How To Describe an Injury by Mark McAndrew, M.D.

While this may sound obvious, it is very important to be able to communicate as precise a description of the injury as possible.

Soft Tissue The soft tissue envelope is extraordinarily important. Description of the extent of the wound is vital to plan management. We generally use a classification system described by Gustilo and Anderson
(JBJS 58A: 453-458, 1976.)

Grade I - Low energy wound less than 1 cm. Often an "Inside to Outside" injury.
Grade II - Moderate energy wound greater than 1 cm and less than 10 cm.
Grade III - High energy or highly contaminated wound, larger than Grade II

BEWARE: Crushing, significant abrasions, or burns increase the grade/even if the opening is small.

IIIA - Limited periosteal stripping, adequate tissue for coverage
IIIB - Extensive periosteal and soft tissue stripping (degloving) without
adequate tissue for coverage
IIIC - Associated neurovascular injury

Fractures:

An easy seven point method of description will give nearly all the information required to make treatment decision

1. Which bone is fractured?
2. Where in the bone is the fracture?
   Proximal or distal
   Metaphysis or diaphys
3. What is the fracture pattern? transverse, oblique, comminuted
4. What is the degree of comminution, angulation or displacement?
5. How bad is the overlying soft tissue injury?
6. Is it an OPEN or CLOSED fracture?
7. Is there an associated neurological or vascular injury or compartment syndrome?
   
   An Example: "The injury is a Grade II open, comminuted fracture of the left femoral shaft; he is neurovascularly intact distally, and the compartments are soft.

Joint Aspiration

Occasionally you will be called upon to aspirate a joint. This procedure is used to rule out septic arthritis, gout, or to determine whether a traumatic arthrotomy has occurred. IT IS VITAL THAT ANY JOINT ASPIRATION BE PERFORMED UNDER THE STRICTEST OF ASEPTIC TECHNIQUE. A wheal of 1% lidocaine at the site of aspiration makes this procedure much less painful.

The fluid should be sent for CULTURE, GRAM STAIN, CELL COUNT & CRYSTALS. Fluid exam specimen goes in a PURPLE TOP TUBE.

ANKLE

LANDMARKS: 1-1.5 cm above the lines joining the tips of the malleoli.
After routine sterile prep, using sterile technique, palpate the medial and lateral maleolli. Palpate the dosalis pedis pulse, and choose an injection site into the anterior ankle away from the artery. Enter the joint parallel to the articular surface.

ELBOW

LANDMARKS: The triangle formed by the lateral epicondyle, the radial head and the tip of the olecranon with the elbow flexed 90 degrees.
Prep and drape the elbow in a sterile manner. Insert the needle at the point where a vertical line from the lateral epicondyle bisects the line formed from the radial head and olecranon.

KNEE

LANDMARKS: The lateral edge of the patella, and the patellofemoral joint.
The patient should be supine. Prep and drape the knee in a sterile manner. With the non-dominant gloved hand, translate the patella laterally and palpate the patellofemoral joint with that thumb. In a horizontal direction pass the needle posterior to the patella, parallel to the articular surface. If resistance is met, redirect slightly posteriorly. A medial approach is satisfactory. If there is excess fluid, insert the needle just above the patella into the suprapatellar bursa.

HIP

This is the most complex joint to aspirate. You need FLUOROSCOPY, an 18 gauge spinal needle, a three-way stopcock, an empty 20cc syringe, and a 12cc syringe with dilute omnipaque contrast for your arthrogram. Assemble your setup as follows:
Spinal needle on stopcock on 20cc syringe. Attach 12cc syringe with contrast to side port of stopcock and start with flow to larger syringe.
Locate the hip joint on spot fluoro scans, estimating the general direction to the hip joint. Because most of the femoral neck is intraarticular, it is usually easier to aim to the base of the femoral head rather than the joint line itself. A POST-PROCEDURE ARTHROGRAM (HARDCOPY) IS VITAL TO DOCUMENT INTRAARTICULAR ASPIRATION OF FLUID.

