ACC Treatment Profiles 2001

ACC5157 Cover a/w.fh8 11/12/00 1:06 PM Page 1 rne eebr20 SN0481766ACC 579 ISBN0-478-11756-6 Printed December2000 Treatment Proﬁles

2001 Treatment Proﬁles 2001

Composite ACC5157 Cover a/w.fh8 11/12/00 1:06 PM Page 2

IMPORTANT PLEASE READ BEFORE CONTINUING

These Profiles are made available by ACC to the recipient on the basis that they will be kept and used only by the recipient, and not lent, sold or otherwise made available to any third party or reproduced in any way, without ACC’s prior written consent. By opening these Profiles the recipient is agreeing to this condition but, if not agreed to, these Profiles are to be promptly returned to ACC.

Composite Treatment Profiles 2001

CONTENTS

1 Return to Work

2 Fractures/Dislocations – Plastering Guide

3 Burns

4 Gradual Onset

5 Sprains

6 Lacerations/Abrasions

7 Contusions/Crush Injuries

8 Miscellaneous Introduction

KEY POINTS • Treatment Profiles 2001 are consensus-based (not evidence-based) guidelines and are NOT rigid protocols. They are intended as a resource for clinicians to help summarise current practice in management of common injuries • Read codes: recording of injury diagnosis as Read codes is essential. Record the lowest relevant level of Read code For multiple injuries record Read codes for each injury If you cannot find a Read code for the injury, use code Z (unspecified conditions) and provide an accurate written diagnosis • Incapacity Duration Guides contained in the Profiles should be used where possible for any “time off work” certification

ACC is responsible for providing access to the most effective treatment, rehabilitation and support services to help claimants lead as normal a life as possible after an injury. These Treatment Profiles are available to assist treatment providers, working with ACC, to achieve this goal.

What is a Treatment Profile? A Treatment Profile is a guide to the treatment and rehabilitation services ACC expects claimants to receive for a particular injury. Most of the Profiles were developed by medical organisations as a summary of current good practice, which includes diagnosis, investigation, treatment, referral indications and expected outcomes (including incapacity duration).

The Profiles cover a wide range of common injuries but are not rigid prescriptions. They are intended to provide flexibility and choice in clinical judgment according to patients’ individual circumstances.

Why use Treatment Profiles? • As an aid for clinical management • To help clinicians manage expectations of patients, providers, employers and case managers. Experience shows this is the key to achieving timely, lasting and cost-effective outcomes • As an insurer, ACC works to balance the interests of premium payers and claimant needs by purchasing effective, affordable health provider services. The Profiles provide a benchmark for ACC to effectively monitor these services

How were the Profiles Developed? ACC selected approximately 150 Read codes that cover most primary care injuries. Based on these codes and advice from various health providers, the Treatment Profiles were organised into several categories.

Treatment Profiles were written by a wide range of health professionals and subjected to thorough peer review. These Profiles are consensus-based guidelines and are not evidence based. continued overleaf...

ACC Treatment Proﬁles – 2001 Introduction Introduction

Using Treatment Profiles Content: Two distinct information sections are contained for each profile. • The major section of the profile contains the consensus-developed clinical information as a summary of current good practice • The section titled Optimal Work Incapacity Duration Guides summarises data covering the likely incapacity durations. These have not been subjected to consensus review.

Read Coding Developed in the UK, this is a multi-level system of diagnosis coding that aims to help GPs, primary care providers and funders in managing clinical practice. For example, by using Read codes, a GP can keep track of all patients who suffer low back strains and implement health management strategies accordingly.

The New Zealand Health Information Service (NZHIS) is the New Zealand agent for the codes and is providing the system free of charge to providers and agencies. NZHIS encourages GPs to adopt the system for their own benefit as well as to provide accurate reports to NZHIS for planning and funding purposes. Practice management system developers are also modifying their systems to incorporate Read codes.

Providers must record Read codes for all ACC claims. For GPs without Read code software, ACC can provide a quick Read code reference list sorted by type and location of injury.

Points to note: • Read codes are a hierarchical coding system – each level provides more specific diagnosis. Please record the lowest relevant level of Read code. • Where there are multiple injuries, please record the Read code for each injury • If you cannot source a Read code, use code Z (unspecified condition) and provide an accurate written diagnosis. An ACC Case Manager may contact you to clarify and confirm the diagnosis.

If you have any questions about using Read codes please contact NZHIS or your local ACC branch.

Incapacity Durations Each Treatment Profile indicates the possible “time off work” required. This is based on a return to work duration: when most people without significant treatment complications or co-morbid medical conditions are likely to be able to return to work.

Most Treatment Profiles provide five occupational classes based on the amount and frequency of exertion or force required in their work duties.

For example: •“Sedentary” work requires sitting most of the time but can include walking or standing for brief periods •“Very Heavy” work involves exerting 45kg occasionally, and/or 23kg frequently and/or 9kg constantly continued overleaf...

Introduction ACC Treatment Proﬁles – 2001 Introduction

Please use the following guide to determine the appropriate occupational class based on your patient’s usual work duties: • Sedentary, eg office worker/receptionist • Light, eg shop assistant/parking warden • Medium, eg shelf packer/light factory worker • Heavy, eg mechanic/plasterer • Very Heavy, eg labourer/drain layer

ACC Case Managers will develop your patient’s rehabilitation plan based on this guide. The information you provide will help them liaise with the employer and patient about return to work goals and alternative work duties, if appropriate.

Please also use the duration guides for any “time off work” certification for injuries covered by the Profiles. Obviously, some patients may take less or more time to recover so please modify the durations as required. To help with rehabilitation planning, an ACC Case Manager may contact you to discuss these special circumstances.

Any listed injury is not necessarily covered by ACC in every instance: eg an injury with a gradual onset over several weeks, but caused by a non-work activity. Cover under the ACC scheme is determined by legislation.

ACC Treatment Proﬁles – 2001 Introduction Introduction

Thank You ACC would like to acknowledge the following groups in particular, for their considerable contribution to the original 1999 Treatment Profiles:

• First Health, Auckland • Integrated Primary Care Services Ltd, in conjunction with the National Institute of Health and Safety Ltd • Pinnacle IPA, Hamilton • Wellington IPA • Papanui Medical Centre

Valuable contributions also came from the New Zealand Society of Physiotherapists, the Royal Australasian College of Radiologists, Smith and Nephew Limited, the New Zealand Medical Association and the National Poisons Centre.

The following organisations and people have contributed extensively to this 2001 edition: • Royal New Zealand College of GPs Jim Vause, Rob Williams, Carole Atmore, Mick Ozimek, Janet Irvine, Saji Weerasinghe

• Accident and Medical Practitioners Association Alistair Sullivan, Rob Kofed

• Australasian College of Emergency Medicine Michael Roberts, Scott Pearson

• Faculty of Rehabilitation Medicine Tudor Caradoc-Davies

• New Zealand Orthopaedic Association Alan Panting

• Faculty of Occupational Health Medicine Des Gorman

• National Poisons Centre John Fountain

• Doctors for Sexual Abuse Counselling

Regular updating of these Treatment Profiles will be undertaken. ACC’s health services subsidiary company (ACC Healthwise) will be responsible for the Treatment Profiles.

Introduction ACC Treatment Proﬁles – 2001 work return to return Section 1 Return to Work 1

CONTENTS

Optimal Work Incapacity Duration Guides –

Fractures/Dislocations

Gradual Onset

Sprains

Miscellaneous

Return to Work Optimal Work Incapacity Durations

WORK DEFINITIONS Five job classifications based on the amount of physical effort required, are used [*] Reprinted with permission from the Medical in this book. The classifications are taken from the Strength Factor classifications Disability Advisor: Workplace Guidelines for described in the United States Department of Labour’s Dictionary of Occupational Disability Duration, Third Edition (1997), Titles. Presley Reed, MD (Reed Group, Ltd. Boulder, Colorado, USA. (303) 247 1860. All rights Sedentary Work reserved, http://www.rgl.net Exerting up to 4.5kg of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 9kg of force occasionally and/or up to 4.5kg of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 22.5kg of force occasionally, and/or up to 9kg of force frequently, and /or up to 4.5kg of forces constantly to move objects.

Heavy Work Exerting up to 45kg of force occasionally, and/or in excess of 22.5kg of force frequently, and/or in excess of 9kg of force constantly to move objects.

Very Heavy Work Exerting in excess of 45kg of force occasionally, and/or in excess of 22.5kg of force frequently, and/or in excess of 9 kg of force constantly to move objects.

Other important factors, in addition to kilograms of force, may help define an individual’s job classification. These factors include posture, biomechanics (size, shape and manageability of the object being moved), height from and to which the object is lifted, and frequency of exertion. Each of these factors (and any other job-specific requirements) should be considered when determining expected length of disability.

The above classifications focus on physical effort only and may not be relevant to the duration of some disability.

The guideline tables on the following pages provide the optimum time for each job classification. This data is most useful when envisioned as a continuum in the case management process. It does not represent the absolute length of disability at which an individual must or should return to work. Rather, it represents an important point of time at which, if full recovery has not occurred, additional evaluation should take place. This allows for individual differences in recovery times based on the innumerable variables that impact disability duration.

The diagnosis for which duration guidelines have been included are those where an expectation can reasonably be established. Durations for lacerations, contusions and burns are dependent on the extent and nature of the injury and work environment. Providers are expected to take these factors into consideration when determining optimum duration for these injuries.

ACC Treatment Proﬁles – 2001 Optimal Work Incapacity Durations Fractures/Dislocations Read Code - Description

Return to Work Durations* by Occupational Class Sedentary Light Medium Heavy Very Heavy [*] Reprinted with permission from the Medical Disability Advisor: Workplace Guidelines for S120. Closed Rib Fracture Disability Duration, Third Edition (1997), 1421212828Presley Reed, MD (Reed Group, Ltd. Boulder, S200. Closed and Non-displaced Clavicle Fracture Colorado, USA. (303) 247 1860. All rights 14 28 56 84 84 reserved, http://www.rgl.net

S22.. Closed Fracture of Humerus 14 28 91 119 147

S2241 Closed Fracture of Distal Humerus, Supracondylar 14 21 91 182 182

S230.S231. Fracture of the Proximal Radius and Ulna 14 28 91 119 147

S232.S233. Fracture of the Shaft of Radius and Ulna 14 28 70 91 147

S234.S235. Fracture of the Distal Radius and Ulna 14 21 91 182 182

S2401. Closed Fracture of Scaphoid 21 28 119 147 182

S242. Fracture of Carpal Bone 21 28 119 147 182

S25.. Fracture of Metacarpal Bone 714212842

S26.. Fracture of Phalanges of the Hand 14 14 28 42 42

S33.. Fracture of Tibia 28 42 182 224 273

S33.. Fracture of Fibula 7 14 4277 98

S340/3 Fracture of the Ankle - Medial or Lateral 14 28 56 84 112

S344/5 Fracture of the Ankle - Bimalleolar 14 28 70 112 112

S352. Closed Fracture of Other Tarsal/Metatarsal 7 21 42 70 70

S36.. Closed Fracture of Phalanges of the Foot 714213535

S41.. Dislocation/Subluxation of the Shoulder 1428284263

S44.. Dislocation/Subluxation of the Finger/Thumb 33333

Fractures/Dislocations ACC Treatment Proﬁles – 2001 Gradual Onset Read Code - Description

Return to Work Durations* by Occupational Class [*] Reprinted with permission from the Medical Sedentary Light Medium Heavy Very Heavy Disability Advisor: Workplace Guidelines for Disability Duration, Third Edition (1997), F340. Carpal Tunnel Presley Reed, MD (Reed Group, Ltd. Boulder, 7 7 14 21 28 Colorado, USA. (303) 247 1860. All rights reserved, http://www.rgl.net N211. Rotator Cuff Shoulder Syndrome 3 3 21 42 42

N2131 Medial Epicondylitis – Elbow 14 14 21 28 28

N2132 Lateral Epicondylitis – Elbow 14 14 21 28 28

N2165 Prepatellar Bursitis 7-14 14 84 140 140

N2174 Achilles Tendonitis 7 7 14 14 21

S5504 Sprain, Tendocalcaneous (Achilles Tendon) 3-7 7-21 7-28 21-56 21-56

N220. Synovitis/Tenosynovitis 7 7 14 14 21

ACC Treatment Proﬁles – 2001 Gradual Onset Sprains Read Code - Description

Return to Work Durations* by Occupational Class [*] Reprinted with permission from the Medical Sedentary Light Medium Heavy Very Heavy Disability Advisor: Workplace Guidelines for Disability Duration, Third Edition (1997), N142. Low Back Pain, Acute Back Pain – Lumbar, Lumbago Presley Reed, MD (Reed Group, Ltd. Boulder, 1371014 Colorado, USA. (303) 247 1860. All rights reserved, http://www.rgl.net S572. Lumbar Sprain 7771417

N143. Sciatica 714215691

Medical certificates for time off work should seldom, if ever, be provided for more than 1 week at a time, within the first 4 weeks

N131. Cervicalgia – Neck Pain 1371014

S570. Neck Sprain 3 7 14 21 28

Medical certificates for time off work should be seldom, if ever, provided for more than 1 week at a time, within the first 4 weeks.

N2264 Hand/Wrist Flexor Tendon Rupture 56 70 84 84 84

S460. Meniscal Tear – Medial 714283542

S461. Meniscal Tear – Lateral 714283542

S500. Sprain, Acromio-Clavicular Ligament 7-14 7-14 21-42 21-70 21-70

Grade 3: May not be able to return to heavy or very heavy work

S503. Sprain, Infraspinatus Tendon 7-14 7-14 21-42 28-70 28-70

S504. Rotator Cuff Sprain 7-14 7-14 21-42 28-70 28-70

S507. Sprain Shoulder Joint 3-7 7 14-21 21 21-28

S5Q2. Rupture of Supraspinatus 7-14 7-14 21-42 28-70 28-70

Sprains ACC Treatment Proﬁles – 2001 Sprains

Read Code - Description

Return to Work Durations* by Occupational Class Sedentary Light Medium Heavy Very Heavy [*] Reprinted with permission from the Medical Disability Advisor: Workplace Guidelines for S51.. Sprain Elbow/Forearm Disability Duration, Third Edition (1997), 3371021Presley Reed, MD (Reed Group, Ltd. Boulder, Colorado, USA. (303) 247 1860. All rights S52.. Sprain Wrist or Hand (includes carpal and carpometacarpal ligament sprains) reserved, http://www.rgl.net 14 21 14-28 21-35 28-42

S524. Sprain Tendon Wrist or Hand 1-14 7-21 14-28 21-35 28-42

S5204 Sprain Radial Collateral Ligament (Thumb) 14 14-21 14-28 21-35 28-42

S522. Sprain Thumb 2121214242

S523. Sprain Finger 7-14 7-14 14-21 21-28 21-28

S53.. Sprain Hip/Thigh 3371010

S533. Sprain Quadriceps Tendon 3371010

S540./1Sprain Collateral Ligament Knee 7 7 7 14-21 14-21

S542. Sprain Cruciate Ligament Knee 7 7 7 14-21 14-21

S54x1 Sprain Gastrocnemius 7 7 7 14-21 14-21

S550. Sprain Ankle 7772121

S5512 Sprain of Metatarso-Phalangeal Joint 7771421

S5513 Interphalangeal Joint 7771421

S5Q4. Rupture of Biceps Tendon 3371010

S5y3. Sprain Rib 11233

ACC Treatment Proﬁles – 2001 Sprains Miscellaneous Read Code - Description

Return to Work Durations* by Occupational Class [*] Reprinted with permission from the Medical Sedentary Light Medium Heavy Very Heavy Disability Advisor: Workplace Guidelines for Disability Duration, Third Edition (1997), F542. Tympanic Membrane Perforation Presley Reed, MD (Reed Group, Ltd. Boulder, 33333 Colorado, USA. (303) 247 1860. All rights reserved, http://www.rgl.net M2y5. Foreign Body in Skin or Subcutaneous Tissue 0 0 0 0 0-7 days

SD810 Corneal Abrasion 1-21-21-21-21-2

SG00. Corneal Foreign Body 1-21-21-21-21-2

SG1.. Foreign Body in Ear 00000

SG2.. Foreign Body in Nose 00000

TE53. Toxic Reaction Bee Sting 00000

TE60. Dog Bite TLxyo Human Bite (Also Cat) Depends on site and severity

Miscellaneous ACC Treatment Proﬁles – 2001 Return to Work

KEY POINTS • Planning a successful return to work (RTW), either to the same job or a different one, needs to be incorporated in the management of any injury from the earliest stage. This ensures positive expectations for all concerned. • Work provides many positive benefits for individuals, in addition to income generation. Remaining off work deprives people of these benefits. It also increases the risks of not returning to work with all of the subsequent negative effects of long-term unemployment. • The workplace must be an integral part of the work rehabilitation process. It is inappropriate to think of work merely as a place to return to once a person is fully recovered. • A successful and sustainable return to work involves collaboration between the injured person, the treatment provider, the employer (supervisor or manager), co-workers, family members, and the case manager (where applicable). • Barriers to return to work may arise from the views held by any, or all, of these key parties. Barriers need to be identified so that specific strategies can be used to manage them effectively. • Fear of movement is a strong predictor of not returning to work. These fears are commonly driven by beliefs arising directly from explanations given by the treatment provider. • Allowing the level of activity to be based solely on pain severity has been demonstrated to produce worse outcomes across a wide range of variables. Therefore, it is imperative to link activities to a quota or amount based on time, at the earliest stage for every person. • Establishing a successful RTW programme requires knowledge of the specific job demands. Communication with the employer is fundamental. • Accommodation of functional limitations through modified work tasks should be time-limited and reviewed regularly.

Benefits of Returning to Work Benefits include working part-time, being on a graded return to work programme, or temporarily working on selected/alternate duties.

Work fulfils many roles for people, not just income generation. It maintains work habits; daily routine; social status as a worker and contributor; workplace relationships; social contacts; and psychological well-being.

Risks of Staying Off Work Long-Term It is accepted that the longer a person is off work the greater the chance that they will never return. The adoption of a passive “sick-role” is clearly detrimental.

The loss of paid employment due to extended time off work is the most serious consequence, and significantly compounds the rehabilitation process. Injured people are equally prone as any others to the major negative effects of long-term unemployment.

Return to Work Strategies The only successful return to the workplace is a sustainable one. There are a number of key techniques and strategies to achieve this outcome. Several of these involve communication with the employer. A full description of the employer role is provided in “Active and Working! An Employer’s Guide to Managing Acute Low Back Pain in the Workplace” (Note 3). Consider referral to a suitable provider if you are unable or unwilling to undertake this process.

ACC Treatment Proﬁles – 2001 Return to Work Return to Work

1. Knowledge of the specific job demands Identify tasks required for work. Examples are sitting, standing, climbing a ladder, lifting heavy loads such as 50 Kg, or working on a keyboard most of the day. Ask the employer what the minimum requirements will be for the person to be useful at work in any capacity.

Check whether the person can complete any of those tasks. Asking the patient is insufficient and likely to be unreliable. A direct observational test is the most accurate. This may require referral to a suitable provider (see below).

2. Identify barriers to RTW Injury factors These include safety, biomechanical, cognitive, perceptual, and functional limitations. Remember pain is not by itself a contraindication to activity and work. If you identify specific safety concerns remember these probably apply to only part of the job. Make sure you identify what part of their job the person can still do. These are the important starting points for returning the person to work part-time, or using a graduated approach.

Individual factors* These include beliefs about their injury and symptoms such as pain. Important examples include the belief that pain intensity always directly signals significant damage to the body, and that all activity and work must be avoided until the problem is completely fixed. Fear of movement and activity (kinesiophobia) is very important to identify early, and counter with suitable reassurance.

Workplace factors* These include satisfaction with the job, work organisation issues, and relationships with managers and co-workers. The willingness and/or ability of a workplace to offer temporary modifications to work tasks is very critical.

* See the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk factors for long-term disability and work loss for a full outline of individual and workplace factors (Note 1).

3. Identify parts of the job the person can still do If the person can undertake all of the tasks involved in their job, then return them to full-time work.

If there are restrictions or limitations in certain areas, then it becomes critical to identify those tasks the person can still undertake.

The person may be returned to work in a number of different ways. The key goal should be to return the person to a full day of selected duties and activity, rather than to a limited day of full duties.

a Selected/alternate duties. The tasks that the person can still undertake temporarily become the focus of their work activity.

b Graded RTW programmes. Either full duties or selected duties are commenced for part of the day, and steadily increased over a limited period of time such as 3 to 4 weeks.

Return to Work ACC Treatment Proﬁles – 2001 Return to Work

c Part-time work. This should only be used in exceptional circumstances such as a significant fatigue problem, or serious medication side-effects, for example. It should always be time-limited, and is considered the choice of last resort since the person risks becoming settled into a different daily routine and set of work habits.

Trouble-shooting RTW plans The most common problem encountered in returning a person to work is that they are using “pain as a guide” to all of their movement and activity. In reality this means that the person is often responding to the anticipation that it is going to hurt, and this becomes the genesis of a “fear-and-avoidance cycle”. It is imperative that in the absence of specific safety concerns activity levels be time-contingent (ie based on a quota) rather than pain-contingent (based on pain). Patients need to be given clear guidelines about managing their activity level on a steadily increasing basis. Failure to do this produces a greatly increased chance that the person will develop long-term withdrawal from activity and ultimately a disuse or inactivity syndrome.

Another very common problem with RTW plans is the person reaching a plateau of participation. For example, the Graded RTW programme may not advance beyond 4 hours per day. These may be completed between mid- morning and mid-afternoon. This situation is often predictable, and commonly occurs when “lifestyle substitution” has become a buffer to progress. The positive benefits of work (such as the social status as a worker) are being experienced, but the lifestyle pressures associated with working longer hours are being avoided. For example, child care of school-aged children may be considerably easier. A useful method to change this pattern is to direct the person to work one full day followed by one short day, and then steadily move toward every day being a full day.

Failing to identify important barriers to RTW also occurs often. This emphasises the need to remain vigilant for barriers that were not originally disclosed or identified. Fear of movement and activity is a strong predictor of poor outcome. It is a common consequence of injury. Overcoming fear requires reassurance, motivation and encouragement.

Ergonomic reviews of the workplace may be required, along with work organisation and work processes. This does not imply that these factors caused the injury, but without alteration they may become barriers to a full and sustainable return to work. Health professionals who are specialised in the occupational setting (see referral section) will usually conduct these reviews.

The received wisdom, based on anecdotal evidence, is that highly motivated people such as the self-employed return to work faster than other groups of workers. A minority of the highly motivated people may require close monitoring to ensure that they do not end up in a boom-and-bust cycle through unwillingness to temporarily modify their workloads.

Most problems in returning someone to work can be resolved through contact with the Case Manager and/or the Employer (manager or supervisor). If this fails to achieve the desired outcome, consider referral.

ACC Treatment Proﬁles – 2001 Return to Work Return to Work

Referral There are a number of health professions who are specialised in the occupational setting. Selection of which to refer to depends on availability and the problems of the individual claimant. • Occupational physicians • Occupational therapists • Occupational physiotherapists • Occupational health nurses • Vocational rehabilitation providers

Notes 1 A full outline of barriers to return to work in acute low back pain is available in the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk factors for long-term disability and work loss (Kendall, Linton, & Main, 1997) published by ACC and the National Health Committee.

2 A template for devising a return to work plan with a claimant is provided in the Patient Guide to Acute Low Back Pain Management published by ACC and the National Health Committee. Free copies are available in packs of 50 by contacting Wickliffe Press Fax (03) 477-5682 E-mail [email protected]

3 Full outline of the employer role in facilitating the RTW process is available in Active and Working! An Employer’s guide to Managing Acute Low Back Pain in the Workplace published by ACC and the National Health Committee.

Return to Work ACC Treatment Proﬁles – 2001 Section 2 Fractures/Dislocations

CONTENTS Read Code

dislocations fractures/ Closed Rib Fracture S120. 2 Closed and Non-displaced Clavicle Fracture S20.. Closed Fracture of Humerus, Proximal Shaft S22..

Closed Fracture of Distal Humerus, Supracondylar S2241 Fracture of the Proximal Radius and Ulna S230./S231. Fracture of the Shaft of Radius and Ulna S232./S233.

Fracture of the Distal Radius and Ulna S234./S235. Closed Fracture of Scaphoid S2401 Fracture of Carpal Bone (No Other Symptoms) S24z.

Fracture of Metacarpal Bone S25..

Fracture of Phalanges of the Hand S26..

Fracture of Tibia and Fibula S33..

Fracture of the Ankle S34..

Closed Fracture of Other Tarsal/Metatarsal S352.

Closed Fracture of Phalanges of the Foot S36..

Dislocation/Subluxation of the Shoulder S41..

Dislocation/Subluxation of the Finger/Thumb S44..

Plastering Guide Closed Rib Fracture Read Code: S120..

KEY POINTS The great majority of rib trauma is mild and can be treated conservatively. Manubrium However, certain features are important: Body of sternum Rib fractures in children can indicate severe trauma because of the usual elasticity of a child's thorax (see rib contusion) Rib fractures in the elderly may warrant admission to hospital • Beware of damage to other structures Xiphoid process • 1st/2nd rib fractures: mortality up to 30% due to aorta and subclavian artery damage, brachial plexus injury • Rib fractures can compromise ventilation by: Causing splinting, leading to atelectasis, and pneumonia Multiple rib fractures (eg flail chest) interfering with normal Floating ribs costovertebral and diaphragmatic muscle excursion Fractured ribs can puncture surrounding tissues and cause haemothorax and/or pneumothorax • Posterior rib cage trauma may present as a back injury Vertebra • Ensure adequate pain relief to limit pulmonary complications

Complications • Pneumonia • Atelectasis • Respiratory distress • Pneumothorax • Haemothorax • Cardiac contusion

History • Direct blunt blow to the chest: projectile, fall, collision • Pain on inspiration • Motor vehicle accidents with activation of airbags and/or a deformed steering wheel • Haemoptysis • Respiratory distress

Examination • ABC • General examination: Respiratory – ventilatory sufficiency, cyanosis, tachypnoea, trachea, lung fields, accessory muscle use, oximetry Cardiovascular – blood pressure, heart rate, heart sounds, perfusion/shock etc Gastrointestinal system – bowel sounds, tenderness/guarding etc, mass, haematuria • Local examination – tenderness on palpation or crepitus, local chest wall deformity, paradoxical movements with flail chest • Depending on location of pain – consider other structures eg: Lower ribs (L) – spleen Lower ribs (R) – liver Ribs 11/12 – kidneys • Examine other systems as necessary continued overleaf...

ACC Treatment Proﬁles – 2001 Closed Rib Fracture S12o. Closed Rib Fracture

Differential Diagnosis • Sternal fracture • Sternoclavicular joint injury • Scapular fracture • Acute respiratory distress syndrome • Aortic dissection • Pneumothorax • Pneumonia/RTI • Pulmonary embolus • Spinal injury • Child abuse • Abdominal trauma, blunt or penetrating • Abdominal viscus injury

Investigation • If minor trauma, further investigation not necessary except as for key points • Urinalysis • X-rays (only 50% detection on first X-ray): PA chest (especially to exclude underlying damage) Lateral chest Oblique view of the side involved Coned upper abdominal AP view if lower ribs involved Others to consider: inspiratory views, plain abdomen (erect, lateral decubitus) • Ultrasound: renal, upper abdomen • IVU • Oximetry • Blood tests – FBC

Treatment • The main focus of treatment is maintaining active breathing – avoid splinting, taping etc • Analgesia – NSAIDs may be useful, warn of increased pain after 3-5 days • Consider admitting single, closed rib fractures if unable to cough, cannot clear secretions or significant co-morbidity especially in the elderly • Severe trauma: maintenance of ABC • Chest drain if tension pneumothorax

Referral to Specialist • Single, closed rib fractures without significant trauma or complications do not warrant referral • Patient with 3 or more fractured ribs • Any patient with fractured rib 1 or 2 • Other specialists as appropriate for complications eg general/trauma surgeon, ICU, vascular, cardiothoracic surgeon, plastic or neurosurgeon, urologist • Physiotherapy for education if breathing or coughing problems • Elderly living alone may require occupational therapy for Instrumental Activity of Daily Living (IADL) assessment, and assessment for support for independence or assisting devices

Closed Rib Fracture S12o. ACC Treatment Proﬁles – 2001 Closed & Non-displaced Clavicle Fracture Read Code: S20..

KEY POINTS Clavicle • Clavicular fractures are common injuries. Acromion

• Nearly 50% of all clavicular fractures occur before 7 years of age as Greater Coracoid process greenstick fractures tubercle • In neonates and children clavicular fractures heal very well, whereas in Head of adults the force required to cause a fracture is greater, healing takes longer humerus

and the potential for complications is greater Scapula • It is almost impossible to immobilise displaced fractures, however non- Humerus Glenoid union is extremely rare cavity • Displaced clavicle fragments can injure structures in close proximity because of the sharp edges of the fracture (major underlying vessels, the lung, and the brachial plexus) • Support for the weight of the arm is essential for the comfort of the patient. Immobilise the upper extremity with a broad arm sling

Classifications • Class A: middle third of the clavicle. Site of 80% of clavicle fractures • Class B: distal or lateral third of the clavicle. Site of 15% of clavicle fractures: Type 1, non-displaced (the supporting ligaments remain intact with no significant displacement of the fracture fragments) Type 2, displaced (the coracoclavicular ligament ruptures with resultant upward displacement of the proximal segment of the sternocleidomastoid muscle) Type 3, articular surface (involving the acromioclavicular joint) • Class C: proximal or medial third of the clavicle. Site of 5% of clavicle fractures

Complications • Neurovascular injury • Injury to the underlying lung • Delayed union/non-union • Deformity (cosmetic implications)

History • Clavicular fractures can result from a fall on to the side or an outstretched arm • Most occur from a direct blow, or fall, on to the point of the shoulder

Examination • The patient may support the injured limb with the other hand • Palpation along the length of the clavicle reveals an area of tenderness, perhaps swelling, crepitus, oedema and deformity • Ecchymosis can occur especially when displacement causes tenting of the skin and/or if injury occurred a day or more ago • Neurovascular exam of the arm and hand is vital • Lung auscultation to clinically exclude pneumothorax continued overleaf...

ACC Treatment Proﬁles – 2001 Clavicle Fracture S2o.. Closed & Non-displaced Clavicle Fracture

• Assessment of the extent of injury and presence of signs and symptoms of complications

Differential Diagnosis • Acromioclavicular injury • Dislocation of the shoulder • Fracture of the ribs • Pneumothorax/tension and traumatic • Rotator cuff injuries • Sternoclavicular joint injury

Investigation Recommended X-rays: AP shoulder girdle AP clavicle with 15° cranial angulation • Apical lordotic views may be required to demonstrate the degree of displacement • Other tests may be necessary to assess the possibility of other injury associated with the fracture: Chest X-ray if pneumothorax suspected Angiography if vascular injury suspected

Treatment • Adequate pain relief • Apply ice cold pack to the injury • Support for the weight of the arm is essential for the comfort of the patient • Undisplaced closed fractures will require: A broad arm sling Wearing the sling underneath clothing may add further fixation The sling should be worn for 2 weeks or until tenderness disappears from the fracture site Appropriate pain relief should be prescribed • Use of a figure of 8 bandage has no advantage over sling or collar and cuff and likely to press on fracture site, increasing pain

Referral to Orthopaedic Specialist • Multi-system involvement • Open fracture • Displaced fractures • Neurovascular damage

Other Referral • Referral to a physiotherapist is generally not required. The elderly patient may acquire shoulder stiffness and require range of motion exercises • Referral to occupational therapy for ADL assessment may be needed for the elderly, particularly those who live alone • Consider home help for elderly living alone • Consider child care/home help for primary parent of young children

Claimant Education • Education on use of the sling • Report back to doctor if changes develop: Swelling continued overleaf...

Clavicle Fracture S2o.. ACC Treatment Proﬁles – 2001 Closed & Non-displaced Clavicle Fracture

Skin breakage Loss of sensation of the extremity • Pain relief as required • Mobilise shoulder as comfort permits • Resume sport when fracture consolidated at approximately 3 months • Re-X-ray at 4-6 weeks for evidence of fracture union. Children do not require re-X-ray • Union at the fracture site may have a lump in both children and adults. In children this generally resolves over 2-3 months, but in adults may always be present

ACC Treatment Proﬁles – 2001 Clavicle Fracture S2o.. Closed Fracture of Humerus, Proximal Shaft Read Code: S22..

KEYPOINTS RED FLAG: • In children greenstick fracture of the surgical neck is the most common type A humerus fracture in a child presenting • The patient gives a history of trauma: with a trivial or inconsistent injury By a direct blow to the arm or shoulder should raise suspicion of non- By a fall on to an outstretched hand accidental injury • Elderly patients more prone to fracture due to osteoporosis • Non-displaced fracture of the greater tuberosity in children and adults can be managed in primary care • Non-displaced fractures require support, then mobilisation after 1-2 weeks • Impacted fractures of the neck of humerus are often missed

Complications • Nerve injury: Neuropraxia of the ulna nerve from inadequate padding over the medial epicondyle when applying the splint Radial nerve Axillary nerve Acromion Brachial plexus Glenoid cavity • Avascular necrosis seen in fractures of the surgical neck of the humerus Head of humerus

or multiple (3-4) part fractures Scapula • Problems of maintaining the position of any cast • Joint stiffness, particularly in the elderly • Non-union of a shaft fracture

Humerus History

• The patient gives a history of trauma: Lateral epicondyle By a direct blow to the arm or shoulder Medial epicondyle By a fall on to an outstretched abducted arm Capitellum By axial loading through elbow Trochlea Radius • Pathological fractures may occur with minimal trauma • Patients with a history of the following are most at risk of pathological Ulna fractures: Metastatic cancer of the bone Paget's disease Osteoporosis Bone cyst • Pain • Oedema • Decreased range of motion

Examination Proximal Humeral Fracture: • The proximal humerus has 4 parts: the joint surface, greater tuberosity, lesser tuberosity and humeral shaft – all should be examined radiologically for a fracture: • The Neer classification describes these fractures and amounts of displacement in detail • Surgical treatment options are based on the number of segments involved and degree of displacement. If unsure of the classification always discuss or refer to orthopaedic surgeon • Note that in children the epiphyseal line is frequently mistaken for a fracture

Humerus Shaft Fracture: • Can be transverse, oblique or spiral and may require CT or MRI evaluation • Rarely occurs in children continued overleaf...

ACC Treatment Proﬁles – 2001 Humerus Fracture S22.. Closed Fracture of Humerus, Proximal Shaft

• Neurovascular examination of the affected limb – radial nerve damage following humeral fracture is relatively common • Pain occurs with palpation and/or movement of the shoulder or elbow (especially humeral rotation) • Ecchymosis is usually present

Differential Diagnosis • Dislocation of the shoulder • Fracture, clavicle • Fracture, elbow • Fracture, scapula • Rotator cuff tear

Investigation Recommended X-rays: AP Lateral +/- transthoracic and axillary views

Treatment Initial treatment: • Immobilise • Provide adequate pain relief • Sitting is frequently more comfortable than lying down • Consult or refer to orthopaedic surgeon if required or unsure of treatment

Non-displaced fracture of the proximal humerus: • Arm support in a collar and cuff sling until the acute symptoms have resolved (1-2 weeks) • Under a T-shirt often more comfortable • Commence mobilisation when acute symptoms resolved • In children the collar and cuff may be adequate, although some children (and their parents) often feel more secure with a U slab that goes up over the acromion • Consider U slab protection for adults for first 2 weeks • Watch for late displacement (may need X-raying weekly for 4 weeks)

Referral to Orthopaedic Specialist • Intra-articular damage • Humeral shaft fracture • Open fractures require surgery and should be referred immediately • Displaced or angulated fractures • Penetrating trauma requires careful neurological assessment and therefore consultation or referral • Neurovascular damage • Associated gleno-humeral dislocation • Additional fractures eg fracture of forearm bones

Other Referral Non-displaced neck of the humerus: • In adults: consult physiotherapist when sling removed and pain free continued overleaf...

