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Minor Orthopaedic Emergencies MINOR CUTS AND LACERATED WOUNDS

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 Chapter Minor Orthopaedic
Emergencies

20 MS Dhillon, Ravi Gupta

Minor or trivial orthopedic emergencies are the conditions Diagnosis

related to musculoskeletal system that can be definitely
Diagnosis of these wounds is straight forward. Such injuries
managed by a primary care physician. A knowledge of these are immediately noticed and reported by the patients due
conditions is mandatory for every primay care physician so to oozing blood from the wound. The main attention of
that a timely diagnosis and treatment can me imparted to the physician needs to focus on the function of the
the injured patient. The common conditions include: underlying vital structures including nerves, vessels, muscles

Minor Cuts & lacerated wounds and tendons. If the examination of the vital structures is

Animal Bites difficult due to pain, the use of local anesthetic on the

Back Pain margins of the wound may be helpful.

Closed Bone Fracures and Dislocaitons

Sprains, Strains, Soft tissue injuries

Foreign bodies

Acute cervical strain

Acute fibrositis

Pulled Elbow Syndrome

Human bite (Fight bite)

Ligament strains of small joints of fingers

Subungual hematoma

MINOR CUTS AND LACERATED WOUNDS

The minor cuts or lacerated wounds usually involve distal
parts of the upper and lower limbs. They are relatively clean
Fig. 20.1: Cut median nerve (Arrows B-B) and Flexor tendons
wounds. from a cut glass with piece of glass inside the wound (Arrow A)
154 First Aid and Emergency Management in Orthopaedic Injuries
If the underlying structures are not affected, these
wounds are treated with thorough irrigation and debride-
ment ensuring removal foreign material, if any, followed by
primary suturing of the wound.
ANIMAL BITES
The animal bites usually result in the wounds on the distal
parts of the limbs, which wounds are often puncture wounds
and rarely lacerated. As in lacerated wounds, one should
examine for the function of underlying vital structures like
nerves, vessels, tendons and muscles. Treatment includes a
thorough irrigation and debridement. If there is a concern
of the animal to be potential source of rabies, the wounds
are allowed to heal by secondary intention.
ACUTE BACK PAIN
The commonest cause of acute back pain is acute
lumbosacral strain which often responds to analgesics, local
heat and bed rest. If there is not improvement in 5-7 days
or worsening of symptoms, one should look forward for
the expert opinion.
CLOSED BONE FRACTURES AND DISLOCATIONS
The fractures and dislocations result in severe pain and often
require the advice on an orthopedic expert. However,
primary care physician is required to give first aid in the
form of splint application, analgesic and treatment of
associated haemodynamic abnormality if any. Undisplaced
fractures or soft tissue injuries around the joint may be
treated with short term immobilization.
PULLED ELBOW SYNDROME
(NURSEMAID’S ELBOW)
Pulled elbow is a common injury that occurs in children
aged between 1 to 6 years1. It occurs due to the subluxation
or partial slippage of the annular ligament into the
radiocapitellar space resulting from history pulling of the
elbow in the form of longitudinal traction with the forearm
in supination, followed by an episode of pain that makes
the child hold the arm close to the body in pronation and
partial flexion2.
Patho-Anatomy
When a longitudinal traction force is applied to the forearm
of the child, the annular ligament slips from the head of
radius and gets incarcerated between the radial head and
the proximal ulna. (Figure 2).
Clinical Features
The child present to the emergency usually with
continuously crying and not moving his affected upper limb.
Although the child is apprehensive of the slightest movement
there usually is a small arc of pain free flexion and extension.
Local tenderness may be present over the radial head. Where
there has not been an adult witness to the episode of
longitudinal traction, or there is no proper history, occult
radial head fractures/ supracondylar fracture humerus/ septic
arthritis should be primarily ruled out.
Imaging
Imaging is not necessary if the classical history is present
and if the clinical presentation is typical. In all other cases
manipulation is to be attempted only after imaging by
antero-posterior and lateral x-rays have ruled out an occult
fracture.
Management
Reduction by manipulation: It is usually an OPD procedure
and no anesthesia is required.
We should explain to the parents that during mani-