Anterior Approach
LANDMARKS: 2 cm below ASIS and 3 cm lateral to femoral pulse.
With the hip externally rotated and abducted slightly, prep and drape in a sterile manner. Locate the femoral pulse and insert the needle directed 60 degrees posteriorly and medially toward the base of the femoral head. Walk the needle up the neck, aspirating as you view on fluoro. Once fluid is obtained, inject a SMALL amount of contrast as a confirmatory arthrogram.

Medial Approach
LANDMARKS: Posterior to the adductor group of the medial proximal thigh.
With the hip externally rotated, flexed, and abducted slightly, prep and drape in a sterile manner. Using fluoro, palpate the femoral pulse, and direct the needle toward the ipsilateral shoulder starting posterior to the adductor mass. Once fluid is obtained, perform an arthrogram as described above.

Analgesia and Sedation

You will be called on numerous times to perform procedures in the ER which would be painful to the patient if not properly anesthetized or sedated. Below are guidelines for using a variety of agents and techniques. BE VERY CAREFUL TO DOCUMENT ANY PRIOR ALLERGIC REACTIONS AND THE SPECIFIC MODALITY USED.

Analgesia

Used in such circumstances as closed reduction of dislocations where pain relief and muscle relaxation is needed.

NARCOTICS ARE REVERSED WITH NARCAN - 10ug/kg IV

1. Fentanyl - 2-10 mcg/kg IV, titrate to effect q5 min
   - Short half life
   - Effect noted when patient rubs nose
2. Morphine/Demerol + Versed IV - titrate to effect
3. Ketamine - 0.5-2 mg/kg IV, 4 mg/kg IM, 10 mg/kg PO
   - May cause increased ICP, heart rate & secretions

Sedation

To quiet patients for studies or minor procedures where local/regional anesthesia will be used. These are generally NOT analgesics.

VERSED IS REVERSED WITH FLUMAZENIL - 0.2 mg IV

Children

1. Chloral Hydrate - 75mg/kg PR or PO
2. "DPT" -
   Demerol 2mg/kg
   Phenergan 1mg/kg IM
   Thorazine 1mg/kg
3. Versed - 0.7-1.0 mg/kg PO

Adults

1. Versed - 0.1-0.2 mg/kg IV

Regional Anesthesia

Used for pain free outpatient procedures. May be combined with sedation if desired. Patience (i.e. TIME) is needed to allow the block to work.

Digital Block

Ideal for finger/toe lacerations, nailbed injuries, reduction of phalangeal fractures or dislocations, or testing of ligamentous stability of the digits.
What you will need ...

- 22 gauge needle
- 5-10cc 1% Lidocaine WITHOUT epinephrine

Procedure

1. Clean area to be blocked with betadine
2. Inject 2-3 cc at the radial and ulnar base of proximal phalanx between the metacarpal\metatarsal heads from a dorsal approach. Always aspirate to assure extra-vascular location.

Hematoma Block

Useful for simple closed reduction of distal forearm or phalanx fractures.
What you will need ...

- 22 gauge needle
- 5-10cc 1% Lidocaine WITHOUT epinephrine

Procedure

1. Clean area to be injected with betadine
2. Palpate the fracture site, and SLOWLY inject into the fracture hematoma from the dorsal or volar side. BEWARE the median nerve.

Wrist Block

Useful for more involved hand and finger injuries. Nice for pain relief when waiting to go to the O.R. for formal debridement/reconstruction.
What you will need ...

- 22 gauge needle (1.5" or longer)
- 5-10 cc 1% Lidocaine WITHOUT epinephrine

Procedure

1. Prep the volar and dorsal wrist with betadine
2. Block the Median nerve:
   - At the distal wrist crease, direct the needle distally, entering just ulnar to the palmaris longus (In line with the radial border of the ring finger) Inject 2-5cc.
3. Block the Ulnar nerve:
   - Palpate the ECU tendon and the ulnar pulse. Direct the needle distally from the proximal wrist crease and inject 1-3 cc.
4. Block the superficial Radial nerve:
   - Subcutaneously, directed radial to ulnar in the dorsum of the wrist, inject 2-5 cc, creating a "bracelet" of infiltration.

Ankle Block

Very useful for injuries and procedures to the foot. Complex, however since you must block 5 nerves.
What you will need ...