Humerus Fracture S22.. ACC Treatment Proﬁles – 2001 Closed Fracture of Humerus, Proximal Shaft

• Early referral to physiotherapist in elderly patients for education and rehabilitation programme to avoid a frozen shoulder • In children: not generally necessary unless nerve paralysis • Elderly living alone may require assessment of ADLs and IADLs, provision of assistive equipment, and referral to community services for bath/shower and dressing • Children with radial or ulna nerve injury will require assessment and intervention in ADLs, play to ensure continuing normal development • Radial nerve paralysis may require sensation testing, education and dynamic extensor splinting • Neuropraxia of the ulna nerve may require sensation testing, education, treatment and splinting to prevent contractures • Young people may require a writer to continue education or sit exams

ACC Treatment Proﬁles – 2001 Humerus Fracture S22.. Closed Fracture of Distal Humerus, Supracondylar Read Code: S2241

KEY POINTS RED FLAG: • A supracondylar fracture of the humerus occurs just proximal to the bone Document neurovascular status on an masses of the trochlea, capitellum and often runs through the apices of ongoing basis the coronoid and olecranon fossae Absent radial pulse, pallor, coldness, • The fracture line is generally transverse pain or paraesthesiae in the forearm • Most common fracture of the elbow in children 3-11 years • 20-30% have little or no displacement, 20% are greenstick => urgent referral • Rare in adults, and they usually require surgical intervention Inability to fully extend fingers or pain • In children non-displaced, non-angulated fractures can be splinted with on passive extension of fingers are ° 90 of flexion important signs suggesting ischaemic changes or development of Complications compartment syndrome of the forearm • Nerve injuries following a fracture can be as high as 12%. The most Check vascular status after any elbow common is damage to the anterior interosseous branch of the median nerve • Arterial damage – brachial artery movement • Compartment syndrome and the sequelae – Volkmann’s Contracture • Cubitus varus resulting from the initial fracture may lead to a Gunstock deformity

History • Usual mechanism of injury is a fall on an outstretched hand with an extended elbow which can cause posterior displacement • Always suspect when a child complains of pain in the elbow after a fall

Examination • Tenderness and swelling over the distal humerus • Examine the wrist and shoulder on the affected side • Assess and document circulation as the brachial artery may be disrupted • Assess and document neurological status (the median nerve especially) at regular intervals • The olecranon and medial and lateral epicondyles preserve their normal equilateral triangular relationship (unlike dislocation of the elbow)

Humerus Differential Diagnosis Olecranon fossa • Dislocation of the elbow Lateral epicondyle Capitellum Medial • Fracture forearm epicondyle • Pulled elbow Head of radius Neck Trochlea • Septic arthritis Radial tuberosity Investigation • Radiography is essential and interpretation requires care Radius Ulna • Films of the other side should be taken for direct comparison, if there is

any doubt in interpretation Head of ulna continued overleaf... Styloid process Styloid process

ACC Treatment Proﬁles – 2001 Distal Humerus Fracture S2241 Closed Fracture of Distal Humerus, Supracondylar

Recommended X-rays: AP Lateral Oblique

If study is performed to evaluate the elbow: AP Lateral Lateral tube angulated 45° • In adults (the fracture line tends to lie a little more proximal than in children) comminution, obliquity or spiralling and medial or lateral tilting are common • The epiphyses make interpretation of the X-rays difficult in children • Fat-Pad signs (both anterior and posterior) may be the only evidence of a fracture in growing children • Check for Baumann’s angle. The normal carrying angle of the elbow is about 10˚

Treatment Type 1: Minimal or no displacement: • These are stable fractures which require splinting of elbow at 90˚ (for child's comfort) • Provide adequate pain relief • Long arm backslab and collar and cuff or broad arm sling with no less than 90° flexion, or as much as the circulation can tolerate without compromise • Elbow flexion greater than 90° may produce neurovascular compromise • Assess and document the neurovascular examination during and after treatment • Neurovascular compromise requires urgent specialist advice

Follow-up care Type 1: • Re-X-ray at 7-10 days to exclude displacement • Assess union by tenderness and X-ray at 3-4 weeks for children, 6-8 weeks for adults • If satisfactory union mobilise from a sling. Remove sling 3-4 times a day for 10 minutes and actively exercise. Discard sling when discomfort settles • Note any cubitus varus or valgus and refer early if concerned • X-ray weekly if risk of displacement

Type 2: Angulated fractures which are not completely displaced: • The extremity needs immobilisation with a posterior long arm splint (axilla to metacarpal heads) • The person should be hospitalised for potential neurovascular compromise

Type 3: Completely displaced fractures: • Require immediate orthopaedic assessment • The potential for neurovascular injury and compartment syndromes is high • Fractures associated with limb-threatening vascular compromise should be reduced by experienced doctor only if an orthopaedic specialist is not acutely available continued overleaf...

Distal Humerus Fracture S2241 ACC Treatment Proﬁles – 2001 Closed Fracture of Distal Humerus, Supracondylar

Referral to Orthopaedic Specialist • Discuss with or refer to orthopaedic specialist for all or any concerns • Neurovascular compromise • All displaced and angulated fractures • Intra-articular damage • Adult fractures usually require surgery • Lateral condylar fractures • Cubitus varus and cubitus valgus deformities – do not remodel well

Other Referral • Physiotherapy referral may not be required in children, although recovery of full elbow extension may take 3 months • Median nerve damage – referral for possible splinting and education regarding functional activities and sensory deficits

ACC Treatment Proﬁles – 2001 Distal Humerus Fracture S2241 Fracture of the Proximal Radius & Ulna Read Code: S230./S231.

KEY POINTS • The majority of radial head fractures can be managed conservatively Humerus • Radial head dislocation/fracture can easily be missed Lateral Olecranon epicondyle fossa • Hand dominance/occupation may affect management Capitellum Medial epicondyle Head of radius Complications Trochlea Neck • Fracture slipping; redisplacement or late angulation Radial • Neurovascular injuries tuberosity • Radial head fractures generally get good recovery of pronation/supination but full extension may be long delayed Radius Ulna History • Mechanism of injury: Head of ulna Styloid Fall on outstretched hand process Styloid Direct blow to the elbow process • Pain (location, radiation)

Examination • Swelling, localised tenderness • Skin for open wound • Range of movement • Specific findings: Radial head # - pain on pronation/supination Olecranon # - decreased elbow extension • Neurovascular examination • Always examine elbow and wrist +/- shoulder

Differential Diagnosis • Distal humerus fractures • Dislocation/subluxation of proximal radio-ulnar joint • Ligamentous injuries around the elbow • Soft tissue injuries eg contusions to forearm • Dislocation of elbow • Pulled elbow in children

Investigation Recommended X-rays: AP Lateral Radio-capitellar • Both views should include the elbow and wrist on the films • Check anterior and/or posterior fat pad signs • It may be helpful to have comparison views of the other wrist

Treatment Initial treatment: • RICE • Splint • Analgesia

Fractures of the radial head and neck: • Radial head – non-displaced => sling, range of motion exercises after 7 days continued overleaf...

ACC Treatment Proﬁles – 2001 Proximal Radius & Ulna Fracture S23o./S231. Fracture of the Proximal Radius & Ulna

• Radial head – displaced/comminuted => refer • Radial neck – undisplaced/angulated less than 15˚ => above elbow cast 3-4 weeks (child), 6-8 weeks (adult) • Radial neck – angulated more than 15˚ => refer • Radial neck – comminuted/displaced => refer • Slipped upper radial epiphysis => refer if displaced, else put in POP for 3 weeks at 90° flexion

Coronoid process fractures: • Fractures involving 50% or more of the process => refer acutely • If less than 50% => above elbow cast. Mobilise at 3 weeks

Fractures of the olecranon: • If undisplaced, above elbow cast and refer non-acutely • Refer all displaced acutely for orthopaedic assessment • Non-operative fractures – start range of motion exercises after a few weeks

Follow-up care: • Plaster check at 24 hours and plaster completed if a backslab has been applied • Clinical exam the next day should include assessment for neurovascular status and pain control • Follow-up X-ray at 7 days if potential instability

Referral to Orthopaedic Specialist • Any open fracture • All displaced olecranon fractures refer acutely • Intra-articular damage • Fractures of the proximal head of the radius if there is angulation at the neck greater than 15˚ or if greater than 1/3 of the articular surface of the head is involved and displaced more than 2mm • Comminuted or major chip fractures

Proximal Radius & Ulna Fracture S23o./S231. ACC Treatment Proﬁles – 2001 Fracture of the Shaft of Radius & Ulna Read Code: S232./S233.

KEY POINTS This includes: Humerus Olecranon Isolated fractures of middle third of radius and/or ulna, including Lateral fossa epicondyle greenstick fractures in children Medial Galeazzi fracture dislocation (often missed) Capitellum epicondyle Monteggia fracture dislocation (often missed) Head of radius Fractures of both radius and ulna shafts in adults and children Neck Trochlea Radial • The outcome following forearm fractures in terms of function and bony tuberosity union is related to degree of trauma and type of fracture. It is optimised by early and appropriate treatment Radius • Morbidity is high in missed/late diagnosis of open fracture or fracture Ulna plus dislocation • There is a higher frequency of morbidity from forearm fractures than Head of ulna elbow or wrist fractures Styloid process • In children most are greenstick in pattern Styloid • Treatment is largely determined by the amount of angulation and the process amount of displacement • Hand dominance/occupation may affect management

Complications • Fracture slipping; redisplacement or late angulation • Compartment syndrome • Neurovascular injury • Complex regional pain syndrome • Growth arrest • Radio-ulnar synostosis after delayed treatment • Axial mal-rotation may occur in fracture of the radius. Rarely present in fracture of the ulna

History • Mechanism of injury – indirect violence such as a fall on to an outstretched hand • Direct blow to the arm

Examination • Pain – location, swelling • Skin – open wound, tenting, infection (note high frequency of open fractures of forearm) • Neurovascular status • Deformity/angulation/displacement • Examine elbow and wrist always

Differential Diagnosis • Dislocation of elbow or wrist • Fractures elbow/wrist • Contusions forearm

Investigation Radiology: Standard X-rays AP Lateral continued overleaf...

ACC Treatment Proﬁles – 2001 Radius, Ulna Shaft Fracture S232./S233. Fracture of the Shaft of Radius & Ulna

Other: Include wrist and/or elbow in film Must do separate elbow X-ray views because radio-ulnar dislocation often missed unless X-ray beam is centred on joint Obliques as necessary

Treatment Initial treatment: • Ice, elevate, splint • Analgesia • If deformity exists that is threatening the overlying skin it may be advisable to correct this with gentle repositioning of the limb, with analgesia administered

Undisplaced non-angulated greenstick fractures in children: • Small child can be treated in an above-elbow backslab • An above elbow POP cast is required where deformity has been corrected • Patient should have a broad arm sling or a collar and cuff • Child should be seen within 24 hours of the plaster application. Check neurovascular status • Compartment syndrome associated with these fractures • In unstable fractures the position of the fracture should be X-rayed and checked each week for 3-4 weeks • Arm should remain in plaster for 4-6 weeks in 5-10-year-olds and 3-5 weeks in 1-4-year-olds • Mobilisation should be started from a sling

Undisplaced fracture of ulna and radius in adults: • Above elbow POP for 6-8 weeks • All should be reviewed by orthopaedic surgeon • Compartment syndrome associated with these fractures • Plaster must be checked weekly for looseness and changed if necessary • Patients treated conservatively should have a broad arm sling, not a collar and cuff • Check position after 1 week with X-ray • After POP removal mobilise with an active exercise programme

Isolated fracture ulna shaft (eg nightstick fracture): • Treat in AE cast for 6-8 weeks in adult, 3-5 weeks for child if undisplaced • If >5mm displacement or >10º angulation then refer for ORIF

Galeazzi fracture/dislocation: • Fracture of the radius with dislocation of the inferior radio-ulnar joint • Refer all

Monteggia fracture/dislocation: • Fracture of the ulna with dislocation of the superior radio-ulnar joint • Refer all

Follow-up care: • Plaster check at 24 hours • Clinical exam the next day should include assessment for pain control continued overleaf...

Radius, Ulna Shaft Fracture S232./S233. ACC Treatment Proﬁles – 2001 Fracture of the Shaft of Radius & Ulna

Referral to Orthopaedic Specialist • Fracture displaced or at risk of displacement • Fractures of shafts of both radius and ulna will generally require internal fixation in adults • Angulation of the fracture • Displaced fractures of either radius, ulna or both • Axial rotation usually of the radius, rarely of the ulna • Any open/comminuted fracture • Fracture dislocation (Galeazzi and Monteggia fractures) require surgery • Fractures which do not reduce well

Other Referral • Any complication to appropriate specialist • Physiotherapy – refer early for mobilisation • In the elderly, especially those living alone, assess ADLs and IADLs and need for support for independence

ACC Treatment Proﬁles – 2001 Radius, Ulna Shaft Fracture S232./S233. Fracture of the Distal Radius & Ulna Read Code: S234./S235.

KEY POINTS Includes: Humerus Isolated distal radius or ulna fractures, adults and children Lateral Olecranon epicondyle fossa Combined distal radius and ulna fractures in adults and children Medial Colles’ type fractures Capitellum epicondyle Head of radius Smith’s type fractures Trochlea Neck Growth plate injuries in children Radial Fractures of the distal radius and ulna are common in children (lower tuberosity end of radius and ulna) • Reduction may be difficult Radius • In adults Colles’ fracture is common and often associated with fracture Ulna of the ulna styloid • Complications are common with Colles’ and Smith’s fractures Head of ulna • Hand dominance/occupation may affect management Styloid process Styloid Complications process • Fracture slipping; redisplacement or late angulation • Extensor pollicis longus rupture especially Colles’ • Subluxation/dislocation of distal radio-ulnar joint • Ulnar nerve injury • Median nerve injury/carpal tunnel syndrome • Osteoarthritis • Growth arrest • Complex regional pain syndrome • Ulnar artery damage • Non-union especially ulnar styloid fracture • Wrist joint ligament ruptures and/or triangular fibro-cartilage injuries associated with ulnar styloid fractures

History • Mechanism of injury – fall on to an outstretched hand • Direct blow to the arm (rare) • Occupation/pastimes • Handedness • Previous fractures in elderly

Examination • Location of pain, swelling • Skin – open wound, tenting, infection (note high frequency of open fractures of forearm) • Neurovascular status • Deformity/angulation/displacement • Examine elbow, hand and wrist always

Differential Diagnosis • Other fractures of the radius or the ulna • Fractures of the hand, elbow, forearm • Dislocations of wrist, elbow • Contusions of wrist, forearm, hand continued overleaf...

ACC Treatment Proﬁles – 2001 Distal Radius, Ulna Fracture S234./S235. Fracture of the Distal Radius & Ulna

Investigation Radiology: Standard X-rays: AP Lateral

Other: Include hand and/or elbow in film Must do separate elbow X-ray views because radio-ulnar dislocation often missed unless X-ray beam is centred on joint Obliques as necessary

If the study is performed to evaluate the distal forearm: AP Lateral 45° oblique • It may be helpful to have comparison views of the other wrist

Undisplaced greenstick fractures in children: • No reduction required if angulation less than 10° • Can be treated in a backslab or below elbow cast unless >2 cm from epiphysis (treat as mid-shaft fracture) • Patients should have a broad arm sling or collar and cuff • See within 24 hours of the plaster application. Check neurovascular status • In unstable fractures the position of the fracture should be X-rayed and checked each week for 3-4 weeks. In stable fractures fortnightly checks should be adequate • The arm should remain in plaster for 4-6 weeks in 5-10 year-olds and 3-5 weeks in 1-4 year-olds • Mobilisation should be started from a sling

Colles’ type fractures in adults: • Reduce under anaesthesia if experienced, otherwise refer • Post reduction put in backslab or splint below elbow plaster and review neurovascular status in 24 hours • Complete POP when swelling decreased and review at 1 week (re-X-ray) • Ensure patient mobilises fingers, elbow and shoulder regularly from the time of injury • Plaster must be checked weekly for looseness and changed if necessary • Patients treated conservatively should have a broad arm sling, not a collar and cuff • Weekly X-rays to check for early slipping for 2 weeks • After POP removal mobilise with an active exercise programme continued overleaf...

Distal Radius, Ulna Fracture S234./S235. ACC Treatment Proﬁles – 2001 Fracture of the Distal Radius & Ulna

Referral to Orthopaedic Specialist • All Smith’s type fractures • Epiphyseal fractures • Any open fracture • Intra-articular damage • Comminuted or complicated fractures • Any fracture which does not reduce well

ACC Treatment Proﬁles – 2001 Distal Radius, Ulna Fracture S234./S235. Closed Fracture of Scaphoid Read Code: S2401

KEY POINTS

• Often missed initially owing to the relative absence of pain Distal phalanx • Predominantly an injury of young adults and adults (less common in children and the elderly) Middle phalanx • Occurs frequently from a fall on an outstretched hand Proximal • Majority of clinically suspected scaphoid fractures will not be evident on phalanx

X-ray but have to be treated as such due to the potential for avascular Phalanges Distal phalanx necrosis of the scaphoid (a severe and permanent disability) of thumb 5 4 3 Proximal • In a true scaphoid fracture tenderness will be present when pressure is 2 phalanx applied over the dorsal and palmar aspects of the scaphoid. Tenderness of thumb Metacarpals 1 in the anatomical snuffbox, while a very sensitive sign, is non-specific Hamate Trapezoid Pisiform Trapezium • Lunate dislocations may be missed on initial assessment Lunate • Initial X-rays often show no fracture: repeat views at 10-14 days are Capitate Ulna Scaphoid important. Bone scan also helpful • Delayed union, non-union and avascular necrosis are relatively common Radius • Displaced fractures need referral

Complications • Avascular necrosis of proximal fragment • Sudeck’s atrophy (Reflex Sympathetic Dystrophy/complex regional pain syndrome) • Non-union seen at 3-6 months • Osteoarthritis

History • Direct significant force to outstretched dorsiflexed hand (axial loading from base of hand towards elbow) eg fall on to an outstretched hand (snowboarding) • A direct blow to the scaphoid area or a twisting injury to the wrist is highly unlikely to fracture the scaphoid and therefore does not need to be treated as a clinical scaphoid fracture if X-rays are normal • Kickback when using starting handles on internal combustion generators, pumps, compressors and inboard marine engines • First presentation may be a number of days after injury

Examination • Tenderness over the scaphoid tubercle especially the dorsal and palmar aspects • Intolerance of dorsiflexion of the wrist • Tenderness in the anatomical snuffbox (although this is less specific)

Differential Diagnosis • Bennett’s fracture of the thumb metacarpal • Fracture of the radial styloid • Dislocations of the wrist • Tendonitis • Wrist sprain without # • Rupture of the scapho-lunate ligament

Investigation Radiology: Recommended X-rays: PA PA with ulnar deviation Oblique 45° Lateral continued overleaf...

ACC Treatment Proﬁles – 2001 Scaphoid Fracture S24o1 Closed Fracture of Scaphoid

• Follow-up views at 14 days if clinical suspicion is high; repeat all 4 views

Additional scaphoid views may be useful: PA ulnar deviation at 12° caudal PA ulnar deviation at 30° caudal PA ulnar deviation 12° cranial • The fracture may be very difficult to visualise • An AP view with the wrist in ulnar deviation may make the fracture more apparent • X-rays may or may not confirm a fracture even if there is strong clinical suspicion • A bone scan is an excellent and cost-effective investigation to confirm or rule out a scaphoid fracture when suspected clinically with normal X-rays. It is likely to save the patient 2 weeks of time off work and unnecessary cast immobilisation

Treatment • Because of likelihood of complications caution is essential

Clinically suspected (signs and symptoms above) but normal X-ray: • Scaphoid plaster 10-14 days, then repeat X-rays after removal of plaster

X-ray proven undisplaced fracture: • Scaphoid plaster 6 weeks: check at 24 hours and 2 weeks • At 6 weeks remove plaster, assess clinically and repeat scaphoid views • If the fracture appears united on X-ray (this is rare) and there is no tenderness over the dorsal surface or at the snuffbox, the plaster should be removed and the wrist checked in 2 weeks • If the fracture is still present on X-ray or indicates union, but there is continued tenderness, re-apply the plaster for another 4 weeks, then remove, X-ray and re-examine • Refer early if uncertain about management or concerned about progress

Referral to Orthopaedic Specialist • Intra-articular damage • If the fracture is displaced or at risk of displacement and non-union eg oblique fracture through waist of scaphoid • If it was initially unclear if a fracture was present, a cast was applied and at re-X-ray it is still not clear and symptoms/signs persist • If there is incomplete healing at 8 weeks

Other Referral • In the elderly, especially those living alone, assess ADLs and IADLs and need for support for independence

Scaphoid Fracture S24o1 ACC Treatment Proﬁles – 2001 Fracture Carpal Bone (No Other Symptoms) Read Code: S24Z.

KEY POINTS • The function of the hand, especially gripping, is dependent on the stability and integrity of the carpal bones and ligaments Distal phalanx

• There are 8 carpal bones arranged in 2 rows Middle phalanx • The motion of the wrist occurs between the radius and carpal bones Proximal • The major types of injuries include fractures of the carpal bones, phalanx

dislocations and fracture/dislocations Phalanges Distal phalanx • Because of the potentially serious consequences of these types of injuries, of thumb always document the neurovascular status of the hand at initial examination 5 4 3 2 Proximal and at regular intervals phalanx

Metacarpals 1 of thumb • A fall on to an outstretched hand is the primary mechanism Hamate Trapezoid • Usually requires rest in plaster Pisiform Trapezium • Carpal instabilities may develop early or late after a carpal injury Lunate Capitate • The more energy involved in the injury the increased likelihood that there Ulna Scaphoid Radius will be severe injury even in the presence of a normal X-ray • Major ligament injuries, bone surface injuries and triangular fibrocartilage injuries are frequently missed because wrist injuries with normal X-rays are dismissed as sprains • Hand dominance/occupation may affect management

Complications • Ulnar nerve palsy may occur with fractures of the Hamate and Pisiform • Carpal instabilities may develop early or late after a carpal injury • Median nerve damage is associated with lunate dislocation and perilunate fracture and is manifested by sensory disturbances in the thumb, index and long fingers

History Dislocations: • Lunate/perilunate – usually the result of extreme flexion/extension injuries of the wrist. These require urgent assessment and treatment with ORIF

Fractures: • # Lunate – Dorsiflexion injury, or impact of the heel of the hand with a hard surface • # Capitate – 15% of all carpal bone #s. • Caused from direct blow or fall on to hard surfaces with the hand in dorsiflexion and are often associated with other injuries • Small chip fractures of the carpus are common and generally result from hyperflexion or hyperextension injuries of the wrist • Fractures through the bodies of the carpal bones except the scaphoid are rare

Examination Dislocation (lunate/perilunate): • Pain is usually severe and located on the dorsal or volar aspect of the wrist over the lunate • Movement causes pain • Wrist deformity and swelling

Fractures: • Although ecchymosis is not always present, oedema and point tenderness may indicate a fracture • A thorough range of motion examination with pronation and supination to document pain and limitation of movement • Lunate fractures are associated with point tenderness over the lunate fossa continued overleaf...

ACC Treatment Proﬁles – 2001 Carpal Bone Fracture S24Z. Fracture Carpal Bone (No other Symptoms)

Differential Diagnosis • Triangular fibrocartilage injuries • Chondral fractures • Major ligament injuries • Fractures of the forearm • Dislocations of the wrist • Tendonitis • Scapholunate instability

Investigation Recommended X-Rays: • The majority can be adequately assessed by good AP and lateral. On the lateral X-ray 11˚ of palmar angulation of the articular radial surface is normal • Consider scaphoid views • Consider clenched fist AP views • Consider bone scan for occult fractures

Treatment Initial treatment: • Urgent reduction of a fracture (or dislocation) is necessary when the neurovascular status is compromised • Provide adequate pain relief • Lunate fractures often associated with wrist ligament injury. Splint the wrist and refer for orthopaedic evaluation in 2-4 days • Rest small chip fractures of the carpus in plaster for 3 weeks • Rest undisplaced fracture through the body of a carpal bone for 6 weeks in a Colles or scaphoid plaster with check X-ray at 1 week • Refer immediately if fracture displaced • Peri-lunar and peri-scapholunar dislocation of the carpus require immediate specialist management

Follow-up care: • Check X-ray in POP at 1 week

Referral to Orthopaedic Specialist • Unstable fractures • Intra-articular damage • Hook of Hamate fracture • Lunate fractures • Inability to reduce fracture or hold in acceptable position • Significant soft tissue injury • Multiple fractures • All dislocations and fracture dislocations • Major ligament injuries • Unsure of diagnosis

Other Referral • May be required to mobilise the wrist, after full period of immobilisation • In the elderly, especially those living alone, assess ADLs and IADLs and need for support for independence • Sensation testing and education if nerve damage present • May require splinting if ulna nerve damage present

Carpal Bone Fracture S24Z. ACC Treatment Proﬁles – 2001 Fracture of Metacarpal Bone Read Code: S25..

KEY POINTS

• Terminology varies but it is best to refer to metacarpals as relating to Distal phalanx fingers eg thumb MC, index MC, middle MC, ring MC, little MC • This code includes fractures to head, neck, shaft and base of each metacarpal Middle phalanx (plus Bennett’s, Rolando’s and some Gamekeeper’s fractures) Proximal • Hand dominance/occupation may affect management phalanx

Phalanges Distal phalanx Complications of thumb 4 5 3 Proximal • Loss of functioning, eg hand stiffness, is the most common 2 phalanx of thumb • Delayed/mal-union Metacarpals 1 • Avascular necrosis Hamate Trapezoid Pisiform Trapezium • Post-traumatic arthritis Lunate Capitate Ulna Scaphoid History Radius • Document side of injury • Document any pre-existing disability or deformity • Document occupation or hobbies that require dexterity • Identify the dominant hand of the patient • Note the time, mechanism (eg potential for FB), environment (clean, dirty) of injury

Examination Compare with uninjured hand and document: • Skin/soft tissue injury eg crushing, bruising, lacerations, deformity • Location of tenderness • Hand function should dictate management

Function: Range of motion of hand; CMC joints, fingers Neurovascular status Mal-rotation of fingers, shortening

Interpret X-rays with regard to: Fractures – site, angulation, rotation, displacement, number, relation to joint surfaces, stability Presence or absence of related injuries eg air, FB, infection

Acceptable angulation in MC neck fractures: If not rotated and stable: <15˚ for index and middle MC <30˚ for the ring and little MC

Acceptable angulation in shaft fractures: <10˚ in index and middle MC <20˚ in ring and little MC • At least 50% bony contact is required

Differential Diagnosis • Wrist fractures/dislocations • Metacarpophalangeal dislocation • Contusions/sprains continued overleaf...

ACC Treatment Proﬁles – 2001 Metacarpal Bone Fracture S25.. Fracture of Metacarpal Bone

Investigation Recommended X-rays: Thumb metacarpal AP Lateral Index to little metacarpals PA 45˚ (oblique) Lateral • Compare with uninjured side if required • Scrutinise points of insertion of ligaments and tendons and the alignment of articular surfaces

Treatment • Initial: ice, elevate, splint, analgesia • If there is no significant soft tissue damage, the fracture is in an acceptable position and the fracture is stable: Elevation of the arm in a broad arm sling Mobilise early

Metacarpal head fractures: • Often comminuted • If undisplaced, POP/splint as appropriate, refer non-acutely • Refer acutely or discuss all fractures that are complicated (displaced, comminuted, tendon injury, mal-rotation, FB, infection, joint surfaces involved, air, unstable)

Metacarpal neck fractures: • Often occur after direct blow (note all little MCP fractures are boxer’s fractures until proven otherwise) • There is debate over the significance of acceptable volar angulation • Check carefully for rotational deformity (common) • If patient can fully flex and extend their small finger without any tendency to claw then closed manipulation under anaesthesia and immobilisation in a volar POP/splint for up to 3 weeks • Refer acutely or discuss all fractures that are complicated (displaced, comminuted, tendon injury, mal-rotation, FB, infection, joint surfaces involved, air, unstable)

Metacarpal base: • Index, middle (uncomplicated) – splint as appropriate eg volar POP/splint 5-10 days, mobilise early • Index, middle (complicated) – refer or discuss acutely • Ring – refer acutely or discuss (often associated with subluxation of CMC joint) • Thumb (Bennett’s or Rolando’s fracture) – refer all

Mid-shaft fractures: • Uncomplicated eg stable solitary fracture, no rotation, no shortening, and acceptable angulation: rest on volar slab 5-10 days, mobilise • Complicated – refer or discuss acutely continued overleaf...

Metacarpal Bone Fracture S25.. ACC Treatment Proﬁles – 2001 Fracture of Metacarpal Bone

Referral to Orthopaedic Specialist • Any shortening • Infection, FB • Any rotational deformity • Significant angulation or displacement • Metacarpal head fractures • Bennett’s/Rolando’s fracture • Multiple metacarpal fractures • Intra-articular fractures • Open fractures

Other Referral • Physiotherapist for early mobilisation • Other specialist as appropriate eg plastics, vascular, neurosurgeon • In the elderly, especially those living alone, assess ADLs and IADLs and need for support for independence. May need assistive devices while in POP and hand therapy for stiffness and reduced function after POP is removed

ACC Treatment Proﬁles – 2001 Metacarpal Bone Fracture S25.. Fracture of Phalanges of the Hand Read Code: S26.. continued overleaf... KEY POINTS • Much of the morbidity and disability can be prevented if proper Distal management is begun early phalanx • Do not underestimate fractures in children. Remodelling can occur only Middle in those fragments angulated in the line of the pull of the tendons. Lateral phalanx Proximal angulation and rotational mal-alignment, not obvious on X-ray will never phalanx remodel and require accurate reduction • If angulation greater than 10˚ refer for reduction Phalanges Distal phalanx • Internal fixation or traction splinting if the fracture is unstable of thumb • Mobilise early to avoid stiffness. From 7-14 days is ideal 5 4 3 Proximal 2 phalanx • Reduction can be performed under an ulna nerve block or mixed of thumb Metacarpals 1 median/radial nerve block as required Hamate Trapezoid • Where possible referrals should be to a hand surgeon/orthopaedic surgeon Pisiform Trapezium • Hand dominance/occupation may affect management Lunate Capitate Ulna Scaphoid Complications Radius • Finger stiffness due to joint adhesions is the most common and can result in permanent loss of range of motion and function • Infection from open fractures • Mal-union • Mallet finger

History • Establish mechanism and force of injury Axial compression from ball versus fingertip Rotational injury Crush injury • Potential compound wound • Joint injury • Social and occupational activity

Examination • Compare with the uninjured side • Note erythema, ecchymosis and swelling • Check vascular status by noting capillary refill • Assess the extent of nerve, tendon or skin loss and document carefully • Assess neurovascular status prior to administration of local anaesthetic or regional block • Determine the exact location of tenderness • Assess the degree of displacement • Assess the stability of the fracture • Assess any rotational deformity

Differential Diagnosis • Sprains of the fingers • Lateral subluxation of finger • Avulsed tendons or damaged tendons (eg extensor hood damage causing boutonniere deformity, or extensor avulsion causing mallet finger) • Volar plate injury • Missed dislocations of the IP joints

Investigation Recommended X-rays: AP 45˚ oblique Lateral continued overleaf...

ACC Treatment Proﬁles – 2001 Hand Phalanges Fracture S26.. Fracture of Phalanges of the Hand

• Compare with uninjured side if required RED FLAG: The position of function of • Scrutinise points of insertion of ligaments and tendons and the alignment the hand for splinting purposes is with of articular surfaces the IP joints held in extension, MCP Treatment joints at 90˚ and the wrist dorsiflexed at 45˚ (the “cobra” position) • Provide adequate pain relief • Control swelling • Compound wounds require comprehensive irrigation • Minimise movement at the fracture site • Stabilise the fracture site by controlling movement at the joint proximal and distal to the fracture • Hand function should ultimately dictate management • Unaffected fingers should be left free and exercised • The splint or slab should be removed as soon as possible (pain free) to allow exercise of the fingers • The splint or POP can, in some circumstances, be replaced with buddy strapping after 2 weeks • The metacarpal joints should never be fixed in extension • Early return to work should be encouraged

Internal fixation may be necessary: • If angulation is greater than 10˚ • If the fracture is unstable • If the bony fragment is large (greater than 30% of articular surface) • Rotational deformity

Fractures of the proximal and middle phalanges: • Non-displaced and stable fractures of the shaft, base, neck, intercondylar region or epiphyseal injuries: Should have splint applied for 1-3 weeks and checked at weekly intervals If symptoms are marked, apply a Zimmer splint (in position of function) Re-examine and re-X-ray in 1 week to ensure no displacement (if any concerns refer early to hand specialist) • Seek advice for any displaced fractures, angulated fractures, compound fractures, growth plate injuries, and fractures extending into a joint.

Fractures of the terminal phalanx (the neck and the base): • Most common injury is a comminuted fracture of the terminal tuft. There is usually no angulation or displacement. Associated subungal haematomas may be treated with trephination (antibiotics are usually not required) • For displaced or angulated fractures seek advice early • Prioritise soft tissue injury treatment • Pain relief may be gained by strapping the finger to a spatula or using a plastic finger splint • Fractures or fracture/dislocations at the base of the terminal phalanx can lead to mallet finger deformity. Therefore test the power of extension at the DIP joint. If there is a possibility of a mallet finger splint DIP joint in full extension for 8 weeks, seek advice early if unsure. Tell the patient that the finger must at all times be held in full extension to help prevent a permanent disability continued overleaf...

Hand Phalanges Fracture S26.. ACC Treatment Proﬁles – 2001 Fracture of Phalanges of the Hand

Referral to Orthopaedic Specialist • Intra-articular damage • Any rotational fracture • Significant angulation • Multiple phalanges fractures • Displaced intra-articular fractures and those that will interfere with joint movement • Unstable fractures • Bony fragment 30% of joint surface • Unsure of diagnosis

Other Referral • Physiotherapy assistance often required • Should be established as soon as the affected finger can be exercised • Hand therapy, sensation testing and education if nerve damage present • Buddy strapping to encourage movement • If dominant hand, may require assistive devices and work site modification

ACC Treatment Proﬁles – 2001 Hand Phalanges Fracture S26.. Fracture of Tibia & Fibula Read Code: S33..

KEY POINTS • Fractures of the tibia are generally associated with fractures of the fibula, although isolated fractures of either can occur • Most common long bone fractured • Fractures are often open because of the length of the tibia, which is in close proximity to the skin • Admission of tibial fractures to hospital may be necessary for elevation, pain relief and monitoring of the circulation Fibula • Toddler’s fracture is a distal spiral fracture of the tibia most common in the age group 9 months to 3 years Tibia • Suspect child abuse with mid-shaft fractures of the tibia unrelated to Medial history of significant trauma malleous • Ensure X-ray visualisation of the whole length of the fibula before Talus diagnosing an isolated tibia fracture Lateral • Non-displaced, closed fractures of the tibia and fibula treated with long leg cast malleous

Complications • Delayed union • Non-union (tibia is the most common long bone non-union) • Arthritis Femur Femur Lateral • Fat emboli epicondyle • Peroneal nerve injury Patella • Compartment syndrome Medial Lateral condyle condyle Patella Tibial History tuberosity Causes: • Often tortional injuries from sport, for example skiing Tibia Fibula Tibia • Falls from a height on to feet • Direct blows, for example motor vehicle accidents • Oblique and tortional injuries are common • Pain and swelling and inability to weight bear are associated with tibial fractures

Examination • Establish that the fracture is closed • Assess neurovascular status • Assess the degree of soft tissue damage • The popliteal artery is vulnerable to damage in displaced upper tibial fractures • Ability to walk (isolated fibula fractures are able to walk) • Check the whole leg • Note any deformity, ecchymosis, point tenderness, oedema and crepitance

Differential Diagnosis • Ankle, soft tissue injuries • Compartment syndrome, extremity • Fracture, knee (tibial plateau) • Fracture, ankle • Paediatrics, child abuse • Peripheral vascular injuries • Tendonitis

Investigation Recommended X-rays: AP Lateral Both views should include the knee and ankle joint • X-ray the length of the leg to ensure fractures at other sites are ruled out continued overleaf...

