If the source patient is known to be (or suspected of being) HIV + ve, follow local guideli nes and/or refer immediately to an infectious dis- eases specialist to discuss post-exposur e prophylaxis and follow-up. Follow Department of Health guidance on www.dh.gov.uk Combined prophylaxis therapy (eg 1 Truvada tablet od and 2 Kaletra tablets bd \200\223 ie 24 5mg tenofovir od + 200mg emtricitabine od + 400mg lopinavir bd + 100mg ritonavir bd) is mos t effective if started within an hour of exposure, but may be worth considering up to 72hr. However, prophylaxis has side effects, especially diarrhea. Involve both healthcare worker and a local expert in deciding whether or not to start prophylaxis. Either way, advise the patient to use barrier contraception and not to give blood as a donor until subsequent HIV seroconversion has been ruled out. Take baseline blood for storing (serology for possible future testing), and in the case of a possible HIV source patient, also take FBC, U&E, LFTs, and amylase). If the incident occurred in hospital, report it to Occupational Health. 419 PUNCTURE WOUNDS Puncture wounds Puncture wounds are small skin wounds with possible deep penetration. Stab wounds to the trunk and neck are considered elsewhere ( b Penetrating chest injury, p. 340). Puncture wounds often involve the sole of the foot, patients having trodden on a nail . Examine to exclude neurovascular injury, then obtain an X-ray looking for FB. If signi \201 cant foreign material is present radiologically, or the patient has associated fractur e, tendon injury, or neurovascular de \201 cit, refer for formal exploration and cleaning in theater under a bloodless \201 eld. Otherwise: \200 Irrigate and clean other wounds under local anesthetic (LA) where possible (consider nerve blocks). For wounds to the sole of the foot this may be impractical. As a compromise, immerse foot in warm anti- septic (eg povidone iodine solution) for 15min. Apply a dressing and advise review/follow-up with GP as appropriate. \200 Ensure adequate tetanus cover ( b Tetanus prophylaxis, p.410). \200 Prescribe simple analgesia. \200 S trongly consider prophylactic oral antibiotic cover (eg co-amoxiclav). Some puncture wounds may become infected despite treatment. This may be due to retained foreign material in the wound. Pseudomonas osteitis is an uncommon, but recognized complication of puncture wounds to the foot, particularly where a nail has gone through training shoes to cause the wound. Refer infected wounds for formal exploration and irrigation. 420 CHAPTER 9 Wounds, fractures, orthopedics How to describe a fracture Clear, precise, complete descriptions of fractures aid accuracy and save time when referring patients. System for describing fractures \200 State the age of the patient and how the injury occu rred. \200 If the fracture is compound, state this \201 rst (and Gustilo type \200\224 b p.422). Name the bone (specify right or left, and for the hand, whether dominant). \200 Describe the position of the fracture (eg proximal, supracondylar). \200 Name the type of fracture (eg simple, spiral, comminuted, crush). \200 Mention any intra-articular involvement. \200 Describe deformity (eg displacement, angulation) from anatomical position. State grade or classi \201 cation of fracture (eg Garden IV). \200 State presence of any complications (eg pulse absent, paraesthesia, tissue loss). Other injuries and medical problems. Example using this system \200\23029 year old male mo torcyclist with a compound fracture of the left humerus. It is a transverse fracture of the humeral shaft and is Gustilo type I compound and minimally displaced with no neurovascular compromise \200 \200\231 Type of fracture Simple Single transverse fracture of bone with only 2 main fragments. Obli que Single oblique fracture with only 2 main fragments. Spiral Seen in long bones as a resu lt of twisting injuries, only 2 main fragments. Comminuted Complex fracture resulting in > 2 fragments. Crush Loss of bone volume due to compression. Wedge Compression to one area of bone resulting in wedge shape (eg vertebra). Burst Comminuted compression fracture with sc attering of fragments. Impacted Bone ends driven into each other. Avulsion Bony attachment of ligament or muscle is pulled off. Hairline Barely visible lucency with no discernible di splacement. Greenstick Incomplete fracture of immature bone follows angulatory force, with one side of the bone failing in compression, the other side in tension. Torus/buckle Kinkin g of the metaphyseal cortex follows axial compression. Plastic deformation Deformation beyo nd the elastic limit but below the fracture point results in bending of bone microfractu res (not apparent on X-ray). Pathological Fracture due to underlying disease (eg osteoporos is, metastasis, Paget \200\231s disease). 