pulation there will be a brief episode of pain followed by
Fig. 20.2: Patho- anatomy of pulled elbow
 Minor Orthopaedic Emergencies
relief. Seat the patient in the parents lap. Stabilize the elbow
with one hand while the other hand supinates the forearm.
In case this fails to produce the characteristic snap then
take the forearm to maximal flexion. If this still does not
achieve reduction, then reduction can be attempted by
hyperpronation. Reduction should produce a dramatic
improvement in pain. If this does not occur then do
radiographs to rule out a fracture.
CERVICAL STRAINS AND SPRAINS
Description
Neck or cervical strains and sprains constitute one of the
most common groups of patients attending the emergency
room after trauma3. It is also known as hyperextension
strain, acceleration-deceleration injury, hyperextension-
hyperflexion injury, neck strain, neck sprain, and whiplash
injury. Common whiplash is a trauma causing cervical
musculo-ligamental sprain or strain due to hyperextension-
flexion and excludes fractures or dislocations of the cervical
spine, head injury, or alteration of consciousness4 A neck
sprain is stretching and/or tearing of the soft tissues of the
neck, including muscles, tendons, and ligaments.
A cervical strain involves injury to cervical muscles or
tendons, whereas a cervical sprain involves injury to the
cervical ligaments5. Mild sprains may involve only stretching
of the ligaments, whereas more severe sprains would involve
partial tears.
Clinical Features
Patients often complain of pain and stiffness and typically
the pain is delayed for a number of hours following an
accident. Pain may be referred to shoulder, upper limb, and
head. Other symptoms may include unusual skin sensations
at head/face, dizziness, light-headedness, concentration and
Fig. 20.3: Mechanism of injury of whiplash injury.
155
memory deficits, tinnitus, blurred vision, hearing
difficulties, and other cranial nerve deficit complaints3,4.
Limitation in range of motion at neck and tenderness at
cervical paraspinal muscles, often with hypertonicity or
“spasm” may also be assiciated. Neurological examination
is usually normal although subjective sensory deficits may
be present. However some patients may develop the central
cord syndrome following a whiplash injury, which may
occur in the presence of cervical spondylosis, spinal stenosis,
ankylosing spondylitis, or disk herniation. Physical
examination findings of central cord syndrome include
weakness that is disproportionately greater in the upper
extremities than the lower extremities, and it can be
accompanied by variable sensory loss. Any neurologic
findings after whiplash injury should be evaluated for brain
or spinal cord injury or vertebral artery dissection6.
Differential Diagnosis
Cervical fracture and cervical instability
Cervical Disc disease
Cervical radiculopathy, myelopathy, brachial plexus injury
Facet joint injury
Rotator cuff injury
Myofascial pain
Thoracic outlet syndrome
(Deep tendon reflexes/muscle stretch reflexes and
Hoffman or Babinski signs, help in identifying myelopathy,
radiculopathy, and brachial plexopathy. Special provocative
tests like Spurling sign, Lhermitte sign, and Adson test are
negative in cases of pure neck strain.
Imaging
Plain radiographs: Anteroposterior, lateral and oblique
cervical spine views for evidence of acute fracture or
subluxation with trauma. An open mouth view can be used
to check for evidence of atlantoaxial injuey. Flexion and
extension views are to be done to check for evidence of
spinal instability. Greater than 3.5 mm AP displacement
on flexion and extension views, or 11° of rotation on AP
radiographs, indicate cervical ligamentous laxity 5 .
Computed tomography offers superior sensitivity and
specificity for acute fractures, and a CT associated with a
myelography has a high sensitivity for radiculopathy and
stenosis. Magnetic resonance imaging is the study of choice
to detect soft tissue pathology, including disc and ligament
156 First Aid and Emergency Management in Orthopaedic Injuries
disruption and nerve root or spinal cord compression/
injury7.
Electro-diagnostic Studies
It can be used to diagnose nerve root dysfunction when the
diagnosis is uncertain or to distinguish a cervical
radiculopathy from other lesions that are unclear on physical
examination. It should be done 3 or more weeks after injury,
as diagnostic abnormalities will appear after 18–21 days of
the onset of radiculopathy.
Management
Acute Phase
Treatment is primarily directed at reducing pain and
inflammation. These include local icing, nonsteroidal anti-
inflammatory drugs, relative rest, avoiding positions that
increase symptoms, and manual or mechanical traction.