ACC Treatment Proﬁles – 2001 Tibia, Fibula Fracture S33.. Fracture of Tibia & Fibula

• In all cases of fracture of the tibia in high energy accidents it is essential to check hip clinically and X-ray • Consider a bone scan for suspected stress fractures

Treatment Initial treatment: • ABCs • Provide adequate pain relief • Splint the affected leg if transporting • Patient may need to be admitted • Check neurovascular status

Non-displaced, closed tibia fractures in adults (discuss with or refer to orthopaedic specialist): • Apply a long leg plaster • Re-check X-rays of the limb. The knee should be at 5-10˚ flexed • Split the cast and review indications for admission • Patient should be able to mobilise the next day – NWB and crutches • Complete cast after 3-7 days • Patient should be seen weekly with X-rays and for review of the cast • Avoid full replacement of the cast until 3-4 weeks when the fracture is more stable • Sarmiento or patellar tendon bearing cast could be applied at this time (if appropriate experience exists) • Partial weight bearing may commence when swelling settled (about 7-10 days)

Non-displaced closed tibial fracture in children (discuss with or refer to orthopaedic specialist): • As above, POP backslab or split-cast, above knee, non-weight bearing for 1 week • At 1 week, re-X-ray for position, replace cast only if necessary and encourage weight bearing as tolerated • If there was any displacement, X-ray at 2 weeks and review at 4-6 weeks depending upon age

Referral to Orthopaedic Specialist • Intra-articular damage • All displaced fractures, angulated fractures and high violence trauma require admission for elevation, analgesia, circulatory observation and fracture management • Open fracture • Isolated fibula fractures associated with severe ligament rupture at the ankle require open reduction and internal fixation (Maissoneuve type fractures). These are found with isolated fractures of the proximal fibula where the cause was NOT from a direct blow to the fibula but rather as a result of ankle trauma (eg twisting injuries on a weight bearing fixed foot). Where the force of the injury can rupture the medial ligament of the ankle followed by rupture of the inferior tibiofibular ligament followed by a fracture of the proximal fibula. This is a significant injury and requires early referral

Other Referral • If ankle and subtalar joints stiff may need physiotherapy • Is advisable to encourage knee flexion, to develop the quadriceps and to help restore the gait • Elderly living alone may require ADL and IADL assessment and assistive devices while in POP and on crutches. May require support for independence

Tibia, Fibula Fracture S33.. ACC Treatment Proﬁles – 2001 Fracture of the Ankle Read Code: S34.. continued overleaf... KEY POINTS • Ankle fractures can result from eversion, inversion and external rotation injuries Fracture types: • The most common ankle injury is when the talus is rotated in the mortise, • Weber type A: transverse fibular avulsion fracturing one or both malleoli (below horizontal ankle joint line). • Excellent results from conservative treatment can be obtained in the These result from internal rotation and majority of ankle fractures adduction injuries. Usually stable • Open fractures have a high risk of infection • Internal fixation should be considered in the presence of significant • Weber type B: oblique fracture lateral diastasis or unstable bimalleolar or trimalleolar fractures malleolus, with or without rupture • Undisplaced single malleolus fracture can be managed in a POP cast for of the tibiofibular syndesmosis and medial 4-5 weeks ligament injury (either medial malleolar • Delay in treatment increases the risk of complications fracture or deltoid ligament rupture). These • Diligent follow-up is required result from external rotational injuries and Complications are either unstable or potentially unstable • Swelling persisting for weeks or months after fracture union is very common • Weber type C: high fibular fracture with • Suspect Sudeck’s atrophy where pain or swelling is gross and especially rupture of the tibiofibular and if the toes are involved or if the patient complains of cold and sweating transverse avulsion fracture of the medial • Stiffness, weakness and disturbance of gait respond well to physiotherapy malleolus. Result from adduction after good union or abduction with external rotation • Instability due to lateral ligament ruptures may occur • Osteoarthritis is common if the initial fracture is not adequately managed • Late complications include osteochondral fractures. Re-X-ray and refer if ankle not clinically improving after appropriate treatment • The more severe the fracture the greater the likelihood of arthritis

History Fibula • Understanding the mechanics of the injury may aid in diagnosis and treatment Tibia • Can involve severe trauma or subtle trauma (eg stepping from a curb Medial causing sudden pain in an elderly patient) malleous Talus Examination Lateral malleous • Check neurovascular status (posterior tibial pulse, dorsalis pedis pulse and capillary return) • Examine the joint and lower limb carefully Fibula • Note presence of haemoarthosis, any changes in the relation of foot to Tibia the ankle, any deformity, swelling and bruising, any point tenderness, Navicular Talus Cuneiforms discolouration, temperature (especially cold) and inability to weight bear Distal – these are all indicators of a fracture and need to X-ray (also refer to phalanx Ottawa ankle rules) Metatarsals • Fractures of the lateral malleolus can often be differentiated from Proximal phalanx ligamentous strains as the area of maximal tenderness is over the lateral Calcaneus malleolus (or just above it), as distinct from over one of the collateral ligament fasiculi • Diastasis is diagnosed on X-ray when the talus is not positioned symmetrically in the ankle mortise

Differential Diagnosis • Ankle sprain • Ankle dislocation • Fracture, foot • Fracture, tibia • Lateral or medial ligament injury continued overleaf...

ACC Treatment Proﬁles – 2001 Ankle Fracture S34.. Fracture of the Ankle

Investigation Ottawa ankle rules: Recommended X-rays: • X-ray patients who are AP Unable to take 4 weight-bearing Mortise view – radiographic AP steps at time of examination Lateral Tender behind or at distal end of either malleolus • The whole fibula should be examined. High shaft fractures can be associated with ligament damage at the ankle • Does not include calcaneal fractures • If in doubt about ligament integrity, stress films may be helpful • X-rays should include base of 5th metatarsal if tenderness or pain localised to lateral aspect of the foot

Treatment • Urgent reduction or referral is necessary when the neurovascular status is compromised • Adequate pain relief • Stabilise and elevate limb • Excellent results from conservative treatment can be obtained in the majority of ankle fractures • If transfer is required ensure adequate pain relief, reduce the deformity if possible (with gentle traction) and splint securely

Undisplaced single malleolus fractures: Discuss or refer Weber B or C fractures BKPOP non-weight bearing for 2 weeks then weight bearing for 4 weeks Crutches Follow-up and re-X-ray after 1 week (and fracture clinic review) Further weekly follow-up is required for up to 3 weeks, with assessment of the need for re-application of the plaster Supportive elastic bandaging after the POP is removed Replace POP if loose or breaking up (risk losing the reduction) Isolated stable laterial malleolus and tibial fracture may not require POP (discuss with specialist if unsure)

Avulsion fractures (Weber A): May not require cast. Be guided by the degree of discomfort An airsplint may be adequate A below knee cast or backslab is a good option for 1 week to control pain and excessive movement which may exacerbate swelling

Referral to Orthopaedic Specialist • Intra-articular damage • All bimalleolar and trimalleolar fractures • Any displaced fracture • Any fractures with the potential for lateral shift of the talus in the ankle mortise (Weber B, C) • Any open fractures • Where there is potential rupture of the deltoid ligament ie medial joint tenderness (Weber B) continued overleaf...

Ankle Fracture S34.. ACC Treatment Proﬁles – 2001 Fracture of the Ankle

Other Referral • Gait and muscle strength advice • Physiotherapy may not be required for single malleolus fractures, but generally is required for displaced fractures • Any persistent swelling, weakness, stiffness or disturbance in gait indicates a need for physiotherapy • May require ADL and IADL assessment, assistive devices/support for independence if elderly or living alone

ACC Treatment Proﬁles – 2001 Ankle Fracture S34.. Closed Fracture of Other Tarsal/Metatarsal Read Code: S352.

KEY POINTS Metatarsals Middle The code includes: Proximal Laterial Distal cuneiform Metatarsals 1-5 fractures (including March and Jones) Cuboid Lis-Franc fractures/dislocations Calcaneus Talus fractures (including avulsion fractures, talar dome and lateral process) Navicular fractures Talus Os Calcis fractures (including avulsion fractures) Medial Navicular cuneiform • Fracture of the 5th metatarsal is the most common fracture of the lower Intermediate limb (the patient may complain of having sprained their ankle, as the cuneiform injury is the result of an inversion injury) Tibia Fibula Complications Navicular Talus Cuneiforms • Gait disturbance Distal • Compartment syndrome (a very dangerous acute complication in fracture phalanx of the foot – after a crushing incident) Metatarsals • Non-union (especially base 5th metatarsal) Proximal phalanx • Avascular necrosis (talar neck, navicula body) Calcaneus • Complex regional pain syndrome (Lis-Franc) • Post-traumatic arthritis (Lis-Franc)

History • Inversion eg base 5th metatarsal • Crushing eg metatarsals 2-4 • Twisting/torsion eg Lis-Franc • Fall from height eg Os Calcis • Snowboarding eg lateral process of talus

Examination • Compare with the other foot • Assess weight bearing/gait • Look for bruising, swelling, deformity, lacerations/open wounds • Palpate – site of tenderness • Neurovascular status • Range of motion all joints – ankle, subtalar, TMT, MTP • Associated structures eg tendon power

Differential Diagnosis • Sprain eg ankle, MTP joint • Dislocation eg subtalar • Contusions foot/ankle • Arthritis eg gout

Investigation Recommended X-rays: Foot: AP (dorsiplantar) Oblique Lateral continued overleaf...

ACC Treatment Proﬁles – 2001 Other Tarsal, Metatarsal Fracture S352. Closed Fracture of Other Tarsal/Metatarsal

If the study is to evaluate the mid-foot: Coned AP mid-foot Coned oblique mid-foot Lateral foot

If the study is to evaluate the calcaneus: Lateral hind-foot Tangential view (axial) hind-foot • With the multiple growth centres in children it may be helpful to have view of the uninjured foot

Treatment • Provide adequate pain relief • Rest, ice and elevation of the limb

Fracture of the 5th metatarsal base: • Usually non-displaced, but marked displacement warrants reduction and internal fixation • If symptoms are mild, use a compression bandage for support for 2-3 weeks with crutches • Below knee walking plaster or plaster boot for 3-6 weeks if symptoms are more severe • Occasionally delayed union requires surgery

Second metatarsal stress (March) fracture: • Often not seen on X-ray – refer if suspected in runner • If seen on X-ray at an early stage and severe pain exists, a below knee walking plaster until union has taken place may be necessary, otherwise light support for 2-3 weeks

First metatarsal fractures: • Undisplaced – crutches + BKPOP • Displaced or complicated – refer acutely or discuss

Fractures metatarsals 2-4: • Undisplaced + single – symptomatic treatment eg nil to BKPOP 1-3 weeks • Displaced/multiple/complicated – refer or discuss acutely

Lis-Franc joint fracture/dislocations: • The most commonly missed foot fracture • To diagnose, look for diastasis of 2-5mm between 1st and 2nd metatarsal base, or diastasis between medial cuneiforms, or fracture of base of 2nd metatarsal • Refer all acutely for ORIF, discuss all suspected

Talus fractures: • Neck/body: undisplaced 6-10 weeks BKPOP, refer non-acutely. Displaced – refer all acutely • Talar dome (osteochondral): refer all. Often delayed presentation with pain, crepitus, locking

Lateral process: Snowboarders fracture, increasing frequency. BKPOP and refer non-acutely continued overleaf...

Other Tarsal, Metatarsal Fracture S352. ACC Treatment Proﬁles – 2001 Closed Fracture of Other Tarsal/Metatarsal

Navicular fractures: • Often stress fractures • Undisplaced – BKPOP refer non-acutely • Displaced – refer all acutely (high risk of avascular necrosis) for ORIF

Os Calcis fractures: • High rate of associated injuries eg lumbar spine fracture, forearm fractures • Intra-articular – refer or discuss all – check Bohler’s angle; if <20˚ needs ORIF • Extra-articular – discuss or refer acutely. BKPOP or ORIF

Minor avulsion fractures from Os Calcis, navicular: • Often associated with ligamentous insertions • Treat symptomatically eg small – early mobilisation, large – BKPOP 1-4 weeks

Referral to Orthopaedic Specialist • All open or complicated fractures (displaced, multiple, comminuted, mal- union, tendon injury, mal-rotation, joint surfaces involved, air, unstable, suspected compartment or complex regional pain syndrome) • Lis-Franc fractures/dislocations, Jones fractures, all talar dome and displaced navicular or talar neck fractures

Other Referral • Other specialists eg neurosurgeon, vascular, pain as needed • Early physiotherapy because most fractures associated with ligamentous, proprioceptive, or gait problems and subsequent muscle weakness

ACC Treatment Proﬁles – 2001 Other Tarsal, Metatarsal Fracture S352. Closed Fracture of Phalanges of the Foot Read Code: S36..

KEY POINTS • Toe fractures nearly always heal with very little treatment Middle Metatarsals Proximal Laterial cuneiform • Fractures in children are more difficult to recognise because of the multiple Distal Cuboid growth centres Calcaneus • Ensure fracture will heal in shape to fit comfortably into a shoe

Talus Complications Medial cuneiform Navicular • Infection Intermediate cuneiform • Non-union • Gait disturbances Tibia • Arthritis Fibula • Inability to fit into shoes NavicularTalus Cuneiforms Distal History phalanx

• Establish mechanism and force of injury Metatarsals • Common fractures in men, often caused by a heavy object dropped on Proximal phalanx Calcaneus to the foot • The big or little toes stubbed on an immovable object is another cause

Examination • Compare with the other foot • Assess weight bearing/gait • Look for bruising, swelling, deformity, lacerations/open wounds • Palpate – site of tenderness • Neurovascular status • Range of motion all joints – IP, MTP • Associated structures eg tendon power • Mild deformity in children may increase with age

Differential Diagnosis • Toe dislocations • Contusions/sprains • Tendon injuries • Metatarsal fractures

Investigation Recommended X-rays: AP Oblique Lateral

Treatment Initial treatment: • Provide adequate pain relief • Rest, ice and elevation of the limb • Splint • Toe fractures will often heal with very little treatment • Buddy splint the broken toe to the adjacent toe with gauze pads between toes • Consider managing by wearing a stout shoe with the toe cut out for comfort or an orthopaedic shoe continued overleaf...

ACC Treatment Proﬁles – 2001 Foot Phalanges Fracture S36.. Closed Fracture of Phalanges of the Foot

Great toe fractures: • Undisplaced: splint + crutches. Consider BKPOP with toe platform • Displaced: refer acutely or discuss

Toes 2-5: • Undisplaced: buddy splint as above +/- crutches • Displaced especially little toe: reduce if significant deformity under local block, splint as above

Referral to Orthopaedic Specialist • Displaced great toe fracture • All open or complicated fractures (tendon injury, FB, infection)

Other Referral • May assist in mobilisation and gain correction in the elderly

Foot Phalanges Fracture S36.. ACC Treatment Proﬁles – 2001 Dislocation/Subluxation of the Shoulder Read Code: S41..

KEY POINTS Sterno- • First time dislocations cause severe pain, decreased range of motion and clavicular joint Acromion Clavicle follow history of trauma, but subsequent or recurrent dislocations may Coracoid be much less painful process • Anterior dislocations account for 95% of shoulder dislocations

• The key to a successful reduction is slow but steady manipulation with Sternum Humeral adequate analgesia and relaxation head • The rate of recurrence is high, particularly in the under 20-year age group Scapula Humerus • Children are more likely to fracture the proximal humerus • Patients over 40 years have a high incidence of complete rupture of the supraspinatus tendon

Complications • Axillary nerve palsy is the most common neurological complication • Recurrence • Rotator cuff tear • Associated fractures eg greater tuberosity, Hill-Sachs, Bankart lesions • Vascular injury, axillary artery most common

History • History of significant trauma unless recurrent • Mechanism of anterior is abduction, external rotation, extension. Falls on to an outstretched hand a common cause in older adults • Posterior dislocations are caused by severe internal rotation and adduction usually during a seizure, fall on an outstretched arm and occasionally by a direct blow or electric shock • Inferior usually caused by indirect forces hyperabducting the arm

Examination Anterior: • Look for loss of normal shoulder contour cf other side • The humeral head may be felt lying anteriorly and inferiorly to clavicle and coracoid • Arm is usually held slightly abducted and externally rotated • Neurovascular assessment – note peripheral pulses on both sides. The axillary nerve (regimental) must be evaluated.

Posterior: • Arm held in adduction and internal rotation • Anterior shoulder is squared off, flat with the prominent coracoid process when viewed from above • Neurovascular deficits infrequent • Patient resists external rotation

Inferior: • Arm fully abducted with elbow commonly flexed or behind the head • Humeral head may be palpable on the lateral chest wall

Differential Diagnosis • Acromioclavicular injury • Rotator cuff tear • Fractures of the humerus continued overleaf...

ACC Treatment Proﬁles – 2001 Shoulder Dislocation, Subluxation S41.. Dislocation/Subluxation of the Shoulder

Investigation Recommended X-rays: AP joint space (Glenoid fossa view) Transcapular lateral or axillary view AP internal rotation shoulder girdle Posterior dislocations are often missed, so careful examination of the appropriate X-rays is important

Treatment • Adequate pain relief • Reduce. The degree and route of analgesia and sedation will be determined by the experience of staff and the number of doctors on duty • A variety of techniques may be used for reduction: Kochers, Hippocratic, Stimson, scapular rotation etc • In paediatric patients gentle reduction is used as the epiphyseal plate is prone to fracture • Successful reduction is evidenced by a palpable or audible relocation, marked reduction in pain and increased range of motion • 1st dislocation, broad arm sling 3-6 weeks with orthopaedic review if aged >40 or complication present • If the dislocation is recurrent, sling and rest until comfortable. Specialist review for all. Start physiotherapy and mobilise at 1 week • Check dislocations in elderly patients at 1 week for rotator cuff injury • Unreduced posterior dislocated shoulders of greater than 3 weeks should be admitted as there is a danger of rupture of the brachial artery during reduction • In the posterior dislocated shoulder and fracture of the humeral neck there may be a need for shoulder spica, if the reduction is unstable

Post reduction: • Post reduction X-ray should be done • Axillary nerve status assessed and documented again • In the elderly mobilisation should be started at 1 week to reduce the occurrence of stiffness • NSAIDs for pain relief

Referral to Orthopaedic Specialist • Recommended for all complicated first time dislocations, any dislocation age >40 years, all recurrent • In axillary nerve palsy with loss of deltoid function refer for stabilisation • Dislocations with surgical neck fractures • Inability to reduce • Supraspinatus tendon rupture or associated complication

Other Referral • Physiotherapy • In the elderly, especially those living alone, assess ADLs and IADLs and need for home help. May require assistance for housework and bath/shower etc • Children with axillary nerve palsy require retraining in daily activities, play and education for continuing normal development • School or work site assessment and modifications may be necessary, especially if dominant arm is involved

Shoulder Dislocation, Subluxation S41.. ACC Treatment Proﬁles – 2001 Dislocation/Subluxation of the Finger/Thumb Read Code: S44..

KEY POINTS • Typically associated with forced hyperextension or hyperflexion of the Distal phalanx digit and requires immediate reduction Middle phalanx • Check for concentric reduction Proximal • Splint in 30˚ flexion (Zimmer splint) for 2-3 weeks phalanx Phalanges Distal phalanx • If stable consider mobilisation after pain and swelling have settled (3-5 days) of thumb • If unstable refer for specialist management Proximal 5 4 3 • Hand dominance may affect management 2 phalanx of thumb

Metacarpals 1 Hamate Trapezoid Complications Pisiform Trapezium Lunate Capitate • Late or delayed reduction may result in loss of joint motion, joint instability Ulna Scaphoid and limitation of hand function Radius • Gamekeeper’s Thumb – if unrecognised and untreated, may lead to progressive MP subluxation with interference with the grasp, causing significant disability

History • Jammed or bent backwards during sport is typical • Identify the patient’s dominant hand • Occupation – may impact work situation

Examination • 2-phase test for functional stability done under digital or wrist block: Active stability: the patient moves the digit through its normal range of motion. Full range of motion indicates adequate joint stability and only brief immobilisation is required Passive stability: gentle lateral stress is applied to each collateral ligament as well as shear stress in the PA plane to test volar support. Compare with normal contralateral joint • The diagnosis of incomplete or partial ruptures (sprains) is made when the joint is stable to active and passive stress but is significantly swollen with pain elicited on stress of the involved ligament. In such cases, stress the joint obliquely to put tension on the accessory collateral ligament • Neurovascular assessment • Test for rupture of the ulna MCPJ collateral ligament of the thumb by examining for passive abduction of more than 30˚ in a radial direction

Differential Diagnosis • Dislocations, hand • Fractures, hand • Hand injuries, soft tissue • Gamekeeper’s Thumb (Skier’s Thumb)

Investigation Recommended X-rays: AP Lateral Oblique • Always X-ray even where the dislocation has been reduced continued overleaf...

ACC Treatment Proﬁles – 2001 Finger Dislocation, Subluxation S44.. Dislocation/Subluxation of the Finger/Thumb

Treatment • Provide adequate pain relief • Control swelling • Elevate limb

For reduction: • Digital block anaesthesia 10-15mins prior to reduction • Remove rings • Brace the hand securely, grasp the dislocated finger (a dry gauze wrapped around the finger will improve grip) • Hyperextend the joint slightly with gentle longitudinal traction for a dorsal dislocation and hyperflex for a volar dislocation. Gradually push the finger into its normal position • Do not apply vigorous traction in a child as it may interpose soft tissue or an interchondral fragment into the joint space and prevent reduction • After reduction examine the joint for instability of the medial-lateral or dorsal-volar directions, range of motion, localised tenderness and flexor- extensor tendon function • Check for concentric reduction – do not accept anything less than perfect • Should have normal range of motion • Note that some dislocations will require open reduction, therefore do not try excessively

Dorsal: • Immobilise in Zimmer splint for 3-4 days, then: Mobilise strapped to the adjacent digit for 2-3 weeks or leave free Additional strapping during sport for a further 3 weeks • If not stable it may indicate need for repair of the collateral ligament

Volar: • Apply the splint only to the DIP joint on the volar aspect; the distal inter-phalangeal joint should be in full extension

Chronic instability: • Assess clinically and refer to specialist for repair and reconstruction

Referral to Orthopaedic Specialist • Any neurovascular compromise • Open joint dislocation • Ligament or volar plate rupture • Joint instability • An associated fracture • Re-evaluation by an orthopaedic specialist is advisable for all dislocations

Other Referral • Not generally required • Lightweight, short-term splinting • ADL and IADL assessment and work modification – especially for dominant hand

Finger Dislocation, Subluxation S44.. ACC Treatment Proﬁles – 2001 Plastering Guide Support Material for the Fracture Treatment Profiles

OVERVIEW Plaster of Paris (eg Gypsona) is a useful, cheap and efﬁcient material commonly used to treat orthopaedic conditions.

However, Plaster of Paris does have drawbacks. The problems of pressure and neurovascular damage from badly applied casts can have serious consequences. The person applying the cast is responsible for ensuring it functions efﬁciently and does not cause the patient any harm.

The applications shown in this publication are not the only effective methods. They are samples of procedures to ensure an efﬁcient, safe and comfortable cast can be achieved every time.

This publication has two sections: • General Application • Applying Basic Casts

ACC Treatment Proﬁles – 2001 Plastering Guide General Application Principles, Problems and Answers

BEFORE YOU START Immobilise Joints in the Position of Function Some exceptions include when a speciﬁc treatment position is ordered: • Ankle plantarflexed after repair of the Achilles tendon • Wrist in flexion after flexor tendon repair

Remember: There is a risk of stiffness with any immobilisation. If a joint stiffens Wrong in a non-functional position, a serious disability may result. This is especially true with the hand.

Full Range of Movement of Unaffected Joints The patient must be instructed to move all joints not immobilised in the cast. This is especially important in the upper limbs.

Remember: An elderly patient with a simple wrist fracture, immobilised in a below the elbow cast and full arm sling, will need clear instructions on how to avoid shoulder, elbow, and ﬁnger stiffness or serious functional impairment. Right All Acute Injuries Should be Immobilised in a Padded Split Cast A padded split cast consists of an encircling layer of padding over the whole limb. Then a complete cast is applied and split longitudinally. To prevent the cast spreading apart, a wet gauze bandage (eg Easiﬁx) is then applied.

For exceptions to this rule, see Dorsal Slab, Above Elbow Back Slab, Scaphoid Cast and U slab.

This type of cast does not prevent swelling. If elevation does not control swelling, or if you notice any neurovascular impairment of the extremities, the cast is designed so that it is relatively simple to check the problem. • Remove gauze bandage • Spring the cast apart • Cut all padding to expose the skin. This is essential because the cast padding can also cause constriction, especially if there has been any bleeding or serous ooze into it

In situations where excessive swelling is anticipated, instead of just splitting the cast, remove a 1 cm strip of plaster. This ensures that no threads of plaster remain, and then it is quite simple to cut the cast padding. continued overleaf...

ACC Treatment Proﬁles – 2001 General Application General Application

Splitting Wet Casts • The best method is to use a B.P. handle with a No. 20 blade • The movement of the blade should be down, never along the cast • Simple pressure on the cast padding will not cut it, but dragging the blade across or along it will

Remember: • Always cut over soft tissue – not over the bony prominences – as the soft tissue will ‘give’ • Always rest the limb on a pillow so that the ‘dead’ space within the cast is where you are cutting • Always split along a line away from nerves and vessels

Back Slabs Back slabs can be used for most acute fractures but are best on lower limbs if the patient is mobile. They are appropriate if: • You anticipate increased swelling and/or full examination of a joint or limb is required (eg acute osteomyelitis, cellulitis) • Supervised joint movement is prescribed (eg following internal ﬁxation of ankle fractures) • Redressing of large wounds means you need to be able to completely remove the cast

In situations where immobilisation with wound inspection and/or redressing is required, a full cast with a window is often more suitable than a back slab (eg lacerated knee). This enables a well ﬁtting, stronger, lighter cast to be applied and movement will not cause the cast to slip.

These casts are often quicker and easier to apply and are less easily discarded by a patient who cannot see why a ‘cut’ needs a cast.

Patient Information Patients must be given information about how to care for their cast. They need to know how to recognise a problem and what to do about it. Follow- up plaster check appointments and future care should also be arranged. For acute injuries, every patient should have a ‘plaster check’ 24 hours after its application. This check should include: • Neurovascular state of limbs • Movement of extremity • Cast comfort • Cast integrity

General Application ACC Treatment Proﬁles – 2001 General Application

APPLCATION TECHNIQUES Water Remember: Plaster + Water = Heat Warn your patients of this. Always start your ‘plastering career’ using cold water – you’ll have more time to work. When you become more comfortable, start using more tepid water. Never use warmer than tepid water or you’ll end up with a very quick setting, brittle cast with little time to smooth or mould the cast.

Padding (eg Soffban) • Apply padding ﬁrmly, but without tension – loosely applied padding results in a bulky, ill ﬁtting cast • Tear to negotiate corners

Remember: Extra padding will not protect your patient from a badly applied cast and it may cause pressure and constriction.

Stockinette • Choose the correct width • When in doubt, use a smaller size that has been stretched • Wrinkles and tucks in the stockinette can cause pressure

Plaster (eg Gypsona) • Use a suitable size for the limb Adult Leg – 15 cm Arm – 10 cm Child Leg – 10 cm Arm – 7.5 cm • Hold the bandage with the end free so after soaking the end will be easy to detach from the bandage • Immerse the bandage in water until the bubbles stop • Squeeze gently to remove excess water. Too much will make the bandage set, and not enough will make the bandage hard to manage • Roll the bandage around the limb from the outside in, using pleats to change direction • Keep the ‘body’ of the bandage roll against the limb; Two reasons: The bandage cannot be applied with too much tension, or in constricting bands The limb being plastered helps to support the bandage – acting as a ‘third’ hand • You’ll need to do a quick smoothing between layers. If the successive layers are applied quickly, all the smoothing can be done after you complete each section. This will ensure you achieve a strong light cast that will not delaminate

Remember: When each section of the cast is complete, it should still be soft enough for the surgeon to perform any moulding that is required.

Soaking Slabs • Fold as shown • Hold ends loosely and soak while it is still folded • Remove from water and squeeze gently • Pull out the slab – it will be straight and ready to apply. continued overleaf...

ACC Treatment Proﬁles – 2001 General Application General Application

Moulding • Always use the flat of the hand and keep the hands moving – sustained pressure in one place will cause pressure on the limb • When your hands will not slide easily on the plaster, maintain the moulding position until the cast is fully set – constant movement of the cast will break it

Joining Two Sections of the Cast When a cast is applied in sections (eg an above knee cast where the below knee section is applied ﬁrst), it is important to ensure adequate immobilisation to avoid causing pressure at the junction.

Unfortunately it is not uncommon to see patients with their fractured tibia ‘immobilised’ in a cast where the above knee section can swivel around the below knee section. This lack of stability can be painful for the patient. It will also hinder free movement and it could move the fracture position. When attaching one section to another: • Apply the cast padding to both sections at the start of the procedure • Before starting the second section, ensure the edges of the ﬁrst section do not press into the limb • Cover at least 15-20 cm of the ﬁrst section with the next layer of plaster – this does not need to be a thick layer

Caring for the Newly Applied Cast • Handle all casts with the flat of your hand. Never clutch at a wet cast – the indentations may cause pressure on the underlying skin • Support the length of the cast to prevent cracking • Use pillows when resting wet casts so they can conform to the contours • X-ray plates are hard so always use foam pads to protect the cast • In lower limb casts which include the foot, avoid pressure on the heel by making sure it is free from the pillow • In casts where the foot is not included, support the heel to prevent pressure on the Achilles tendon

Check • Don’t ruin your cast by careless handling after completion.

General Application ACC Treatment Proﬁles – 2001 General Application

Watch Out for Potential Complications Neurovascular Damage It is important to make frequent and regular neurovascular observations. These need to be recorded and the plaster should be opened at the ﬁrst sign of a neurovascular problem.

A rigid cast on a swelling limb may cause neurovascular compromise. This is why padded split casts are preferred for all acute and post-operative casts.

Local pressure on a nerve may also cause symptoms (eg a common peroneal nerve may be affected by cast pressure over a ﬁbula head).

Pressure Local pressure can be caused while the cast is being made or by incorrect handling.

Any complaint of pressure, burning, pain or discomfort under a cast must be investigated immediately by cutting a window and inspecting the area.

Remember: Some patients will not, or cannot, complain (eg infants, patients with head injuries, or patients with anaesthetic limbs).

CUTTING A WINDOW • Mark the area • Remove the window with an oscillating cast cutter • Inspect the area and pad • When repadding the area, to prevent pressure, make sure it extends beyond the edges of the window • Replace the window, ensuring the edges do not cause pressure, and plaster back in position

It is important that the window is replaced to prevent further damage to the skin and to prevent swelling of the soft tissues through the window. This is especially true for independent areas such as the heel or elbow. If it is necessary to reinspect the area, use a non-stretch adhesive plaster to hold the window in place.

Remember: After a few hours of pressure, skin becomes insensitive. This means the patient may not feel pain but full thickness skin loss may result.

POSITIONING THE PATIENT Your patient should be comfortable during the application of the cast. It is hard to plaster a moving target.

In many cases you will need an assistant to support the limb. Your patient should be positioned so your assistant can do this without having to strain.

ACC Treatment Proﬁles – 2001 General Application General Application

NOTES FOR THE ASSISTANT OR HOLDER • Decide the position in which the limb is going to be immobilised and position the limb correctly at the start of the procedure • Do not alter the position of the joint after the procedure starts. Flexing or extending a joint once the padding and/or plaster has been applied will cause pressure and constriction • Allow the plasterer to complete each section of the cast before you start to mould. Hopefully, by allowing the plasterer uninterrupted access to the limb, the cast will still be plastic enough to mould

FINAL CHECK • Have you applied the right type of cast to the right area? • Is the cast comfortable – no pressure or rough edges? • Can the patient move all other joints? • Does the patient know the movements allowed and encouraged? • Does the patient understand about plaster care and what to do if problems arise? • Have you remembered the follow-up?

REMOVING THE CAST As a general rule, all limb casts should be bivalved (eg split both sides of the cast). If the cast is split along one side only, this could create a twisting force as the limb is extricated from the cast.

Bivalving provides a ‘back-slab’ for the limb to rest in if there is a delay in reapplying the cast or reaching a clinical decision to remove it.

It is possible to tie both sections of the cast together if the patient needs to be moved to another area.

Remember: Patients should not bear weight on a bivalved cast.

The Procedure • Mark the cast where you intend to cut • Ensure you’re not cutting over a bony prominence (eg when removing a cast from the lower limb you may elect to cut behind the medial malleolus and in front of the lateral malleolus) • Use either plaster shears or an oscillating plaster cutter

Remember: Explain the procedure to your patient – both these tools look pretty frightening if you’re inside the cast!

Shears Technique • Insert the blade between the cast and the padding • Keep the near arm of the shears parallel to the cast • Move the outer arm towards the cast – this brings the blade away from the limb

Remember: Short ‘bites’ will prevent the shears from jamming. If the cast is well padded, withdraw the blade frequently and re-insert between the cast and the padding. continued overleaf...

General Application ACC Treatment Proﬁles – 2001 General Application

Oscillating Saw Technique • Hold the blade at right angles to the cast • Hold the moving blade against the cast until you feel it start to go through, then withdraw immediately – the sound will change when it is through • Continue moving along the cast in a series of cuts – never use one continuous sweep along the cast • Only one part of the blade is being used so it will become hot. Make sure you change to a different part of the blade after making three or four cuts. This is especially important with synthetic casts

Remember: It’s better to use an oscillating saw with a dust extractor – it protects both patient and clinician (eg De Soutter CCS saw and extractor).

ACC Treatment Proﬁles – 2001 General Application Applying Basic Casts

This section shows one method that can be used to apply some common casts.

• Use reinforcing slabs to give a strong, yet light cast. Commercial slabs are available, or slabs can be made from a plaster bandage • For an average adult the following sizes are suggested: Four layers of 10 cm bandage for upper limb Six layers of 15 cm bandage for lower limb • For acute and post-operative casts, do not use a stockinette. A padded split cast should be applied instead • For deﬁnitive casts, use a stockinette with minimal padding over bony prominences and sections where the cast may be joined

DORSAL SLAB Use this slab for below elbow immobilisation in the acute injury. It is better than a padded split cast for several reasons: • With the wrist in a functional position, the forearm has no well deﬁned contours. The amount of padding needed for safe splitting means the cast tends to become loose as the swelling subsides. The position can be lost and the cast then needs changing • A well constructed dorsal slab offers the same safety features as a padded, split cast (eg if swelling can’t be controlled by elevation, the cast can easily be split – there’s no plaster on the ventral aspect of the forearm) • When the swelling subsides and an X-ray checks the position, the cast can be completed and, if necessary, tightened by removing the outer bandage and replacing it with a plaster bandage. Since the cast has not been changed, there is no risk of losing the fracture position

Method Apply a stockinette and a thin layer of Soffban or just a thin layer of padding to the whole area being immobilised. (Loose padding will prevent a ‘good fit’ when applying a dorsal slab.) • Measure from 3 cm below the elbow crease to the metacarpal heads • Make a slab using a whole 15 cm plaster (eg Gypsona) and spread it approximately 20 cm wide • Trim as shown in the diagram • Apply the slab to the radial aspect first • Fit the slab around the thumb and then smooth it round to the ulnar border. Take care to keep it up to the metacarpal heads • Check the slab does not overlap, turn back the edges if necessary. Allow a gap of at least 2 cm • Bind with a wet gauze bandage (eg Easifix) • If the slab is too narrow and does not support the ulnar aspect of the forearm, simply cut another 10 cm slab to the correct length and apply it to fill the gap

Check • Full flexion and extension of the MCP joints • Full flexion and extension of the elbow joint • Opposition of the thumb

Teach the Patient • All above movements • Shoulder movements

ACC Treatment Proﬁles – 2001 Applying Basic Casts Applying Basic Casts

BELOW ELBOW CLAM SLABS To support the hand in a functional position. Particularly suitable for soft tissue injuries since it can be removed for wound inspection, and reapplied.

Method • Make two slabs (eg Gypsona) 8-10 layers, 10 cm wide at the required length • Cut two double layers of cast padding (eg Soffban), twice the length of the slabs • Soak the slab • Lay the slab on padding and fold the rest of padding back over slab • Repeat with second slab • Apply dorsal and ventral slabs • Bandage with crepe or cotton (eg Elastolite crepe bandage) • Hold until set

Check • Hand is in functional position • Elbow movements • Thumb opposition

Teach the Patient Elbow and shoulder movements

BELOW ELBOW CAST To immobilise the wrist in non-acute injuries, or when swelling is unlikely.

Method Make two reinforcing slabs (eg Gypsona) using four thicknesses of 10 cm plaster: for the ulnar border for the hand, this slab is split. • Apply the stockinette to the limb and add a layer of cast padding (eg Soffban) around the wrist to protect the styloid processes • Apply the slabs as shown in the diagram • Turn back the edges of the stockinette and complete the plaster with a 10 cm plaster bandage

Check • Full flexion and extension of the MCP joints • Full flexion and extension of the elbow joint • Opposition of thumb

Teach the Patient • All above movements • Shoulder movements

Applying Basic Casts ACC Treatment Proﬁles – 2001 Applying Basic Casts

SCAPHOID CAST To hold the thumb in opposition following fractures of the carpel scaphoid. This may be applied over stockinette even in the acute stage, unless associated with other injuries (eg fracture radius) which are likely to cause swelling. During the cast application, the thumb should be held in opposition and the wrist in slight radial deviation. The plaster should be moulded well into the palm. The plaster does not need to extend to the metacarpal heads.

Method • Make two reinforcing slabs (eg Gypsona) using four thicknesses of 10 cm plaster: A radial slab which is split A palmar slab • Make a third slab with one layer of plaster 15 cm long, folded in three lengthwise • Apply a stockinette to the limb, with a layer of cast padding round the wrist and thumb to the IP joint • Apply slabs as shown in the diagram • Turn back the stockinette, and complete the cast with a 10 cm plaster

Check • Flexion and extension of MCP joints • Flexion and extension of elbow joint

Teach the Patient • Above movements • Shoulder movements

ABOVE ELBOW CAST To immobilise the forearm and elbow. A padded plaster is used for acute injuries. It is applied over padding and is split lengthwise from palm to medial epicondyle to axilla. A non-padded plaster is used for non-acute injuries. It is applied over a stockinette with padding (eg Soffban) round the elbow and wrist. 4

Method 3

Make two reinforcing slabs (eg Gypsona) using four thicknesses 5

of 10 cm plaster: 2 For the ulnar border 1 For the hand, this slab is split. • Apply as shown in the diagram • Turn down the edges of stockinette • Complete the cast with two or three 10 cm bandages

Hints It may be easier to apply one Plaster of Paris bandage (eg Gypsona) before applying the slabs. This makes the slabs easier to apply because they adhere to wet bandage better than to stockinette and undercast padding. This ﬁrst bandage should be applied as shown.

Caution • To prevent any pressure in the antecubital fossa, it is important that the Soffban is torn as it crosses the anticubital fossa, and that the ﬁrst turns of plaster are applied as shown. • Make sure the elbow is held in the correct degree of flexion throughout the application of the cast continued overleaf...

ACC Treatment Proﬁles – 2001 Applying Basic Casts Applying Basic Casts

Check Flexion and extension of MCP joints

Teach the Patient Finger and shoulder movements

ABOVE ELBOW BACK SLAB To immobilise the elbow and lower end of the humerus (especially supracondylar fractures of the humerus in children).