421 HOW TO DESCRIBE A FRACTURE Stress Certain bones are prone to fracture after repetitive minor injury. Fracture-dislocat ion Fracture adjacent to or in combination with a dislocated joint. Deformity Describe defo rmity using the terms displacement, angulation and rotation. Displacement ( \200\230transla tion \200\231) Describe the relative position of two bone ends to each other. Further descr ibe the direction that the distal fragment is displaced from the anatomical position (eg vo lar, lateral). Also estimate the degree of apposition of the bone ends (eg 50 % ). Angulati on This is usually described in terms of the position of the point of the angle (eg posteri or angulation means that the distal fragment is pointing anteriorly). This can sometimes be confusing. Although a little long-winded, one way to avoid confusion is to describe the di rection in which the distal part points, relative to the anatomical position (eg a Colles \200\231 fracture may be described as a \200\230fracture of the distal radius in which the distal fragment points dorsally \200\231). Try to measure the angle on X-ray. Rotation Des cribe the degree of rotation from the anatomical position, in terms of the direction (eg ex ternal or internal rotation) in which the distal part has moved. Fractures \200\224 the role of osteoporosis Osteoporosis is an important factor in a signi \201 cant proportion of fractures seen in the ED. The following fractures are frequently (but by no means exclusively) associated with osteoporosis: \200 Colles \200\231 fracture ( b p.444). \200 Fracture of surgical neck of humerus ( b p.459). \200 Lumbar spine ve rtebral fracture. \200 Fracture of neck of femur ( b p.470). \200 Pubic rami fracture ( b p.466). Patients with post-menopausal osteoporosis may be treated with a biphosphonate i n an attempt to d risk of future fractures, but do not commence this treatment in the ED. Long bone anatomy Each long bone has a shaft or diaphysis with an epiphysis at each end. Wh ile the bone is growing these are separated by an epiphyseal growth plate and this narrows down into the bone shaft. The transitional area of bone is the metaphysis. In addition to t hese landmarks, the femur and humerus have a ball-shaped head, a narrower neck, and at the lower ends a widened area consisting of the medial and lateral condyles of the femur, and t he medial and lateral epicondyles of the humerus. Fractures prox- imal to these areas of th e femur and humerus are termed supracondylar. Intercondylar fractures involve the central, distal, and juxta-articular portion. Fractures of the proximal femur between the greater an d lesser trochanters are termed intertrochanteric. 422 CHAPTER 9 Wounds, fractures, orthopedics Compound fractures Compound (or open) fractures occur when a fracture is open to the air th rough a skin wound. They incur a risk of infection and can be associated with gross soft ti ssue damage, severe hemorrhage, or vascular injury. Treat as orthopedic emergencies requiri ng rapid assessment and treatment. Classi \201 cation of compound injuries Gustilo classi \201 cation of compound injuries: Type I Compound fracture where wound is <1cm long and ap pears clean. Type II Compound fracture where wound > 1cm, but is not associated with extens ive soft tissue damage, tissue loss, or \202 ap lacerations. Type IIIA Either: compound f racture with adequate soft tissue coverage of bone despite extensive soft tissue damage or \202 ap laceration or any fracture involving high energy trauma or bone shattering regard less of wound size. Type IIIB Compound fracture with extensive soft tissue loss, periosteal stripping, and exposure of bone. Type IIIC Compound fracture associated with vascular inju ry needing repair. Management Provide adequate \202 uid replacement, analgesia, splintage , antibiotics, and tetanus prophylaxis prior to surgical treatment. Rapidly complete the fo llowing steps while contacting orthopedic service: \200 Treat life-threatening injuries b efore limb threatening injuries. Do not be distracted from initial priorities by dramatic distal limb injuries. Control obvious hemorrhage by direct manual pressure whilst commencing IV \202 uids and/or blood replacement. Give analgesia in the form of incremental IV opioids ( b p.276). \200 Once analgesia is a dequate, correct obvious severe deformities with gentle traction and splint. Certain disloc ations may require immediate correction. Remove obvious contaminants if possible (eg large lumps of debris or plant matter). \200\230Routine \200\231 wound swabs for bacteriological culture are no longer recom- mend ed. They do not alter management and are poor predictors of deep infection. If available, take digital photographs of the wound (this helps to avoid the need for repeated inspection by different clinicians). Irrigate with saline, then cover the wound with a sterile moist dressing (eg saline soaked pads). Immobilize the limb in a POP backslab. Do