Note: Monteggia fracture-dislocations are not infrequently missed at initial presentation, due to attention being distracted by the ulna fracture (Fig. 9.27 ). To avoid this: \200 Request elbow and wrist X-rays in any patient with forearm shaft fracture. Check all elbow X-rays carefully to ensure that the radial shaft is normally aligned and that the radial head abuts the capitellum. Dislocated radial head Fracture of the ulna Fig. 9.27 Monteggia fracture-dislocation. Isolated radial shaft fracture These are very uncommon. Always treat and assume that there is some associated damage to the distal radio-ulnar joint at the wrist. 450 CHAPTER 9 Wounds, fractures, orthopedics Elbow injuries In any injured elbow look speci \201 cally for: \200 Elbow effusion (felt as a tense, bulging swelling halfway between the lateral epicondyle and the point of the olecranon). The normal relationship between the olecranon and the lateral and medial epicondyles: all s hould form an equilateral triangle with the elbow \202 exed. Range of movement: X-ray patients who cannot fully extend the elbow and \202 ex to touch the shoulder tip. Olecranon fractures Follow falls onto the point of the elbow. The olecranon fragment may di s- place proximally due to pull of triceps. Swelling, tenderness, or crepitus are present o n examination. In the young, the olecranon epiphysis may cause con- fusion on X-rays. Treat undisplaced or hairline fractures in an above elbow backslab POP at 90 * , provide analges ia and arrange fracture clinic follow-up. Refer fractures that are displaced or involve the elbow joint for ORIF. Radial head/neck fractures Follow falls onto outstretched wrist (the radial head impacts against the capitellum) or direct trauma to the elbow. They sometimes occur in combination with a wrist fracture. Examine movements \200\224 extension and \202 exion are usually limited, but supination and pronation may be relatively normal. Look for an elbow effusion and palpate for tenderness over the radial head while supinating/pro nating the elbow. X-ray con \201 rms elbow effusion, but fractures may be dif \201 cult t o see. Treat undisplaced fractures with analgesia, and a collar and cuff sling. If very pai nful, immobilize in an above elbow POP backslab at 90 * . Arrange fracture clinic review. R efer comminuted or displaced fractures as they may require MUA, internal \201 xation or o ccasionally excision/replacement of the radial head. Elbow effusion, no visible fracture Al ways assume that a radial head/neck fracture is present: provide analgesia, a collar and cu ff sling, and arrange review to ensure that full movement is regained. Extra symptomatic re lief may be achieved by aspiration of the elbow joint (via a point midway between the olecr anon and lateral epicondyle) under aseptic conditions. Elbow fat pad sign Elevated anterior fat pad Fractured radial head Posterior fat pad Fig. 9.28 Elbow fat pad sign. 451 ELBOW INJURIES Dislocated elbow Examination reveals loss of the normal triangular relationship between the olecranon and epicondyles. Check distal pulses and sensation as brachial artery, median an d ulnar nerves may be damaged. Elbow dislocations may be classi \201 ed according to the d irection of dislocation and the presence of associated fractures (eg fractured coronoid). T he most frequent injury is postero-lateral dislocation (ie movement of the distal part in a postero- lateral direction). After analgesia and X-ray, most dislocations may be reduced in the ED under IV sedation wit h full monitoring ( b Sedation, p.308). However, GA is sometimes required. Reduction Choose between the following techniques for reduction of postero-lateral dislocat ions: \200 Flex the elbow to 60 * with countertraction on the upper arm. Pull on the full y pronated forearm at this angle. Slight \202 exion at the elbow may be necessary. Alternatively, lever the olecranon forward with both thumbs while holding the elbow \202 exed and while an assistant provides traction on the forearm. Reduction is con \201 rmed by a \200\230clunk \200\231 and restoration of the normal tria ngular relationship of the elbow landmarks. Once reduced, recheck pulses and sensation, imm obilize in an above elbow POP backslab at 90 * and X-ray again (looking for associated frac tures). Consider admission for analgesia and observation for possible signi \201 cant limb swelling. If unable to reduce, refer for reduction under GA. Supracondylar fractures (see b p.722) Fractures of the distal