- 22 gauge needle (1.5" or longer)
- 10-30 cc 1% Lidocaine WITHOUT epinephrine

Procedure

1. Prep the entire foot and ankle with betadine
2. Block the Posterior Tibial nerve:
   - Palpate the posterior tibial pulse and direct the needle just posterior. Inject 5-10 cc.
3. Block the Superficial Peroneal nerve:
   - Direct the needle subcutaneously starting 2 fingerbredths superior to the tip of the lateral malleolus, across the anterior fibula & tibia. Inject 3-5 cc.
4. Block the Deep Peroneal nerve:
   - Palpate the tibialis anterior and extensor hallucis longus tendons, and direct the needle perpendicular to the bone between the tendons. Inject 5-7 cc.
5. Block the Sural nerve:
   - Direct the needle subcutaneously, starting 1 cm posterior to the peroneal tendons at the lateral malleolus, and inject 3-5 cc.
6. Block the Saphenous nerve:
   - Direct the needle subcutaneously, 1 fingerbreadth superior to the tip of the medial malleolus, injecting 3-5 cc anterior to the tibia.
   

Axillary Block

Useful for extended procedures or complex reductions in the arm below the elbow. This is a rather complex procedure with moderate risk. Perform only if you are comfortable with the procedure, and have sufficient monitoring available.
What you will need ...

- 35cc syringe
- 23 gauge butterfly
- 1-2% Lidocaine WITHOUT epinephrine (0.5cc/kg)

Procedure

1. Position the patient supine with the shoulder fully externally rotated and abducted to 90 degrees
2. Thoroughly clean the axilla with betadine
   
3. Palpate the axillary artery pulse and direct the butterfly needle TRANS-ARTERIALLY until you detect a flash of arterial blood
   
4. Direct the needle through the artery until you just lose the flash
   
5. Slowly inject the appropriate amount of anesthetic, checking occasionally asuring extravascular infiltration
   
6. Withdraw needle and hold pressure for 5 minutes, and let set up for 15 minutes

YOU MUST ASSURE EXTRA-VASCULAR INFILTRATION
Intravascular injection of lidocaine may precipitate seizures, arrhythmias, or DEATH

IV Regional Block (Bier Block)

Very useful type of anesthesia for extensive outpatient procedures or reductions. It does require care and several pieces of equipment

What you will need ...

- EKG & SaO2 monitors
- Peripheral IV (at least 18 gauge)
- 20 gauge Heparin lock
- Dual cuff tourniquet
- 1/2% Lidocaine WITHOUT epinephrine - 3mg/kg

Procedure

1. Test both tourniquet cuffs to 300mm Hg
2. Place heparin lock distally in affected side
3. Exsanguinate arm with elevation or esmarch
4. Inflate DISTAL cuff, the PROXIMAL cuff to 100mm Hg above systolic
5. Deflate DISTAL cuff
6. Inject lidocaine into heplock - note mottled appearance of skin
7. Complete the reduction/procedure
8. If the patient experiences pain at the tourniquet (usually about 30 minutes),
   inflate the DISTAL cuff, then deflate the PROXIMAL cuff.
   ALWAYS INFLATE ONE OF THE CUFFS PRIOR TO DEFLATING THE OTHER.
9. At the completion, deflate the tourniquet by releasing the pressure for 2 seconds,
   then reinflating for 20 seconds. Repeat this cycle for 5 minutes to assure that there is not a bolus of lidocaine released into the system.

The toxic dose of Lidocaine is 7 mg/kg
The toxic dose of Marcaine is unknown

Commonly Used Medications

X-Ray Pearls

The majority of your diagnoses will come from a good history and physical, along with appropriate x-rays. In the ER you can obtain plain films, CT scans, ultrasound, arteriography, and MRI if needed. MAKE SURE YOU HAVE ADEQUATE X-RAYS OF THE AFFECTED AREAS.