not repeatedly inspect the wound as this g reatly i risk of infection. Once dressed and in POP, leave injuries covered until surgery. Give IV antibiotics (eg co-amoxiclav (1.2g) or cefuroxime (1.5g) according to local policy) . Consider adding gentamicin or metronida- zole if the wound is grossly contaminated. Give tetanus toxoid if indicated, and give HATI if gross wound contamination present (b p.410). Record presence/absence of distal pulses/sensation and recheck frequently. Limb salvage or amputation Orthopedic surgeons often face a dif \201 cult decision as to whether or not a limb can be salvaged. Gustilo type IIIC injuries are associated with a high rate of amputat ion. The Gustilo classi \201 cation alone is not always an accurate predictor of outcome: other tools have been developed to assist. For example, the Mangled Extremity Severity Scor e takes into account the extent of skeletal and soft tissue damage, the extent and severity of limb ischaemia, associated shock, and age. 423 DISLOCATIONS Dislocations A dislocation involves complete loss of congruity between articular surfaces, whereas a subluxation implies movement of the bones of the joint, but with some parts of th e articular surface still in contact. Describe dislocations in terms of the displacement of the distal bone. For example, the most common shoulder dislocation is described as \200 \230anterior \200\231, with the humeral head lying in front of the glenoid. Aim to reduce d islocations as soon as possible in order to prevent neurovascular complications, d risk of recurrence and d pain. However, in general, aim to X-ray (to identify the exact dislocation associated fracture) before attempting a reduction. Exceptions to this principle are: \200 Dislocations associated with considerable neurovascular compromise requiring urgent i ntervention (this includes some ankle fracture- dislocations). Uncomplicated patellar dislocations (see b Knee fractures and dislocations, p.476). Uncomplicated mandibular dislocations (see b Mandibular injuries, p.376). Some patients with (very) recurrent shoulder dislocations, where there may be longer-term concerns regarding radiation exposure. Some patients with collagen disorders resulting in hypermobility (eg Ehlers \200\223Danlos syndrome) and unusual/recurrent dislocations without signi \201 cant trauma. \200\230Pulled elbow \200\231 in young children (see b Pediatric upper limb injuries, p.724). Use analgesia/sedation/anesthesia appropriate to the dislocation and the individual circums tances. For example, patellar dislocations often reduce under Entonox , \201 nger prox imal interphalangeal joint (PIPJ) dislocations with LA digital nerve blocks, shoulder dislo cations with IV analgesia sedation, whereas posterior hip dislocations typically require manipulation under GA. Except in very exceptional circumstances, X-ray after manipulation to con \201 rm adequate reduction and also to check for fractures which may not have been apparent on initial X-rays. 424 CHAPTER 9 Wounds, fractures, orthopedics Casts and their problems Plaster of Paris (POP) POP is cheap, easy to use and can be molded . Usually applied in the form of a bandage or multiply folded as a supporting slab (see Fig s 9.7 and 9.8 ). Disadvantages are susceptibility to damage (POP rapidly disintegrates if w et) and that it takes up to 48hr for larger casts to dry fully after application. Cut slabs to shape prior to use and apply over wool roll and stockinette. Mold with palms (not \201 ngertips) to avoid point indentation of plaster. Resin casts More costly, but lighter and stronger than POP and more resistant to water or o ther damage. Made of cotton or \201 breglass impregnated with resin that hardens after co ntact with water. Sets in 5 \200\22310min, maximally strong after 30min. Resin casts are mo re dif \201 cult to apply and remove. Being more rigid and harder to mold, there is i risk of problems from swelling or pressure necrosis. Remove/cover any sharp edges on the cast. Complications of casts Give all patients discharged with casts clear written instructions ( including a contact phone number) to return if they develop pain or other symp- toms in the immobilized limb. Formal cast checks within 24hr are only required if there is particular concern about swelling. Simple swelling or discolouration of \201 ngers or toes usually r esponds to elevation and simple exercises. Is the cast too tight? Act immediately upon susp icion of circulatory compromise from a cast. Look for the \200\230 \201 ve p \200\231s: p ain, pallor, paraesthesia, paralysis, and \200\230perishing cold \200\231. If any of these are present: \200 Elevate limb. \200 Cut wool and bandages of backslab until skin is v isible along the whole length of limb. Split full casts and cut through all layers until skin is visible along the whole length of limb. Any undivided layers will continue