third of the humerus usually occur from falls onto the out stretched hand. They are most common in children (b p.722), but also occur in adults. The e lbow may be grossly swollen and deformed, but the normal triangular relationship of the ole cranon and epicondyles is characteristically preserved. Check distal pulses and sensation c arefully as the brachial artery, ulnar, median, and radial nerves can all be damaged. Immob ilize in an above elbow backslab POP and give analgesia. Refer to the orthopedic surgeon as MUA/ORIF are usually required. Fractures of the capitellum occasionally occur in isolation. If undisplaced, treat conserva tively with analgesia and POP. Refer those with displaced fractures for specialist treatmen t (possibly ORIF). Medial collateral ligament injury Instability on stress testing of the medial (ulnar collat eral) ligament implies a signi \201 cant injury. Treat in backslab POP with the elbow \202 exed to 90 * and supported in a sling. Arrange fracture clinic follow-up. Other elbow injuries Elbow injuries are relatively common in children. Speci \201 c injuri es in children are considered as follows: \200 Supracondylar fracture ( b Pediatric upper limb injuries, p.722). \200 Lateral and medial condylar injury \200\224 ( b p.724). \200 Pulled elbow \200\224 ( b Pediatric upper limb injuries, p.724). 452 CHAPTER 9 Wounds, fractures, orthopedics Soft tissue elbow problems Injuries to biceps and brachialis In \202 ammation of biceps an d/or brachialis at the site of attachment at the elbow can cause persistent symptoms: treat with rest and NSAID. Biceps brachii can rupture either at its long head in the bicipital g roove or near the elbow insertion. Long head ruptures typically affect the elderly and resu lt in a characteristic abnormal shape and low biceps position on attempted elbow \202 exi on against resistance: unless the patient is young, \201 t, and active, surgical repair i s rarely indicated. Distal ruptures are some- times treated conservatively, but some may be ne \201 t from repair: arrange orthopedic review to consider this. Lateral epicondylitis This is commonly called \200\230tennis elbow \200\231. It follows re petitive or exces- sive stress to the origin of the forearm and hand extensor muscles at th e lateral epicondyle. It can occur spontaneously, but usually follows repetitive lifting, p ulling, or sports (eg as a result of an incorrect backhand technique in tennis). In \202 a mmation, oedema, and microtears occur within the extensor insertion. Look for localized swelling, warmth or tenderness over the lateral epicondyle and immediate ly distal to it. Examine movements: dorsi \202 exion of the pronated wrist against resistance will reproduc e symptoms. X-ray if the problem follows acute injury. Refer to the orthopedic surgeon if there is an a vulsion fracture. Treat with analgesia (preferably NSAID) and ice application. Support the arm in a broad arm sling and advise rest, followed by progressive exercise and avoidance of aggravating movem ents. If symptoms are recurrent or prolonged, refer as steroid injection, forearm clasp, ph ysiotherapy, and occasionally surgery may help. Current evidence suggests that corticostero id injection may provide short-term relief, but long-term bene \201 t remains unproven. Medial epicondylitis Often called \200\230golfer \200\231s elbow \200\231, this condition has a similar pathophysiology to lateral epicondylitis: it is frequently seen in racket spo rts and golf. Examine for localized tenderness and swelling over the forearm \202 exor insertion at the medial epicondyle. Flexion of the supinated wrist against resistance will reproduce sympto ms. There may be d grip strength and \211\210 60 % of patients have some symptoms of assoc iated ulnar neuritis. Treat as for lateral epicondylitis. Osteochondritis dissecans This can affect the elbow and cause locking of the elbow joint. X -rays may reveal a defect and/or loose body. Refer to the orthopedic team. 453 SOFT TISSUE ELBOW PROBLEMS Olecranon bursitis In \202 ammation, swelling and pain in the olecranon bursa may follow m inor trauma or occur spontaneously. Other causes include bacterial infection (sometimes fol lowing penetrating injury) and gout. Elbow movements are usually not limited. Look for over lying cellulitis, wounds, and systemic symptoms and check for i T * (these suggest infectio n). Gout or bacterial infection can be con \201 rmed by aspiration of the bursa under asep tic conditions and