Cervical collar may be prescribed to give rest to the neck.
Modalities such as electrical stimulation may be helpful in
reducing the associated muscle pain and spasm. Local
injections and trigger spot injections may be considered for
severe pain not controlled by initial therapies in the acute
phase. Gentle physiotherapy including gradual stretching
followed by strengthening exercises may be used. All
exercises should be performed without pain8.
Recovery Phase
Appropriate progressive passive and active stretching,
mobilization, and manipulation are begun. This is followed
by progressive strengthening (isometric to isotonic) with
independent single-plane and complex multiple-plane
coordinated motions to include cervicothoracic, scapulo-
thoracic, and scapulohumeral stabilization activities8.
Maintenance Phase
It is directed toward sport/activity-specific training.
‘FIGHT BITE’ AND ‘CLENCHED-FIST INJURY’
Description
Human bites deserve special consideration, as they tend to
be more serious than those from domestic animals.
There are two possible mechanisms of a human bite
injury: the first is a direct bite to the hand. The more
common mechanism is a “clenched fist” injury, which occurs
over the metacarpophalangeal joint (the knuckle) when a
fist strikes an opponent’s mouth. This seemingly benign
injury is, in fact, treacherous and is unfortunately common9.
A tooth may lacerate the extensor tendon, the joint capsule,
or the joint itself. After contact is made, the patient is likely
to extend the hand, which deeply inoculates oral bacteria
into the wound. As the digit is straightened, the underlying
wound is obscured by normal soft tissue. Staphylococcus
aureus is the most common bacterial species isolated from
human bite wounds followed by Streptococcus spp.,
Corynebacterium spp., and Eikenella corrodens.
Clinical Features
On clinical examination, a puncture or laceration wound
is present.
Associated swelling and erythema may be present.
Cellulitis and lymphangitis are present in late presentations,
if there is an infection. If a tendon has been lacerated, the
patient may experience difficulty with finger extension. If
the injury is of a clenched fist type, asking the patient to
make a fist may reveal the underlying soft tissue damage
and may facilitate deep wound inspection. There will be
decreased hand function, such as difficulty with grasping
or moving an individual digit.
Imaging
Radiographs should be taken to look for fractures and to
rule out the presence of foreign bodies (tooth fragments).
Management
Suturing
Do not suture bite wounds, and such wounds of the hand
should generally not be sutured since a closed-space
infection of the hand can result in loss of function.
Tetanus Toxoid
Tetanus toxoid should be administered if the patient has
not been immunized within the past 10 years
Prophylactic Antibiotics
Advocated agents include cefuroxime, amoxicillin-
clavulanic acid. In the penicillin-allergic patient,
clindamycin plus a fluoroquinolone may be administered.
 Minor Orthopaedic Emergencies
Antibiotics should be continued for 5 to 7 days in the
absence of overt infection.
Surgical Treatment
Vigorous cleansing and irrigation of the wound as well as
débridement of necrotic material are the most important
factors in decreasing the incidence of infections. After
irrigation and débridement, the wound should be packed,
and the hand should be immobilized and elevated.
If infection is present upon wound inspection, the
wound should undergo repeat irrigation and débridement,
and the patient should be admitted for parenteral antibiotic
therapy.
Immediate referral to a hand specialist should be
considered for any patient presenting later than 24 hours
after the initial injury, for those who have infected wounds,
and for those who have sustained injury to the tendon,
capsule, joint, or bone.
SUBUNGUAL HAEMATOMA
Description
Subungual haematoma is one of the most common hand
injuries seen in the office or emergency room10,11 It is a
localized collection of blood between the fingernail and nail
bed that results from an injury or laceration of the soft tissue
of the nail bed under an intact nail. Pressure of the
haematoma against the periosteum of the distal phalanx
produces significant pain.
History
The most common mechanism of injury is crushing
between a door and the door frame, followed by smashing
between two objects and injury by a saw.
Clinical Features
The patient complains of localized pain. Nail deformity is
a late sign of a neglected nail bed injury. The haematoma is
visible through the fingernail.
Always rule out an underlying fracture of the distal