to obstruct the circulation until released. If this acti on fails to completely relieve the symptoms, contact orthopedic and vascular surgery staff immediately, as angiography and urgent surgical intervention may be required. Note that com partment syndrome may occur in the presence of normal pulses. Is the cast too loose? Test b y trying to move the plaster longitudinally along the limb. Replace excessively loose or da maged casts, unless there is an outweighing risk of fracture slippage. Local discomfort If there is local pressure discomfort (eg over a malleolus), cut a window in the cast to allow direct inspection of the skin. Trim or replace plasters, which restrict movement unduly. Cast removal Standard POP and selected resin casts may be removed with plaster shears. Use a plaster saw only after instruction in its proper use. In both cases, be careful to avoid skin damage. 425 CASTS AND THEIR PROBLEMS Application of stockinette Application of wool roll Limb positional POP shape Fig. 9.7 Application of a Colles \200\231 backslab POP. Limb position Scaphoid POP shape Fig. 9.8 Application of a scaphoid POP. 426 CHAPTER 9 Wounds, fractures, orthopedics Soft tissue injuries Sprains These occur from overstretching and tearing of ligaments. Spra ins vary from sparse \201 brous tears to complete disruption of a ligament complex. The r esults are pain, tenderness, and soft tissue swelling. Ligament sprains are traditionally g raded into three types, although distinguishing clinically between them may be dif \201 cu lt: \200 First degree sprains involve minor tearing of ligament \201 bres and are entirely stable. Second degree sprains are more severe partial sprains \200\224 there may be some resultant slight ligamentous laxity, but with a de \201 nite end-point on stressing. \200 Third d egree sprains re \202 ect completely torn ligaments causing signi \201 cant laxity: patie nts sometimes report hearing a \200\230snap \200\231 at the time of injury. Ligament sprai ns are very common, but there is a lack of reliable evidence about treatment. Prolonged imm obilization seems to be detrimental to recovery, due to muscle wasting and loss of proprioc eption. Painful minor sprains respond well to traditional measures: ice, compression with e lastic support/strapping, elevation and progressive mobilization as soon as symptoms allow. Simple analgesics such as paracetamol or NSAID (eg ibuprofen) may help. Complete ligament rupture can be relatively painless, but if associated with gross joint instability may requ ire surgical repair. Associated haemarthroses require orthopedic appraisal, aspiration, and often initially, protection and immobilization in POP. Strains Indirect injury involving muscle-tendon units may be classi \201 ed in a similar f ashion to ligament sprains. Pain on palpation over the site of injury is also reproduced by passive stress or active contraction of the affected muscle unit. Sometimes, a palpable de fect may be apparent in complete ruptures (which typically occur at the musculotendinous ju nction). However, asso- ciated swelling may prevent any defect from being easily palpable. Treat minor strains similarly to sprains; consider specialist review for complete ruptures, some of which may require surgical repair. Direct muscle injuries These result from direct impact causing local pain, bruising, and so ft tissue swelling. Note that associated bone contusions can occur, such as in the perimeni scal areas of the knee (these are visible on MRI). Treat minor injuries with ice, analgesia , and early mobilization within the limits of symptoms. For more signi \201 cant injuries, consider and treat according to possible risks of compartment and crush syndromes (with rh abdomy- olysis) and large haematomas (see next section). Haematomas Blood can accumulate as a result of traumatic disruption of the vascular struc- tures in bone, muscle, or soft tissues. Deceptively large volumes of blood can be accommoda ted within the soft tissue planes of the chest wall or thigh. In the presence of massive vi sible bruising of the torso or a limb, check for shock and measure Hb and Hct. Perform a co agulation screen. Blood trans- fusion may be necessary. Treat minor haematomas with compres sion dress- ings, ice and consider ultrasound therapy. Large haematomas or supervening infe ction requires selective surgical drainage, haemostasis and antibiotics. 