immediate microscopy for crystals or bacteria. Aspirate using a small ne edle at a shallow angle and try to aspirate the bursa completely. Non-infective bursitis Provide analgesia, NSAID, and rest the arm in a broad arm sling. Sym ptoms should resolve with rest over a period of weeks. Rarely, persistent symptoms require surgical excision of the olecranon bursa. Gout bursitis Treat as above. Arrange follow-up through the patient \200\231s GP. Infective bursitis If there is evidence of underlying infection, treat with rest, NSAID and start antibiotics (eg co-amoxiclav or \202 ucloxacillin + penicillin). Occasionally, inf ection requires referral to the orthopedic surgeon for surgical drainage. Olecranon bursa haematoma A history of blunt trauma to the olecranon followed rapidly by \200\230golf ball-sized \200\231 swelling over the olecranon, but with a full range of elbo w movement (and no evidence of fracture), implies a haematoma in the olecranon bursa. Treat conservatively: attempts at drainage may result in secondary infection. Nerve compression Ulnar nerve entrapment at the elbow ( \200\230cubital tunnel syndrome \200\231) is the second most common upper limb nerve entrapment (median nerve compression i n carpal tunnel syndrome is the commonest. Refer these chronic conditions back to the GP. Acute radial nerve palsy above the elbow presents with sudden wrist drop following a histor y of compression (eg crutch use, falling asleep with arm over the back of a chair). The und erlying injury is usually a neurapraxia, which has the potential to recover completely give n time with conservative measures. It is crucial to ensure that \202 exion contractures d o not develop in the meantime: provide a removable wrist splint, advise regular passive wri st exercises, and refer for physiotherapy and follow-up to ensure recovery. 454 CHAPTER 9 Wounds, fractures, orthopedics Anterior shoulder dislocation This is a common injury, which typically results from forced external rotation/abduction of the shoulder. The humeral head usually dislocates to lie ant erior and slightly inferior to the glenoid. Patients often present supporting the affected arm with the uninjured arm. The diagnosis is usually obvious on examination. Look for: \200 Step-off deformity at the acromion with palpable gap below the acromion. Humeral head palpable antero-inferiorly to the glenoid. \200 Evidence of complications: c heck especially for distal pulses and d sensation over the lateral aspect of the shoulder ( the \200\230badge \200\231 area) supplied by the axillary nerve. Give analgesia and support in a temporary sling. X-ray before reduction to exclude associat ed fractures. X-rays show loss of congruity between humeral head and the glenoid. The humer al head is displaced medially and inferiorly on an antero-posterior (AP) shoulder X-ray. Treatment Reduce under sedation/analgesia with full monitoring, using one of the methods de scribed below/opposite. The choice of technique is personal and depends partly upon familia rity. Apply minimal force to prevent humeral fracture or further soft tissue damage. In pat ients with habitual recurrent dislocation (and in a signi \201 cant proportion of other pa tients as well), reduction may be easily achievable with minimal use of drugs (eg Entonox alone). Take time and perform the maneuver slowly. Note that in situations where IV sedat ion cannot be used or needs to be avoided, intra-articular lidocaine is an option. External rotation method This simple technique has a good rate of success. With the patient reclining at 45 * , slowly and gently (without force) externally rotate the shoulder to 90 * . If the dislocation has not yet reduced, forward \202 ex (elevate) the shoulder slowl y. Kocher \200\231s method Lie the patient back almost \202 at, and once sedation and analge sia are adequate: \200 With the elbow \202 exed to 90 * , slowly externally rotate the shoulder. Pause if there is any resistance and continue only when muscles relax. \200 Slo wly adduct the upper arm across the chest with the shoulder still held in external rotation. Once adducted as far as possible, internally rotate the shoulder by \202 ipping the forearm towards the opposite shoulder. Reduction may occur at any time during the maneuver: success is more likely if the patient is relaxed (avoid traction) and if initial external rotation reaches 90 * . A \200\230clun k \200\231 or return of normal glenoid contour con \201 rms success. 