial av ulsion, tibial plateau, or other fractures. An acute haemarthrosis indicates serious injury . Refer for orthopedic appraisal following splintage, analgesia and appropriate X-rays. Asp iration of a haemarthrosis (advocated by some experts to provide analgesia) requires strict aseptic technique. Cruciate ligament rupture The combination of considerable pain and swel ling can make it dif \201 cult to elicit classical physical signs of a fresh cruciate tear . A history of an audible \200\230pop \200\231 at the time of injury is highly suggestive of anterior cruciate rupture. Anterior cruciate tears often occur in association with tears of the medial collateral liga ment and/or medial meniscus. Examine for the presence of haemarthrosis, abnormal i anterior glide of the tibia ( \200\230 + ve anterior draw test \200\231) and injuries to the medial collateral ligament or other structures. Look carefully at X-rays for avulsion of the ante rior tibial spine (anterior cruciate insertion). Give analgesia and refer to the orthopedic surgeon. In posterior cruciate ligament tears , the tibia may appear to sag back when the knee is \202 exed, so the tibia can be pulled into a more normal position causing a \200\230false + ve \200\231 anterior draw. X-rays may reveal the relevant posterior tibial spine to be av ulsed. Provide analgesia and refer. Collateral ligament injuries Tenderness over the medial or lateral collateral ligament, with pain at this site on stress testing, indicates collat eral ligament injury. Most injuries are isolated, and have no associated haemarthrosis and no abnormality on X-ray. Compare the injured knee with the uninjured one. The degree of lax ity on stress testing will help to guide treatment: \200 Local tenderness with no laxity (or very slight laxity) implies a grade I injury. Treat with analgesia, physiotherapy ( crutches) in the expecta- tion of full recovery in 2 \200\2234weeks. 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.