427 OTHER SOFT TISSUE PROBLEMS Other soft tissue problems Myositis ossi \201 cans After some muscle or joint injuries, ca lci \201 cation can occur within a hae- matoma leading to restriction of movement and loss of function. Frequent sites include calci \201 cation within a quadriceps haematoma (eg f ollowing a rugby injury) where inability to \202 ex the knee > 90 * at 48hr after injury indicates an i risk of myositis ossi \201 cans. Other sites include the elbow and femur. P assive stretching movements of joints may be implicated in the development of myositis ossi \201 cans. This particularly applies at the shoulder, hip, and knee, where passive exerci ses are performed for spasticity following paraplegia or head injury. Treatment involves immobilizing the limb or joint for a period of weeks, under specialist s upervision. Early excision is contraindicated, as it is invariably followed by massive recu rrence, but delayed excision (after 6 \200\22312 months) can improve function. Tendonitis/tenosynovitis This includes a wide range of conditions, some of which may have m edico- legal implications ( \200\230overuse \200\231 or \200\230repetitive strain \200\231 injury). Examples include: \200 Classic tenosynovitis : swelling along a tendon sheath, with pain on passive stretching or upon attempted active movement against resistance. Chronic paratendonitis (eg affecting Achilles tendon): swelling around the tendon with localized pain and tenderness. Tendon insertion in \202 ammation causes epicondylitis in adults (see b p.452) and tractio n apophysitis in children ( b Osteochondritis, p.708). Appropriate initial treatment usuall y includes rest, immobilization, and NSAID. Later, consider involving an appropriate specia list (eg physiotherapist or hand therapist). Bursitis frequently affects the subacromial, In \202 ammation of bursae most olecranon, an d prepatellar bursae. There is localized swelling and tenderness: generalized joint effusio n and/or tenderness along the whole joint line suggests an alternative diagnosis. In many i nstances, bursitis is non-infective, and responds to rest and NSAID. Signi \201 cant warmt h and erythema raise the possibility of an infective origin. In this case, consider aspirat ion for bacteriological culture and provide antibiotics (eg co-amoxiclav or penicillin + \202 ucloxacillin). Other problems Other causes of joint or limb pain with no speci \201 c history of trauma i n the adult patient include stress fractures, cellulitis, and other infections, osteoarthri tis and other forms of acute arthritis, and nerve compression (eg carpal tunnel syndrome). Apparently atraumatic limb pain in children may present with limping \200\224 likely under lying causes vary according to the age ( b The limping child, p.704). 428 CHAPTER 9 Wounds, fractures, orthopedics Physiotherapy in the ED At its simplest, the term \200\230physiotherapy \200\231 in the ED includes the advice given to each patient following minor injury. At the other extreme, it encompasses the assessment and treatment of selected patients by skilled, experienced phys iotherapists. It is valuable for a department to have close links with a physiotherapy unit , preferably with designated physiotherapy staff responsible for ED referrals. Find out loc al arrangements for access to and use of physiotherapy services. \200\230Everyday \200\231 physiotherapy Minor soft tissue injuries are amongst the most commonly seen problems in ED s. Once bony injury has been excluded (clinically and/or radiologi- cally) ensure that pati ents are discharged with clear, consistent advice on how to manage their own injuries in ev ery case: \200 Be clear and speci \201 c about what the patient is to do. \200 Set a r ealistic time limit after which the patient should seek further attention if their symptoms are not improving. Give additional written instructions for reinforcement (eg ankle sprains, minor knee injuries) as patients forget much verbal advice. Protection/rest/ice/compression/elevation (PRICE) This forms the traditional basic framewor k for treatment of most acute soft tissue injuries. Protection Protect the injured part (eg using crutches or a walking stick). Rest With most acute injuries, advise a period of 24 \200\22348hr rest after an injury. Ice Ice is often advocated both in immediate \201 rst aid of soft tissue injuries, and in subsequent treatment. Crushed ice cubes wrapped in a da mp cloth (to avoid direct contact with the skin) placed against an injured joint may d swel ling and pain. Do not apply for more than 10 \200\22315min at a time. Repeat every few hour s initially. A cold pack or bag of frozen vegetables can be used (do not refreeze if for co nsumption!). Compression Despite a distinct lack of evidence, injured joints (particularly the ankle) are often treated in some support. The easiest to use is an elasticated tubular bandage (eg Tubigrip ), either single or doubled over. If provided, advise not to wear i t in bed and to discard as soon as convenient. If not provided, explain why, or the patient may feel inadequately treated. Avoid providing support bandages to patients with elbow and knee injuries \200\224 the bandage tends to be uncomfortable and \200\230dig in \200\231 and in the case of the knee, may affect venous return and i chance of DVT. Elevation Initi ally, advise elevation of injured limbs above