455 ANTERIOR SHOULDER DISLOCATION Modi \201 ed Milch method Slowly abduct the straight arm to 110 * . With the elbow extende d, apply gentle steady traction to the arm, while an assistant controls movement of the hum eral head back into the glenoid. Other techniques Scapular manipulation With the patient lying prone, \200\230manipulate \200\231 the scapula onto the glenoid by pushing the inferior tip of the scapula medially a nd the superior part laterally. Stimson \200\231s technique A more traditional method with the patient prone. Apply a weigh t strapped to the forearm/wrist of the affected side as it hangs down and await reduction. Hippocratic methods Many techniques have been described over many centuries, but are probab ly of historical interest only. Post-reduction After reduction, recheck pulses and sensation (including axillary and radial nerves), and obtain a check X-ray. Immobilize in a collar and cuff, and body bandage. Loca l policy sometimes includes shoulder immobilization webbing or braces as standard. Provide analgesia (eg co-dydramol) and arrange follow-up. If unsuccessful, dif \201 cult or if sho ulder has been dislocated > 24hr, refer for reduction under GA. Fracture-dislocation of the shoulder Most involve fractures of the greater tuberosity assoc iated with ante- rior dislocation of the shoulder (Fig. 9.29 ). Reduce under sedation as wi th uncomplicated dislocations \200\224 in most cases the fracture will reduce satisfactori ly along with the dislocation. However, refer large or complex fracture-dislocations involv ing the humeral head, neck or shaft. Fig. 9.29 Anterior dislocation of the right shoulder. 456 CHAPTER 9 Wounds, fractures, orthopedics Other types of shoulder dislocation Posterior dislocation This uncommon injury is easy to m iss. It results from a blow onto the anterior shoulder or a fall onto the internally rotate d arm. It may also occur during seizures or after an electric shock (when other injuries an d medical problems may be partly responsible for it being initially over- looked). The pati ent presents with the shoulder internally rotated. AP shoulder X-ray may appear normal, but careful inspection reveals an abnormally symmetrical appearance of the humeral head ( \200 \230light bulb sign \200\231) and loss of congruity between the humeral head and the glenoi d (Figs 9.30 and 9.31 ). A modi \201 ed axial shoulder X-ray (from above) or a translatera l view will con \201 rm posterior dislocation of the humeral head. Manipulate under sedati on by applying traction and external rotation to the upper limb at 90 * to the body. If dif \201 cult, refer for reduction under GA. Treat and follow-up as for anterior dislocation. Fig. 9.30 AP view of posterior shoulder dislocation: light bulb sign. Fig. 9.31 Modi \201 ed axial view of posterior shoulder dislocation. 457 OTHER TYPES OF SHOULDER DISLOCATION Luxatio erecta This is a rare inferior dislocation of the humeral head. The patient present s with arm held abducted above head. Check carefully for neurovascular complications. Reduc e under sedation by traction in line with the abducted upper arm, followed by adduction of the shoulder. May require reduction under GA. Treat and follow-up as for anterior dislocati on. 458 CHAPTER 9 Wounds, fractures, orthopedics Other shoulder injuries Acromio-clavicular (AC) joint injury Common injuries which usually follow falls onto the shoulder or violent sudden movements of the upper limb. Look for loca l pain, swelling, or a palpable step over the AC joint. X-rays show fractures or AC joint d isruption (vertical subluxation of the AC joint > 1 \200\2232mm) (Fig. 9.32 ). The diagnosi s may be made more obvious by asking the patient to hold a heavy object while the X-ray is taken. AC joint injuries are classi \201 ed: \200 Grade I : minimal separation. Only acr omio-clavicular ligaments involved. \200 Grade II : obvious subluxation, but still some a pposition of bony ends. \200 Grade III : complete dislocation of AC joint, indicating rup ture of the conoid and trapezoid ligaments, in addition to the acromio-clavicular ligaments . Treat with analgesia, support in a broad arm sling, and arrange follow-up for grades II and III injuries. These measures allow complete recovery in most cases. Occasionally, selected patients bene \201 t from internal \201 xation. Acromio-clavicular ligament Grade III Conoid and trapezoid ligaments Fig. 9.32 Clavicle fracture This common injury results from direct trauma or from falls onto the out- stretched hand