The slab is applied so there is no plaster or padding in front of the antecubital fossa.

Method • Apply a double layer of cast padding (eg Soffban) across the back of the elbow joint • Hold in place and roll on as shown for the ﬁrst bandage of the above elbow cast, avoiding the antecubital fossa • Three six-thickness slabs (eg Gypsona) are applied as shown, and held in place with a crepe or cotton bandage (eg Elastolite crepe) using the same method of bandaging

Remember: The size of cast padding used depends on the size of the limb. Don’t end the slab at the wrist because this often results in increased pressure. Support with a collar and cuff sling. A stockinette sling may be used for small children.

Check • Finger movements • Access to radial pulse

Teach the Patient • Finger movements • Shoulder movements within the limitation of sling

BELOW KNEE CAST This cast immobilises the ankle and should extend from the tibial tuberosity to the web of the toes. It should be low enough behind the knee to allow full knee flexion. If necessary (eg injuries to the metatarsals) the plaster may extend to form a toe platform, but otherwise it is trimmed back to allow toe movement.

Method • Rest the knee on a wedge and have an assistant hold the foot in the plantargrade position • For a padded split plaster, apply padding (eg Soffban) to the limb. For an unpadded cast apply a stockinette with a layer of padding (eg Soffban) to protect the malleoli and the heel • Start below the knee, apply the cast. For the average adult cast you’ll need: One 15 cm plaster (eg Gypsona) A 15 cm reinforcing slab (eg Gypsona) One or two more bandages (eg Gypsona) • If the cast is to be weight-bearing, reinforce the sole with a 15 cm slab (eg Gypsona) attached with a 10 cm bandage. A walking block, or a cast boot may be used continued overleaf...

Applying Basic Casts ACC Treatment Proﬁles – 2001 Applying Basic Casts

Check • Knee flexion • That there is no pressure over common peroneal nerve at the ﬁbula head

Teach the Patient • Elevation when not moving • Toe movements • Crutch walking

ABOVE KNEE CAST To immobilise knee or tibial injuries.

Method • Apply padding (eg Soffban) to the whole limb for a padded split cast • Apply stockinette and a layer of padding around the knee and ankle for a definitive cast • Rest the knee on a wedge, and have an assistant hold the foot in the plantargrade position • Complete the below knee section just as you would for a below knee cast • Ensure that the knee is held on the wedge in the required amount of flexion (usually 10-15 degrees) • Commence the above knee portion of the cast • Apply one 15 cm plaster (eg Gypsona) bandage from upper thigh to below the knee, using figure eight turns around the wedge • Keep close to the wedge so that there is only a small gap behind the knee • Repeat with a second bandage • Check that there is sufficient overlap of the two portions of the cast • When the cast is sufficiently set, remove the wedge • Apply a posterior slab (eg Gypsona) as shown in the diagram at right. This completes the gap left by the wedge, and reinforces the back of the thigh cast • Use a final bandage (eg Gypsona) to complete the cast and attach the slab. Make sure the degree of knee flexion is not altered

Check • Toe movement • No pressure behind knee

Teach the Patient • Elevation when not moving • The patient should protect the back of the cast when sitting, by either sitting with their leg elevated and supported, or by ‘perching’ on a chair with the cast free • Crutch walking

CYLINDER CAST Used to immobilise the knee.

Method • It is important to position the patient carefully – raise the buttocks on a sandbag or pillow • Use two wedges to rest the leg in the required position, usually with the knee straight, but not hyperextended • Protect the malleoli and Achilles tendon with felt or sponge continued overleaf...

ACC Treatment Proﬁles – 2001 Applying Basic Casts Applying Basic Casts

• Apply cast padding (eg Soffban) for a padded split cast, or a stockinette with padding (eg Soffban) around knee and ankle for a definitive cast • Apply two 15 cm plaster (eg Gypsona) bandages, starting at the thigh and covering the whole area, using a figure eight method around the wedge • Apply anterior slab (eg Gypsona), and then two more bandages • Mould cast on either side of the thigh, just proximal to the femoral condyles, and on either side of the calf just above the malleoli. This will help to prevent the cast slipping down • Trim plaster at the ankle front and back so the ankle movement is not restricted. Check there is no pressure on the Achilles tendon • When the plaster is firm, remove the knee wedge • Apply second slab as shown in the diagram and attach with a fifth bandage

For padded split casts, apply the anterior slab slightly medially, and split the cast slightly laterally. This avoids cutting through the slab.

Check • Ankle movement • No pressure over Achilles tendon

Teach the Patient • Elevation • Crutch walking • Cast protection when sitting (see ‘Above Knee Cast’)

BELOW KNEE TOTAL CONTACT CAST (TCC) Sometimes referred to as Patella Tendon Bearing Cast – Sarmiento Cast.

Conservative management of tibial fractures.

Control of the tibia fracture is achieved by: • A closely moulded, unpadded cast • Moulding the upper section in a triangular fashion, with the apex anteriorly and a flattened base in the popliteal space • Carefully moulding over the patellar tendon and round the femoral condyles

Remember: This is a deﬁnitive cast and is best applied at 2-3 weeks post injury – when the swelling has subsided but before the knee stiffens.

Method Preparation • Bivalve the above knee cast and inspect the limb for any contraindications to a TCC (eg skin defect, excessive swelling) • Bind both sections of the cast together ﬁrmly • Split the posterior half below the knee so the posterior thigh cast can be removed. This allows knee flexion to be achieved whilst maintaining the position of the fracture • Position the patient comfortably, supporting the unaffected leg with pillows • Slowly flex the affected leg over the end of the couch and support the thigh on a sandbag. (The plasterer should use a low stool) • Flex the knee to 90 degrees • Remove the cast and use the plasterer’s knee to support the patient’s foot continued overleaf...

Applying Basic Casts ACC Treatment Proﬁles – 2001 Applying Basic Casts

Remember: The ability of this cast to maintain the correct fracture alignment depends on careful moulding of a closely ﬁtted cast.

The cast must be moulded ﬁrmly in a triangular fashion at the upper end of the tibia, the apex of the triangle being over the tibial tuberosity.

When the knee is flexed to 45 degrees to relax the quadriceps, the upper section of the cast is moulded well over the patellar tendon and around the femoral condyles.

Application • Roll on a stockinette to above the femoral condyles • Place one layer of padding over the heel and malleoli • Apply one 10 cm bandage (eg Gypsona) round the foot and ankle. Check the foot is plantargrade

The next step depends on the type of fracture.

Low fracture that needs corrective moulding: • Apply two 15 cm plaster (eg Gypsona) bandages about 7 cm below the tibial tubercle to the heel • Overlap the previously applied plaster • Mould the fracture • When plaster sets, add 15 cm plaster (eg Gypsona) bandage from the tibial tubercle to join with the second layer. This allows two separate mouldings to be made – the triangular moulding round the upper end of the tibia is vital

Low fracture that does not need corrective moulding: • Use two or three bandages (eg Gypsona) to complete this section in one piece • Extend the knee to 45 degrees to relax quadriceps tendon • Apply slab and attach with a 10 cm bandage • Hold the back of the cast firmly against the limb to prevent a loose fit • Mould well over the patellar tendon and around the femoral condyles. The patient must be relaxed for this moulding • Trim the top of the cast to expose the proximal border of the patella. The lateral wings should fit snugly around the femoral condyles • Trim the back of the cast to allow knee flexion • Apply walker

Check • That there is no pressure near ﬁbula head • Patient can flex knee comfortably

Teach the Patient Crutch walking, progressing to weight bearing

ACC Treatment Proﬁles – 2001 Applying Basic Casts Section 3 CONTENTS Burns Burn Wrist(s) andHand Burn ofLowerLimbs Burn Trunk/Burn Arm-(ExcludingWrist, Hand)/ Burn Face,Head,Neck Burn EyeandAdnexa Burns Overview Read Code 0.. SH4.. SH2../SH3../SH5.. SH1.. SH

3 burns Burns Overview

KEY POINTS FOR MANAGEMENT Resuscitation • Assess and treat as appropriate • Airway, breathing, circulation, neurological state (if reduced level of consciousness or confusion, suspect carbon monoxide exposure and give high flow oxygen) • Assessment for potential airway compromise

Depth Colour Blisters Capillary Refill Sensation Healing Superficial/Erythema Red No Present Present Yes Superficial Pale pink Small Present Painful Yes 7-10 days Partial thickness Deep Partial thickness Blotchy red Larger absent Absent Absent Prolonged Full thickness White No Absent Absent No

History • Time and duration of exposure • Nature of exposure • First aid measures • Co-morbidities • Medications/allergies • Tetanus immunisation status • Fire in contained space, exposure to fumes, smoke or gases • Drug or ethanol intoxication

Examination • Location • Body surface area • Depth • Singeing of nasal hair • Carbonaceous sputum • Dysphonia/hoarseness • Stridor • Intraoral/pharyngeal burns • Respiratory distress • Identify other significant injuries

Treatment Cooling: • 15 minutes under running tap water OR saline/water soaked dressings • Avoid ice (may exacerbate tissue injury) • Be aware of potential for hypothermia, especially in children with large burns

Analgesia: • Oral OR intravenous (aliquots of morphine) OR inhaled eg nitrous oxide – if possible avoid intramuscular/subcutaneous routes (erratic absorption and slower onset of action)

ACC Treatment Proﬁles – 2001 Overview Burns Overview

Dressings: All contaminated burns should be washed with dilute antibacterial agent such as aqueous chlorhexadine 0.1-0.2% OR, if not available, with bland soap and water.

Superficial: • No treatment other than moisturising ointment eg liquid paraffin OR film dressing eg Opsite, Tegaderm, OR retentive dressing eg Hypafix, Mefix

Partial Thickness: • There are many commercial dressings available for use on these burns and selection is controversial. The following represents a number of approaches in current use:

1 Retentive dressings eg Hypofix, Mefix

2 Tulle gras multi-layered dressing eg Jelonet with overlying absorbent dressing Change of absorbent layer at 48 hours Remove absorbent dressing and tulle gras at 5-7 days and reassess wound Reapply if necessary Reassess earlier if signs of infection eg increasing pain, fever, offensive discharge

3 Silver sulphadiazine (SSD) applied to burn and covered with absorbent dressing Reassess and redress daily After 3 days then tulle gras dressing as above unless concerns ie infection

4 Hydrocolloid dressing eg Duoderm Change every 3-5 days, earlier if signs of infection

Blister Management: • If burst: carefully deroof • If intact and not impairing function, leave intact • If intact and impairing joint function, aspirate with needle/syringe • NB see individual profiles

Full Thickness: • Daily SSD dressings as above OR as advised by specialist, with whom the patient has been discussed continued overleaf...

Overview ACC Treatment Proﬁles – 2001 Burns Overview

Tetanus Toxoid Immunisation • If required (see Laceration/Abrasion section)

Chemical Burns • Majority are acids and alkalis • Injury may occur as a result of direct tissue burn and/or toxicity from systemic absorption • Management focuses on decontamination, antidotes where appropriate and treatment of systemic toxicity • Initially brush off dry chemical particles then copious irrigation with running water or saline • Duration of irrigation dependent on agent. Alkalis may require prolonged irrigation, especially the eye • pH testing with litmus paper can be used to guide duration of irrigation • Metal fragments embedded in skin should be covered with mineral oil or sand NOT water • Seek immediate advice regarding management of chemical burns, especially exposure to hydrofluoric acid (HFA), metals or alkalis • Hydrofluoric acid burns: individuals should have calcium gluconate gel applied to the area (if available) prior to transfer to hospital (made by mixing KY jelly with calcium gluconate to make a 2.5-10% solution)

Electrical Burns • May be superficial – full thickness • Deeper structures, particularly nerves and blood vessels, may be severely damaged • Ensure full assessment to exclude other injuries • Ongoing management of individuals with electrical burns (unless trivial) should be discussed immediately with hospital specialist • Pregnant women suffering an electrical injury should be referred urgently to hospital for foetal assessment • Individuals exposed to low voltage electrical injuries (ie domestic supply) should have an ECG performed: If normal – cardiac monitoring is not necessary unless known ischaemic heart disease If abnormal – patient should be transferred immediately to hospital by ambulance for assessment • Individuals exposed to high voltage electrical injuries should be transferred to hospital by ambulance for immediate assessment

ACC Treatment Proﬁles – 2001 Overview Burns Overview

A “RULE of NINES” diagram B Lund and Browder chart for estimation of % body surface area in adults for estimation of % body surface area in children

Overview ACC Treatment Proﬁles – 2001 Burn Eye & Adnexa Read Code: SH0..

KEY POINTS Ocular burns: RED FLAG: • Potentially blinding Irrigation of ocular burns should • Commonly caused by contact with chemicals or over-exposure to UV commence before detailed history light (welding, sun-beds) or examination: Chemical burns: • Alkali burns (bleach, chemical detergents, plaster/concrete) are true ocular emergencies • All chemical burns should be managed initially by copious irrigation • Cycloplegic agents provide considerable pain relief in ultraviolet keratitis

Thermal burns: • Commonly affect the lids because of the protective blink reflex • Rarely affect the eyes • Silver Sulphadiazine (SSD) should not be used on the eyelids in thermal burns

Complications Thermal: • Scarring • Contractures

Chemical: • Perforation of globe • Corneal scarring • Adhesion of lids to globe • Glaucoma • Cataracts • Retinal damage

History • Nature of exposure • Time and duration of exposure • First aid administered • Co-morbidities eg diabetes/immunocompromise • Current medications and allergies • Tetanus immunisation status

Examination • Initial focus on airway, breathing, circulation and neurological state as appropriate

After irrigation (or cooling of thermal burns) assess: Visual acuity Nature, depth, area of burn Ophthalmoscopy with fluorescein to assess corneal epithelial damage

Differential Diagnosis • Other causes of keratitis for UV burns

Investigation • Nil appropriate if isolated eye/adnexal burn continued overleaf...

ACC Treatment Proﬁles – 2001 Burn Eye & Adnexa SHo.. Burn Eye & Adnexa

Treatment Chemical burns: • Topical anaesthetic, then irrigate with saline through an IV giving set for 15-20 mins. Tap water if saline is not immediately available. Check fornices/double evert upper lid to detect and remove particulate matter with moist cotton bud • Continue irrigation until pH of tear film is 7.0-7.4. Recheck pH after 10 mins • Urgent referral of all alkali burns If uncertainty about pH in alkali burn continue irrigation throughout transfer to hospital • Non-alkali burns – after irrigation – stain with fluorescein to assess damage to corneal epithelium but note widespread epithelia destruction causes poor uptake of fluorescein, which may be confusing • Apply chlormycetin ointment and double pad eye • Analgesia – oral/IV depending on severity

Thermal burns of lids: • Superficial (no blistering): apply antibiotic ointment eg Chloramphenicol based • Partial thickness/full thickness: as above and referral • Appropriate analgesia

UV burns: • Topical antibiotic • Cycloplegic agent – Cyclopentolate 1% TDS • Analgesia • Pad • Reassess at 24 hours

Referral to Specialist • Chemical burns: urgent referral to ophthalmologist alkali burn or evidence of corneal damage • Thermal burns: partial/full thickness – refer to ophthalmologist if localised to eyelids, otherwise to plastic surgeon • Ultraviolet keratitis: refer to ophthalmologist if not settled within 48 hours

Burn Eye & Adnexa SHo.. ACC Treatment Proﬁles – 2001 Burn Face, Head, Neck Read Code: SH1..

KEY POINTS • Resuscitate if appropriate • Patients with history/examination findings suggestive of inhalation injury should be transferred to hospital urgently • Adequate cooling for all burns – 15 mins under running water or saline/water soaked dressings • Analgesia as appropriate • Oral and perioral burns are the most common electrical injury in children and result from chewing on a live cable. An apparently trivial burn may later cause severe haemorrhage from the labial artery

Complications • Airway compromise • Respiratory embarrassment • Scarring/Contractures • Perioral electrical burns: Delayed haemorrhage Scarring Impaired jaw growth Abnormal speech development • Infection

History • Nature of exposure • Risk factors for inhalation injury • Time and duration of exposure • First aid administered • Co-morbidities especially asthma/respiratory disease/diabetes/ immunocompromise • Current medications and allergies • Tetanus immunisation status

Examination • Initial focus on airway, breathing, circulation and neurological state as appropriate • Signs suggestive of inhalation injury: Oral/pharyngeal burns Stridor/hoarseness/dysphonia Respiratory distress Carbonaceous sputum Singed nasal hair Reduced level of consciousness • After cooling assess nature, depth and area of burn

Investigation • Nil initially if isolated thermal burn to face, head or neck • Burn swab and culture may be required later if infection develops • Electrical burn – see Overview

Treatment • Resuscitation as necessary – see Overview • Rapid cooling for 15mins • Analgesia as appropriate • Superficial (erythema only): no treatment other than moisturising ointment or film dressings continued overleaf...

ACC Treatment Proﬁles – 2001 Burn Face, Head, Neck SH1.. Burn Face, Head, Neck

• Superficial partial thickness (small blisters only): Blister management

Face: Liquid paraffin 2-4 hourly to keep moist Eyelids – Chlormycetin ointment Ears – Chlormycetin ointment Neck – tulle gras/SSD – see Overview • Deep partial thickness (larger blisters)/full thickness: tulle gras and discuss with plastic surgeon

Referral to Specialist • Actual or potential inhalation injury – refer urgently to local emergency department • All partial thickness/full thickness burns to face or ears – discuss with plastic surgeon to determine need for immediate referral or to agree further management • Other indications – see Overview

Burn Face, Head, Neck SH1.. ACC Treatment Proﬁles – 2001 Burn Trunk/Arm (excluding wrist, hand)/Lower Limbs Read Code: SH2../SH3../SH5..

KEY POINTS • Resuscitate if appropriate (see Overview) • Adequate cooling: 15 mins under running tap water or saline/water soaked dressings • Analgesia as appropriate • Assessment of burn, documenting area involved, depth and location

Complications • Shock (requirement for IV fluid therapy if body surfaces are burnt >20% in adult or >15% in child or clinical signs of shock) • Hypothermia (care with cooling large area involved and/or child) • Infection • Scarring/Contractures

History • Nature of exposure: Flame Chemical Hot fluid Superheated gas Electrical • First aid administered • Time and duration of exposure • Contamination of burn • Co-morbidities eg diabetes/immunocompromise • Current medications/allergies • Tetanus immunisation status

Examination • Initial focus on airway, breathing, circulation and neurological state • Assess area, depth, location of burn • Note circumferential burns • Check neurovascular status of limb • Examine for injury to deeper structures

Investigation • Nil initially if isolated thermal burn to face, head or neck • Burn swab and culture may be required later if infection develops • Electrical burn – see Overview

Treatment • Resuscitation as necessary • Rapid cooling for 15 mins • Analgesia as appropriate • Dressings – see Overview • Advise elevation of limb burns continued overleaf...

ACC Treatment Proﬁles – 2001 Burn Trunk/Arm/Lower Limbs SH2../SH3../SH5.. Burn Trunk/Arm (excluding wrist, hand)/Lower Limbs

Referral to Specialist Immediate: • Actual or potential inhalation injury, refer urgently to local emergency department • Burns associated with other serious injuries • Partial thickness burns: >15% BSA all ages >10% BSA <10 or >50 years • Smaller burns if significant co-morbidities • Possibility of non-accidental injury in children • Full thickness burns >3% BSA in any age groups • Burns involving feet (unless trivial), genitalia, perineum • Any heavily contaminated burn • Persisting requirement for IV analgesia after dressing completed • High voltage electrical burns

Delayed: • Individuals with minor electrical burns should be discussed with a specialist – follow-up as agreed • Infection

Other Referral • Refer burns affecting joint mobility to a physiotherapist

Burn Trunk/Arm/Lower Limbs SH2../SH3../SH5.. ACC Treatment Proﬁles – 2001 Burn Wrist & Hand Read Code: SH4..

KEY POINTS • Resuscitate if appropriate (see Overview) • Adequate cooling: 15 mins under running tap water, longer if alkali chemical burn • Analgesia as appropriate • Assessment of burn. Emphasis on nature of exposure, depth and impairment of hand function

Complications • Scarring/contractures • Loss of function

History • Nature of exposure: Flame Chemical (particularly hydrofluoric acid) Hot fluid Superheated gas Electrical • Time and duration of exposure • First aid administered • Contamination of burn • Co-morbidities eg diabetes/immunocompromise • Current medications/allergies • Tetanus immunisation status

Examination • Initial focus on airway, breathing, circulation and neurological state • Assess area, depth of burn • Note circumferential burns • Identify entry/exit burns in electrical injuries • Identify injury to deeper structures, particularly neurovascular status in electrical burns • Note blister formation around joints

Investigations • Electrical burns – ECG

Treatment • Resuscitation as necessary • Rapid cooling for 15 mins • Analgesia as appropriate • Remove jewellery • Dressings – see Overview: Small blisters should be left intact Large blisters should be aspirated. An alternative dressing for the hand and/or fingers is SSD inside a loose fitting thin plastic glove or bag, changed daily Ensure hand is elevated in a high-elevation sling to minimise dependant oedema Hydrofluoric acid burns – see Overview continued overleaf...

ACC Treatment Proﬁles – 2001 Burn Wrist & Hand SH4.. Burn Wrist & Hand

Referral to Specialist Immediate: • Full thickness burns • Circumferential burns • Burns with restriction of joint function due to pain or depth of burn • Some electrical burns eg high voltage • Hydrofluoric acid burns

Delayed: • Individuals with minor electrical burns should be discussed with specialist follow-up as agreed • Infection

Other Referral • Specialist hand physiotherapy is recommended if hand function is impaired

Burn Wrist & Hand SH4.. ACC Treatment Proﬁles – 2001 Section 4 Synovitis/Tenosynovitis Achilles Tendonitis/Sprain Tendocalcaneus (AchillesTendon) Prepatellar Bursitis Medial Epicondylitis Rotator Cuff ShoulderSyndrome Gradual Onset CONTENTS Carpal Tunnel – Elbow/LateralEpicondylitis – Elbow N22 N2174/S55 N2165 N2131/N2132 N211. Read Code F34 0 0 . . 0 4

4 gradual onset Carpal Tunnel Read Code: F340.

KEY POINTS • Modify/avoid precipitating factors • Consider associated conditions such as myxoedema, pregnancy, rheumatoid arthritis, diabetes, gout

Complications • Chronic pain • Paraesthesia • Muscle wasting • Occupational problems

History • Nature of the pain – night pain or tingling in the hand, may radiate to forearm and arm • Loss of sensation or paraesthesia in median nerve distribution • Onset insidious • Pain aggravated by excessive, prolonged or repetitive movements/activity • Weakness of grip • Cervical spine symptoms • Other medical conditions • Occupation

Examination • Phalens test may be positive • Tinels test may be positive • Sensory changes in median nerve distribution • Thenar muscle wasting • Muscle strength – weakness thumb abduction • Cervical spine

Differential Diagnosis • Cervical spine dysfunction • Thoracic outlet syndrome • Previous fracture/trauma to wrist • Connective tissue disorders • Overuse syndrome • Tendonitis wrist and elbow

Investigation • Nerve conduction studies • FBC, rheumatology screen, TFT, uric acid, glucose

Treatment • Identify and modify precipitating factors • Wrist splint • Steroid injection if failure to settle with conservative management • Workplace assessment • Physiotherapy – ultrasound may help

Referral to Specialist • Failure to settle

ACC Treatment Proﬁles – 2001 Carpal Tunnel F34o. Rotator Cuff Shoulder Syndrome Read Code: N211.

KEY POINTS • Defined as shoulder pain associated with any of the following: Neer stages: Overuse Repetitive movement Stage 1 Following a poorly rehabilitated acute injury Dull ache in deltoid region after Movement associated with biomechanical or anatomical abnormalities strenuous exercise • This is a progressive pathological process • Pain is the most common symptom in all gradual onset injuries Stage 2 • May be caused by, or lead to tendonitis • Rotator cuff tendonitis and sub-acromial bursitis both present with Persistent pain (through the night) impingement or painful arc syndrome associated with tendonitis and fibrosis • Impingement – occurs when the space between the underside of the acromion and the top of the glenohumeral joint effectively narrows due Stage 3 to any, or combinations of, the following: Prolonged history with tendon Osteophytes from above degeneration and/or rupture Inflamed subacromial bursa Inflamed/swollen rotator cuff Excessive elevation of the humeral head • Impingement classically occurs between 60° and 120° • Instability –usually occurs following an acute injury to the shoulder causing a dislocation or subluxation. The ball and socket joint becomes unstable and displays excessive movement. This can also lead to irritation and inflammation of the surrounding structures resulting in impingement • Age considerations – tendon degeneration from gradual onset damage to the rotator cuff is age related: Oedema and haemorrhage, age <25 years Fibrosis and tendonitis, age 25-40 years Tears of cuff, age >50 years

Complications • Subscapularis or biceps tendon rupture • Chronic pain and shoulder dysfunction • Failure of conservative treatment will require surgical intervention • Decreased range of motion • Frozen shoulder

History • Age of patient • Site of pain • Duration of pain • Determine any predisposing factors eg history of an acute injury, repetitive movements • Any night pain • Severity of pain • Position of shoulder which exacerbates or relieves pain • Strenuous or repetitive activity especially overhead • Chronic osteoarthritis of GH or AC joint

Examination • Compare with the other shoulder • Local tenderness • Muscle strength and wasting • Assess neuromuscular function • Assess cervical spine • Active movements continued overleaf...

ACC Treatment Proﬁles – 2001 Rotator Cuff N211. Rotator Cuff Shoulder Syndrome

• Passive movements/painful arc • Resisted movements • Special tests Impingement Instability • Crepitus • Swelling

Differential Diagnosis • Arthritis of acromio-clavicular and glenohumeral joints • Calcific tendonitis • Traumatic anterior subluxation of humerus • Traumatic rotator cuff tear/rupture • Subscapularis or biceps tendon rupture • Instability • Avascular necrosis of the humeral head • Capsulitis

Investigation • X-ray • Ultrasound • Arthrogram if chronic

Treatment Stages 1 and 2: Rest initially Maintain range of movement with physio NSAIDs Activity modification Sub-acromial steroid should only be used if not settling

Stage 3: Maintain range of motion Modification of activity Referral

Identify causative factors and advise the patient to change behaviour Modify workstation or technique Modify sporting technique Physiotherapy rehabilitation to stabilise and strengthen the GH joint May require surgical intervention

Referral to Specialist Stages 1 and 2: • No active movement • If no improvement after 2-3 weeks

Stage 3: • Refer all • Elderly patients in danger of developing frozen shoulder • If unsure of diagnosis

Other Referral • Physiotherapy • Home help for elderly

Rotator Cuff N211. ACC Treatment Proﬁles – 2001 Medial Epicondylitis-Elbow/ Lateral Epicondylitis-Elbow Read Code: N2131/N2132

KEY POINTS • Extremely common presentation of sports people and manual workers • For lateral epicondylitis the most common cause is an overuse syndrome related to excessive wrist extension • For medial epicondylitis pain is associated with excessive activity of the wrist flexors • Mostly due to gradual process • Review, reduce or remove stressors • Steroid injections can be effective but have potential side effects, are not an instant cure and should be limited to a maximum of 3 injections • Beware diagnosis <18 years of age

Complications • Fat atrophy from steroid injections • Complex regional pain syndrome • Psychological decompensation

History Pain: Diffuse radiating from lateral or medial epicondyles into proximal forearm muscle masses Occasionally may be more localised Onset acute or insidious Pain may arise from recent changes in training or technique, or equipment used in sport or at work. Severity of pain can range from minor to debilitating that can keep the patient awake at night The pain may be aggravated by simple tasks or by repetitive activities If pain is related to activity it is more likely to be mechanical in origin whereas if pain is persistent and unpredictable it may be referred pain and/or related to posture • Blow to elbow • Past injury • Other upper limb symptoms

Determine if: Gradual process or acute injury Excess repetitive forceful activity New work processes Occupational/sports associated

Examination • Include observation/active movements/passive movements/resisted movements/palpation • Note local tenderness • Note pain with stressing/stretching wrist/extensors or flexors • Examine cervicothoracic spine • Examine wrist, hand and shoulder joints as appropriate • Neurovascular status • Crepitus (tendon) continued overleaf...

ACC Treatment Proﬁles – 2001 Epicondylitis N2131/N2132 Medial Epicondylitis-Elbow/ Lateral Epicondylitis-Elbow

Differential Diagnosis Lateral elbow pain: • Extensor tendinosis • Referred pain – from cervical spine, upper thoracic spine • Synovitis of the radiohumeral joint • Radiohumeral bursitis • Posterior interosseous nerve entrapment • Osteochondritis dissecans – Capitellum, radius (in adolescents)

Medial elbow pain: • Flexor/pronator tendinosis • Medial Collateral Ligament sprain • Ulnar nerve compression • Avulsion fracture of the medial epicondyle • Apophysitis • Referred pain • Bone injury • Neck or shoulder pathology • Nerve entrapment • Tendon rupture • Septic arthritis • Osteoarthritis • Forearm muscle strain

Investigation • X-ray if no response to treatment or atypical features • CBC/Alkaline phosphatase • May require soft tissue ultrasound

Treatment • No single treatment has proven to be totally effective • Because the condition is of gradual onset, advise the patient that there is no quick fix • The aim of treatment is to eliminate pain, identify and change the causative factors and to normalise function • Conservative treatment initially • Remove/reduce stressors • Graduated return to activity • Splint for tenosynovitis with crepitus • Refer if no change after 3 months or if unable to work after 2 weeks • The following may be considered: NSAIDs Steroid injection (Triamcinolone preferred) only after failure of rehabilitation and after 3 months of localised pain. Beware of performing repeated injections • Acupuncture • Physiotherapy • OT for ADL/workplace assessment/sports technique assessment continued overleaf...

Epicondylitis N2131/N2132 ACC Treatment Proﬁles – 2001 Medial Epicondylitis-Elbow/ Lateral Epicondylitis-Elbow

Referral to Specialist • Features of nerve entrapment • Tendon rupture • Suspected sepsis • Unable to work after 2 weeks • 3 months failed conservative treatment • Surgery is rarely indicated

Other Referral • Physiotherapy • OT for ADL/workplace assessment • Possibly home help

ACC Treatment Proﬁles – 2001 Epicondylitis N2131/N2132 Prepatellar Bursitis Read Code: N2165

KEY POINTS • Avoid kneeling • Never incise, rarely aspirate • Consider infection • Consider risk of DVT if immobilised – teach quadriceps exercises

Complications • Infection/septic bursitis • Muscle wasting • Chronic bursitis • Recurrent fluid accumulation • Progressive enlargement of bursa

History • Swelling after kneeling • Blow/pressure to patella • Penetration of skin over patella • Previous history of crystal arthritis • Occupation

Examination • Well-defined prepatellar swelling • Knee joint to exclude other pathology, compare to other side • Local tenderness • Evidence of penetration/foreign body • Toxicity/febrile

Differential Diagnosis • Inflammation of knee joint, patella tendon • Effusion knee joint • Septic bursitis • Crystal arthritis • Injury to patella • Reiter’s disease

Investigation • Aspirate for crystals and culture if suspected sepsis • X-ray/USS if diagnostic doubt

Treatment • Rest • Restriction of precipitating activity • Consider NSAIDs, analgesia • Pressure dressing (tubigrip) • Splint if severe (remember quad exercises and beware DVT) • Antibiotics if indicated • Aspiration and steroid injection may be helpful if recurrent

Referral to Specialist • Febrile/suspected sepsis • Not resolving • Recurrent fluid accumulations • Knee joint involvement

Prepatellar Bursitis N2165 Achilles Tendonitis/Sprain, Tendocalcaneus (Achilles Tendon) Read Code: N2174/S5504

KEY POINTS • If injecting steroid ensure it is into the sheath and not the tendon • Differentiate acute from gradual process • Prolonged recovery common • Heel raise important • Ultrasound is a useful diagnostic tool

Complications • Recurrence • Rupture, particularly after steroid injection • Steroid depositions • POP effects

History • May be slow onset (weeks) • Niggling pain • Severe pain while running • Tightness • Often a trigger event such as change in footwear • Excessive morning stiffness • Previous injury or injection • Gout

Examination • Compare with other side • Swelling of tendon • Pain on dorsiflexion • Crepitus • Tight calf • Tendon tenderness • Calf squeeze to exclude tendon rupture (negative Thompson test)

Differential Diagnosis • Bursitis (retro calcaneal) • DVT • Rupture of Achilles tendon • Gout • Bruising • Osteo or rheumatoid arthritis • Inflammatory arthropathy • Sever’s disease

Investigation • Ultrasound if not settling or if uncertain of tendon integrity • Consider rheumatological screen, uric acid • X-ray if considering Sever’s disease

Treatment • Moderation of activity • Heel raise • Calf stretching once pain reducing continued overleaf...

ACC Treatment Proﬁles – 2001 Achilles Tendonitis N2174/S55o4 Achilles Tendonitis/Sprain, Tendocalcaneus (Achilles Tendon)

Other options include: • Physiotherapy • Calf stretching • Icing • NSAIDs • Crutches • Possibly steroid injection to sheath • Some may require equinus POP for 7-10 days if severe • Podiatry for biomechanical assessment +/- orthotics

Referral to Specialist • Suspected or complete rupture • Suspected DVT • No improvement over 2 months • Failed steroid injection • Previous rupture

Achilles Tendonitis N2174/S55o4 ACC Treatment Proﬁles – 2001 Synovitis/Tenosynovitis Read Code: N220.

KEY POINTS • Tenosynovitis involves inflammation of the tendon and tendon sheath • Examples include De Quervain’s tenosynovitis and trigger finger • Overuse (repetitive stress), poor technique or following on from an acute injury are all causes of tenosynovitis • Beware infection (joint or sheath) • Rest is very important • Consider conditions such as myxoedema or pregnancy • Diagnosis <18 years of age rare • Identify and modify any precipitating activity

Complications • Chronic pain state • Partial tear or rupture of the tendon (especially following steroid injection) • Occupational problems

History • Repetitive injury or function • Pain and/or swelling in or around tendon • Pain in forearm/wrist • Pain brought on by prolonged activity or repetitive movements • Work, sports, hobbies

Examination • Local tenderness and swelling especially along tendon sheath • Local heat • Crepitus (tendons) • Tendon/joint function • Mental status (vague or non-specific pains)

De Quervain’s Tenosynovitis: Pain on palpation along the radial aspect of the wrist Pain with passive range of motion of the thumb Finkelstein’s test

Trigger Finger: Tenderness at the proximal end of the tendon sheath, in the distal palm Palpable tendon thickening and nodularity may be present Crepitation and catching of the tendon may be observed when the finger is flexed

Differential Diagnosis • Carpal tunnel syndrome • Myxoedema/pregnancy • Inflammatory arthritis • Joint sprain/fracture • Nerve entrapment local/distant • Old carpal injury • Ganglion • Gout/pseudogout • Soft tissue infections continued overleaf...

ACC Treatment Proﬁles – 2001 Tenosynovitis N22o. Synovitis/Tenosynovitis

Investigation • X-ray • Nerve conduction tests • Microscopy and culture of joint aspirate • FBC and ESR (possibly rheumatological screening)

Treatment • Reduce stressors • Rest in splint (1 week)

Other options include: • NSAIDs • Physiotherapy • Joint aspiration • Local anaesthetic and steroid injection if not settling after 1 month of conservative treatment (not into tendon) • OT to assess workplace • Occupation advice

Referral to Specialist • Not settling with conservative management • Associated medical problems or inflammatory condition

Other Referral • Physiotherapy • Occupational therapist to assess workplace • Occupation advice

Tenosynovitis N22o. ACC Treatment Proﬁles – 2001 Section 5 Sprains

CONTENTS Read Code

Overview

Low Back Pain, Acute Back Pain – Lumbar, Lumbago/Lumbar Sprain/Sciatica N142./S572./N143.

Cervicalgia – Neck Pain/Neck Sprain N131./S570.

Sprain Rib S5y3. Sprain Acromio-Clavicular Ligament S500. Rupture of Supraspinatus/Biceps Tendon S5Q2./S5Q4. Shoulder/Rotator Cuff Sprains Tendon Tears S503./S504./ (Includes Infraspinatus and Supraspinatus Tear/Sprain) S507./S502. Sprain Elbow/Forearm S51..

Sprain Wrist or Hand (Carpal Ligament and Metacarpal Ligament Sprains)/Sprain Tendon Wrist or Hand S52../S524.

Hand/Wrist Flexor Tendon Rupture N2264 Sprain Radial Collateral Ligament (Thumb) S5204 Sprain Thumb S522.