horizontal to d swelling and discomfort. This is particularly important in hand or foot injuries. Exercise Start gentle, controlled exer cises for any injured joint as soon as symp- toms allow. Demonstrate what is expected and c on \201 rm that the patient understands what to do. 429 PHYSIOTHERAPY IN THE ED Formal physiotherapy Physiotherapists are trained in the rehabilitation and treatment of in jury, based on a detailed knowledge of relevant limb and joint anatomy, bio- mechanics, and physiology. In the ED, physiotherapy staff are valuable in assessment and treatment of acu te soft tissue injuries, patient education and advice, and in the provision of appropriate mobility aids after injury (particularly in the elderly). In order to make the best use of physiotherapy services, follow these guidelines: \200 Refer early if required for acute i njury. Aim for the patient to be seen for initial assessment the same day, so treatment nee ds can be properly assessed. Discuss the problem and treatment options with the physiotherapy staff prior to referral. Use the physiotherapy service for selected cases, not as a general rule. \200 Never use t he physiotherapy department to simply of \202 oad dif \201 cult or problematic patients. Physiotherapists have a range of different treatments at their disposal, which typically fo cus upon regaining range of movement and mobility, improving strength and proprioception. 430 CHAPTER 9 Wounds, fractures, orthopedics Approach to hand injuries The history Determine and record whether the patient is right- or left-handed, their occupation, and social situation. These points may have treatment impli ca- tions, (eg an elderly person living alone with little social support may not cope at ho me after a dominant hand injury). Suspect patients presenting with wounds on the dorsum of the hand over the index, middle, r ing, or little \201 nger MC heads of having sustained a human bite ( \200\230 \201 ght b ite \200\231) whatever history is given ( b p.416). Terminology To avoid confusion always refer to \201 ngers by name not number (index, midd le, ring, little). Use: palmar (or volar), dorsal, radial, ulnar (not anterior, posterior, lateral, medial). Bones of the hand and wrist There are 14 phalanges and 5 metacarpals (MCs). Name the metaca rpals according to the corresponding \201 ngers (ie thumb, index, middle, ring, and littl e) \200\224 this avoids confusion. There are 8 carpal bones arranged in 2 rows. The proxim al row (radial to ulnar) is comprised of scaphoid, lunate, triquetral, and pisiform (Fig. 9 .9 ). The distal row (radial to ulnar) are trape- zium, trapezoid, capitate, and hamate. 1st metacarpal Hook of hamate Hamate Capitate Trapezium Trapezoid Scaphoid Pisiform Triquetral Ulnar styloid Radial styloid Lunate Ulna Radius Fig. 9.9 AP view of normal wrist. 431 APPROACH TO HAND INJURIES Anatomy of \201 nger extensor tendon (Fig. 9.10 ) Distal phalanx Lateral bands insert into distal phalanx Middle phalanx Middle slip of extensor expansion inserts to middle phalanx Proximal phalanx Tendons of intrinsic hand muscles join extensor expansion Fig. 9.10 Anatomy of \201 nger extensor tendon. Insertion of extensor tendon to proximal phalanx Anatomy of \201 nger \202 exor tendon (Fig. 9.11 ) Flexor digitorum profundus insertion to distal phalanx Flexor digitorum superficialis dividing Fig. 9.11 Anatomy of \201 nger \202 exor tendon. 432 CHAPTER 9 Wounds, fractures, orthopedics Clinical signs of hand injury Examination of hand injuries Injury to the hand \200\231s ric h collection of nerves, blood vessels, and tendons results in considerable functional de \201 cit. Assess carefully, taking into account hand anatomy and clinical patterns of injur y (Figs 9.12 and 9.13 ). Speci \201 c signs of injury Table 9.2 Speci \201 c signs of injury d sensation in the palm over radial 3 digits unable to abduct thumb against resistance Median nerve d sensation palmar and dorsal 1 \201 ngers, little \201 nger \202 exed (non-functio ning lumbrical) Ulnar nerve unable to cross index and middle \201 ngers d abduction/adduction d sensation dorsum \201 rst web space (no motor branches in hand, but proximal injury res ults in inability to extend wrist) Radial nerve d sensation along radial or ulnar half of digit distally: note that some sensation is usual ly preserved, even with signi \201 cant nerve injuries Digital nerve Super \201 cial \202 exor hold other \201 ngers straight (immobilizing all deep \202 exors), then unable to \202 ex PIPJ (unreliable for index \201 nger). Also, 8 10 % of individuals do not have a \202 exor super \201 cialis tendon to the little \201 nger Deep \202 exor unable to \202 ex DIPJ Extensors complete division prevents extension (at DIPJ causes mallet deformity) central slip division causes Boutonni re deformity in recent trauma, hold PIPJ at 90 * ove r table edge, and try to extend versus resistance \200\224 DIPJ hyperextends in central sl ip division (Elson \200\231s test) Deformity a small amount of rotational deformity of a digit (typically associated with a spiral/obliq ue MC or \201 nger fracture) can have a dramatic effect upon long-term hand function (see Fig. 9.14): check carefully to ensure that there is no abnormal overlapping of \201 nger tips in the palm on making a \201 st 433 CLINICAL SIGNS OF HAND INJURY Fig. 9.12 Testing super \201 cial \202 exor \201 nger tendon. Fig. 9.13 Testing deep \202 exor \201 nger tendon. PIPJ MCPJ DIPJ Normal Swan neck Boutonni re Mallet Fig. 9.14 Finger deformities. 