or point of the shoulder. Check carefully for neurovascular complications ( these are rare, but potentially life-threatening). Treat with analgesia, a broad arm sling and arrange fracture clinic follow- up. The vast ma jority of fractures unite satisfactorily with conservative treatment. Rarely, grossly displ aced fractures are internally \201 xed. Scapular fracture Usually results from direct trauma and implies a forceful mechanism of in jury. Check carefully for associated injuries to the thorax, such as rib fractures or haemo -pneumothorax. Treat isolated fractures with a broad arm sling, analgesia, and arrange follow-up. 459 OTHER SHOULDER INJURIES Humeral neck/head fracture These result from direct trauma to the upper arm or from falls o nto an outstretched hand. Examine for tenderness or swelling over the proximal humerus. Sho ulder movements are usually limited by pain. X-rays typically reveal impacted or oblique fr actures, with or without associated fractures of the greater and lesser tuberosities. Fract ures may be classi \201 ed as 2, 3, or 4-part fractures according to the number of fragmen ts resulting (eg a fractured humeral neck combined with a fractured greater tuberosity will be a \200\2303 part fracture \200\231). Treat with a collar and cuff support, analgesia, and follow-up. Warn the patient to expect signi \201 cant visible bruising to appear, extending down the arm towards the elbow (for this reason, it is helpful to document the lack of any clinical evidence of elbow injury at \201 rst presentation). Refer all comminuted, displaced, or markedly angulated humeral n eck fractures as MUA and, occasionally, internal \201 xation/hemi-arthroplasty are indica ted. Shaft of humerus fracture Results from a fall onto an outstretched hand or onto the elbow. The fracture may be obvious and palpable. Check distal pulses, radial nerve and elbow joint . X-ray reveals a transverse, comminuted, or spiral humeral shaft fracture. Provide analgesia and support the fracture in a POP U-slab (slab of plaster from the axilla down to and around the olecranon and up the outside of the upper arm). Apply with the elbo w \202 exed to 90 and hold in place with a bandage. Alternative treatment includes a \200\230hanging cast \200\231 POP (above elbow POP at 90 \200\224 the weight of POP and arm hold the fracture in a satisfactory position). Refer if displaced, comminuted, or angu lated, or if neurovascular complications are suspected. MUA and internal \201 xation are required in these cases. Rotator cuff tears Tears (supraspinatus rupture most commonly) usually follow chronic rotat or cuff disease in patients > 40years. May follow trauma (eg falls with hyperabduction or h yperextension of the shoulder). Examine for d range of movement, weakness, crepitus, and te nderness over the cuff insertions and subacromial area. Examine supraspinatus strength by t esting resistance to abduction. Look for bony avulsions on X-ray (tensile strength of the c uff exceeds adjacent bone). Treat conservatively initially with analgesia and support in a broad arm sling, followed by exercises/physiotherapy at \211\210 10days. Arrange follow-up for patients with signi \201 cantly d range of movement \200\224 complete tears (particu larly in younger patients) may require surgical repair. Ruptured biceps The long head of biceps can rupture at its proximal insertion on lifting or pulling (see b Soft tissue elbow problems, p.452). This may follow little force (and with little pain) in the elderly. Look for the ruptured biceps muscle as a bulge above the elbow . Treat with initial analgesia and support in a sling, followed by later exercises. Surgica l repair is rarely indicated. 460 CHAPTER 9 Wounds, fractures, orthopedics Soft tissue shoulder problems The shoulder is vulnerable to degenerative disease and injury , due to its extreme mobility and hence, relative instability. Stability relies mainly on t he rotator cuff, a muscle sheath, which wraps around and inserts into the humeral head unde r the deltoid. The rotator cuff comprises supraspinatus (initiates abduction), infraspinatu s and teres minor (externally rotate), and subscapularis (internally rotates). The rotator cuff may be injured acutely or due to a chronic degenerative process (eg impingement syndro mes or rheumatoid arthritis). Impingement syndromes The acromion process may compress or \200\230impinge \200\231 on the underlying sub- acromial bursa and rotator cuff during repetitive or strenuous shoulder