Sprain Finger S523./S5513 sprains

Sprain Hip/Thigh S53.. 5

Sprain/Strain Quadriceps Tendon S533. Meniscal Tear (Medial/Lateral) S460./S461. Sprain Collateral Ligament Knee S5400/S541. Sprain Cruciate Ligament Knee S542. Sprain Ankle (Lateral Ligaments) S550. Sprain of Metatarso-Phalangeal Joint/Interphalangeal Joint S5512/S5513 Sprains/Strains Overview

ACC/National Health Committee Red Flags for potentially serious conditions: Features of cauda equina syndrome (especially urinary retention, bilateral neurological symptoms and signs, saddle anaesthesia) - this requires very urgent referral Significant trauma Weight loss History of cancer Fever Intravenous drug use Steroid use Patient aged over 50 years Severe, unremitting night-time pain Pain that gets worse when patient is lying down

Yellow Flags: Psychosocial factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain: Attitudes and beliefs about back pain Behaviours Compensation issues Diagnostic and treatment issues Emotions Family Work

Muscle Strains

Grade 1 • Clinical features: localised pain but no loss of strength. • Maybe small amount of bruising • Pathology: small numbers of muscle fibres torn

Grade 2 • Clinical features: pain, swelling, bruising. • Strength is reduced and movement is limited by pain • Pathology: tear of significant number of muscle fibres

Grade 3 • Clinical features: significant loss of movement/strength. • May be no pain • Pathology: complete tear of muscle. Seen most frequently at musculotendinous junction

Predisposing Factors in Development of Muscle Strains: • Insufficient flexibility • Excessive muscle tightness • Fatigue, overuse, inadequate recovery • Muscle imbalance • Inadequate warm-up continued overleaf...

ACC Treatment Proﬁles – 2001 Overview Sprains/Strains Overview

Ligament Sprains Grade 1 • Ligament sprain with no laxity (pain only on stressing)

Grade 2 • Ligament sprain with laxity but definite end point

Grade 3 • Ligament sprain with laxity but NO definite end point (rupture)

Additional Points to Consider: • Children <12 years rarely sprain ligaments • Elderly patients are much more likely to fracture bones than sprain ligaments • Elderly patients are prone to suffer stiffening of their joints eg frozen shoulder even in more peripheral injuries and need early mobilisation • RICE therapy is useful early (first 24 hours, possibly 48) for most strains • Watch for tendon ruptures in older patients

X-ray Rules Ottawa Ankle Rules X-ray if: Unable to bear weight (take four steps) at time of injury and at examination Bone tenderness at posterior edge or tip of either malleolus Bone tenderness over the naviculus or base of fifth metatarsal

Ottawa Knee Rules X-ray if: Patient older than 55 years Tenderness present at head of fibula Isolated tenderness over patella Inability to flex knee to 90 degrees Inability to transfer weight for four steps both immediately after injury and at examination

Exclusion criteria: Age less than 18 years Isolated superficial injuries being re-evaluated Patients with altered levels of consciousness, paraplegia, or multiple injuries

Pittsburgh Knee Rules Indicate radiography if the mechanism of injury is blunt trauma or a fall, and either: The patient is younger than 12 or older than 50 years of age; or The injury causes an inability to walk four weight-bearing steps at examination

Exclusion criteria: Knee injuries that occur over six days before presentation Patients with only superficial lacerations and abrasions Those with a history of previous surgeries or fractures on the affected knee Reassessments of the same injury

Overview ACC Treatment Proﬁles – 2001 Low Back Pain, Acute Back Pain–Lumbar, Lumbago/Lumbar Sprain/Sciatica Read Code: N142./S572./N143.

KEY POINTS RED FLAG: • An adequate clinical history and examination should be sufficient to For potentially serious conditions: identify the need for investigation and specific therapy • Psychosocial factors are better predictors of chronicity than physical Features of cauda equina syndrome factors. Evaluate and address in the context of discussing reasonable (especially urinary retention, expectations for recovery • Unless specifically targeted with appropriate preventive interventions bilateral neurological symptoms and about 7-10% of patients with acute LBP remain disabled and become signs, saddle anaesthesia) - this chronic requires very urgent referral • The mechanism of injury and patient age are important in the severity Significant trauma of injury Weight loss • The majority of all clinically significant lower limb radiculopathy due History of cancer to disc herniation involves the L5 or S1 nerve root at the L4/5 or L5/S1 disc level Fever • Primary care practitioners have a critical role in preventing the development Intravenous drug use of chronic pain-related disability Steroid use • For further information refer to the New Zealand Acute Low Back Pain Patient aged over 50 years (LBP) Guide* (nzgg.org.nz) Severe, unremitting night-time pain Pain that gets worse when patient is The essential components of managing acute LBP are: Identify or exclude major pathology – Red Flags lying down Use appropriate symptom control Return to usual activities as soon as possible YELLOW FLAG: Engage the patient in self-help. Note this usually requires a second Psychosocial factors that increase the consultation risk of developing or perpetuating long- Complications term disability and work loss associated with low back pain: • Chronic LBP (CLBP) causes extensive suffering to individuals and their families. The restoration of function and return to usual activity and work Attitudes and beliefs about back pain is an essential part of preventing long-term disability Behaviours • Recovery from chronic LBP is difficult and demands high levels of resources. Compensation issues Prevention of chronicity requires a high priority. Note that the best Diagnostic and treatment issues opportunity for preventing chronicity occurs within the first few weeks Emotions • Chronic LBP should not be treated as if it were acute or recurrent LBP, Family since this leads to serial investigations and ineffective therapy • Presence of underlying pathology eg Spondylolysis, Spondylolisthesis Work

History • Circumstances of injury: mechanism and timing of injury related to symptom development • Occupation • Other diseases eg osteoporosis, neoplasms continued overleaf...

ACC Treatment Proﬁles – 2001 Back Pain N142./S572./N143. Low Back Pain, Acute Back Pain–Lumbar, Lumbago/Lumbar Sprain/Sciatica

Examination • Area/level of dysfunction • Neurological signs: nerve root and cauda equina • Check for Red and Yellow Flags

Goals for the examination: • Obtain a baseline for the level of function and activity • Alleviate uncertainty about the regional nature of back pain • Exclude neurological catastrophe

Conducting the examination: • Diagnostic triage • Psychosocial barriers to recovery (questionnaire in LBP guidelines)

Differential Diagnosis • Non-specific back pain • Nerve root pain • Red Flags (refer Investigation) • Cauda Equina syndrome • Chronic LBP (requires different management)

Investigation X-ray, full blood count and ESR/CRP if Red Flags present

Treatment Initial treatment and management: If no Red Flags: • Provide (or refer to appropriately qualified provider): Explanation Reassurance Advice on staying active Directive to use short-term alteration for everyday and work activities • Encourage and educate the patient to mobilise early, once Red Flags have been excluded. Explain that no more harm will occur from early mobilisation

Explore opportunities for demedicalising LBP: Encourage directed self-management Provide information Distribute a copy of the Patient Guide: Acute Low Back Pain Management, published by the National Health Committee and ACC. • Note, this nearly always requires a second consultation continued overleaf...

Back Pain N142./S572./N143. ACC Treatment Proﬁles – 2001 Low Back Pain, Acute Back Pain–Lumbar, Lumbago/Lumbar Sprain/Sciatica

• Symptom control May require rest, but no longer than 24-48 hours Analgesics (such as paracetamol and NSAIDs) Manipulation – (refer to a provider with a demonstrated record in providing symptom control as an adjunct to increasing function, and stipulate a time period (preferably less than 4-6 weeks) for reviewing the patient and ceasing the course of therapy. Review and monitor progress, within 1 week

Medical certification: • Short-term depending on occupation: 1-2 days preferably, at least less than 1 week • Certificate for temporary alternative work with clear indication of functional capacity

Ongoing treatment and management: • Review and monitor progress regularly 1-2 days following the initial consultation (issue the initial certificate for only 1-2 days) • Where possible discuss with employer • Conduct a comprehensive reassessment including the patient's pain and disability (activity limitation), and response to treatment

• Recheck for Red and Yellow Flags • Repeat initial management options • Referral to an allied health professional

Reactivation, or reduction of activity intolerance: • Patients who have not returned to usual activities or work, and failed to respond to treatment may require reactivation • Consider referral to a goal-oriented multidisciplinary team who will: Reactivate the patient Provide symptom control Enhance coping and self-management Deal with psychosocial barriers to returning to work or normal activity level

Referral to Specialist • Cauda Equina syndrome (immediate referral) • Serious spinal pathology (prompt referral acted on within 4 weeks) • Nerve root pain that has failed to settle (referral not generally required within first 4 weeks) • Neurological deficit which is progressive and worsening eg foot drop – discuss with specialist at the time of consultation • Persistent back pain <20 years of age

Other Referral • Case management if no RTW after 2 weeks, consider reactivation • Chiropractors • Home help • Occupational therapy continued overleaf...

ACC Treatment Proﬁles – 2001 Back Pain N142./S572./N143. Low Back Pain, Acute Back Pain–Lumbar, Lumbago/Lumbar Sprain/Sciatica

• Osteopath • Physiotherapy • Psychologist or vocational management consultant if significant psychosocial barriers to recovery and return to work

* New Zealand Acute Low Back Pain Guide, Jan 1997, ACC and National Health Committee

Back Pain N142./S572./N143. ACC Treatment Proﬁles – 2001 Cervicalgia – Neck Pain/Neck Sprain Read Code: N131./S570.

KEY POINTS • Take a clinical history including circumstances surrounding onset and conduct an examination to identify the need for investigation and specific therapy • Clinical localisation of the pain source is sometimes possible. There are fewer disc lesions. Manual techniques such as manipulation are easier, but potentially more dangerous. The possibility of adverse effects is hard to predict • The mechanism of injury is important in the severity of injury eg Motor Vehicle Accident (MVA), scrum collapse • Compared with the lumbar spine, the cervical spine is significantly more flexible and: Prone to acceleration/deceleration injury (whiplash) Disc lesions are less common Manipulation is easier but potentially more dangerous • Beware of: Vertebral artery spasm (do not manipulate) Fractures especially with underlying disease Rheumatoid arthritis Neurological signs

Complications • Chronic neck pain is a serious clinical development, and prevention of chronicity requires a high priority. The best opportunity for preventing chronicity occurs within the first few weeks • Chronic neck pain should not be treated as if it were acute or recurrent neck pain, since this leads to serial investigations and ineffective therapy • Vertebral artery spasm. Beware patients with symptoms of vertebral artery insufficiency (syncope/light-headedness with turning, looking up or sustained position). • Neurological sequelae • Acute nerve root compression syndrome

History • Time relationship of symptoms to injury • The mechanism of injury is important in assessing likely severity of injury eg MVA, scrum collapse • Past history – associated diseases eg rheumatoid arthritis, polymyalgia rheumatica, cerebrovascular

Examination • Diagnostic triage • Neurological exam mandatory if pain/related symptoms present below shoulder level • CVS examination may be needed • Psychosocial barriers to recovery (Refer to Yellow Flags)

Goals for the examination: • Obtain a baseline for the level of function and activity • Alleviate uncertainty about the regional nature of neck pain • Exclude neurological/CVS catastrophe: • Vertebral artery insufficiency: syncope/light-headedness with turning, looking up or sustained position continued overleaf...

ACC Treatment Proﬁles – 2001 Cervicalgia–Neck Pain/Neck Sprain N131./S57o. Cervicalgia – Neck Pain/Neck Sprain

Differential Diagnosis • Soft-tissue injury, non-specific neck pain • Myelopathy, occlusion of vertebral artery, fracture • Chronic neck pain (requires different management) • Non-injury neck pain, eg RA, polymyalgia rheumatica • Myelopathy, occlusion of vertebral artery, fracture • Rheumatoid arthritis • Polymyalgia rheumatica

Investigation X-ray, full blood count and ESR/CRP if signs or symptoms of serious disease are present (Red Flags): • The majority of cervical spine injuries do not need radiological imaging unless Red Flags are present

Treatment Contraindications to manipulation include: Severe osteoporosis Metastases Vertebral artery insufficiency Rheumatoid disease of neck Acute nerve root compression Children/infants Last trimester pregnancy Bleeding disorder

Initial treatment and management: • If no Red Flags, or fracture

Provide (or refer to appropriately qualified provider): • Explanation and reassurance (stress the importance of rest for 48 hours only if possible) • Advice on staying active Directive to use short-term alteration for everyday and work activities Explore opportunities for demedicalising neck pain Encourage directed self-management approach

Symptom control: Adequate analgesia – paracetamol/NSAIDs Manipulation from experienced/qualified provider for first 4-6 weeks maximum. Note contraindications to manipulation

• Review and monitor progress, within 1 week continued overleaf...

Cervicalgia–Neck Pain/Neck Sprain N131./S57o. ACC Treatment Proﬁles – 2001 Cervicalgia – Neck Pain/Neck Sprain

Ongoing treatment and management: • Review the patient's pain and disability (activity limitation) and response to treatment early at 1-2 days • Review the patient's pain and disability (activity limitation) and response to treatment at 1 week, then 3-6 weeks (if required) • Check for signs and symptoms of serious disease (Red Flags) and psychosocial barriers to recovery (Yellow Flags). Consider referral or further diagnostic work-up – see Investigation • Repeat initial management options • Conduct a comprehensive reassessment

Reassessment and reactivation, or reduction of activity intolerance (at 3-6 weeks): • Patients who have not returned to usual activities or work, and failed to respond to treatment may require reactivation • Consider referral to a goal-oriented multi-disciplinary team who will: Reactivate the patient Provide symptom control Enhance coping and self-management Deal with psychosocial barriers to returning to work or normal activity level • Where possible discuss with employer

Referral to Specialist • Nerve root pain that fails to settle • Serious spinal pathology • Presence of Red Flags

Other Referral (note flags for manipulation) • Chiropractor • Osteopath • Physiotherapy • Psychologist or vocational management consultant only if significant psychological barriers to recovery and return to work • Home help • Occupational therapy

ACC Treatment Proﬁles – 2001 Cervicalgia–Neck Pain/Neck Sprain N131./S57o. Sprain Rib Read Code: S5y3.

KEY POINTS • This code includes costo-vertebral, costo-chondral and chondro-sternal sprains • Good history and examination of the whole patient are essential • Review the patient and analgesia • Beware children – less fracture chance after major trauma = higher risk of intrathoracic damage • Rib sprains are unlikely to have significant associated pathology • Pain relief is the mainstay of treatment • Investigation is usually not needed

Complications • Respiratory – pneumothorax, haemothorax, pneumonia (hypoxia, hypotension, pain) • Heart (cardiac contusion, haemopericardium, tamponade) • Skeleton – flail chest, fractures, dislocations (especially ribs, sternal joints) • Abdomen – perforated viscus, splenic contusion, renal contusion, liver • Neurological – subclavian, spinal, intercostal nerves • Vascular – intercostal, subclavian vessels, haemoperitoneum • Infection – fever, sepsis

History • Mechanism of injury – direct blow/A-P crush/fall from height – may be a good indicator of more severe pathology • Pleuritic chest pain, often localised • Pain – location, nature, radiation, aggravating/relieving factors • Full functional enquiry • Check for aggravating factors in past history: COPD, neoplasias, smoker, past trauma, asthma • Check for important symptoms eg haemoptysis • Exclude other causes eg DVT • 1st rib sprain may be associated with brachial plexus symptoms

Examination • Pain – location, nature etc • Examine whole patient before individual ribs: Assess the chest: examine heart and lungs (stigmata of respiratory distress including oxygen saturation, trachea midline, lung integrity, auscultate heart +/- ECG, distal circulation) Assess the abdomen: examine diaphragm, viscera, liver, spleen, kidneys Assess the bony skeleton: examine spine, ribs, sternum, clavicles, check for flail segment, limb function Assess the neurological status: check Cspine, Tspine, brachial plexus, intercostals, subclavian Assess vascular status: general circulation, subclavian, intercostals • Check for complications • Exclude rib fracture • Check thoracic/cervical spine for associated dysfunctions especially first rib

Differential Diagnosis • Contusion • Respiratory – infection/pleurisy/pulmonary embolus (see complications) • Cardiac – beware MI, pericarditis • Fracture – stress (rowers), sternum, ribs especially 1st ribs, spine • Musculoskeletal – chronic conditions eg OA, costochondritis, ankylosing spondylitis continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Rib S5y3. Sprain Rib

• G.I. – GORD, PUD, hepatitis, biliary • Dislocation: costo-vert or costo-sternal/costo-costal • DVT, pulmonary embolus • Costochondritis

Investigation • Usually not necessary • Oxygen saturation • X-ray Chest – expiratory and oblique (if severe fracture suspected) Abdomen – erect, supine, lateral decubitusCspine, Tspine, Sternum • May need CT views if 1st rib involved

Treatment • Pain relief • Consider I/C nerve block (beware iatrogenic pneumothorax) • Depot intra-articular steroid with LA • Musculo-skeletal manipulation (only if trained in technique) • Physiotherapy • Resuscitation – ABCD, primary and secondary surveys • Mobilisation/manipulation

Referral to Specialist • Not needed unless significant underlying disease/injury • Impaired ventilation – pneumothorax (discuss all), flail chest • Impaired perfusion – haemothorax, haemopericardium, cardiac contusion, arterial injury • Impaired nerve function – Cspine, Tspine, brachial plexus • Impaired skeletal integrity – first rib fracture, multiple rib fractures, sternal dislocation, discuss spinal fractures • Significant complication – viscus perforation, splenic contusion, liver contusion, pneumonia, discuss renal contusions

Other Referral • Physiotherapy • Osteopath • Chiropractor • Acupuncture

Sprain Rib S5y3. ACC Treatment Proﬁles – 2001 Sprain, Acromio-Clavicular Ligament Read Code: S500.

KEY POINTS • See Sprain/Strain introduction • Always X-ray, including weight bearing • Children <12 years rarely sprain ligaments • Early physio to mobilise the synovial AC joint and supervise return to sport • Elderly patients more likely to fracture than sprain • Elderly more prone to stiffening eg frozen shoulder • Rest Ice Compression Elevation (RICE) therapy early • Watch tendon rupture in elderly

Complications • Non-healing/non-union • Chronic recurrent injury • Unstable joints if Grade 3 not referred • Delayed rupture of major sprains • Development of tendonitis in partial tendon tear • Damage to underlying structures (neurovascular, tendon, lung) • Frozen shoulder in elderly

History • Blow or fall on to shoulder • Contact sport • Repetitive action • Previous shoulder dislocation • Associated fracture

Examination • Compare with other side • Tender AC joint • Local deformity/swelling • Step or instability in AC joint • Grade 2 sprains may be difficult (have only a step deformity + too tender to elicit laxity) • Full flexion • Pain on horizontal adduction and weight bearing • Weakness • Screen neck movement

Differential Diagnosis • Fractured clavicle, humeral neck • Dislocated shoulder • Bruising • Congenital • Cervical spine injury • Supraspinatus/acromial bursa injury

Investigation • X-ray for all AC joint injuries to determine grade in association with clinical findings • Consider X-ray weight bearing continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain, Acromio-Clavicular S5oo. Sprain, Acromio-Clavicular Ligament

Treatment • All grades should have physiotherapy to mobilise the joint early and supervise return to sport • RICE 24-48 hours • Pain relief as required • Rest (avoid sport and lifting) • Sling

Grade 1-2 • Rest 2-3 weeks – as pain allows

Grade 3 • Rest up to 6 weeks • Refer if no improvement after 2 weeks

Education: • Early referral to physiotherapy

Referral to Specialist • Diagnostic uncertainty • Associated fracture • Grade 3 ligament injuries • Chronic ligamentous or tendinous inflammation • Full tear in elite athlete • A/C joint dislocations

Other Referral Physiotherapy for all grades as above

Sprain, Acromio-Clavicular S5oo. ACC Treatment Proﬁles – 2001 Rupture of Supraspinatus/Biceps Tendon Read Code: S5Q2./S5Q4.

KEY POINTS • Occasionally due to inappropriate use of steroids (abuse or injection) • Refer distal rupture early to specialist • Functional impairment variable • Always examine shoulder and elbow as well • Often misdiagnosed as rotator cuff strain

Complications • Loss of function and/or power • Deformity

History • Mechanism of injury – trauma or repetitive strain (weights) • Corticosteroid injection • Steroid abuse (eg weight lifters)

Examination • Compare with other side • Deformity • Moved muscle belly accentuated by contraction (pain may be absent) • Ecchymosis • Range of motion especially weakness of biceps power • Palpate bicipital groove proximally near attachment to glenoid

Differential Diagnosis • Shoulder sprain or contusion • Subacromial bursitis/impingement • Rotator cuff strain/tear • Fracture humerus • Pectoralis Major tear/strain • Subluxation/dislocation/fracture of shoulder • Glenoid labrum tear

Investigation • X-ray

Treatment Dependent on diagnosis: Tendonitis – RICE, NSAIDs, physiotherapy Rupture (proximal) – RICE, NSAIDs, high-arm sling 1-2 weeks, physiotherapy, specialist referral at 1 week if age >50 years Rupture (distal) – specialist referral stat • Confirm no fracture

Referral to Specialist • Proximal biceps tendon >50 years at 1 week • Significant loss of function/uncertain diagnosis • Distal biceps tendon – refer all • Persisting tendonitis

Other Referral • Physiotherapy • Consider home help in elderly

ACC Treatment Proﬁles – 2001 Biceps Tendon Rupture S5Q2./S5Q4. Shoulder/Rotator Cuff Sprains & Tendon Tears (Includes Infraspinatus) Read Code: S507./S504./S503./S502.

KEY POINTS RED FLAG: • The rotator cuff (R/C) is a thin sheet of tissue made up from tendons If patient cannot push hand away arising from scapular muscles including infraspinatus, teres minor, from lumbar region, this indicates subscapularis and supraspinatus. The function of the R/C is to stabilise a major tear of R/C the glenohumeral joint during power movements performed by the prime Elderly patients (more likely to mover muscles (eg pectoralis major, latissimus dorsi and deltoid). The secondary function of the R/C is rotation and abduction of the glenohumeral fracture and develop stiff joint) joint and this is used as the clinical method of testing the R/C to ascertain which of the R/C muscles/tendons is predominantly injured • Patients >40 with a significant shoulder injury are more likely to have a tear of their R/C • 50% of patients >40 years, with a dislocated shoulder, will have a R/C tear • Significant R/C tears do NOT heal (due to poor blood supply) and require surgical repair • Referral to a specialist should be made early if a significant R/C tear is suspected • Ultrasound is a good investigation (always request comparison of both sides) for establishing the degree of R/C tear (can be operator dependent) • Early mobilisation • Rest Ice Compression Elevation (RICE) therapy early

Complications • Chronic pain and inflammation/tendonitis • Permanent loss of function. The ability to repair surgically an R/C tear diminishes with time (window of opportunity to surgically repair is optimally in the first 3 weeks) • Instability • Impingement

History • Mechanism of injury • Sports injury eg direct blow, throwing injury, fall • Trauma. Refer early significant shoulder trauma in patients >40 years • Occupational history

Examination • Observe – deformity/swelling. Compare both shoulders

• Active range of motion: Abduction. Note painful arc if present Internal rotation. External rotation. Inability to actively externally rotate can indicate significant R/C tear – early referral indicated continued overleaf...

ACC Treatment Proﬁles – 2001 Shoulder Sprains, Tendon Tears S5o7./S5o4./S5o3./S5o2. Shoulder/Rotator Cuff Sprains & Tendon Tears (Includes Infraspinatus)

• Passive range of motion • Resisted movements. Note pain/decreased power • Special tests. Impingement and instability tests • Neurovascular status • Cervical spine

Differential Diagnosis • Rotator cuff sprain, sprain shoulder joint = painful arc, decreased active abduction, pain on abduction and rotational active movements • Infraspinatus sprain = pain external rotation and minor active and resisted weakness of external rotation • Supraspinatus tear/rotator cuff tear = painful arc, significant reduction of active and resisted movements eg abduction, ext rotation, int rotation • Instability • Fracture • Impingement • Subluxation, dislocation • Subacromial bursitis • Ruptured biceps • Calcific tendonitis

Investigation • X-ray • Consider ultrasound – operator dependent

Treatment • Broad arm sling if necessary (beware stiffness in elderly) • RICE 24-48 hours • NSAIDs • Pain relief • Refer Red Flags early: Suspicion of major tear of R/C (from history or clinical or investigations) Elderly patient • Physiotherapy/rehabilitation – mobilise, strengthen and monitor progress • Review at 1 week – if no improvement, refer • Education • Steroid injection if not settling and can rule out significant tear

Referral to Specialist • If unable to exclude rupture • Patient >40 years with significant trauma and symptoms/signs • If no active movement – stat • If no improvement after 1 week

Other Referral • Physiotherapy • Occupational therapy • Consider home help in the elderly

Shoulder Sprains, Tendon Tears S5o7./S5o4./S5o3./S5o2. ACC Treatment Proﬁles – 2001 Sprain Elbow/Forearm Read Code: S51..

KEY POINTS • Children <12 years rarely sprain ligaments, therefore need X-ray • Elderly patients are much more likely to fracture bones than sprain ligaments, therefore need X-ray • Elderly patients are prone to suffer stiffening of their joints eg frozen shoulder even in more peripheral injuries and need early mobilisation • RICE therapy is useful early (first 24 hours, possibly 48) for most sprains • Watch for tendon ruptures in older patients

Complications • Chronic, recurrent injury, tendonitis • Unstable joints if Grade 3 sprains are not referred • Development of tendonitis in partial tendon tear • Chronic pain and loss of function

History • Fall • Trip • Sports injury • Twisting injury with hand fixed

Examination • Decreased range of motion. Unable to fully extend or flex when compared to normal side. Record range of motion • Pain and/or instability when stressing specific ligament or tendon • Function to exclude fracture • Specific ligament stability and function. Check collateral ligaments, can be graded 1, 2 or 3 • Bone tenderness • Joint effusion

Differential Diagnosis • Fracture – radial head, supracondylar • Dislocation • Infection • Tendon rupture. Biceps or triceps • Tennis elbow • Golfer’s elbow • Triceps tendonitis • Olecranon bursitis

Investigation • X-ray (to exclude fracture). Check lateral for fat pad (sail sign) • In children a comparison view of the normal side is often helpful to determine bone/joint pathology

Treatment • RICE in first 24-48 hours • NSAIDs may have a place but may delay healing • Splintage as required for pain relief (broad arm sling or collar and cuff) • Early mobilisation especially in elderly • Isometric exercise training as prevention of muscle wasting continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Elbow/Forearm S51.. Sprain Elbow/Forearm

Referral to Specialist • Fracture • Grade 3 ligament injuries • Ligamentous or tendinous inflammation has become chronic • Rapid haemarthrosis • Significant decreased range of motion of elbow persists 2 weeks after injury

Other Referral • Physiotherapy

Sprain Elbow/Forearm S51.. ACC Treatment Proﬁles – 2001 Sprain Wrist or Hand (Carpal Ligament & Metacarpal Ligament Sprains)/Sprain Tendon Wrist or Hand Read Code: S52../S524.

KEY POINTS • See Sprain/strain introduction • Children <12 years rarely sprain ligaments – X-ray • Elderly patients more likely to fracture than sprain • Elderly require early mobilisation • Elderly patient at risk of frozen shoulder with prolonged immobilisation • Rest Ice Compression Elevation (RICE) therapy early • Beware scaphoid fracture in adults • Beware tendon rupture in elderly

Complications • Chronic recurrent tendonitis • Unstable joints • Osteoarthritis • Chronic pain • Weakness of grip • Permanent disability

History • Mechanism of injury (acute cause and effect) – fall, trauma, implement, twisting injury while gripping fixed object • Duration of symptoms • Activity • Pre-existing pathology • Hand dominance • Occupation

Examination • Deformity • Tenderness • Swelling • Ability to grip • Special tests eg Watson’s test • Range of movement (active/passive) • Exclude fracture • Neurovascular status • Crepitus • Lateral stability

Differential Diagnosis • Triangular fibro-cartilage injuries • Tendonitis • Fracture, especially scaphoid, Colles, Bennett’s, growth plate # (tender anatomical snuffbox) • Dislocation of inferior radio-ulnar joint or carpal bones (carpal dislocations require urgent referral) • Scapho-lunate disassociation (tenderness in fossa distal to Lister’s tubercle) • Ligamentous instability continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Wrist or Hand, Tendon, Wrist or Hand S52../S524. Sprain Wrist or Hand (Carpal Ligament & Metacarpal Ligament Sprains)/Sprain Tendon Wrist or Hand

Investigation • X-ray to exclude fracture/dislocation and consider repeat at 2 weeks if suspicion remains • Pain distal to Lister’s Tubercle +/- pain on gripping ask for bilateral AP clenched fist views to exclude scapho-lunate disassociation

Treatment • RICE • Pain relief • Immobilisation by splinting in position of function (early mobilisation in the elderly) • Crepe bandage and broad arm sling • If strong clinical suspicion of scaphoid fracture, apply POP and treat according to Scaphoid Fracture Profile

Referral to Specialist • Fracture according to relevant Fracture Profile • Dislocation (refer urgently if unable to rule out carpal dislocation) • Gross instability • Neurovascular impairment • No improvement after 2 weeks • Suspected carpal instability

Other Referral • Physiotherapy if persistent • Occupational therapy • Consider home help in the elderly

Sprain Wrist or Hand, Tendon, Wrist or Hand S52../S524. ACC Treatment Proﬁles – 2001 Hand/Wrist Flexor Tendon Rupture Read Code: N2264

KEY POINTS • Can be secondary to rheumatoid or osteoarthritis • Occasionally due to inappropriate use of corticosteroids • Can be secondary to laceration proximal to hand and wrist

Complications • Osteoarthritis • Joint subluxation • Loss of function • Chronic pain

History • Rheumatoid or osteoarthritis • Trauma • Corticosteroid injection(s) • Localised pain and decreased function

Examination • Loss of function • Swelling • Pain on movement

Specific examination for hand/finger flexor tendon rupture: Profundus tendon of finger: • Hold PIP joint of examining finger in full extension, ask patient to flex at DIP joint

Sublimis/superficialis tendon of finger: • Extend and hold all fingers (DIP and PIP joints of all fingers not being tested) then ask patient to flex at PIP joint of the finger being tested

Wrist tendons: • Resist palmar flexion. Look and feel for Palmaris Longus (not always present), Flexor Carpi Ulnaris (test with resisted ulnar deviation and palmar flexion), Flexor Carpi Radialis (test with resisted radial deviation and palmar flexion)

Differential Diagnosis • Spain/strain • Fracture • Infection • Carpal ligament injury

Investigation • X-ray • Check for scapholunate instability with bilateral AP clenched fist views

Treatment • Confirm no fracture • Splint with a position of function splint (DIP and PIP joints extended, MCP 90˚, wrist dorsiflexed 45˚) • Referral for repair acutely if suspect rupture of any flexor tendon

Referral to Specialist • To plastic, hand, or orthopaedic specialist for consideration of repair acutely

ACC Treatment Proﬁles – 2001 Hand/Wrist Flexor Tendon Rupture N2264 Sprain Radial Collateral Ligament (Thumb) Read Code: S5204

KEY POINTS • Less common than UCL sprains • Measure instability in extension by comparison with uninjured side • Complete tears as disabling as complete UCL tears – need referral <7 days • >30° movement on stressing RCL implies rupture and must be referred • Mobilisation with physiotherapy must start by 7-10 days • X-ray all but most trivial injuries • Elderly patients more likely to fracture than sprain • Elderly require early mobilisation • Rest Ice Compression Elevation (RICE) therapy early • Watch tendon rupture in elderly • Look carefully for associated injuries eg dislocation reduced previously, tendon rupture in elderly

Complications • Complex regional pain syndrome • Dysfunctional grip from instability • Stiffness • Degeneration of joint surfaces

History • Mechanism of injury – force, degree and direction • Duration of symptoms • Past injury/arthritis • Occupation/hobby • Hand dominance

Examination • Determine degree of sprain (Grade 1, 2 or 3) • Measure instability in extension • >30° movement on stressing RCL implies rupture • Tenderness over joint • Joint stability – passive and active • Tendons • Neurovascular status

Differential Diagnosis • Full rupture • Dislocation reduced elsewhere • Fracture • Tendon injury • 1st MCP joint sprain

Investigation • X-ray

Treatment Ruptured RCL: Grade 1 • RICE • Thumb spica/elastoplast • Physiotherapy continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Radial Collateral Ligament (Thumb) S52o4 Sprain Radial Collateral Ligament (Thumb)

Grade 2 • Thumb spica • Physiotherapy

Grade 3 • Refer (urgent)

Referral to Specialist • Radial collateral ligament rupture (Grade 3 strain) • Associated fractures (qv)

Sprain Radial Collateral Ligament (Thumb) S52o4 ACC Treatment Proﬁles – 2001 Sprain Thumb

Read Code: S522. (Most important is Ulna Collateral ligament sprain)

KEY POINTS Diagnoses include: Ulna collateral ligament sprain (Skier’s, Gamekeeper’s thumb) Capsular strain of 1st MCP joint IP joint strain Radial collateral ligament strain (see S5204) • Measure instability in extension using comparison with non-injured side • Unstable injuries need referral • Collateral ligament tear (complete) needs referral <7 days • >30° movement on stressing UCL implies rupture and must be referred • Mobilisation with physiotherapy must start by 7-10 days • X-ray all but most trivial injuries • Elderly patients more likely to fracture than sprain • Elderly require early mobilisation • RICE therapy early • Look carefully for associated injuries eg dislocation reduced previously, tendon rupture in elderly

Complications • Complex regional pain syndrome • Dysfunctional grip from instability • Stiffness • Degeneration of joint surfaces

History • Mechanism of injury – force, degree and direction • Capsular sprain of 1st MCP joint: common mechanism is hyperextension or axial compression • Duration of symptoms • Past injury/arthritis • Occupation/hobby • Hand dominance

Examination • Determine degree of sprain (Grade 1, 2 or 3) • Measure instability in extension • >30° movement on stressing UCL implies rupture • Tenderness over joint • Joint stability – passive and active • Collaterals especially UCL and IP joint sprains • Volar Plate • Tendons • Weakness of pinch grip (Grade 2 or 3 UCL injury) • Neurovascular status

Differential Diagnosis • Degree of strain • Dislocation reduced elsewhere • Fracture • Tendon injury continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Thumb S522. Sprain Thumb

Investigation • X-ray • Stress X-ray (under nerve block) if thumb UCL injury

Treatment Ruptured UCL: Grade 1 • RICE • Thumb spica/elastoplast • Physiotherapy

Grade 2 • Thumb spica splint/plaster for 4-6 weeks • Physiotherapy

Grade 3 • Refer <7 days as ligaments become degraded very quickly making acute repair difficult • Chronic UCL injuries with residual instability, pain, and weakness of pinch grip need referral for surgery

Capsular MCP joint sprain: • Brace/splint 7-10 days to prevent hyperextension • Prone to recurrence • Referral not usually needed

IP joint sprains: • Partial tear – buddy strap 7-10 days, physio • Volar plate – splint for 5-10/7 at 10-15° flexion • Complete rupture – refer

Referral to Specialist • Ulna collateral ligament rupture • Unstable volar plate injuries • Rupture of central extensor slip • Grade 3 ligament damage • Associated fracture (qv)

Other Referral • Physiotherapy (hand specialist if available)

UCL Grade 1 • If no improvement in 1 week

UCL Grade 2 • Stable volar plate injury

• Occupational therapy

Sprain Thumb S522. Sprain Finger Read Code: S523./S5513

KEY POINTS • See Sprain/Strain introduction • The key is to maintain mobility while keeping stability, sensation and analgesia • Early mobilisation requires early review usually at 7-10 days • These codes include: MCP joint strains PIP joint strains especially volar plate tears (often missed) DIP joint strains • Children <12 years rarely sprain ligaments (probably likely to fracture growth plates or suffer greenstick injury) • Elderly patients more likely to fracture than sprain • Rest Ice Compression Elevation (RICE) therapy early • Watch tendon rupture in elderly

Complications • Chronic recurrent tendonitis • Unstable joints • Boutonnière Deformity (after volar plate injury – usually develops after initial injury) • Chronic mallet deformity • Chronic swelling

History • Direct impact • Traction • Torsional forces • Duration of symptoms • Acute or chronic event • Site of pain • Recurrence • Occupational • Hand dominance • History of dislocation

Examination • Tenderness • Swelling • Deformity • Stability • Range of movement, passive and active checking, also tendon function • Determine grade of sprain • PIP joint exam – often best done under digital block if significant injury: can assess active range of motion and passive stability. Assess true collateral ligaments in flexion when accessory collaterals lax • Early volar plate injuries often indicated by PIP joint swelling, tenderness at dorsum of middle phalanx base and mild flexion deformity

Differential Diagnosis • Fracture (fractures involving avulsions of <30% of joint surface from the volar plate can be treated as per sprains) • Dislocation • Tendon injuries (note FDP avulsions often missed) • Arthropathies • Neurovascular injuries continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Finger S523./S5513 Sprain Finger

Investigation • X-ray all but most trivial injuries

Treatment • RICE • Pain relief • Immobilisation/strapping – buddy strapping • Volar plate injuries: actual or suspected – extension block splint • Review 7-10 days • Early mobilisation in elderly • Exercises

Referral to Specialist • Grade 3 injury • Discuss volar plate injuries or suspected injuries with hand specialist

Other Referral • Physiotherapy – Grade 1 and 2 • Consider home help in the elderly

Sprain Finger S523./S5513 ACC Treatment Proﬁles – 2001 Sprain Hip/Thigh Read Code: S53..