434 CHAPTER 9 Wounds, fractures, orthopedics Hand wounds and associated injuries General principles of treating hand wounds \200 Remov e rings as soon as possible after any hand or arm injury as swelling can develop relatively rapidly. Try soap or water-based lubricant before using ring-cutters. Alternatively, pass string or 0/0 silk under the ring and wrap it \201 rmly around the \201 nger distally, allowing the ring to come off over the compressed tissues. Elevate to diminish swelling and pain. \200 Avoid subcutaneous sutures. \200 For patien ts who are uncooperative due to excess alcohol consumption, consider admission for a few ho urs to allow suturing with better co-operation later. X-ray any hand injury caused by glass. \200 Remember to consider tetanus cover. Exploration under anesthesia If it is obvious that surgical intervention by a hand surgeon is required, do not explore the wound in the ED. This particularly applies to suspected ner ve injuries, where the use of LA renders subsequent assessment dif \201 - cult. Conversely , clinical assessment of tendon injuries can be misleading if the patient is reluctant to m ove due to pain. Exploration under anesthesia is necessary in this situation and to exclude division of > 50 % of a tendon (where clinical examination may be normal, but repair is re quired). Use an appropriate LA nerve block (as outlined on b Nerve blocks at the wrist, pp. 296 \200\223299). During exploration, consider the position of the hand at the time of injury: reproducing th is may reveal injuries otherwise hidden. Therefore, put all mobile structures through their full range of movement. Extensor tendon injuries > 50 % or complete division needs repair (eg 4/0 or 5/0 non-absorb able mono \201 lament using Bunnell or Kessler stitch) by an experienced surgeon. This may be achieved under LA in the ED, depending on facilities and expertise. Follow extensor ten don repair with appropriate immobi- lization (eg volar slab type POP with \201 nger joint s in full extension and slight \202 exion at the MCPJs). Treat <50 % division by splintag e in extension (eg POP slab as above) under the care of the hand surgeon. Flexor tendon injuries Refer immediately for specialist repair. Nerve injuries Complete division of a nerve may cause surprisingly little sensory loss, so take complaints of any altered sensation very seriously. Refer patients with suspected nerv e injuries. Digital nerves can be repaired up to the level of the distal phalangeal joint ( DIPJ), although it may be decided not to attempt to repair injuries which are distal to the PIPJ. Remember that it is functionally important to have intact sensation over the \200 \230edges \200\231 of the hand (the thumb, the radial aspect of the index \201 nger or ul nar aspect of the little \201 nger). Patients sometimes present late after digital nerve injuries \200\224 repair can still be quite successful up to 2 weeks after injury. 435 HAND WOUNDS AND ASSOCIATED INJURIES Reverse \201 ght bites Treat and refer as outlined in b Speci \201 c bites and stings, p .416. Consider transfer of blood-borne infection as discussed in b Needlestick injury, p.41 8. Amputations Refer patients with partial or complete digital amputation with bony loss. Rece nt proximal amputations without crush injury in \201 t young patients may be suitable for re-implantation: others may be treated with \200\230termi- nalization \200\231 or advance ment \202 ap. Let the hand surgeon decide. Meanwhile, dress, bandage and elevate, give IV analgesia, tetanus cover, broad spec- trum antibiotics (eg cephalosporin), and keep fasted . Wrap the amputated part in moist saline swabs and place in a sealed plastic bag, surround ed by ice/water mix at 4 * C. Note: Do not freeze or place the amputated part directly in s olution. Finger pad amputations Skin loss less than 1cm 2 without bony exposure may be allowed to he al with non-adherent dressings. Larger areas of tissue loss (particularly in adults) may re quire skin grafting or advancement \202 ap, but some do heal satisfactorily with simple d ressings. Ring avulsions Refer all circumferential and signi \201 cant degloving injuries. Compound injuries Wounds over dislocations or fractures usually require specialist atten- t