us e. Supraspinatus and its tendon are most commonly affected. Minor impingement is associated with in \202 ammation, pain, and loss of function and is reversible with treatment. Rotat or cuff tendonitis is more chronic and can lead to degeneration or tearing of the cuff. Alt hough rotator cuff tendonitis and degenerative tears usually occur in later life, acute tea rs can occur in younger patients. Examination of the shoulder Examine both shoulders for comparison with the patient sitting relaxed. Look for deformity of the clavicle or sternoclavicular joint, AC joint deformity ( eg OA or injury), wasting of the deltoid muscle (axillary nerve damage), a step in the delt oid contour, or a gap below the acromion (subluxation or dislocation). Feel for tenderness over sternoclavicular joint, clavicle, AC joint, subacromial area, rota tor cuff insertion, biceps tendon insertion. Move the shoulder gently in all directions to test passive movements. Test strength of acti ve movements. Test abduction (normal range 0 \200\223170 ), forward \202 exion (0 \200 \223160 ), backward extension (0 \200\22360 ), external rotation (put hand on back of head), internal rotation (put hand behind back to touch shoulder blade). Examine for crepitus on movement, restriction, pain (note any painful arc) and weakness of particular movements. Test sensation over the badge area (upper outer arm) supplied by axillary nerve. Examine th e cervical spine when shoulder examination does not reveal a cause for symptoms. In suspect ed impingement syndromes consider the following: Neer \200\231s impingement test Fully abdu cting the straight arm will re-create symptoms. Hawkin \200\231s impingement test Hold the arm at 90 abduction and 90 elbow \202 ex ion. Rotating the arm across the body will recreate symptoms. LA injection of 10mL 1 % plain lidocaine into the subacromial bursa (approach just under ac romion process from behind) should help pain, but will not affect strength or range of move ment, aiding assessment. Adding hydrocortisone, methylprednisolone or triamcinolone to LA i njection is useful for \201 rst presentation of acute impingement. Warn that symptoms may i brie \202 y after steroid injection. Avoid repeated injection as it can precipitate ten don rupture. 461 SOFT TISSUE SHOULDER PROBLEMS Differential diagnosis of shoulder pain Includes referred pain from a degenerative cervical spine, C5/6 disc pro- lapse, brachial plexus neuritis, axillary vein thrombosis, suprascap ular nerve compression, Pancoast \200\231s syndrome, or cervical rib. Subacromial bursitis Early form of impingement in younger patients. Follows unaccustomed ac tivity or exercise. Look for a painful arc of 60 \200\223100 abduction with dull, aching pain, worse on activity. Differential diagnosis includes gout, sepsis, or RA. Treat with a nalgesia, NSAID, and ice. Demonstrate simple exercises (eg gentle pendulum swings and circl ing movements of the arm, crawling \201 ngers up a wall). LA injection will improve pain, movement, and help con \201 rm diagnosis. Consider steroid injection if \201 rst presen tation. Rotator cuff tendonitis Usually a longer history, chronic pain ( sleep disturbance), in patients aged 25 \200\22340years. Examine for tenderness and crepitus over humeral insertio ns of the rotator cuff and d active and passive shoulder movements. X-ray may show osteophy tes or subacromial calci \201 cation. LA injection may d pain, but usually does not i stre ngth or range of movement. Treat as for subacromial bursitis. In more severe cases, conside r formal physiotherapy and orthopedic referral. Calci \201 c tendonitis A poorly understood process of calcium deposition and resorption w ithin the rotator cuff tendon. Commoner in women. May be related to degenerative change or follow minor trauma. Most common site is within supraspinatus 1 \200\2232cm proximal to hum eral insertion. Acute pain (occurs during periods of calcium resorption, granulation, and h ealing) often starts at rest, worsens on movement and at night. Examine for tenderness at t he rotator cuff insertion. There may be crepitus, painful limitation of move- ment or a pai nful arc. The calcium deposits may be evident on X-ray. Most episodes spontaneously resolve in 1 \200\2232weeks. Treat with analgesia, NSAID, and i ce. Immobilize brie \202 y in a broad arm sling, but start gentle exercises (as above) onc e symptoms allow. Arrange orthopedic follow-up; steroid injection and/or physiotherapy and, rarely, surgical treatment, may be required. Adhesive capsulitis A misleading term, since it is caused by a generalized contracture of t he shoulder capsule, not adhesions. Causes include immobilization, injury, or diabetes. Com moner in women and rare <40 or > 70years old. Insidious onset results in diffuse, aching pa in (worse at night) and restricted active and passive shoulder movements. The cuff is usual ly not tender. X-rays exclude posterior dislocation ( b p.456). Refer to orthopedics for MU A, arthroscopy, and capsulotomy. 