KEY POINTS • See Sprain/Strain introduction RED FLAG: • Children <12 years rarely sprain ligaments. Consider infection, irritable Children and elderly - a careful hip, SUFE, Perthes and traction apophysitis (avulsion fractures) assessment is required where the • Elderly patients are much more likely to fracture bones than sprain ligaments history is not consistent with the • Elderly patients are prone to suffer stiffening of their joints and need severity of symptoms. Seek early mobilisation advice early • Watch for tendon ruptures in older patients

Complications • Chronic, recurrent injury, tendonitis • Osteoarthritis • Septic arthritis • Osteomyelitis • Pain/loss of function if inadequately rehabilitated

History • Mechanism of injury • Site of pain

Examination • Temperature, pulse, BP • Active and passive range of motion of hip joint and resisted movements • Record capsular irritation (pain and reduced internal and external rotation with a flexed hip and knee at 90˚) • Palpate for bony and muscular tenderness • Resting position of leg externally rotated • Exclude hernia • Examination of lower back may be indicated

Differential Diagnosis • Fracture/Dislocation • Infection • Tendon rupture/strain – hip flexors, hip extensors, hip rotators • Arthritis • Children – Perthes, SUFE, septic arthritis, irritable hip, osteomyelitis • Pain radiating from lower back, SI joint • Hernias • Greater trochanteric bursitis

Investigation • X-ray (to exclude fracture) • Consider FBC, ESR, blood cultures • Consider ultrasound

Treatment • RICE in first 24-48 hours • NSAIDs • Crutches or wheelchair if required • Early mobilisation especially in elderly • Isometric exercise training as prevention of muscle wasting • Discuss with specialist if unsure of diagnosis in children continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Hip/Thigh S53.. Sprain Hip/Thigh

Referral to Specialist • Fracture • Red Flags: children and elderly • Unstable hip joint, non-weight-bearing, progressive and worsening antalgic gait • No improvement after 2 weeks

Other Referral • Physiotherapy rehabilitation and to monitor progress • Children do not need physiotherapy

Sprain Hip/Thigh S53.. ACC Treatment Proﬁles – 2001 Sprain/Strain Quadriceps Tendon Read Code: S533.

KEY POINTS • See Sprain/Strain introduction • Children <12 years rarely sprain ligaments • In children consider irritable hip, infection, Perthes, slipped upper femoral epiphysis • Elderly patients are much more likely to fracture bones than sprain ligaments • Elderly patients are prone to suffer stiffening of their joints eg frozen shoulder even in more peripheral injuries and need early mobilisation • RICE therapy is useful early (first 24 hours, possibly 48) for most sprains • Watch for tendon ruptures in older patients • One of the quadriceps muscles (rectus femoris) covers both the hip and the knee, thus it is important to consider both joints when examining

Complications • Chronic, recurrent injury, tendonitis • Muscle wasting • Quadriceps haematoma • Myositis Ossificans

History • Mechanism of injury • Over stretching • Direct blow – contusion • Running/kicking – strain • Site of pain

Examination • Pain and/or instability when stressing tendon • Function to exclude fracture • Gap in tendon • Site of tenderness • Ability to actively straight leg raise • Passive, active, resisted movements of knee joint

Differential Diagnosis • Fracture • Tendon rupture • Muscle tear • Infection/abscess • Traction apophysitis (avulsion fractures in children) • Lumbar spine strain • SI joint strain • Contusions/corked thigh/haematoma • Hernias • Traumatic osteitis pubic symphysis • Children – consider Perthes, slipped upper femoral epiphysis, infection, cancer, irritable hip

Investigation • X-ray (to exclude fracture), especially children and the elderly • Consider FBC, ESR in children • Consider ultrasound continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain/Strain Quadriceps Tendon S533. Sprain/Strain Quadriceps Tendon

Treatment • Control of haemorrhage – RICE in first 24-48 hours • Early referral to physiotherapy • Restoration of pain free range of motion (physiotherapy) • Functional rehabilitation (physiotherapy and education) • Graduated return to activity (education and monitoring) • NSAIDs may have a place, but may also delay healing • Splintage or knee brace as required for pain (only for a short period, up to 1 week) • Early mobilisation especially in elderly • Isometric exercise training as prevention of muscle wasting, especially for all knee injuries

Referral to Specialist • Fracture • Grade 3 muscle strains (refer to grades of muscle strains in introduction) • No improvement after 2 weeks • Large haematoma • Associated knee effusion

Other Referral • Physiotherapy

Sprain/Strain Quadriceps Tendon S533. ACC Treatment Proﬁles – 2001 Meniscal Tear (Medial/Lateral) Read Code: S460./S461.

KEY POINTS • History important – especially in sports person • Exclude meniscal tear if persistent symptoms in "sprained" knee • Aspiration if tense effusion or to exclude haemarthrosis (fracture, ruptured ACL, dislocated patella, intra-articular fracture) • Check for additional injuries to knee structures eg ACL • Some tears require referral and possible arthroscopy • Haemarthrosis uncommon – aspiration if tense effusion • Early rehab (physio) mandatory to reduce effusion ASAP. Maximises range of motion, allowing early strengthening and proprioceptive retraining and return to work/sport • Advice to patient about avoiding re-injury and further effusion is essential • May present as chronic knee pain in older people • Lateral tears are rarer than medial and can be associated with ACL injury. Also often require more rehabilitation

Complications • Wasting of quadriceps muscles, especially VMO • Long-term degenerative osteoarthritis • Other underlying abnormalities present eg spasticity, congenital deformities, valgus/varus deformity • Chronic pain

History • Usually a twist injury with flexed knee with a fixed foot • Sudden onset of painful knee while running, jumping, twisting or even kneeling • Swelling usually >4 hours or next day • Degree of force • Mobility since injury • Locking/giving way • Consistent localised pain (especially joint line)

Examination • Effusion – haemarthrosis not always present • Pain variable • Check range of motion – may have "springy" resistance to extension • Tenderness on joint line • Ligamentous instability especially ACL • Special tests – McMurray's, Tibial Torsion • Pain with tibial rotation at 90( flexion • Pain on flexion/extension with foot rotated, medially or laterally (McMurrray’s test)

Differential Diagnosis • Torn cruciate ligament • Torn medial/collateral ligaments • Osteochondral fracture • Patella dislocation/subluxation • Degenerative joint disease • Other abnormalities eg spasticity, congential deformities, valgus/varus deformity continued overleaf...

ACC Treatment Proﬁles – 2001 Meniscal Tear (Medial/Lateral) S46o./S461. Meniscal Tear (Medial/Lateral)

Investigation X-ray if : Suspected fracture Child/adolescent High speed injury Loose body Haemarthrosis present • Refer Ottawa/Pittsburgh knee rules

Treatment • RICE/Rehab (physio) early • Padded crepe bandage or tubigrip and knee brace • Gradual mobilisation • Aspiration if tense effusion or to exclude haemarthrosis • Crutches • Passive quadriceps exercises • Analgesia as necessary/NSAIDs • Physiotherapy for muscle balance assessment and strengthening programme

Referral to Specialist • At 1-2 weeks post-injury if: Not full range of motion (active/passive) Effusion still present Pain still present Giving way still present Locking present NB: Locked knee = either loss of end-range extension or loss of all range of motion: Loss of end-range extension >5,(refer at 1-3 weeks) Loss of all active/passive range of motion, refer acutely • +ve McMurray test after 2 weeks • Haemarthrosis detected

Other Referral Physiotherapy for muscle balance assessment and strengthening programme

Meniscal Tear (Medial/Lateral) S46o./S461. ACC Treatment Proﬁles – 2001 Sprain Collateral Ligament Knee Read Code: S5400/S541.

KEY POINTS • See Sprain/Strain Introduction and Pittsburgh/Ottawa rules for X-raying knee Ottawa Knee Rules • RICE therapy early X-ray if: • Use removable splints and physio rather than casts Patient older than 55 years • Children <12 years rarely sprain ligaments Tenderness present at head of fibula • Elderly patients more likely to fracture than sprain Isolated tenderness over patella • Majority achieve functional recovery if uncomplicated Inability to flex knee to 90 degrees • Large knee effusions can cause loss of range of motion and muscle wasting Inability to transfer weight for four steps thus early rehabilitation is essential both immediately after injury and at • Medial collateral ligament injury much more common than lateral ligament examination Complications Exclusion criteria: • Patello-femoral syndrome • Unstable knee Age less than 18 years • Wasting of quadriceps Isolated superficial injuries being • Meniscal injuries re-evaluated • Osteoarthritis if not rehabilitated appropriately Patients with altered levels of consciousness, paraplegia, History or multiple injuries • Determine mechanism of injury – direct, indirect blow • Location of pain/tenderness Pittsburgh Knee Rules • Loss of function Indicate radiography if the mechanism of injury • Valgus injury on a weight-bearing flexed knee causes stress and injury to is blunt trauma or a fall, and either: the MCL The patient is younger than 12 or older • Varus injury on a weight-bearing flexed knee causes stress and injury to than 50 years of age; or the LCL The injury causes an inability to walk four weight-bearing steps at Examination examination • Observe gait, swelling, range of motion • Ligament laxity/resistance Exclusion criteria: • Stress the ligaments with the knee in a slightly flexed position to determine Knee injuries that occur over six days the grade before presentation Differential Diagnosis Patients with only superficial lacerations and abrasions • Cruciate ligament injury • Meniscal injury Those with a history of previous • Fracture surgeries or fractures on the • Patella subluxation/dislocation/# affected knee Reassessments of the same injury Investigation • X-ray if swollen, possible fracture, severe trauma (see Ottawa and RED FLAG: Pittsburgh rules) If the knee opens to valgus/varus stress while fully extended this Treatment implies a posterior capsular tear of Grades 1 and 2 the knee and should be referred • RICE • Analgesia • Tubigrip and crutches. Mobilise with partial weight-bearing flexion extension only • May require or benefit from hinged knee brace • Physiotherapy for range of motion and strengthening of the dynamic stabilisers of the knee continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Collateral Ligament Knee S54oo/S541. Sprain Collateral Ligament Knee

• Advise on preventing further injury, especially from weight-bearing and twisting on a flexed knee (eg getting in and out of vehicles)

Grade 3 • Refer • Probable associated meniscal tear • May also have associated cruciate rupture

Referral to Specialist • Grade 3 • Recurrent strains • Instability • Significant trauma • Fracture

Other Referral • Physiotherapy • Occupational therapy

Sprain Collateral Ligament Knee S54oo/S541. ACC Treatment Proﬁles – 2001 Sprain Cruciate Ligament Knee Read Code: S542.

KEY POINTS • See Sprain/strain Overview Ottawa Knee Rules • Start static muscle exercises early to prevent muscle wasting X-ray if: • Knee should not be immobilised for more than 2 days Patient older than 55 years • Ottawa or Pittsburgh rules for X-raying knee Tenderness present at head of fibula • Use removable splints and physiotherapy rather than casts Isolated tenderness over patella • Meniscal injury should be estimated Inability to flex knee to 90 degrees • Children <12 years rarely sprain ligaments Inability to transfer weight for four steps • Elderly patients more likely to fracture than sprain both immediately after injury and at • Elderly require early mobilisation examination • Rest Ice Compression Elevation (RICE) therapy early • Watch tendon rupture in elderly • Monitor every few days if unsure of diagnosis and refer early Exclusion criteria: • Segond # pathognomonic of ACL rupture Age less than 18 years • ACL ruptures associated with early haemarthrosis Isolated superficial injuries being • PCL ruptures are extracapsular and not always associated with knee re-evaluated joint effusion Patients with altered levels of • PCL ruptures rarely require surgical repair consciousness, paraplegia, or multiple injuries Complications • Patello-femoral syndrome Pittsburgh Knee Rules • Unstable knee Indicate radiography if the mechanism of injury • Muscle wasting causing worsening instability is blunt trauma or a fall, and either: • Rupture of quadriceps mechanism The patient is younger than 12 or older • Meniscal injuries than 50 years of age; or • Osteoarthritis The injury causes an inability to walk History four weight-bearing steps at examination • Mechanism of injury: Landing from a jump, sudden deceleration Twisting injury on a weight-bearing flexed knee Exclusion criteria: Forced hyper extension against resistance Knee injuries that occur over six days Forced flexion before presentation Pivoting on the knee Patients with only superficial lacerations • Audible pop at time of injury and abrasions Those with a history of previous Unresolved previous injury: surgeries or fractures on the Loss of function eg knee giving way affected knee • Rapid swelling (usually in first 4 hours) implies ACL/PCL rupture or Reassessments of the same injury fracture • Complete tears – athletes are unable to keep playing immediately following the injury

Examination • Difficult to examine with large effusion present • Check quadriceps mechanism • Swelling, gait • Joint stability • Range of movement • Stress test • Define end point and resistance • Lachman/pivot shift test for ACL rupture • Sag sign for PCL continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Cruciate Ligament Knee S542. Sprain Cruciate Ligament Knee

Differential Diagnosis • Collateral ligament injury • Fracture/dislocation eg Tibial plateau • Other cruciate: partial/complete tear • Association with meniscus/patella/fractures/articular cartilage • Rupture of quadriceps mechanism

Investigation • X-ray – see Ottawa and Pittsburgh rules (see Sprain/strain introduction)

Treatment • RICE • Splint/crutches • Aspirate tense knee effusions for pain relief and mobilisation • Reassess early (48 hours) • Start static muscle exercises early to prevent muscle wasting • Early referral to physiotherapy for prehab (preparing knee for surgery) and rehab • Reassess 1 week and refer if appropriate (see Referral to Specialist) • Rehabilitation should begin on day 1 and should be a team approach (doctor, specialist, physiotherapist). Patient should be educated that rehabilitation is a long, slow process. Compliance with the rehabilitation programme is crucial for satisfactory outcome and to avoid long-term complications • The ACL has a major proprioception function. Any rehabilitation programme must include ongoing balance retraining

Referral to Specialist • Unsure of diagnosis • No improvement after 1 week • Fracture • Functional instability • Knee giving way • Combined ACL/MCL tear

Rupture: ACL/PCL ACL with bone attached • Meniscal injury • Rupture quadriceps mechanism

Other Referral • Physiotherapy • Occupational therapy • Possibly podiatry

Sprain Cruciate Ligament Knee S542. ACC Treatment Proﬁles – 2001 Sprain Ankle (Lateral Ligaments) Read Code: S550.

KEY POINTS • Ottawa rules for X-raying ankle injury (plus Red Flags) Ottawa Ankle Rules • Inversion injury – exclude fracture of 5th metatarsal X-ray if: • Medial ligament sprain is rarely isolated, review for other sprain or fracture Unable to bear weight (take four steps) • Rupture of tibio-fibular ligaments at time of injury and at examination • Rupture tibialis posterior tendon especially if >45 years Bone tenderness at posterior edge or • Foot needs to be maintained at 90˚ to appose ligament ends for tip of either malleolus perfect healing Bone tenderness over the naviculus or • Children <12 years rarely sprain ligaments base of fifth metatarsal • Elderly patients more likely to fracture than sprain • RICE therapy early RED FLAG: Prolonged symptoms >6 weeks of Complications appropriate rehabilitation (pain, • Instability swelling, antalgia, decreased range • Swelling • Arthritis of motion) suggestive of • Pain syndrome osteochondral injury/capsulitis. • Osteochondral defects Re-X-ray and refer • Capsulitis All children <12 years Elderly patients History • Injury mechanism usually inversion with rotation (for lateral ligament injury) • Record whether weight-bearing • Location of pain will indicate which ligament has been injured • Swelling • Pain elsewhere in the limb • Previous injury – type and residual dysfunction • Eversion injury more suggestive of medial ligament damage or fracture • Compressive type of injury suggestive of osteochondral injury

Examination • Determine degree of ligament damage • Perform anterior draw and talar tilt tests to determine laxity of joint, compare with uninjured ankle • Check function and ability to weight bear • Site of tenderness • Swelling and bruising • Check full length of fibula • Check 5th metatarsal (base) • Range of movement • Neurovascular status • Check proprioception (1 leg standing) continued overleaf...

ACC Treatment Proﬁles – 2001 Sprain Ankle (Lateral Ligaments) S55o. Sprain Ankle (Lateral Ligaments)

Differential Diagnosis • Fracture • Lateral/Medial ankle strain • Anterior inferior tibio-fibular ligament tear

Investigation • X-ray – use Ottawa rules • Full length of fibula • Consider stress views if instability • Consider bone scan if indicated

Treatment The management of lateral ligament injuries of all 3 grades follows the same principles: Initial management RICE Reduction of pain and swelling (NSAIDs at 2-3 days) Muscle conditioning Proprioceptive exercises Functional exercises Return to activity (taping)

Grade 1 • RICE • Education/physiotherapy • Crepe or tubigrip strapping • Review in 1 week if no improvement

Grade 2 • RICE • Simple analgesia • Consider NSAIDs • Physiotherapy • Consider cast/splint for 1 week • Review 1 week if no improvement

Grade 3 • Do not refer acutely • Stabilise in cast/backslab (non-weight-bearing) 7-21 days with weekly clinical review • Physiotherapy/taping • Mobilise with partial weight bearing (at 1-3 weeks) and crutches

Referral to Specialist • 3rd degree sprains • Tendon injuries • Medial ligament sprain • Tibialis posterior rupture • Fibula fracture • Rupture of inferior tibia/fibula ligament

Other Referral • Physiotherapy – Grades 1 and 2

Sprain Ankle (Lateral Ligaments) S55o. ACC Treatment Proﬁles – 2001 Sprain of Metatarso-Phalangeal Joint/ Interphalangeal Joint Read Code: S5512/S5513

KEY POINTS • Includes strains of all MTP and IP joints of the foot and toes eg haemarthrosis of MTP joint, sesamoiditis • Good history and examination are important especially of the whole foot; MTP joint strains may reflect whole foot pathology especially in runners • Plantar displacement best seen on lateral X-ray • If persistent pain after 7-10 days need to re-X-ray for occult fracture • Toes must heal in normal shape to fit shoes and avoid pressure areas • Gout may be triggered by trauma, presenting 2-5 days after injury • MTP joints must heal with normal mobility to maintain normal gait

Complications • Gout • Chronic metatarsalgia

History • Twisting injury • Hyper extension • Occupation eg dancer, athlete, • Level of exercise

Examination • Examine whole foot, especially arches, skin • Neurovascular status • Tendons and ligaments: passive and active range of movement • Deformity • Ecchymosis • Swelling, erythema • Point tenderness • Pain on stressing ligaments • Gait

Differential Diagnosis • Fracture of MT neck with/without plantar tilt of MT head • Stress fractures of metatarsal neck • Dislocation • Infection • Tendon rupture • Metatarsalgia due to hallux rigidus or hallux valgus • Gout • Intra-articular fracture • Plantar fasciitis • Interdigital neuroma (Morton’s neuroma)

Investigation • X-ray toe and foot if fracture suspected • Aspirate joint +/- uric acid if gout suspected

Treatment • RICE • Buddy strap • Analgesia • Hard-soled shoes • Orthotics continued overleaf...

ACC Treatment Proﬁles – 2001 Foot Joint Sprain S5512/S5513 Sprain of Metatarso-Phalangeal Joint/ Interphalangeal Joint

Referral to Specialist • Fracture of the MT neck with tilt on MT head • Displaced intra-articular fracture • Tendon rupture • Discuss possible stress fractures with specialist

Other Referral • Physiotherapy for gait assistance and joint mobilisation if restriction present • Podiatry

Foot Joint Sprain S5512/S5513 ACC Treatment Proﬁles – 2001 Section 6 Amputation ofFinger(s) Open Wound UpperLimb/Shoulder,Knee/Leg/Ankle,Foot/Toe Open Wound Buttock/ExtGenitalia Open Wound Elbow/Forearm,Wrist/Hand,Finger/ Thumb Open Wound Nose/Cheek/Eyebrow/Lip/Jaw/Mouth Lacerations/Abrasions CONTENTS Open Wound Scalp/OpenWound Forehead Open Wound Ear Open Wound Head/Neck/Trunk Avulsion ofNail/OpenWound Fingernail Abrasion Trunk Abrasion Shoulder/UpperArm/LowerArm/Knee/Leg Abrasion Face Overview SA2../SA3.. S96.. S9../S9 S8344/S8345/S836 S832./S8341/S8343/ S87../S88.. S91../S92../S93.. Read Code 000 S83 S82.. S8... 7G321/S935. SD1 SD2../SD3../ /SD6.. SD 0. 0. /S8342 0.. /SA1 0. /

6 lacerations/ abrasions Lacerations/Abrasions Overview

Timely and appropriate management of wounds can greatly reduce subsequent morbidity.

History Mechanism of injury: • Type of injury – wounding agent, crush/shear/stab • Potential contaminants and foreign bodies – note Luge injuries • Species of animal if bite wound

Circumstances of injury: • Work-related • Assault (possible domestic violence) • Self-inflicted wound

Age of wound

Associated symptoms: • Pain, paraesthesia, anaesthesia, weakness, loss of function

Tetanus immunisation status

Current medications and allergies

Prior medical history: • Previous injury/illness with residual disability in the wounded area • Immunosuppression/corticosteroid use • Diabetes mellitus • Heart disease requiring endocarditis prophylaxis • Previous keloid or hypertrophic scar formation • Asplenia • Peripheral vascular disease/venous hypertension • Bleeding disorders • Implanted prosthesis

Social history: • Occupation/hobbies • Handedness if upper limb injury • Carers available if required

Examination • Airways, breathing, circulation • Vital signs recorded • Secondary survey if required • Weight for children for calculating drug dosage

Wound inspection: Document: • Length, width, depth • Location • Shape of wound continued overleaf...

ACC Treatment Proﬁles – 2001 Overview Lacerations/Abrasions Overview

• Direction of wound related to skin surface – perpendicular/oblique eg flap wound on cheek requires special consideration • Vascular integrity • Distal nerve and tendon function • Evidence of obvious contamination – note Luge injuries may be contaminated with minute rubber particles which must be removed • Viability of tissues • Signs of infection

Explore: • Throughout full range of motion, both active and passive, of adjacent joints if possible tendon injury

Imaging: • Imaging is essential if there is suspicion of an associated fracture or foreign body • Radio-opaque objects are easily visualised on plain radiographs. They include metallic objects other than aluminium, almost all types of glass, some plastics and gravel • Radiolucent objects such as wood, thorns and some plastics may best be visualised with ultrasound • Occasionally MRI scanning may be necessary to identify plastic foreign bodies

Anaesthesia and Analgesia • Adequate pain relief is essential if wounds are to be cleaned, inspected and repaired under optimal conditions • Anaesthesia of the affected area may need to be supplemented by: Sedation in anxious and paediatric patients Systemic analgesic agents if injuries are extensive or associated with underlying fractures • An assistant may be useful when suturing children • A variety of anaesthetic techniques are available: Local anaesthesia – topical or by infiltration Regional General

Local anaesthesia: • Topical agents eg Amethocaine/Lignocaine/Adrenaline solutions (eg Emla, Ametop gel) are particularly suited to use in children and provide excellent levels of local anaesthesia without discomfort • Infiltration agents – several are available:

Agent Onset of Action Duration of Action Max Dose Lignocaine 1 minute 30-60 minutes 4mg/kg Lignocaine/Adrenaline 1 minute 60-120 minutes 7mg/kg Bupivicaine 5 - 10 minutes 90-180 minutes 3mg/kg

The discomfort of local anaesthetic infiltration has been shown to be minimised by: Slow infiltration (facilitated by use of small gauge needles) Infiltration into subcutaneous fat Infiltration as the needle is withdrawn Warming of anaesthetic solution to 37˚ to 40˚ C continued overleaf...

Overview ACC Treatment Proﬁles – 2001 Lacerations/Abrasions Overview

Buffering with Bicarbonate (1 ml of 8.4% Sodium Bicarbonate/9mls of 1% Lignocaine). As well as reducing discomfort this technique increases the intensity of the blockade

Side effects of local anaesthetic agents: Allergic reactions Systemic toxicity • Allergic reactions are very uncommon and are normally to the preservative in the solution rather than the anaesthetic agent • Systemic toxicity is manifested by Tachycardia Perioral tingling or numbness Nausea Vomiting Seizures CVS collapse

It is related either to administration of an excessive amount of the agent or to its inadvertent intravenous injection. Management involves: Discontinuing administration Attention to airway, breathing and circulation Seizure activity can be terminated by administration of Benzodiazepines Cardiovascular collapse is treated with intravenous fluid administration and if necessary a vasopressor such as Adrenaline

Contraindications to use of Adrenaline: Proximity to arterial supply eg digits Extremities eg nose, ear, penis Contaminated wounds (increases infection rate)

Regional anaesthesia: • Digital block – ring block of fingers or toes. It is essential to deposit anaesthetic in the vicinity of both dorsal and palmar digital nerves if full anaesthesia of a digit is to be secured • Sole of the foot. Local infiltration here is particularly painful. Regional blockade of the sural and tibial nerve is much less painful to the patient and provides excellent anaesthesia

Sedation: • Whenever conscious sedation is used the patient should be monitored continuously. Children may take 2-3 hours to recover. Monitor: 02 saturation Respiratory rate Heart rate Blood pressure • Midazolam is particularly useful because it is easy to administer and because it is easily reversed if deleterious side effects develop. It also provides anterograde amnesia.

Midazolam Dosage Recommended Dose Admin Route Onset of Action 0.5mg/kg Oral 20-30 min (may be mixed with juice) 0.2-0.5mg/kg Intranasal 5-15 min Reversal agent Flumazenil – dose O.Olmg/kg IV continued overleaf...

ACC Treatment Proﬁles – 2001 Overview Lacerations/Abrasions Overview

Systemic Analgesia: • Morphine – given IV (for speed and predictability of onset). Boluses of 1-2.5mg until pain adequately controlled. (Max dose 0.1mg/kg in children) – orally for children (0.1mg/kg)

General Anaesthesia: • Referral for General Anaesthesia may be appropriate for: Young children if unco-operative, even with relatively minor wounds Adults with more extensive wounds

Wound preparation Careful wound preparation optimises conditions for wound healing without infection.

Cleaning: • N/Saline or dilute aqueous Chlorhexidine for wound irrigation in all cases • Severely contaminated wounds – aqueous Povidone-Iodine can be used as its ability to reduce pathogen load outweighs the disadvantage of tissue damage associated with its use • Wounds should be irrigated under pressure • If it is necessary to remove hair in the course of wound repair it should be trimmed rather than shaved • Scrubbing of wounds may be necessary. Luge wounds impregnated with rubber (which may not be obvious) require thorough cleaning by scrubbing to avoid infection

Debridement: • Devitalised tissue should be carefully debrided • Irregular wound edges, other than on the face, should be trimmed

Antibiotic prophylaxis and Tetanus prophylaxis Tetanus vaccination schedule for acute wound management

Hx of Time Since Type of DTP/ Tet Vaccination Last Dose Wound DT/TT Immunoglobulin 3 doses or more <5 years All No No 5-10 years Clean/minor No No >10 years All wounds Yes No Unknown/less than Clean/minor Yes No 3 doses Others Yes Yes

DTP for children <8 yrs ADT for patients >8 yrs

Allergic reactions to Tetanus toxoid are extremely rare, although local reactions are common. If the possibility has been raised, the patient can be treated with Tetanus immune globulin if considered appropriate and they can then be referred for allergen testing to confirm or refute the possibility of allergy. continued overleaf...

Overview ACC Treatment Proﬁles – 2001 Lacerations/Abrasions Overview

Antibiotic prophylaxis has been shown to reduce wound infection rates in RED FLAG: a number of situations: Patients at risk of endocarditis or with • Wounds caused by a crush injury orthopaedic implants DO NOT require • Wounds contaminated with soil, vegetation or faeces • Late presentation (hand/foot wounds more than 8 hours after injury, other antibiotic prophylaxis for clean, areas more than 12 hours after injury) uncomplicated wounds. • High-risk bite wounds (see section 8) • Circulatory impairment – peripheral vascular disease or lymphoedema RED FLAG: • Impaired host defence – immunosuppression, diabetes mellitus Tape closure is not appropriate in areas • Wounds affecting cartilage (ear/nose), tendon, bone and joint where skin is moist, on the scalp or near joints. They cannot be used to Choice of antibiotic agent: Single agent prophylaxis is preferred – encourages compliance close wounds that are actively Animal bites/faecal contamination – Amoxycillin/clavulanate bleeding. They should not be placed Puncture wounds to foot through sole of shoe – Ciprofloxacin (gives cover circumferentially on fingers. Friar's for Pseudomonas) All other wounds requiring prophylaxis – Flucloxacillin/ Balsam may improve tape adhesion. Dicloxacillin/Amoxycillinclavulanate/Doxycycline/metronidazole/clindam ycin/ciprofloxacin (Recommendations vary) • Optimal duration of therapy is unclear – 5 days is commonly recommended

Wound closure Several different techniques of wound closure are available: • Tape • Adhesives • Staples • Sutures

Tape: Wound taping has several advantages over suturing in the closure of certain wounds: • Simplicity of application • Reduced need for anaesthesia • Elimination of need for suture removal • Lower infection rate than sutured wounds

Wounds suitable for taping: • Superficial straight lacerations under little tension • Lacerations and bite wounds with a high potential for infection • Lacerations in which skin edges are thin (the elderly, steroid dependent patients and in flaps where sutures might compromise perfusion of the wound edges) • Tapes may also be used to support lacerations after suture removal to minimise widening of the scar

Adhesives: • Tissue adhesives give a cosmetic result equal to suturing under certain circumstances. Characteristics of suitable wounds: Lacerations with sharp edges and under little tension where no deep sutures are required Laceration 5cm or less in length • If used on the face, steps must be taken to prevent the adhesive from accidentally reaching the eye • Adhesives are not suitable for Lacerations subject to deforming stresses such as near joints Lacerations that are actively bleeding continued overleaf...

ACC Treatment Proﬁles – 2001 Overview Lacerations/Abrasions Overview

Staples: Stapling gives as good a cosmetic result as suture closure and is very much quicker. Cost of disposable stapling devices may be offset by time saved in wound closure and by the reduced need for wound closure instruments.

Wounds suitable for stapling: Linear lacerations of the scalp, trunk and extremities Staples should be avoided for facial and hand lacerations

Sutures: • Interrupted sutures most commonly used • Monofilament sutures are preferred • Silk/absorbable sutures may be more comfortable in the mouth • Use absorbable sutures for deep tissue planes

Guide to appropriate suture size and time for removal according to location of wound

Body region Suture size Time for removal Scalp3/0-4/0 7 days Face 6/0 5 days Trunk 3/0-4/0 Front 7 days Back 10 days Arm/Leg 4/0 10 days Hand/Foot 4/0-5/0 12 days

• Add 2-3 days for wounds crossing extensor surfaces and subtract 2-3 days in young children

Dressings: • Many different dressings are available commercially and recommendations are contentious • Heavily contaminated wounds should be reviewed and redressed after 2 days • Dressings for abraded wounds are detailed in the relevant profiles • Sutured wounds should be kept dry – dressings should wick away any fluid oozing from the wound and should only be changed when their absorptive capacity is exceeded or if there are concerns regarding possible infection

Overview ACC Treatment Proﬁles – 2001 Abrasion Face Read Code: SD000

KEY POINTS • Exclude serious underlying injury • Clean wounds meticulously to avoid subsequent tattooing by retained foreign bodies • Clinical examination of facial skeleton is superior to X-ray in detecting fractures • Abraded skin is prone to hyperpigmentation – advise use of sunblock for 6 months post injury

Complications • Infection • Scarring • Tattooing • Missed underlying injury

History • Time of injury • Mechanism of injury • Associated injuries • If associated head injury: Loss of consciousness/duration Clinical course following injury • Co-morbidities • Allergies • Tetanus immunisation status • Symptoms suggestive of blow out fracture of orbit: Diplopia/pain on upward or lateral gaze • Symptoms suggestive of mandibular/maxillary fracture: Malocclusion/pain on biting

Differential Diagnosis • Underlying facial fractures • Ocular trauma

Investigation • X-ray facial bones if possible fractures • Wound culture if late presentation and wound infection apparent

Treatment • Analgesia to allow thorough cleaning: Local anaesthetic if small area For larger areas nerve blocks, IV opiates or Entonox may be appropriate • Clean with warm N/Saline • Remove all foreign material (use scrubbing brush/sterile soft toothbrush if necessary) continued overleaf...

ACC Treatment Proﬁles – 2001 Abrasion Face SDooo Abrasion Face

• Dress with hydrocolloid/Tegaderm or leave open and keep moist with Bacitracin or Chlomycetin ointment • Inspect at 5 days unless signs of infection develop earlier • Provide tetanus prophylaxis as necessary – see Overview

Referral to Specialist To plastic surgeon: • If patient’s age or extent of abrasions precludes adequate cleaning • Management of facial fractures

To maxillo-facial surgeon: • Mandibular/maxillary fractures – according to local practice

Abrasion Face SDooo ACC Treatment Proﬁles – 2001 Abrasion Shoulder/Upper Arm (No Infection), Abrasion/ Friction Burn Lower Arm, Abrasion Knee/Leg Read Code: SD20./SD30./SD602/SD60.

KEY POINTS • Exclude serious underlying injury • Clean wounds thoroughly to avoid subsequent tattooing by retained foreign bodies • Soft tissue injury alone or in combination with an underlying fracture may cause a compartment syndrome • Abraded skin is prone to hyperpigmentation – advise use of sunblock for 6 months post injury

Complications • Infection • Scarring • Tattooing • Ischaemic contractures from compartment syndromes

History • Time of injury • Mechanism of injury • Co-morbidities • Tetanus immunisation status • Symptoms of compartment syndrome: Disproportionately severe, poorly localised pain Severe swelling Hyperaesthesia/paraesthesia in distribution of nerves crossing compartment

Examination • Deformity/limitation of movement of limb suggesting underlying fracture, dislocation or closed tendon injury • Note area, depth, shape, location of wounds • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • Signs of compartment syndrome Pain on passive stretching or active flexion of affected muscle groups Distal sensory abnormalities • NB Normal distal pulses, skin colour and capillary return do not exclude compartment syndrome

Differential Diagnosis • Underlying fracture • Compartment syndrome

Investigation • X-ray if possible underlying fracture/dislocation • Wound culture if late presentation and wound infection apparent

Treatment • Analgesia to allow thorough cleaning: Local anaesthetic if small area For larger areas IV opiates or Entonox may be appropriate • Clean with warm N/Saline continued overleaf...

ACC Treatment Proﬁles – 2001 Abrasion Arm, Leg SD20./SD30./SD602/SD60. Abrasion Shoulder/Upper Arm (No Infection), Abrasion/Friction Burn Lower Arm, Abrasion Knee/Leg

• Remove all foreign material (use scrubbing brush if necessary) • Dress with tulle gras • Inspect at 2 days unless signs of infection develop earlier. Redress with tulle gras/hydrocolloid • Provide tetanus prophylaxis as necessary -see Overview

Referral to Specialist To plastic/orthopaedic surgeon: • Patient’s age or extent of abrasions precludes adequate cleaning

To orthopaedic surgeon: • Underlying fracture/dislocation or potential/actual compartment syndrome

Abrasion Arm, Leg SD20./SD30./SD602/SD60. ACC Treatment Proﬁles – 2001 Abrasion Trunk Read Code: SD10.

KEY POINTS • Exclude serious underlying injury. NB: In children the highly compliant rib cage may allow serious intra-thoracic or abdominal injury to occur with relatively minor evidence of injury externally • Clean wounds thoroughly to avoid subsequent tattooing by retained foreign bodies • Abraded skin is prone to hyperpigmentation – advise use of sunblock for 6 months post injury

Complications • Infection • Scarring • Tattooing • Co-existent intra-thoracic and abdominal injuries

History • Time of injury • Mechanism of injury • Co-morbidities • Tetanus immunisation status

Examination • Initial assessment of airway, breathing, circulation and neurological state • Secondary survey of chest and abdomen if appropriate • Note area, depth, shape, location of wounds • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies

Differential Diagnosis • Underlying fracture • Intra-thoracic/intra-abdominal injury

Investigation • Chest X-ray and ECG if significant chest trauma • Urinalysis if significant abdominal trauma • Wound culture if late presentation and wound infection apparent

Treatment • Analgesia to allow thorough cleaning: Local anaesthetic if small area For larger areas IV opiates or Entonox may be appropriate • Clean with warm N/Saline • Remove all foreign material (use scrubbing brush if necessary) • Dress with tulle gras • Inspect at 2 days unless signs of infection develop earlier • Redress with tulle gras/hydrocolloid • Provide tetanus prophylaxis as necessary – see Overview

Referral to Specialist To local emergency department: • Evidence of actual or potential internal injury

To plastic/orthopaedic surgeon: • Patient’s age or extent of abrasions precludes adequate cleaning

ACC Treatment Proﬁles – 2001 Abrasion Trunk SD10. Avulsion of Nail/Open Wound Fingernail Read Code: 7G321/S935.

KEY POINTS • See Overview • Inadequate repair of damage to nail bed or matrix may lead to long-term nail deformity • Subsequent revision surgery is disappointing • Associated mallet finger deformity in children is an epiphyseal injury requiring reduction and possible internal fixation

Complications • Nail deformity • Non-adherence of new nail • Persistent mallet finger • Osteomyelitis

History • Mechanism of injury • Time of injury • Age • Occupation • Leisure activities • Hand dominance • Co-morbidities • Tetanus immunisation status

Examination • If nail remains attached and nail bed/matrix laceration apparent or >50% subungual haematoma present – remove nail to allow full assessment and appropriate treatment

Assess for: Nail bed/matrix laceration or tissue loss Exposed bone/compound fracture Associated mallet finger deformity If late presentation signs of infection

Investigation • X-ray if mechanism of injury/clinical examination suggests fracture or if mallet finger deformity • Wound culture if late presentation and signs of infection present

Treatment • Provide analgesia with digital nerve block (never with adrenaline) • Remove nail if remains attached • Clean • Suture nail bed laceration with 6/0 absorbable (preferable) suture • Trim sides of nail and replace to prevent formation of adhesions within nail fold. NB Also greatly reduces pain of dressing changes • If nail unavailable use sterile Silastic sheet or part of suture packet • Prophylactic antibiotics if exposed bone/compound fracture – see Overview • Mallet finger deformity Adults – splint in full extension – refer if >25% of articular surface of distal phalanx is involved Children – refer • Provide tetanus prophylaxis (see Overview) continued overleaf...