ion. Distal compound phalangeal fractures may be treated in the ED with wound cleaning, clo sure, review, and prophylactic antibiotics. Crush injuries Frequently cause \200\230burst \200\231 injury \201 ngertip wounds. Clean the wounds and take into account the likely swelling when considering closure. Elevate, dr ess, give analgesia, and arrange review. Nail bed lacerations Accurate repair (eg 6/0 Vicryl) may prevent nail deformity. Nailfold-l acerations extending towards the nail bed require removal of the nail to allow suture. Cons ider replacing the nail after to act as a temporary dressing. Foreign bodies under nail Splinters and other FBs under \201 ngernails are relatively com mon. Apply a digital block and remove with \201 ne forceps. If the FB cannot be reached e asily, cut away an appropriate piece of nail. Subungual haematomas Blood frequently collects under the nail after a crush injury, causing pain by pressure. If > 50 % of the nail is affected, trephine the nail distal to the lunul a, using a red hot paper clip or battery operated drill. High pressure injection injuries Industrial grease or paint guns may cause small skin wound s, which initially appear trivial, disguising a devastating injury with risk of permanent s tiff- ness and signi \201 cant tissue loss. X-rays may help to identify the extent of fore ign material. Refer all such patients to a hand surgeon for immediate exploration and debri dement. 436 CHAPTER 9 Wounds, fractures, orthopedics Hand fractures and dislocations Distal phalangeal fractures Treat closed fractures of the d istal portion (tuft) of the distal phalanx with analgesia and elevation. Treat compound bur st injuries (from crushing injuries or hammer blows) with meticulous exploration, wound toi let/ repair under LA and arrange follow-up. Give antibiotics (not a substitute for primary surgical treatment). Mallet \201 nger with fracture \200\230Mallet \201 nger \200\231 injury may be associa ted with a small fracture at the base of the distal phalanx at the point of attachment of t he extensor tendon. Treat as for (the more usual) mallet \201 nger injury without fractur e by plastic mallet splint for \211\210 6weeks, advice and follow-up (see details on b Sof t tissue hand injuries, p.440). Refer larger bony fragments ( > 1 / 3 articular surface) wi th mallet deformity or those with subluxation for pos- sible K-wire internal \201 xation. Fig. 9.15 Mallet \201 nger deformity. Fig. 9.16 Mallet \201 nger with avulsion fracture. Proximal and middle phalangeal fractures Treat undisplaced fractures with elevation, neighb or strapping (Fig. 9.17 ), and analgesia. Manipulate angulated proximal and middle phalange al frac- tures under digital or wrist blocks. A useful tip for proximal phalangeal fracture s is to use a needle-holder or pencil placed adjacent to the web space as a fulcrum. Mainta in reduction using neighbor strapping and a volar slab POP or \202 exible padded aluminum (Zimmer) splint, although the latter can be dif \201 cult to secure. If reduction is unsa tisfactory or cannot be maintained, refer for surgical \201 xation. Index, middle, and ring metacarpal fractures Check for displacement or rotational deformity and refer if present. Treat with analgesia, elevation, and protect in a volar slab POP. In ternal \201 xation may be considered for midshaft MC fractures with marked angulation, bu t can be complicated by marked post-operative stiffness. Phalangeal dislocations X-ray all dislocations prior to reduction for presence of associate d fractures. Reduce under digital or metacarpal nerve block ( b p.294) or Entonox by tra ction and gentle manipulation, then check integrity of the collateral ligaments. Con \201 rm reduction on X-ray and immobilize the \201 nger by neighbor strapping. Elevate the han d, provide oral analgesia and arrange follow-up. 437 HAND FRACTURES AND DISLOCATIONS Fig. 9.17 Neighbor (buddy) strapping. Little (5th) metacarpal fractures Common result of punching. Check for rotational deformity by gently \202 exing \201 ngers into the palm (they should point roughly to the thenar emi- nence and touch, but not overlap adjacent \201 ngers on \202 exion). Angulation i s common with neck fractures and rarely requires correction, with even up to 40 * being acc epted. Apply neighbor strapping, elevate and give analgesia. A volar slab POP for 2weeks is sometimes advocated \200\224 follow local protocols. Warn the patient that the 5th knuckl e will be shorter than before. Arrange follow-up and advise hand exercises as soon as possi ble. Refer to orthopedic team if there is rotational deformity or signi \201 cant angulation, p articularly with base and shaft fractures, which may need surgery. Also refer patients with associated wounds, remembering that these may be compound human bites ( \200\230reverse \201 ght-bites \200\231 \200\224 b Speci \201 c bites and stings, p.416).