phalanx, where there will be diffuse swelling of the fingertip.
157
Differential Diagnosis
Subungual melanoma
Pyogenic granuloma
Imaging
Plain films of the affected finger should be obtained to rule
out an associated fracture
Management
General Measures
In both adults and children with a subungual haematoma
with no other significant finger tip injury, treatment by
trephining (making a hole in the nail), with a high-tempera-
ture microcautery device or an 16 or 18-gauge needle, gives
a good cosmetic and functional result12. Use of heated paper
clips may introduce carbon particles known as “lampblack”
into the nail bed. Anesthesia is not usually required for
trephination, and pain relief is immediate following
decompression
If fracture is present, splint the distal phalanx as well. If
the fracture is displaced, it should be reduced and fixed.
Prescribe nonsteroidal antiinflammatory drugs for pain
relief.
Surgical Treatment
Surgical repair of a nail bed laceration requires removal of
the fingernail13. Under anaesthesia, the distal edge of the
nail is grasped with a clamp, and the nail is bluntly dissected
from the nail bed and eponychium. The laceration is
repaired with fine absorbable suture. The eponychial fold
must be splinted to prevent formation of adhesions, which
can result in deformity of the regrown nail. The exposed
nail bed is covered with petroleum gauze, and a tubular
gauze dressing is applied.
Complications
Fingernail deformity (i.e., fissured nail) if the eponychial
fold is not properly splinted after removal of the nail.
Osteomyelitis; may occur if the haematoma is not
drained in a sterile manner.
158 First Aid and Emergency Management in Orthopaedic Injuries
INTERPHALANGEAL COLLATERAL LIGAMENT SPRAIN
Description
Injury to a collateral ligament at the interphalangeal joint
of the finger, usually the proximal interphalangeal joint (PIP)
can occur with abduction or adduction forces applied to
the finger, usually while extended14. The Index finger is
most often affected. The radial collateral ligament (RCL) is
more often affected than the ulnar collateral ligament
(UCL).
Clinical Features
Clinical examination has to be gentle to avoid overstressing
the joint and prevent converting a partial tear into a
complete one. There is pain and swelling over lateral aspects
of PIP joint and decreased range of motion secondary to
pain and swelling. Instability may occur in more severe
injuries. Ensure that maximum tenderness is over lateral
aspects and not dorsal (suggestive of central slip injury,
which can have significant consequences if missed). Test
for stability in extension and with 20 to 30 degrees of flexion.
Instability with lateral stress (opening beyond 20 degrees)
suggests loss of integrity. Loss of active ROM may be due
to either pain or volar plate/central slip injury, so digital
block may be necessary to test active ROM. Assess function
of flexor and extensor tendons at MCP, PIP, and DIP joints
to rule out tendon injury. The injury is divided into three
degrees depending upon the severity of injury:
1st degree: pain, but no laxity with stress.
2nd degree: pain and laxity, but firm end point with stress.
3rd degree: pain and loss of firm end point with stress.
Differential Diagnosis
Phalangeal fracture
IP dislocation
Central slip injury
Volar plate injury
Very often they coexist with interphlangeal collateral liga-
ment sprain.
Imaging
Posteroanterior, true lateral, and oblique radiographs of
involved fingers
Management
Immobilization
Treatment is guided by which finger is involved, level of
activity, and degree of pain and disability
1st degree: buddy tape continuously for 10 to 14 days
followed by buddy taping during physical activity for an
additional 2 to 4 weeks.
2nd degree: splint in 30 degrees of flexion acutely; buddy
tape or splint in 30 degrees of flexion continuously for 2 to
3 weeks, then buddy tape during physical activity for an
additional 4 to 6 weeks.
3rd degree: some treat as severe 2nd degree, but surgery
may be warranted if “unstressed instability,” tissue
interposition limiting joint motion, or lack of joint
congruity is observed on radiographs.
Rehabilitation
Depending on severity, begin passive ROM exercises in 1st
week and active ROM after 1 to 2 weeks, later for more
severe injuries.
Surgical Treatment
Surgery may be necessary if instability with active ROM,
tissue interposition limiting joint motion, or lack of joint
congruity are observed on radiographs,
If uncertain of possible central slip/volar plate injury,
refer to a hand specialist.
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 Minor Orthopaedic Emergencies
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