ACC Treatment Proﬁles – 2001 Avulsion Nail 7G321/S935. Avulsion of Nail/Open Wound Fingernail

Referral to Specialist: • Complex or extensive nail bed laceration • Nail matrix laceration • Partial nail bed avulsion – refer with (appropriately chilled) avulsed tissue if possible • Mallet finger deformity in adults – refer if >25% of articular surface of distal phalanx is involved • All mallet finger deformities in children • Unstable distal phalanx fracture (unusual) • Inadvertent ring block with adrenaline – refer urgently

Avulsion Nail 7G321/S935. ACC Treatment Proﬁles – 2001 Open Wound Trunk Read Code: S8...

KEY POINTS • See Overview • History of injury and events following is critical • If conscious level impaired never attribute to alcohol/drugs even if such ingestions are known to have occurred • Seemingly trivial penetrating wounds of the abdomen may also involve intra-thoracic structures and vice versa

Complications • Infection • Co-existent intra-thoracic and abdominal injuries • Scarring • Tattooing • Pneumo/haemothorax – other intra-thoracic/abdominal organ damage

History • Time of injury • Mechanism of injury • Clinical course following injury • Associated symptoms/injuries • Co-morbidities • Medication especially Warfarin • Allergies • Tetanus immunisation status • History from a witness

Examination • Vital signs • Examination of chest and abdomen, to exclude associated injuries • Note length, depth, shape, location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • After instillation of local anaesthetic assess depth of wound on trunk

Investigation • Chest X-ray and ECG if significant chest trauma • Urinalysis if significant abdominal trauma • Wound culture if late presentation and wound infection apparent • Soft tissue X-ray if possible retained foreign body

Treatment • Anaesthesia to allow adequate cleaning and examination of wound – local infiltration Lignocaine with Adrenaline or topical anaesthetic in children • Clean wound and remove devitalised tissue • Oversew bleeding vessels • Suture/staple/glue skin – see Overview • Provide tetanus prophylaxis as necessary – see Overview

Referral to Specialist • Evidence of actual or potential internal injury • Stab wounds to chest or abdomen unless trivial • To plastic surgeon if patient’s age or extent of wounds precludes adequate treatment

ACC Treatment Proﬁles – 2001 Open Wound Trunk S8... Open Wound Ear Read Code: S82..

KEY POINTS • See Overview • Exclude associated head injury • Auricular haematoma/tympanic membrane perforations (from slapping) may represent non-accidental injury • Minimal debridement of lacerations to avoid distortion of cartilage • Lacerations involving auricular cartilage merit antibiotic prophylaxis • Acute vertigo/deafness implies inner/middle ear damage • Avulsions – if avulsed tissue available transfer with patient to plastic surgeon

Complications • Chronic TM perforations • Cosmetic deformity • External auditory canal stenoses • Auricular cartilage necrosis secondary to infection • Auricular cartilage overgrowth secondary to auricular haematoma

History • Time of injury • Mechanism of injury • Associated injuries • If associated head injury: Loss of consciousness/duration Clinical course following injury • Acute vertigo/deafness • Co-morbidities • Allergies • Tetanus immunisation status

Examination • Length, depth, shape, location of wound • Evidence of retained foreign body • Extent of contamination/devitalised tissue/cartilage involvement • Tympanic membrane/external auditory canal trauma • Check for hearing loss, test with tuning fork

Investigation • Audiogram if hearing impaired

Treatment Laceration: Local anaesthesia with field block around base of ear, no adrenaline Clean wounds Minimal debridement Approximate skin with 6/0 sutures but minimal/no suturing to cartilage Well padded and shaped pressure dressing to reduce risk of auricular haematoma • TM Perforation – see Section 8

Specialist Referral • Full thickness skin loss +/- perichondral loss • Partial/complete avulsions • Auricular haematoma (discuss to agree plan for follow-up) • Acute vertigo/deafness • Chronic perforation

ACC Treatment Proﬁles – 2001 Open Wound Ear S82.. OpenWound Scalp/OpenWound Forehead Read Code: S830./S8342

KEY POINTS • See Overview RED FLAG: • Assume cervical spine injury until such injury can be confidently excluded CLEARING THE CERVICAL SPINE • History of injury and events following is critical If high risk injury: • If conscious level impaired never attribute to alcohol/drugs even if such are known to have occurred High speed MVA • Fatal air embolism may occur through apparently trivial wounds of the Fall from height neck which involve the great veins Altered level of consciousness Intoxicated Complications Focal neurological signs • Infection Neck pain/midline cervical • Cosmetic deformity tenderness • Associated head/cervical spine injury Major distracting injuries • Concussion • Skull fracture • Intracranial haemorrhage Then X-ray. • Dural tear with CSF leak If none of the above, no X-ray • Scarring required and cervical spine can be • Tattooing cleared if full range of motion is History painless If in doubt refer • Time of injury • Mechanism of injury • Loss of consciousness/duration • Clinical course following injury • Associated injuries • Co-morbidities • Medication especially Warfarin • Allergies • Tetanus immunisation status • History from a witness

Examination • Initial focus on airway, breathing and circulation followed by neurological examination if head injury: Pupils Glasgow Coma Scale Cranial nerves Focal neurological signs in limbs

• Assess cervical spine: Tenderness Steps/deformity Crepitus Maintain protective measures until injury excluded • Note length, depth, shape, location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • After instillation of local anaesthetic palpate for underlying skull fracture • If anterior neck wounds have penetrated the superficial fascia – do not examine further – refer (see further details under Treatment)

Investigation • Skull X-ray/CT scan as discussed in Section 8, Concussion • Wound culture if late presentation and wound infection apparent • Soft tissue X-ray if possible retained foreign body continued overleaf...

ACC Treatment Proﬁles – 2001 Open Wound Scalp, Forehead S83o./S8342 OpenWound Scalp/OpenWound Forehead

Treatment • Cervical spine protection until injury excluded • Anaesthesia to allow adequate cleaning and examination of wound: Local infiltration Lignocaine with Adrenaline or topical anaesthetic in children Forehead laceration – consider supraorbital nerve block • Clean wound (N/Saline) and remove devitalised tissue • Oversew bleeding vessels • Suture/staple/glue skin – see Overview • Scalp laceration – if galea aponeurotica involved close with absorbable 3/0 sutures • Forehead laceration – transverse wrinkles of forehead act as landmarks for accurate apposition of skin edges. Young patients can raise eyebrows to create wrinkles • Provide tetanus prophylaxis as necessary – see Overview • In penetrating neck trauma do not allow patient to sit/stand until airtight dressing covering wound to prevent air embolism

Referral to Specialist • Evidence of actual or potential internal injury or skull fracture • Lacerations associated with head injury if SXR/CT required • If possible cervical spine injury • To ENT/general/cardiothoracic surgeons (according to nature of injury and local practices) • Neck wounds penetrating superficial fascia • If patient’s age or extent of wounds precludes adequate treatment, children requiring GA • Complex forehead laceration or significant tissue loss • Degloving/scalping wounds – send avulsed tissue with patient

Open Wound Scalp, Forehead S83o./S8342 ACC Treatment Proﬁles – 2001 Open Wound Nose/Cheek/Eyebrow Lip/Jaw/Mouth Read Code: S832./S8341/S8343/S8344/S8345/S836.

KEY POINTS • See Overview • For ears refer Open Wound Ear • Aim to repair wounds with optimal recovery of function and restoration of appearance • When closing wounds use key sutures first to approximate landmarks • Never shave eyebrows – regrowth is unpredictable • Bite wounds to the face should be closed after thorough cleaning and debridement

Complications • Nerve, vessel, muscle, eye injury • Facial fracture • Infection – potentially fatal if mid-facial and leads to cavernous sinus thrombosis • Cosmetic deformity • Facial palsy • Epiphora/Corneal exposure if tissue loss/contracture of scar of eyelids • Salivary fistula • Associated head/cervical spine injury

History • Time of injury • Mechanism of injury • Loss of consciousness/duration • Clinical course following injury • Associated injuries • Symptoms suggestive of blow out fracture of orbit: Diplopia/pain on upward or lateral gaze • Symptoms suggestive of mandibular/maxillary fracture: Malocclusion/pain on biting • Co-morbidities • Allergies • Tetanus immunisation status

Examination • Initial focus on airway, breathing and circulation followed by neurological examination if associated head injury • Check stability of maxilla if possible mid-facial fractures • Note length, depth, shape, location of wound and check for intra-oral involvement • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • Periorbital injuries: Full eye examination including visual acuity. Assess integrity of canthal ligaments/lacrimal apparatus • Cheek injuries – between tragus of ear and mid-pupillary line: Check facial nerve function and look for evidence of Parotid duct damage continued overleaf...

ACC Treatment Proﬁles – 2001 Open Wound Face S832./S8341/S8343/S8344/S8345/S836. Open Wound Nose/Cheek/EyebrowLip/Jaw/Mouth

Investigation • X-ray facial bones if possible fracture or if possible retained foreign body • SXR/CT scan as discussed under Concussion

Treatment • Local infiltration Lignocaine with Adrenaline – except nose, contaminated wounds – or topical anaesthetic in children • Use regional block for lips to minimise distortion • Clean wound and remove devitalised tissue • Oversew bleeding vessels and repair muscle layer • Align landmarks • Suture/glue/steristrip skin • Tetanus prophylaxis – see Overview

Specialist Referral – dependent on local resources • Lacerations associated with head injury if SXR/CT required • Eyelids – avulsion/canthal ligament damage/lacrimal duct damage • Evidence of facial nerve damage • Complex/extensive wounds including flap lacerations of face • Tissue loss – avulsion/devitalisation • Full thickness nose/lip lacerations • Facial fractures (may be plastic surgeon or maxillofacial surgeon according to local protocols) • Mandibular fractures/significant intra-oral wounds • Complications

Open Wound Face S832./S8341/S8343/S8344/S8345/S836. ACC Treatment Proﬁles – 2001 OpenWound Elbow/Forearm/Wrist/Hand (+Tendon Involved)/Finger(s)/Thumb Read Code: S922./S93..

KEY POINTS • See Overview • Thorough initial examination will delineate full extent of injuries. This allows early definitive treatment and minimises morbidity • Tendon sheath, web space and palmar space infection require urgent hospital treatment • High pressure injection injuries may present with minor symptoms and signs but over a few hours may cause irreversible ischaemic injury unless decompressed • Punch injuries (lacerations from opponent’s teeth over MC heads) are at very high risk of infection • Physiotherapy may speed recovery

Complications • Infection • Scarring • Missed neurological/tendon injury • Stiffness

History • Time of injury • Mechanism of injury • Posture of hand at time of injury • Age • Occupation • Leisure activities • Hand dominance • Previous injury/disability • Co-morbidities • Tetanus immunisation status

Examination Assess neurologic function before using local anaesthesia • Position at rest • Vascular: Colour/warmth Pulses Capillary refill • Neurologic: Motor: Ulnar n – finger ab/adduction Radial n – wrist extension Median n – function of Ab Pollicis Brevis/thumb opposition to fingers • Sensory: Ulnar n – tip of little finger Radial n – dorsal 1st web space Median n – tip of index finger Digital nerves – 2 point discrimination on ulnar/radial borders of all finger pulps • Bone and joint: Deformity Local tenderness Pain with axial compression Joint range of motion Ligamentous stability: DIP, PIP, MCP joints continued overleaf...

ACC Treatment Proﬁles – 2001 Open Wound Arm, Hand S922./S93.. OpenWound Elbow/Forearm/Wrist/Hand (+Tendon Involved)/Finger(s)/Thumb

• Musculotendinous: Function of each muscle-tendon group Strength against resistance Pain with motion • Explore wound with hand/finger in position in which injury occurred and then through full range of active and passive movement to maximise chance of identifying divided/partially divided structures • Note length, depth, shape, location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • If presentation is delayed by more than a few hours exclude infection: Tendon sheath infection causes tenderness along tendon affected, symmetric swelling of finger, pain on passive extension and the affected finger is held flexed Deep fascial space infections may present with swelling over the dorsum or palmar aspect of the hand or over the thenar eminence. Passive movement of adjacent digits causes pain • Remove rings if severe finger injuries

Investigation X-ray to check for: Associated fracture Retained foreign body Penetration of joint capsule (air within joint) Fight bites – for tooth fragments/compound fracture 5th MC neck • Ultrasound if possible non-radio-opaque retained foreign body • Wound culture if late presentation and signs of infection apparent

Treatment • Provide anaesthesia/analgesia by local/regional block • Clean wounds • Debride as necessary • Suture with absorbable sutures to subcutaneous layers, monofilament non-absorbable to skin • Consider steristrips for hands if appropriate • Non-adherent dressing • Provide tetanus prophylaxis as necessary • Antibiotic prophylaxis for high-risk wounds: More than 8 hours old Heavily contaminated Compromised patient • All tendon and joint injuries should be discussed with local orthopaedic surgeon. Some extensor tendon repairs may be done in the community by experienced practitioners • Physiotherapy if problems with mobility apparent or anticipated

Referral to Specialist • Evidence of vascular compromise of digit or hand (urgent) • High-pressure injection injury (urgent) • Tendon sheath, web space and palmar space infection (urgent) • Any tendon injury – for discussion – see Treatment • Nerve injury proximal to DIP joint • All human bite wounds for exploration and antibiotics unless definitely no deep structures involved

Open Wound Arm, Hand S922./S93.. ACC Treatment Proﬁles – 2001 Open Wound Buttock/Ext Genitalia Read Code: S87../S88..

KEY POINTS • See Overview • Anogenital trauma in children and adults may represent sexual abuse/assault • Consider trauma to rectum/vagina/urethra/testes even in apparently superficial wounds • Obtain patient consent and assistance of a chaperone before conducting examination • If assault/possible abuse refer to or discuss with appropriate agency prior to examination, other than exclusion of life-threatening injury. Particularly for children, it is preferable that only 1 examination is done • If forensic examination required referral to appropriately trained practitioners and use of Police examination kit required • Prophylactic antibiotics for perineal wounds – see Overview • Ensure victims of sexual assault are going to a place of safety with appropriate follow-up

Complications • Infection • Scarring • Secondary to injury to rectum/anal canal/genito-urinary system

History • Time of injury • Mechanism of injury – if paediatric patient document child’s account verbatim as well as that of caregiver • Age • Blood loss PR/PV/PU • Past medical history and co-morbidities • Medications and allergies • Tetanus immunisation status • Features suggestive of child abuse

Examination • Note length, depth, shape, location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • If assault excluded: Rectal examination/proctoscopy for blood if possible rectal trauma – NOT in children Speculum examination if possible vaginal/cervical injury – NOT in children • If assault possible/confirmed, refer to appropriate agency

Differential Diagnosis • Bowel injury • Genito-urinary tract injury • Sciatic nerve injury

Investigation • Urinalysis for occult haematuria • Ultrasound of testes if traumatic hydrocoele or possible rupture continued overleaf...

ACC Treatment Proﬁles – 2001 Open Wound Buttock, Genitalia S87../S88.. Open Wound Buttock/Ext Genitalia

Treatment • Analgesia/local anaesthesia • Clean wounds with N/Saline and debride as necessary • Suture – absorbable suture to subcutaneous layers if wound gaping • Monofilament suture to skin • Apply occlusive dressing, if possible otherwise encourage washing BD • Tetanus prophylaxis – see Overview • Prophylactic antibiotics for perineal wounds – see Overview • Review/redress wounds at 48 hours

Referral to Specialist • General surgeon/gynaecologist/urologist as appropriate if assault not suspected and evidence of trauma affecting rectum/anal canal/genito- urinary system • Paediatrician if possible child sexual abuse – see Section 8 • Appropriate local agencies if sexual assault – see Section 8

Open Wound Buttock, Genitalia S87../S88.. ACC Treatment Proﬁles – 2001 Open Wound Upper Limb/Shoulder/ Lower Limb/Leg/Knee/Foot/Toe Read Code: S87../SA101/SA100/SA2../SA3..

KEY POINTS RED FLAG: • See Overview Normal distal pulses, skin colour and • Exclude serious underlying injury including significant haemorrhage capillary return do not exclude • Assess distal neurovascular and musculotendinous function compartment syndrome • Soft tissue injury alone or in combination with an underlying fracture may cause a compartment syndrome • Forefoot lacerations and puncture wounds are prone to infection. Pseudomonas common infecting organism

Complications • Infection • Scarring • Missed neurovascular injury • Ischaemic contracture secondary to compartment syndrome

History • Time of injury • Mechanism of injury • Co-morbidities • Tetanus immunisation status • Symptoms of compartment syndrome Disproportionately severe, poorly localised pain Hyperaesthesia/paraesthesia in distribution of nerves crossing compartment

Examination • Note length, depth, shape and location of wound • Note extent of contamination/devitalised tissue • Note presence of retained foreign bodies • Deformity/limitation of movement of limb suggesting underlying fracture, dislocation or closed tendon injury • Signs of compartment syndrome: Disproportionate pain increasing in severity Pain on passive stretching or active flexion of affected muscle groups Distal sensory abnormalities Severe swelling

Investigation • X-ray if possible underlying fracture/dislocation • Consider wound culture if late presentation and wound infection apparent

Treatment • Analgesia/local anaesthesia • Clean wounds with and debride as necessary • Suture – vicryl to subcutaneous layers if wound gaping • Monofilament suture to skin • Apply non-adherent dressing • Tetanus prophylaxis – see Overview • Prophylactic antibiotics for foot or otherwise infection prone wounds • Review/redress wounds at 48 hours continued overleaf...

ACC Treatment Proﬁles – 2001 Open Wound Shoulder, Leg S87../SA101/SA100/SA2../SA3.. Open Wound Upper Limb/Shoulder/ Lower Limb/Leg/Knee/Foot/Toe

Specialist Referral • Orthopaedic surgeon: Extensive/complex lacerations Evidence nerve or significant muscle damage Possible compartment syndrome • Vascular surgeon – possible major vessel injury

Open Wound Shoulder, Leg S87../SA101/SA100/SA2../SA3.. ACC Treatment Proﬁles – 2001 Amputation of Finger(s) Read Code: S96..

KEY POINTS • See Overview • Wherever possible: Ensure early functional recovery Maintain good tissue coverage Maintain normal/near normal sensation Maintain finger length • Skin grafting for fingertip injuries often results in decreased sensitivity and tenderness • Physiotherapy may speed recovery

Complications • Decreased sensitivity • Cold intolerance • Cosmetic disability • Osteomyelitis

History • Mechanism of injury • Time of injury • Age • Occupation • Leisure activities • Hand dominance • Co-morbidities • Tetanus immunisation status

Examination • Exclude associated injuries • Establish extent of tissue loss: Bone Soft tissues Nail bed/matrix Finger pulp • If late presentation signs of infection • If amputated tissue is available assess for possible reimplantation: Extent of crushing/tissue distortion Degree of contamination Level of amputation Amputated tissue should never be discarded as it may be used as a source of full thickness skin for grafting even if replantation is not possible

Investigation • X-ray if possible fracture and to define level of bony amputation • Wound culture if late presentation and signs of infection apparent

Treatment Fingertip injuries: Most can be dealt with conservatively: Provide analgesia with digital nerve block. Preferably Bupivicaine 0.5% (Marcaine 0.5%) to maximise duration of anaesthesia – especially if for referral (never with Adrenaline) Clean If bone exposed trim to below level of soft tissues continued overleaf...

ACC Treatment Proﬁles – 2001 Amputation Finger S96.. Amputation of Finger(s)

Cover with non-adherent dressing Review at 2-3 days unless earlier signs of infection and then at 5-7 day intervals Prophylactic antibiotics if exposed bone – see Overview • If more than 50% of nail bed or terminal phalanx involved refer to plastic/hand surgeon

More proximal injuries: • Use systemic analgesics as local infiltration causes tissue distortion, which may interfere with re-implantation • Sterile saline soaked dressing to stump • Wrap amputated tissue in saline-soaked gauze squeezed dry, seal in plastic bag and immerse in ice for transfer with patient • Provide tetanus prophylaxis – see Overview • Referral to physiotherapy if problems with mobility anticipated or apparent

Referral to Specialist • If more than 50% of nail bed or terminal phalanx involved • If resection of prominent bone is necessary and facilities unavailable • Proximal amputations • Inadvertent ring block with Adrenaline – urgent referral to local emergency department

Amputation Finger S96.. ACC Treatment Proﬁles – 2001 Section 7 Contusions/ Crush Injuries

CONTENTS Read Code

Contusion (Bruise) Face, Scalp, Neck/Trunk/ Upper Limb/Lower Limb SE0../SE2../SE3../SE4.. Compartment Syndrome Sk0y. Crush Injury Upper Arm SF203 Crush Injury Wrist or Hand SF22.

Crush Injury Finger(s) SF23.

Crush Injury Finger/Thumb (Open and Closed) SF231/SF233

Closed Crush Injury Foot SF322 crush injuries contusions/ 7 Contusion (Bruise) Face, Scalp, Neck/ Trunk/Upper Limb/Lower Limb Read Code: SE0../SE2../SE3../SE4..

KEY POINTS • Assessment for compartment syndrome risk in limbs. Most sensitive indicator is severe pain/disproportionate pain for injury • All urethral injuries should be referred. Do not catheterise. Always consider urethral injury if perineal bruising • Always ask if history of bleeding disorders or concurrent Warfarin use • Aspiration of haematomata generally discouraged unless infected

Complications • Compartment syndrome/ischaemic contracture(s) if not recognised • Excessive bleeding and haematoma formation • Calcification of haematoma in muscle belly (myosotis ossificans) • Infection • Risk of avascular/septic necrosis of nasal and aural cartilage • Chronic pain

History • Mechanism of injury: Fall Direct blow (with implement or fist) Vehicular/cycle injury • Location of pain and severity • Current medications and allergies • Co-morbidities • Anticoagulants (especially Warfarin, aspirin) or bleeding disorders

Examination • Initial focus on airway, breathing, circulation and neurological state • Assess for associated injuries • Palpate bony landmarks and assess function to exclude fracture • Assess size, site of haematomata • Assess severity of swelling in limbs • Presence of bruising in perineum +/- blood at external urethral meatus suggests urethral injury • Examine nasal septum in all nasal injuries to exclude haematoma • Examine ears for aural haematoma • Muscle compartment contusion • Circulation • Haematuria in back injury or multi-trauma • Nerve injury

Differential Diagnosis • Fracture • Compartment syndrome present or risk • Impaired circulation • Abrasion • Fracture • Neurovascular injury

Investigation • Consider: X-ray (to exclude fracture in specific areas) continued overleaf...

ACC Treatment Proﬁles – 2001 Contusions SEo../SE2../SE3../SE4.. Contusion (Bruise) Face, Scalp, Neck/ Trunk/Upper Limb/Lower Limb

Coagulation studies if on anticoagulants or history of bleeding disorder Urinalysis if back or trunk injury or multi-trauma

Treatment • Resuscitation as necessary • Ice packs applied to area to reduce pain and swelling for 20 minutes every 2-3 hours for first 24 hours • Simple analgesia (avoid aspirin) • Rest/elevate (in sling if forearm or hand)/compression • Reassess next day if significant haematoma forming or patient on anticoagulants

Referral to Specialist • Presence or significant risk of compartment syndrome • Aural haematoma • Nasal septal haematoma/dislocation • Significant genital haematoma or urethral injury • Large haematoma when on anticoagulants or has bleeding disorder • Haematuria

To orthopaedic surgeon: • Suspicion of compartment syndrome • Gross haematoma of any large muscle group eg quadriceps • Neurovascular injury

To ENT surgeon: • Aural haematoma • Nasal septum haematoma

To urologist: • Testicular haematoma

To gynaecologist: • Significant genital haematoma (female)

Other Referral • Physiotherapy to optimise joint function if required • Home help for elderly or disabled may be required

Contusions SEo../SE2../SE3../SE4.. ACC Treatment Proﬁles – 2001 Compartment Syndrome (acute) Read Code: Sk0y.

KEY POINTS • Acute compartment syndrome can occur to a limb following fractures or soft tissue injuries; it requires prompt diagnosis and urgent treatment. Following injury, increased interstitial pressure can lead to obstruction of the microcirculation with resulting tissue necrosis. The commonest site to be affected is the anterior compartment of the lower leg

Clinical features include: Progressive swelling of limb Persistent pain (greater than one would normally expect for a given injury) Erythema Increased tissue tension Extreme pain on passive stretch of involved muscles Progressive loss of sensory and motor function The loss of capillary return and peripheral pulses are unreliable indicators of the severity of the condition

• Following diagnosis, urgent referral is required for immediate decompression, usually by fasciotomy

ACC Treatment Proﬁles – 2001 Compartment Syndrome Skoy. Crush Injury Upper Arm Read Code: SF203

KEY POINTS • Careful assessment to detect compartment syndrome early; if suspicious refer for compartment pressure studies • Meticulous wound management • Assess and document neurovascular status

Complications • Compartment syndrome with ischaemic contractures if unrecognised • Nerve injury • Infection

History • Mechanism of injury: Industrial machinery (rollers) Vehicular accident • Time of injury • Associated injuries • Current medications especially Warfarin and allergies • Co-morbidities especially diabetes and immunocompromise • Tetanus immunisation prophylaxis

Examination • Assess each muscle compartment for swelling and impending compartment syndrome • Skin laceration/abrasion • Assess for presence of foreign bodies • Neurovascular impairment • Crepitus suggesting bony injury

Differential Diagnosis • Laceration • Fracture • Nerve injury • Major vessel injury

Investigation • X-ray to exclude fracture if indicated

Treatment • Treat associated injuries as indicated • Analgesia as required • Tetanus prophylaxis if indicated – see Lacerations/Abrasions section

Open wound: • Document neurovascular status • Refer immediately to hospital if suspicion of compartment syndrome • Infiltrate local anaesthetic for irrigation and meticulous debridement • Close wounds if appropriate • Simple dressing to keep covered and protected • Rest in broad arm sling • Review wounds 24-48 hours • Prophylactic antibiotics if high risk wound – see Lacerations/Abrasions section continued overleaf...

ACC Treatment Proﬁles – 2001 Crush Injury Upper Arm SF2o3 Crush Injury Upper Arm

Closed injury: • Document neurovascular status • Refer immediately to hospital if suspicion of compartment syndrome • Rest in broad arm sling • Review as indicated

Referral to Specialist To orthopaedic surgeon if: • Signs/symptoms suggestive of (or significant risk of) compartment syndrome Severe pain especially on passive extension (earliest and most sensitive sign) Severe swelling Neurological impairment Diminished pulses or perfusion (late sign) • Extensive wounds requiring general anaesthetic for debridement • Nerve/tendon injury • Fracture

To plastic surgeon if: • Significant tissue loss/de-gloving

Other Referral • Consider home help for elderly or disabled • May require physiotherapy to restore normal function

Crush Injury Upper Arm SF2o3 ACC Treatment Proﬁles – 2001 Crush Injury Wrist or Hand Read Code: SF22.

KEY POINTS • Assess compartment syndrome risk • Assessment of neurovascular and tendon function important in open wounds • Refer de-gloving injuries • Meticulous wound management

Complications • Compartment syndrome/ischaemic contracture(s) if not recognised • Nerve injury • Fracture and tendon rupture • Reflex sympathetic dystrophy syndrome – complex regional pain syndrome • Infection • Loss of function

History • Mechanism of injury: Crush Machinery (rollers) Wringer • Site of pain • Time of injury • Associated injuries • Hand dominance • Occupation • Current medications especially Warfarin and allergies • Co-morbidities especially diabetes and immunocompromise • Tetanus immunisation status

Examination • De-vitalised tissue • Assess each muscle compartment for swelling and impending compartment syndrome • Skin laceration/abrasion • Assess for presence of foreign bodies • Neurovascular impairment Motor function: Motor Ulnar n – finger ab/adduction Radial n – wrist extension Median n – function of Abd Pollicis Brevis/Thumb opposition to fingers Sensory: Ulnar n – tip of little finger Radial n – dorsal 1st web space Median n – tip of index finger Digital nerves – two point discrimination on ulnar/radial borders of all finger pulps • Assess tendon function • Crepitus for bony injury continued overleaf...

ACC Treatment Proﬁles – 2001 Crush Injury Wrist or Hand SF22. Crush Injury Wrist or Hand

Differential Diagnosis • Cellulitis • Laceration • Fracture • Nerve injury • Major vessel injury

Investigation • X-ray as appropriate (to exclude fracture or foreign body if risk) • Ultrasound may be indicated if suspicious of non-radio-opaque foreign body

Treatment • Treat associated injuries as indicated • Analgesia as required • Tetanus prophylaxis if indicated – see Lacerations/Abrasions Overview

Open wounds: • Document neurovascular status • Refer immediately to hospital if suspicious of compartment syndrome • Infiltrate local anaesthetic for irrigation and meticulous debridement • Close wounds if appropriate • Simple dressings to keep covered and protected • Splinting of limb in appropriate position if extensive wound or over joint • Elevate in sling • Review wounds in 24-48 hours • Prophylactic antibiotics if high risk – see Lacerations/Abrasions Overview

Closed injury: • Document neurovascular status • Refer immediately to hospital if suspicious of compartment syndrome • Elevate in sling • Review in 24-48 hours

Referral to Specialist To orthopaedic surgeon if: • Signs/symptoms suggestive of (or significant risk of) compartment syndrome: Severe pain especially on passive extension (earliest and most sensitive sign) Severe swelling Neurological impairment Diminished pulses or perfusion (late sign) • Extensive wound/s for debridement and management • Nerve/tendon injury • Fracture (depending on type)

To plastic surgeon if: • Significant tissue loss/de-gloving

Other Referral • Consider home help for elderly or disabled • May require specialist hand physiotherapy

Crush Injury Wrist or Hand SF22. ACC Treatment Proﬁles – 2001 Crush Injury Finger(s) Read Code: SF23.

KEY POINTS • Meticulous assessment of tendon and nerve function important • A subungal haematoma causing pain should be drained to provide relief • Trephining a subungal haematoma in the presence of a fracture constitutes a compound fracture • Consider referral for nail removal and nail bed repair if subungal haematoma >50%

Complications • Nail deformity if injury to nail matrix • Loss of function • Infection (including osteomyelitis)

History • Mechanism of injury: Blow with implement eg hammer Crush in door Machinery • Time of injury • Hand dominance • Occupation • Current medications especially Warfarin and allergies • Co-morbidities especially diabetes and immunocompromise • Tetanus immunisation prophylaxis

Examination • Distal capillary return (circulation) • Presence of subungal haematoma and size • Presence of mallet finger deformity (avulsion extensor tendon) • Clinical likelihood of fracture • Degree of swelling • Joint injury – limitation of movement • Sensation in finger – digital nerve injury

Differential Diagnosis • Cellulitis

Investigation • X-ray to exclude fracture if indicated

Treatment • Analgesia as required • Tetanus prophylaxis as indicated – see Lacerations/Abrasions Overview

No fracture (and no nerve, tendon injury): • Elevate in high sling • If significant subungal haematoma causing pain, trephine with heated paper clip or sterile needle • Consider referral for nail removal and nail bed repair if subungal haematoma >50% • Mobilise early continued overleaf...

ACC Treatment Proﬁles – 2001 Crush Injury Finger(s) SF23. Crush Injury Finger(s)

Tendon injury: • Mallet finger injury X-ray to ensure minor bony avulsion only (if >25% articular surface, refer) Manage in appropriate splint (if not available, refer acutely) Need 6 weeks in splint All children with mallet deformity/injury should be referred acutely.

• Flexor tendon injuries Refer acutely

Nerve injury: • Digital nerve injuries may be repaired acutely • Generally not considered if injury distal to DIP joint • If doubt about appropriateness of referral seek telephone advice • Otherwise refer acutely

Circulatory impairment: • Gross swelling, pain, poor capillary return: Elevate Refer acutely

Referral to Specialist To plastic/hand/orthopaedic specialist according to local practices: • Digital nerve injury • Impaired circulation • Fracture of phalanx if: Significant involvement of articular surface Mal-rotation Mal-alignment Unstable fracture • Flexor tendon injury and some mallet finger injuries • Collateral ligament rupture and instability • Nail bed injury/sub-ungual haematoma >50%

Other Referral • May require specialist hand physiotherapy • Consider home help for disabled or elderly

Crush Injury Finger(s) SF23. ACC Treatment Proﬁles – 2001 Crush Injury Finger/Thumb (Open and Closed) Read Code: SF231

KEY POINTS • Prompt drainage of sub-ungual haematoma relieves pain • Fracture plus broken skin or drilling sub-ungual haematoma = compound fracture • Consider tendon rupture/division • Avoid sutures where possible • Avoid tourniquet or digital vessel clamps • Meticulous assessment of tendon and nerve function important • Consider referral for nail removal and nail bed repair if sub-ungual haematoma >50%

Complications If open wound: • Osteomyelitis from unrecognised compound fracture • Wound infection

All crush injuries: • Separation of new nail from nail bed if significant nail bed injury • Nail deformity if nail matrix injury • Extensor tendon damage • Collateral ligament rupture • Finger/thumb pulp ischaemia • Loss of mobility

History Mechanism of injury: Blow with implement eg hammer Crush in door Machinery • Time of injury • Hand dominance • Occupation • Current medications especially Warfarin and allergies • Co-morbidities especially diabetes and immunocompromise • Tetanus immunisation prophylaxis

Examination • Distal capillary return (circulation) • Presence of sub-ungual haematoma and size • Presence of mallet deformity • Clinical likelihood of fracture • Degree of swelling • Joint injury – limitation of movement • Sensation in thumb – digital nerve injury • Stability of ligaments especially ulnar collateral ligament of MCP joint

Differential Diagnosis • Cellulitis

Investigation • X-ray • Swab for C and S if infected continued overleaf...

ACC Treatment Proﬁles – 2001 Crush Injury Thumb (Open and Closed) SF231 Crush Injury Finger/Thumb (Open and Closed)

Treatment • Analgesia as required • Tetanus prophylaxis if indicated – see Lacerations/Abrasions Overview

No fracture (and no nerve, tendon, ligament injury): • Elevate in high sling • If significant sub-ungual haematoma causing pain, trephine with heated paper clip or sterile needle • Consider referral for removal of nail and repair of nail bed if sub-ungual haematoma >50% • Mobilise early

Ulnar collateral ligament rupture: • See Sprains section

Tendon injury: Mallet deformity/injury: X-ray to ensure minor bony avulsion only (if >25% articular surface, refer) Manage in appropriate splint (if not available refer acutely) Need 6 weeks in splint All children with mallet deformity/injury should be referred acutely Flexor tendon injuries: Refer acutely

Nerve injury: • Digital nerve injuries may be repaired acutely • Generally not repaired if distal to DIP joint • If uncertain about appropriateness of referral, seek telephone advice • Otherwise refer acutely

Circulatory impairment: • Gross swelling, pain, poor capillary return • Refer acutely

Referral to Specialist To plastic/hand/orthopaedic specialist according to local practices • Digital nerve injury • Impaired circulation • Fracture of phalanx if: Significant involvement of articular surface Mal-rotation Mal-alignment Unstable fractures Essentially all fractures except tuft fractures • Flexor tendon injury, some mallet injuries in adults and all in children • Collateral ligament rupture and instability especially ulnar collateral • Nail bed injury/sub-ungual haematoma >50%

Other Referral • May require specialist hand physiotherapy • Consider home help for disabled or elderly

Crush Injury Thumb (Open and Closed) SF231 ACC Treatment Proﬁles – 2001 Closed Crush Injury Foot Read Code: SF322

KEY POINTS • Meticulous assessment of X-rays as Lis-Franc (tarsometatarsal) fractures of the mid-foot are difficult to diagnose and have serious consequences • If unable to weight bear, ensure early follow-up

Complications • Osteoarthritis • Chronic pain • Reflex sympathetic dystrophy – complex regional pain syndrome • Unrecognised fractures of mid-foot with mal-union • Loss of function

History • Mechanism of injury: Crush injury Road trauma Foot run over • Time of injury • Current medications and allergies • Co-morbidities especially diabetes, immunocompromise and peripheral vascular disease • Social support • Tetanus immunisation prophylaxis

Examination • Active and passive range of movement toes and foot • Circulatory impairment • Degree of swelling • Presence of wounds or abrasions • Deformity • Presence of bony tenderness suggesting fracture • Sensory deficit suggesting nerve injury • Ability to bear weight

Differential Diagnosis • Gout • Cellulitis

Investigation • X-ray if indicated to exclude fracture

Treatment • Analgesia if required • Regular application of ice compresses in first 24 hours • Elevate as much as possible • Support if severe in form of bandaging or splinting • Tetanus prophylaxis if indicated – see Lacerations/Abrasions Overview • Review at 2 days if severe and unable to weight bear

Referral to Specialist To orthopaedic surgeon if: • Circulatory impairment • Nerve injury • Unable to weight bear after 2 days

Other Referral • May require physiotherapy if delay in return to function

ACC Treatment Proﬁles – 2001 Closed Crush Injury Foot SF322 Section 8 Miscellaneous

CONTENTS Read Code

Anaphylaxis Treatment Protocol Concussion S60.. Head Injury Risk Groups

Glasgow Coma Score

Post-Concussion Syndrome E2A2.