462 CHAPTER 9 Wounds, fractures, orthopedics Soft tissue neck injuries Neck sprains Neck injuries that do not involve fractures, disloca tions, ligamentous laxity, or spinal cord damage are common. Most follow car crashes involv ing neck hyperextension. These injuries have been referred to as: \200\230whiplash \200 \231 or \200\230whiplash-type \200\231 injuries, \200\230hyperextension \200\231 or \200 \230acceleration \202 exion \200\224 hyperextension \200\231 injuries or most simply, \200\230neck sprains \200\231. Patients with con- tinuing symptoms are often referred to as having a \200\230whiplash-associated disorder \200\231. MRI (which rarely changes managem ent) reveals many to have signi \201 cant soft tissue injuries. History Neck pain and stif fness may not appear until 12hr after injury \200\224 symptoms are typically maximal at \211\210 48hr. Ask about other symptoms (some are relatively common), which include: headac he, shoulder pain, backache, altered limb sensation. A range of other symptoms may also occ ur, including: dizziness, tinnitus, vertigo, and visual disturbance. Examination Perform a neurological examination. In fully alert, neurologically intact patients examine for any mi dline or paravertebral tenderness, muscle spasm or deformity. If there is no midline tender ness, assess active neck movements. If there is localized bony tenderness, pain on active m ove- ments or any neurological symptoms, immobilize fully and X-ray. X-ray 1 Arrange cervic al X-rays (AP, lateral and odontoid peg views) in the pres- ence of high energy trauma, neu rological symptoms or signs, d conscious level or serious injury elsewhere. In the absence of these, do not routinely X-ray if the patient is fully conscious, has no midline neck ten derness, and can rotate the neck by 45 to right and left. Check for evidence of fracture or dislocation. The most common abnormality is loss of the normal cervical lordosis (neck \200\230straightening \200\231) \200\224 this implies neck muscle spasm and does not nece ssarily indicate cervical spine injury. If the patient has severe pain or any abnormal neur ology, but the initial plain X-rays are normal, consider requesting a CT scan. Treatment If there is any clinical or radiological suspicion of vertebral or spinal cord injury, refer urgently, maintaining cervical spine immobilization. Treat patients in whom there is no suspicion of spinal cord or vertebral injury with initia l analgesia (eg co-dydramol and/or ibuprofen) and advise GP follow-up. Leave referral to a physiotherapist for the GP to decide, based upon progression of symptoms. Avoid the use of a soft collar (the evidence is against it), but instead encourage early mobilization. Progn osis The rate of resolution of symptoms after neck sprains is highly variable. Many patient s ( > 40 % ) continue to complain of pain, stiffness, and other symptoms for many months. I t is often dif \201 cult to make a long-term prognosis within 12 months of the injury. 1 Available at : www.ohri.ca/emerg/cdr/cspine.html 463 SOFT TISSUE NECK INJURIES Non-traumatic neck pain Neck pain without injury may result from a variety of causes: \200 Cervical disc herniations : present with neck pain, sensory and motor signs. Even if X-ra ys are normal, refer for further investigation (such as MRI) and treatment. Acute torticollis ( \200\230wry neck \200\231) re \202 ects painful sternocleidomastoid sp asm, which may occur on waking or after sudden neck movement. It responds to NSAID, local h eat (eg heat pad or hot water bottle), and (in severe cases), physiotherapy. Referred pain : eg tonsillitis/quinsy (especially in children). \200 Dystonic reactions : eg drug-induced (see b Complications of psychiatric drugs, p.619). Cervical arthritis : including both OA and RA. 464 CHAPTER 9 Wounds, fractures, orthopedics Facial wounds See also the sections on bony facial injuries ( b pp. 370 \200\223376). 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.