ALL TRAUMA PATIENTS MUST HAVE A CXR, AP PELVIS & C-SPINE XRAY

• With multi-trauma patients, ask the techs to shoot portable films of obvious extremity fractures while they shoot the mandatory pelvis and chest views. This saves lots of grief should there be a delay in obtaining all plain films.
• With comminuted femur & tibia fractures obtain a SCAN-O-GRAM view of the opposite unfractured bone for length measurements for pre-op planning.
• With displaced femoral neck fractures, obtain a TEMPLATED AP pelvis and lateral of the affected side for possible endoprosthesis planning (especially in those patients over 60 years old)
• With acetabular fractures obtain JUDET views (aka 45 degree obliques/illiac & obturator obliques) to assess the three dimensional character of the fracture
• With pelvic ring fracture, obtain INLET & OUTLET views - the inlet allows assessment of lateral instability/deformity, and the outlet allows assessment of vertical instability/deformity
• With pelvic ring fractures, look hard if only one fracture is obvious - it is rare to have only a single fracture in the ring (NB: Look at the SACRUM)
• With acetabular fractures, traumatic hip dislocations or pelvic fractures obtain a CT SCAN with 3mm CUTS to ascertain reduction, determine if fragments of bone are trapped between the joint surfaces, and to clarify the fracture pattern
• Always visualize the joint above and below a fracture
• NEVER obtain cervical flexion/extension views acutely
• In children, obtain views of the opposite side for comparison if theres a question (Especially with fractures and/dislocations about the elbow)
• When evaluating fractures and/or about the shoulder, obtain a "Y" or axillary view to assess sagittal displacement (anterior to posterior)
• Always obtain another set of x-rays after reduction
• You MUST see the C7-T1 level before calling the views adequate - obtain a SWIMMER'S VIEW, or if that is inadequate a CT scan
  
• With EVERY spine fracture, obtain a CT scan from the level above to the level below the fracture to assess neural canal compromise, and associated pathology
  
• Lower extremity or pelvis fractures are often associated with spinal trauma, especially in high speed/energy accidents, or falls
  
• With femur fractures, look carefully for a femoral neck fracture
  
• If a patient goes to the OR, collect all of the films in a labeled jacket, bring to the OR, and leave a note for the radiologist that the films went to the OR. MAKE SURE THE XRAY JACKET IS RETURNED TO THE FILE ROOM WHEN DONE.
  
• Use all of your resources wisely - the trauma resident, the radiology resident, and the ER attending may miss or pick up things that are important

Spine Trauma

There are a large number of spinal injuries seen here. Always be suspicious, particularly of latent injuries in patients with frontal head trauma or loss of consciousness. A protocol for the care of spinal injuries has been developed here.

With EVERY spine injury

- Document a complete neuro exam including:
- Fill out the SPINE INJURY FORM

1) MOTOR STRENGTH

5/5 normal
4/5 slightly diminished
3/5 anti-gravity only
2/5 unable against gravity
1/5 muscle twitch
0/5 absent motor

2) SENSORY

3) REFLEXES

3+ hyperreflexic
2+ normal
1+ diminished
0+ absent
4) RECTAL TONE
5) BULBOCAVERNOSUS REFLEX
6) LONG TRACT SIGNS Hyperreflexia/Babinski/Clonus

PEARLS

• ALWAYS DATE AND TIME YOUR NEURO EXAM
• Obtain a CT scan "one level above to one level below" any fracture
• ALWAYS BE THINKING OF FRACTURES AT OTHER LEVELS
• If the patient is to be left in a C-collar, change them to a Philly collar - the trauma extrication collars can cause necrosis of the scalp if left on for long periods of time
• Don't hesitate to call your upper-level resident to help with a diagnosis or when putting on a halo

The Halo

The Halo-Vest is the most common method we use for immobilization of the cervical spine. It allows fairly rigid fixation, particularly in the upper cervical spine. Its application is complex and often requires two or more people. You should always contact your backup before application of the halo for assistance and/or indication for application. Ultimately it is up to the attending whether a halo is required.

Some indications for application may include:

- "Hangman's fractures" (Fractures of the posterior elements of C2)
- Unilateral/bilateral facet dislocations with or without fracture
- Unstable (2 or 3 column) burst fractures
- Types 2 or 3 odontoid fractures

The method of application of the halo ring is rigorous and fairly complex. The details are too lengthy for this manual, but the following guidelines should help your learning curve:

• Measure for the appropriate size ring and vest as per manufacturer guidelines
  
• The patient should be supine, in a C-collar. A 2-3 inch bump of towels behind the occiput will greatly assist in getting the ring back far enough. (Or you can use the aluminum "spoon" available in the ER to rest the patients head off the head of the table.)
  
• The ring should be positioned just above the level of the eyebrows, and approximately 1cm superior to the ears. Clearance to the skull should be even all the way around.
  
• During placement, have the patient close their eyes firmly, but not tightly. This avoids trapping the frontalis muscle, making it difficult to close one's eyes.
  
• The anterior pins should be at the "corner of the skull". This means, avoid lateral placement in the temporal bone, or anterior placement which could damage the superior orbital nerve.
  
• The posterior pins should rest just inferior to the equator of the skull, aiming slightly anterior, avoiding the mastoid area. (Usually the last or second to last hole in the ring is appropriate.)
  
• Tighten opposing screw pairs together, watching for any shift in ring clearance with the skull. Usually switching back and forth between pairs is easiest.
  
• TIGHTEN TO 8-10 ft. lbs.
  
• You can usually place the vest either by log-rolling the patient, or by sitting
  him/her up. You should have assistance for this procedure.
  
• When secured, the patient should feel like he/she is looking straight ahead, the shoulders of the vest should NOT be riding up (Make sure they clear they clear the earlobes), and the vest should be snug but not constrictive. Only then can you remove the C-collar safely.
• Always obtain a post-placement lateral C-spine x-ray to document position.

Halo Traction

Commonly used to aid in reduction of cervical dislocations. Apply the halo ring as described above. Attach the halo-ring blocks on each side, and attach the halo traction bail to the posterior most bolt you used for the block attachment. For halo traction you will need a traction cart with a simple single pulley set-up at the head of the bed. Make sure you can adjust the pulley to allow traction to be applied from an angle. It is usually very helpful to add a snap-swivel to the rope to allow easy connect/disconnect of the weight from the traction bail assembly.

Guidelines for halo traction:

• Allow 10 lbs for the head and a MAXIMUM of 5 lbs for each level above the affected level. (i.e. A C5/6 bilateral jumped facet should be treated with a maximum of 10 lbs + 5 lbs x 5 levels = 35 lbs)
  
• Always start with a small amount of weight, adding slowly, and checking a portable lateral C-spine film before adding more weight. Allow about 20-30 minutes between each weight change.
  
• Always document a neuro exam when adding weight, or changing position.
  
• Many times, an angle of about 30 degrees of pull (slight flexion) may help in the reduction of the injury.
  

THE ATTENDING WILL TELL YOU THE MAXIMUM AMOUNT OF WEIGHT THAT SHOULD BE USED, AND ANY OTHER MANEUVERS ETC.

DON'T BE A PIONEER

Orthopaedic Emergencies

There are few true orthopaedic emergencies, but those few must be addressed as quickly as possible to avoid serious sequelae.

Pelvic Fractures complicated by Impending Exsanguination

- EVALUATE IMMEDIATELY

• Input & Output
• VSS over time
• Gently check pelvic stability
• START CALLING BACK-UP & ATTENDING

Compartment Syndromes

• History & Clinical Exam
• Measure and record compartment pressures

• Assess neurovascular status
• GENTLY reduce dislocation & immobilize
• Recheck neurovascular status
• Consider an arteriogram with a knee dislocation

In depth history & clinical exam

• Recent febrile illness
• Recent antibiotics
• Chronology of presentation
• Medical problems such as sickle cell, prior osteomyelitis, arthritis etc.

Clinical Exam & Labs

• WBC, ESR
• Joint mobility, bony tenderness, erythema, swelling

Joint Aspiration

• Culture, Gram Stain, Cell Count, Crystals

• Always document the exam (Date & Time!!)

• Record extent of soft-tissue injury
• Record time of injury and delay until treatment
• Record any antibiotics given and when. Consider antibiotic coverage
• Note any contamination present and type (i.e. barnyard, marine, lake/river)