Tympanic Membrane Perforation F542. Loss of Teeth (Accident)/Broken Teeth JO510/S8363 Foreign Body in Skin or Subcutaneous Tissue M2y5. Corneal Abrasion/Corneal Foreign Body SD810/SG00. Foreign Body in Ear/Foreign Body in Nose SG1../SG2..

Ingested Foreign Body SG5..

Toxic Ingestion (Activated Charcoal) SL...

Toxic Reaction Bee Sting TE532 Dog Bite/Human Bite (Also Cat) TE60./U120. Electrical Injury TL01. Management of Sexual Assault/Abuse SN571

Management of Child Sexual Abuse SN571 miscellaneous 8 Anaphylaxis Treatment Protocol

KEY POINTS • There is no place for conservative management of anaphylaxis • Early administration of adrenaline in association with fluid replacement is the mainstay of treatment • In general, the more severe the reaction, the more rapid the onset. Most life-threatening reactions begin within 10 minutes of immunisation. The intensity usually peaks at around 1 hour after onset. Symptoms limited to only one system can occur, leading to delay in diagnosis • Biphasic reactions where symptoms recur 8-12 hours after the onset of the original attack and prolonged attacks lasting up to 48 hours have been described

AETIOLOGY AND RECOGNITION OF ANAPHYLAXIS • Parenteral penicillin, hymenopteran (bees and wasps) stings and foods are the commonest causes of anaphylactic fatalities • Radiocontrast media, aspirin or other NSAIDs are the most common cause of anaphylactoid fatalities (same range of clinical features though not requiring previous exposure) • Characteristically occurs in otherwise fit patients • The speed of onset reflects the severity of the reaction • Most symptoms occur within 30 minutes although symptoms can be delayed for some hours especially with topical or oral exposure • The clinical features described below may occur in combination or as isolated features. The diagnosis may be simple in the classic presentation, however, a presentation with isolated hypotension may be more difficult • Late deterioration may occur in around 5% of individuals; therefore patients in whom adrenaline is used should be hospitalised for a period of 6-8 hours • In severe cases, up to 50% of the circulating volume can be lost from the vascular compartment

Signs and Symptoms

Timelines Signs and Symptoms Severity

Early Warning Signs Dizziness, tingling,warmth, pruritus Mild

Flushing, urticaria, nasal congestion, Mild to Moderate sneezing, lacrimation, angioedema, erythema (especially weals)

Hoarseness, nausea, vomiting, Moderate to Severe Laryngeal oedema, dyspnoea, abdominal pain/cramps

Bronchospasm, stridor, syncope, Life-Threatening Late, Life-Threatening hypotension, dysrhythmias, coma, Symptoms confusion

continued overleaf...

ACC Treatment Proﬁles – 2001 Anaphylaxis Treatment Protocol Anaphylaxis Treatment Protocol

Treatment First line treatment: • Oxygen by face mask 10-15 l/min – can be discontinued if cutaneous manifestation only Adrenaline: Adults 0.5mg IM ie 0.5mls of 1:1000 repeated at 5-10 minute intervals according to response Children – dose dependent on weight/age

EITHER

Age (yrs) Dose(mg) <2 0.0625 2-5 0.125 6-11 0.25 >11 0.5

0.01 mg/kg (IM ie 0.1 mls/kg of 1:10,000)

Repeated at 5-10 minute intervals according to response

• Fluids: 10-20 mls/kg colloid or crystalloid IV repeated according to haemodynamic parameters

Second line treatment: • Nebulised Beta-agonists: Adrenaline if predominant stridor 1mg diluted to 4ml with saline and repeat as necessary Salbutamol if predominant bronchospasm 5mg • Antihistamines: H1 blocker (promethazine or diphenhydramine) are of most value when the allergic condition is mild-moderate, progressing slowly and dominated by cutaneous manifestations They may be used in combination with H2 blockers ie ranitidine Both may be initially given IV, later orally for 2-3 days Steroids: Role in reducing protracted symptoms especially bronchospasm Discharge medication to reduce likelihood of relapse of symptoms 2-3 day course Aminophylline: Severe bronchospasm resistant to adrenaline 5mg/kg over 30 minutes with cardiac monitoring Glucagon: Consider in patients on beta-blockers who may have more symptoms that are difficult to treat; 1mg IV repeated every 5 minutes if necessary.

• Beta–blocked patients may require additional doses of adrenaline.

Anaphylaxis Treatment Protocol ACC Treatment Proﬁles – 2001 Concussion Read Code: S60..

KEY POINTS • History of injury is critical, particularly reports from other people/bystanders RED FLAG: • Frequent neurological assessment necessary to recognise progressive High-risk patients: deterioration. Record observations serially >40 years of age • May need neurophysiological assessment for reaction to safety issues related to machinery at work Students, professionals with jobs • Neurological status is the most important indicator of risk involving complex cognitive demands • X-rays/CT scans do not always identify damage or complications Skilled persons • Intracranial haemorrhage can safely be ruled out only by CT/MRI scan Individuals with psychiatric histories • Patients should only be discharged: and/or personality types When fully alert With competent observer who can arrange prompt reassessment Alcohol/drug dependence With written advice sheet Previous concussion or head injury Head-injured individuals should be warned that post-concussion symptoms are to be expected • Athletes will need clear advice about length of time off. Guidelines based on neurological assessment have been published (available on ACC’s Injury Prevention website www.sportsmart.org.nz) • Concussion may be missed in patients with other life-threatening conditions or multiple injuries

Complications • Post-concussion syndrome (decreased concentration, headaches, sleepiness, fatigue, irritability, dizziness) • Cerebral contusion • Intracranial haemorrhage – operable (subdural, extradural, some intracerebral haematomata) • Intracranial haemorrhage–inoperable (traumatic subarachnoid haemorrhage) • Post-traumatic epilepsy • Persistent hearing loss/sensory problems • Risk of Second Impact Syndrome (a second blow to the head, while still suffering the effects of a prior concussion, can cause serious cerebral oedema out of proportion to the energy of the second injury)

History • Mechanism of injury: Force of impact Distance of fall Vehicular speed • Pattern of patient’s clinical course from time of injury • Current clinical and neurological status • Loss of consciousness Patient’s recollection of events: Retrograde/anterograde amnesia • Associated injuries especially cervical spine • Recreational drug use (including alcohol) • Current medications especially Warfarin and allergies continued overleaf...

ACC Treatment Proﬁles – 2001 Concussion S6o.. Concussion

• Co-morbidities, including psychiatric history • Presence of associated symptoms: Lightheadedness Vertigo Tinnitus Blurred vision/diplopia Headache Nausea/vomiting Photophobia Balance disturbance • Duration of symptoms if post-concussion

Examination • Initial focus on airway, breathing (respiratory rate, O2 sats) and circulation (blood pressure and pulse rate)

• Neurological state: Glasgow Coma Scale score Pupils Focal neurological signs in limbs Assessment of II, III, IV, VI, VII, VIII cranial nerves Assessment of cerebellar function

• Head and neck examination: Nose (CSF rhinorrhoea) Ears (haemotympanum) Cervical tenderness

• Mental status: Orientation Immediate memory Concentration Delayed recall • Look for basal skull fracture signs: Bilateral periorbital bruising (Raccoon’s eyes) Blood or CSF from nose, ear, or blood behind ear drum Bruised mastoid area (Battle’s sign) • Exclude other injury • Test speech, vision, co-ordination • Drug/alcohol intoxication

Differential Diagnosis • Intracranial haemorrhage: Extradural Subdural Intracerebral • Stroke (CVA) • Drug and/or alcohol intoxication • Psychiatric disorder • Post-ictal • Metabolic disturbance eg hypoglycaemia • Other medical causes eg infection continued overleaf...

Concussion S6o.. ACC Treatment Proﬁles – 2001 Concussion

Investigation RED FLAG: Referral for CT head scan if: The decision to refer for urgent CT head • Focal neurological signs scan must be strongly influenced by • Deteriorating level of consciousness (as assessed by GCS score) multiple factors. If any doubt exists the • All patients with GCS <13 patient should be discussed with local • All patients GCS 14 (drowsy, confused) with failure to improve at 3-4 hours (NB these patients will need admission for close observation anyway) emergency physician or neurosurgeon. • Suspected or proven penetrating head injury • Patients in whom neurological assessment is difficult (due to alcohol or RED FLAG: other drug use, language difficulties) If intracranial injury is suspected, • Persistent associated symptoms CT is the examination of choice. Severe headache Vomiting • Compound head injury

Skull X-ray: • Possibility of depressed skull fracture in otherwise well patient (impact with sharp objects or objects with small surface area) • Young children with normal conscious state and clinical suspicion of fracture • Suspicion of compound skull fracture where conscious level normal and CT scan unavailable (due to distance) • Cervical spine X-ray if indicated • Audiogram if hearing loss

Treatment Resuscitation: Assess airway, breathing and circulation and treat as appropriate Prevent hypoxia and hypotension Attention to other injuries • Stabilise cervical spine if indicated • Urgent referral if indicated for CT head scan +/- admission

High risk: • Protect and X-ray cervical spine if drowsy • Stabilise ABC • Urgent head CT • Refer to neurosurgeons promptly

Moderate risk: • CT is the optimum investigation • Consider skull X-ray only if CT unavailable • Fracture – discuss with neurosurgeon • No fracture – observe for 4 hours then reassess • Ongoing observation for deterioration continued overleaf...

ACC Treatment Proﬁles – 2001 Concussion S6o.. Concussion

Low risk: • Check thoroughly, observe • No need for X-ray or CT • Discharge with advice sheet • Must have observer to check frequently“The Grey Zone” A senior MO should review the case. • Neurological observation if history of recent loss of consciousness, with regular reviews and documentation • Mild analgesia (avoid aspirin) • Admission if deterioration • IV line if signs of deterioration

If not hospitalised: Education and explanation to patient and carer Discharge to competent/responsible caregiver Simple analgesia (regular paracetamol, avoid aspirin) Regular reviews Avoid driving of motor vehicle until review at 24-48 hours

Referral to Specialist • All high-risk patients

Requirement for urgent CT head scan: To local emergency department/neurosurgeon • Requirement for close observation (will be influenced by time of day/night, presence or absence of responsible carers, nature of injury, age and social situation of patient): Hospitalise (inpatient speciality according to local practices)

• Refer or discuss if: Skull fracture Not fully recovered after 4 hours (including presumed intoxication) Inadequate support and observation at home for next 20 hours Lives too far from hospital ((45mins) for prompt return Abnormal CT scan Neurological observations show a decline in consciousness/ responsiveness • Neurologist or psychologist referral if: Persistent neuropsychological issues (emotional, sleep, stress disorders) Children with behavioural or educational issues

Other Referral • Audiology as indicated

Concussion S6o.. ACC Treatment Proﬁles – 2001 Head Injury Risk Group

KEY POINTS HIGH RISK • 2% of all head injuries, 30% have intracranial injury • Drowsy/confused (GCS<14) • Focal neurological signs • Delayed convulsion • Deteriorating recordings or symptoms eg GCS fall by 2 pts • Penetrating skull injury or palpable depressed fracture • Basal skull fracture signs: Bilateral periorbital bruising (Raccoon's eyes) Blood or CSF from nose, ear or blood behind ear drum Bruised mastoid area (Battle's sign)

MODERATE RISK • 23% of all head injuries, 4% have intracranial injury • GCS 14 • Severe or worsening headache especially if accompanied by vomiting • Serious facial injury Suspected impingement on to brain tissue: Scalp injury/assault with firm, pointed object Gunshot, missile, shrapnel Possible depressed skull fracture • Bleeding disorder or anticoagulation • Unreliable history of injury (eg language difficulties)

MINOR RISK • 75% of head injuries, minimal risk of intracranial injury • None of the above criteria • Mild headache • Dizzy • Scalp haematoma/laceration/contusion/abrasion ONLY

"THE GREY ZONE" Any history of: Loss of consciousness (KO'd, amnesia) Recurrent vomiting

ACC Treatment Proﬁles – 2001 Head Injury Risk Glasgow Coma Score

Eye Opening Points

Spontaneous 4 To speech 3 To pain 2 Nil 1

Best Motor Response

Obeys commands 6 Localises to pain 5 Withdraws to pain 4 Abnormal flexion 3 Extensor response 2 Nil 1

Verbal Response

Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 Nil 1

Maximum possible score 15 Minimum possible score 3

ACC Treatment Proﬁles – 2001 Glasgow Coma Score Post-Concussion Syndrome Read Code: E2A2.

KEY POINTS • May occur even after relatively minor head injury • Recovery may be slow (1-3 months) • 5% may still be impaired at 2 years

Complications • Psychosocial problems • Work difficulties

History • Head injury • Headache • Decreased concentration, memory difficulties • Sleep disorder • Easily fatigued • Irritability/aggression • Anxiety/depression/affective disorder • Dizziness, tinnitus, vertigo • Photophobia, blurred vision • Social, relationship dysfunction • Occupational difficulties • Previous psychiatric history • Symptoms worse after work/exercise • Onset/worsening of symptoms after head injury

Examination • Rule out intracerebral pathology

Differential Diagnosis • Psychiatric conditions • Chronic fatigue syndrome

Investigation • Consider CT scan • Referral for psychometric testing

Treatment • Education of family and caregivers • Assessment of work safety

Referral • For psychometric testing – attention, memory difficulty • Psychiatrist • Neurologist if symptoms >21 days • Head Injury Society

ACC Treatment Proﬁles – 2001 Post-Concussion Syndrome E2A2. Tympanic Membrane Perforation Read Code: F542.

KEY POINTS • Tympanic membrane heals best if kept clean and dry (water raises risk RED FLAG: of infection) When direct trauma to the ear is • Baro-trauma from diving should be discussed with dive medicine associated with sensori-neural personnel/ENT specialist • SCUBA divers with abrupt onset of balance disturbance while diving hearing loss and/or vertigo the should be referred urgently patient should be referred and • Most ruptures of the tympanic membrane heal spontaneously within 2- surgery may be required 3 weeks; failure to heal is usually due to loss of tissue or infection • Perforations due to welding sparks often fail to heal and should be referred • Aural or oral antibiotics are not indicated unless presence of infection (or perforation occurs in contaminated or tropical waters)

Complications • Chronic perforation with hearing loss • Infection • Ossicular injury • Permanent hearing loss • Cholesteatoma formation

History • Mechanism of injury: Blow to ear (especially open hand) Welding sparks Foreign body insertion Baro-trauma Syringing • Concurrent ear infection • Previous ear disease/hearing impairment • Tinnitus/vertigo • Tetanus immunisation status

Examination External ear: Signs of blood or mucous discharge External ear canal: Lacerations • Tympanic membrane (site and extent of rupture) • Temperature • Assessment of hearing • Nystagmus • Tuning fork tests – Rinne and Weber

Differential Diagnosis • Fractured floor of skull with bleeding from behind tympanic membrane • Tympanic membrane rupture associated with otitis media • Pulsatile discharge in external auditory canal • Laceration to ear/canal • Bleeding from behind tympanic membrane (haemotympanum) continued overleaf...

ACC Treatment Proﬁles – 2001 Tympanic Membrane Perforation F542. Tympanic Membrane Perforation

Investigation • Usually none • If concerns of inner ear damage or persistent impairment of hearing after perforation healed–audiogram

Treatment • Keep ear clean and dry: Use cotton wool plugs with vaseline if necessary or cup over ear when showering • Aural/oral antibiotics not indicated unless infection present (or perforation occurs in contaminated or tropical waters) • Avoid immersion of head until healed (most heal within 2-3 weeks) • Review until healed, initially 2 weekly then monthly • Audiology when healed – expect healing in 4 weeks • Tetanus prophylaxis as indicated – see Lacerations/Abrasions Overview

Referral to Specialist Urgent referral to Dive Medicine/ENT if: • Significant history of baro-trauma especially if associated with balance disturbance or other history of decompression illness or sensori-neural hearing loss.

Urgent referral to otorhinolaryngologist (ENT specialist): • Tympanic membrane perforation and evidence of ossicular disruption (vertigo, persistent nystagmus, tinnitus) • If perforated when syringing • If the edges of the perforation are ragged and hang into the middle ear referral is necessary because of the late complication of cholesteatoma formation. The referral needs to be within the first few days following injury • Sensori-neural hearing loss and vertigo suggesting perilymphatic fistula

Delayed referral to otorhinolaryngologist (ENT specialist): • Persistent hearing impairment after perforation healed • Failure of perforation to heal by 1 month • Perforation due to welding injury as failure to heal is common • If perforation related to diving, careful assessment for evidence of decompression illness and referral to Hyperbaric Medicine Unit as appropriate

Other Referral • Audiologist

Tympanic Membrane Perforation F542. ACC Treatment Proﬁles – 2001 Loss of Teeth (Accident)/Broken Teeth Read Code JO510/S8363

KEY POINTS • Prevention is preferable to repair – encourage sports players to wear mouthguards • Avulsed permanent teeth should be replanted as soon as possible • Intact avulsed teeth have excellent chance of reimplantation if within 4 hours • Attempt to find all avulsed teeth and tooth fragments • Keep avulsed teeth moist in buccal cavity or milk, but preferably replant tooth • Never handle avulsed teeth by the root • Do not discard teeth or remove loose teeth • Consider associated mandibular or maxillary fracture plus other injuries • Check teeth if there is an injury to the mucosal aspect of lip and ensure careful oral examination • All dento-alveolar injuries require referral to a dentist

Complications • Loss of dentition • Infection of gum or pulp/root infection in tooth fractures • Painful TMJ, headaches • Death and/or discolouration of re-implanted tooth

History • Mechanism of injury: Fall Direct blow • Time of injury • Initial first aid • Facial or mouth injury • Associated injuries • Tetanus immunisation status

Examination • Oral cavity – especially tongue and upper and lower labial sulci (stripping lacerations often contain FBs) • Lips – examine under anaesthesia for tooth fragments • Alignment of teeth and bite • Loose/missing teeth – beware apparent avulsed/lost tooth – check inside socket for impaction or backward displacement • Bleeding socket – check for impaction • Examine for mandibular and maxillary fracture • Facial nerve function

Differential Diagnosis • Pulpitis • Dento-alveolar abscess • Gingival inflammation • Alveolar osteitis (dry socket post extraction) • Erupting teeth • Chipped teeth • Fractures of maxilla/mandible • Dental caries, loss of filling continued overleaf...

ACC Treatment Proﬁles – 2001 Loss of Teeth (Accident) JO510/S8363 Loss of Teeth (Accident)/Broken Teeth

Investigation • Chest X-ray if concern about possible tooth or tooth fragment aspiration • Dento-alveolar injuries – intra-oral X-rays (ordered by dentist) • Mandibular injury – OPG, PA and lateral X-rays +/- occlusal views • Maxillary fractures – facial X-rays

Treatment • Find and assess avulsed teeth – handle by crown NEVER by ROOT • Gently wash off dirt with saline • Transport tooth as appropriate – best location is in socket if tooth intact – replace firmly, stabilise with aluminium foil. Next best is in saline, then milk, or plastic wrap • Apply pressure to bleeding tooth socket • Simple analgesics as necessary

Avulsed teeth: Do not attempt to replace if primary dentition Permanent dentition: Long-term prognosis depends on early reimplantation Don’t allow to dry out Gentle irrigation under running water/saline for 15 seconds Replant tooth in socket Refer immediately to dentist • Broken teeth – may require temporary cover depending on extent of damage • Do not reimplant fragments of tooth – refer, especially if red spot present = pulp laceration • Repair skin lacerations with 6/0 nylon and 5/0 absorbable suture to muscle eg undyed polyglactin to muscle, prior to reimplantation • Tetanus prophylaxis if indicated – see Lacerations/Abrasions Overview

Referral to Specialist/Dentist • Avulsion of secondary teeth where teeth are available should be referred urgently • Avulsion of primary teeth can be referred non-urgently • Urgent referral if exposed pulp injury • Dentine-only injuries can be referred non-urgently • Refer urgently if infection present • To faciomaxillary surgeon (or as per local referral practices) if mandibular or maxillary fracture

Loss of Teeth (Accident) JO510/S8363 ACC Treatment Proﬁles – 2001 Foreign Body in Skin or Subcutaneous Tissue Read Code M2y5.

KEY POINTS • Wounds should not be closed if foreign material not completely removed • Most wounds contaminated by <100,000 bacteria/g of tissue heal uneventfully following repair • Good irrigation and a clean technique for repairing wound is essential • Foreign matter greatly enhances the infectivity of a given bacterial inoculation • The procedure is nearly always more difficult than it first appears • Use bony landmarks for identifying location of foreign body (seen on X-ray) • Not all foreign bodies require removal • Glass is nearly always radio-opaque • Historical details are important so appropriate type of imaging is performed if required

Complications • Incomplete removal of foreign body(ies) • Neurovascular injury • Infection locally and via tissue planes • Retained foreign bodies are a common complication of simple wound repair and a frequent source of medical misadventure complaints against emergency doctors

History • Mechanism of injury • Nature of foreign body: Metal Glass Wood Organic eg flax, grass Plastic • Timing of injury • Velocity of foreign body entry • Injury on glass, metal • Penetrating injury eg wood/stick/thorn/palm • Tetanus immunisation status

Examination • Palpate for foreign body • Localise tenderness • Look for puncture wound • Foreign body may be seen in the wound or on X-ray • Neurovascular assessment before surgical exploration • Presence of infection • Assess for signs of injury to deeper structures: Sensory deficits Tendon injuries Vascular compromise

Differential Diagnosis • Laceration • Abscess • Tumour • Infection • Insect bite • Cellulitis continued overleaf...

ACC Treatment Proﬁles – 2001 Foreign Body in Skin M2y5. Foreign Body in Skin or Subcutaneous Tissue

Investigation • If likely foreign body radio-opaque – X-ray area • If likely foreign body non-radio-opaque – ultrasound area • May require MRI for plastic foreign body as density similar to tissue • Although radiographic studies will identify all retained metallic fragments and more than 90% of glass foreign bodies, retained wood and plastic are often detected only by wound exploration

Treatment • Consider leaving open if foreign body not completely removed or wound has been heavily contaminated • Antibiotics are indicated for wounds with a high probability of becoming infected(>10%). This includes wounds repaired more than 12 hours after injury and involving body areas other than the head, for heavily contaminated wounds, and for wounds in patients with immunocompromising conditions or taking immunosuppressive drugs • Referral as necessary if neurovascular compromise

Superficial or open wound: • Explore under local anaesthetic, remove foreign body then treat as normal open wound • Factors to be considered in the decision to either close primarily or to delay repair include host factors (age, general health, presence of immunocompromising conditions and immunosuppresive drugs) and wound factors (likelihood of significant bacterial infection, degree of contamination by soil or other organic debris, time since injury, mechanism of injury and site of wound)

Deeper foreign bodies: • May need exploration under regional or field block with an ischaemic field (tourniquet). This requires greater expertise and time and may justify referral • If possible remove under local anaesthetic and then treat as normal open wound • Daily/alt day dressings, monitor healing • Check tetanus status and decide whether wound is tetanus prone • Consider antibiotics for pseudomonas prone wounds (foreign body/penetrating wound to the sole of the foot via rubber soled shoes) • Soil contaminants are removed by copious irrigation which will significantly help healing by decreasing the infection risk • If the wound is not healing consider: infection, toxic substance, retained foreign body or neoplasm

Referral to Specialist To orthopaedic/general/paediatric surgeon as per local practice: • Deep foreign body needing removal • Child requiring GA • Beyond competence to remove • Significant neurovascular injury • Inappropriate to remove foreign body due to: Lack of equipment Time required Complexity of procedure due to site involved and expertise • Involvement of deeper structures: Major vessel Nerve Tendon Joint/bone

Foreign Body in Skin M2y5. ACC Treatment Proﬁles – 2001 Corneal Abrasion/Corneal Foreign Body Read Code: SD810/SG00.

KEY POINTS • Always assess and record visual acuity before intervention • If blunt or penetrating injury check deeper ocular structures • Do not remove a protruding intraocular foreign body • 24-hour follow-up required and daily review until healed • History of metal vs metal and eye symptoms requires X-ray to exclude intraocular foreign body • Check under lids and double evert upper lid • Always examine after staining with fluorescein • Advise patient of need to wear eyepad or shield eye until anaesthetic drops have worn off – 1-2 hours usually • Photophobia may persist for several days after corneal injury (avoid bright lights, direct sunlight, TV) • Use of pad is contentious for corneal abrasion • Driving is not permitted with a padded eye • Low threshold for specialist referral if slit lamp biomicroscope not available or if not confident • Continued use of local anaesthetic drops delays epithelialisation, decreases protective reflexes, can cause keratitis – do not give to patients to use

Complications • Missed metallic intraocular foreign body leading to siderosis • Infection • Cataract • Corneal instability – recurrent corneal abrasion at site of original abrasion • Loss of vision • Scarring of cornea reducing visual acuity • Secondary opthalmoplegia, glaucoma • Persisting rust ring • Prolapsed iris and risk of intraocular infection with persisting eye wounds

History • Nature of foreign body in eye • Mechanism of injury to eye – blow, gardening, fighting, dust, debris, chemical burns • Time of injury • Site of pain – beware unilateral painful red eye • Watering and photophobia • Metal on metal or welding • Use of protective eyewear • Occupational history • Contact lenses • Tetanus status • Foreign body sensation (irritation, watering/photophobia) • Previous eye problems • Co-morbidities • Medications and allergies

Examination • Visual acuity (bilateral with pin hole/glasses) • Inspect under lids by eversion • Pupil regularity and reactions bilaterally continued overleaf...

ACC Treatment Proﬁles – 2001 Corneal Abrasion/Foreign Body SD81o/SGoo. Corneal Abrasion/Corneal Foreign Body

• Inspect conjunctiva, cornea with magnification, stain with fluorescein, blue light, slit lamp if available • Circumcorneal injection – may indicate more severe pathology eg iritis • Iris, anterior chamber (check for cells, flare, macroscopic/microscopic hyphaema/hypopion) • Fundoscopy – lens, vitreous, retina • Cold compress may reduce blepharospasm • Local anaesthetic drops may facilitate examination • Periorbital/other facial structures

Differential Diagnosis • Conjunctivitis • Corneal ulcer – herpetic, marginal • Corneal burn • Iritis • Keratitis – actinic, punctate • Trichiasis • Entropion • Contact lens trauma • Acute glaucoma

Investigation • X-ray if intraocular foreign body suspected (specify up/down gaze views) • Swab – if infection

Treatment • Instil topical anaesthetic drops to facilitate adequate examination and treatment • Eye should be double padded until anaesthetic wears off (1-2 hours) • Eye padding for longer remains somewhat controversial but tendency is not to pad • Regular systemic (oral) analgesia will usually be required • Tetanus prophylaxis as indicated – see Lacerations/Abrasions section • Follow up until healed

Abrasion: • Irrigate with saline if indicated • Confirm size and location by fluorescein staining • Remove foreign material if necessary • Larger abrasions with ciliary muscle spasm – short acting mydriatics (cyclopentolate 1% tds) will provide some relief of discomfort • If abrasion >30% cornea or over visual axis, refer to ophthalmologist for follow-up • Otherwise daily follow-up until healed (usually 24-48 hours) • Caution with abrasions involving organic material (eg while gardening) as fungal infection may develop • Instil A/B ointment, continue qid 48 hours • Pain relief continued overleaf...

Corneal Abrasion/Foreign Body SD81o/SGoo. ACC Treatment Proﬁles – 2001 Corneal Abrasion/Corneal Foreign Body

Corneal foreign body: • Irrigate with saline • Instil topical anaesthetic drops • Stabilise head (preferably seat patient at slit lamp) • Excellent magnification and lighting required • Short acting mydriatic eg Cyclopentolate 1% tds for ciliary spasm • Remove foreign body using cotton bud, hypodermic needle or dental burr • Inspect for rust ring, remove following day • A/B ointment, continue qid 48 hours • Pain relief • Daily follow-up until healed

Chemical agent: • Instil LA drops • Irrigate with water/saline for 15-20 minutes, using >1000ml then refer immediately (as per eye specialist). Continue irrigation until pH 7.0-7.4, recheck after 10 mins. If uncertainty about pH in alkali burn continue irrigation during transfer to hospital

Intraorbital foreign body: If obvious – refer immediately. Do not examine further. Prevent further injury – stabilise head, apply eyeshield – commercial or styrofoam cup • DO NOT REMOVE protruding FB • Pain relief (consider narcotics) • Anti-emetic to prevent raised IOP

Referral to Specialist Urgent referral to ophthalmologist: • Impaired VA not corrected with pin hole or persisting corneal defect after 48 hours • All full thickness abrasions/lacerations • Significant infection • Intraocular foreign body • Penetrating eye injury • Hyphaema • Corneal abrasion >30% cornea or over visual axis • Central visual axis abrasion or foreign body • Unable to completely remove foreign body • Vitreous haemorrhage suspected

Delayed referral to ophthalmologist: • No improvement in size of corneal abrasion at 24 hours

ACC Treatment Proﬁles – 2001 Corneal Abrasion/ Foreign Body SD81o/SGoo. Foreign Body in Ear/Foreign Body in Nose Read Code: SG1../SG2..

KEY POINTS • Try to ascertain nature of foreign body • In nose/ear attempt to get probe/hook behind foreign body. Do not use forceps • The procedure is nearly always more difficult than it first appears • Good lighting, correct instruments and possibly additional staff member to reassure person during procedure • Avoid repeated attempts • Wounds should not be closed if foreign material not completely removed Ear: Mostly children Most hard, round objects (eg beads) Rarely cause problems until unskilled removal is attempted Can cause permanent damage if child jumps suddenly Nose: Mostly children Most present with unilateral offensive-smelling discharge Foam plastic, beads, calculator batteries, peanuts

• Disc (button) batteries should be removed within 2 hours; caustic leakage can cause injury to epithelium and cartilage • Avoid use of sharp instruments

Complications • Inhalation of foreign body (nose) • Incomplete removal of foreign body • Infection • Damage to tympanic membrane/external auditory canal/ossicular damage • Damage to nasal turbinates/nasal mucosa • Hearing loss

History • Mechanism of injury • Time/date/place of injury • Nature of foreign body • Foul smelling discharge ear/nose • Child placing foreign body up nose or in ear • Insect in ear • Hearing loss/blocked ear • Previous nasal or ear disease • Tetanus immunisation status

Examination • Direct visualisation using headlamp and nasal or aural speculum • Check both sides • Check for damage to ear drum/canal • Tuning fork tests continued overleaf...

ACC Treatment Proﬁles – 2001 Foreign Body in Ear/Nose SG1../SG2.. Foreign Body in Ear/Foreign Body in Nose

Differential Diagnosis • Aural cerumen • Sinusitis • Otitis externa • Intranasal tumour • Cholesteatoma

Investigation • Usually none • X-ray, inspiratory and expiratory views if any suspicion that a nasal foreign body may have been aspirated

Treatment • Do not use sharp hook as may increase damage • Only one person should try removing foreign body • Attempt to get blunt angled probe behind foreign body • Good light source (head lamp), right angled hook (eg paper clip) essential • Tetanus toxoid immunisation if indicated (if abrasion to mucosa) – see Lacerations/Abrasions Overview

Nose: • Administration of a few drops of 4% Lignocaine mixed with a decongestant (eg Otrivine), 5 minutes before removal is helpful • Strong exhalation through nose with contralateral nares occluded, if person co-operative (sneeze) • Use nasal speculum (Thuddicum) if available with good light source (preferably head light) • Remove using flat probe, hook (care as can push object deeper) • Re-examine for signs of mucosal injury or residual foreign body • Low threshold to refer to ENT specialist unless foreign body anterior, good equipment and adequate expertise • Disc (button) batteries remove ASAP – see Key Points

Ear: • Require co-operative, motionless patient • Remove foreign body using canal hook or suction • Live insects can be killed with olive oil, Lignocaine or Ophthalmic Amethocaine drops – useful to provide topical anaesthesia • May need to irrigate ear with warm water • Suction applied if available and by experienced operator (eg ENT Specialist) • Direct visualisation with speculum and good light source • Removal with flat angled probe or microalligator forceps if in lateral half of auditory canal • Do not use forceps unless close to meatus • Syringing with warm water, directed at the posterior wall of the canal may facilitate removal in some cases • Disc (button) batteries remove ASAP – see Key Points • Foreign body in medial half of external auditory canal usually requires greater magnification to prevent damage to the tympanic membrane • If in doubt, safer to refer continued overleaf...

Foreign Body in Ear/Nose SG1../SG2.. ACC Treatment Proﬁles – 2001 Foreign Body in Ear/Foreign Body in Nose

Referral to Specialist • Beyond competence • Risk of damage to ear drum • Failure of one person to remove foreign body • If any suspicion that a nasal foreign body may have been aspirated • Refer to otorhinolaryngologist (ENT specialist) if: Most foreign bodies in young children (occasional GA required) Foreign bodies in medial half of external auditory canal In general, foreign bodies not easily removed • NB Most foreign bodies are successfully removed without a general anaesthetic by ENT specialist

ACC Treatment Proﬁles – 2001 Foreign Body in Ear/Nose SG1../SG2.. Ingested Foreign Body Read Code: SG5..

KEY POINTS • Oesphageal foreign bodies causing complete obstruction are usually caused by meat bolus. There may be underlying oesophageal disease • Distal oesophageal obstruction may present with only occasional regurgitation of saliva • Individuals with persistent symptoms of dysphagia despite normal X-ray and indirect laryngoscopy should be discussed with ENT surgeon to determine appropriate referral • Most ingested foreign bodies in the paediatric age group do not require repeat (serial) X-rays • Children ingesting high risk foreign bodies (very long foreign bodies, sharp foreign bodies, button batteries or heavy metals eg lead) should have their care discussed with a specialist (paediatric surgeon if available) and may require removal of the foreign body by gastroscopy

Complications • Pharyngeal perforation and mediastinitis • Bowel obstruction/perforation

History • Time of ingestion • Nature of agent ingested (if known): Coin Button battery Pins Food bolus Chicken/fish bone • Odynophagia (pain on swallowing) • Dysphagia (difficulty swallowing) • Previous history of same problem • Prior stroke(CVA) • Known oesphageal disease/abnormality • Current medications and allergies

Examination • Observe: Drooling Respiratory distress Continuously spitting Spitting up saliva every few minutes • Level of discomfort: Patient should point to source of pain Helpful if above sternal notch Poor accuracy of localisation if below sternal notch • Palpate neck for tenderness or crepitus • Inspect: Tonsillar fossae Tongue base Piriform fossae (by indirect laryngoscopy) • Auscultate chest if suggested by symptoms continued overleaf...

ACC Treatment Proﬁles – 2001 Ingested Foreign Body SG5.. Ingested Foreign Body

Differential Diagnosis RED FLAG: • Existing oesphageal stricture If it is likely that the food bolus • Other oesphageal disease contains bone, glucagon and/or • Central cause eg stroke carbonated beverage are not • Pharyngeal/oesophageal mucosal abrasion/laceration recommended and the patient • Consider aspiration if respiratory symptoms should be referred for urgent Investigation gastroscopy Obstructed oesophagus in adult • Nil RED FLAG: Paediatric ingestions Although the food bolus may pass into • X-ray chest, neck, abdomen as needed to localise foreign body if radio- the stomach with the above opaque Pharyngeal foreign body in adult treatments, the patient should still • X-ray soft tissues neck have a gastroscopy performed (non- urgent) to exclude oesophageal Treatment pathology Obstructed oesophagus in adult: • A number of agents have been used to relax smooth muscle and allow passage of the food bolus with variable success Glucagon 1mg IV/IM Carbonated beverage orally eg Coke If unsuccessful, or unable to use these agents (see red flag), refer for urgent gastroscopy

Paediatric ingestions: • The majority of swallowed foreign bodies are asymptomatic and pass through the gut without problems • If symptoms of choking, or difficulty swallowing or drooling refer by ambulance to hospital for urgent investigation and treatment • Children who have ingested high-risk foreign bodies (very long foreign bodies, sharp foreign bodies, button batteries, heavy metals eg lead) need close follow-up and may need urgent gastroscopy. Their care should be discussed with a paediatric surgeon or referral as per local practices.

Pharyngeal foreign body in adult: • Often sharp – chicken/fish bone • Occasionally may be seen on X-ray • If no foreign body seen on X-ray or on indirect laryngoscopy but persistent symptoms, telephone consultation with ENT specialist is recommended and F/U as agreed (may be delayed a few days) • If foreign body seen, referral to ENT specialist may be necessary for removal

Referral to Specialist Obstructed oesophagus in adult: • To gastroenterology/ ENT specialist – as per local referral practices (usually distal to gastroenterologist and proximal to ENT although referral practices vary) continued overleaf...

Ingested Foreign Body SG5.. ACC Treatment Proﬁles – 2001 Ingested Foreign Body

Paediatric ingestions: • All oesphageal foreign bodies – to ENT specialist or paediatric surgeon as per local referral practice • Some foreign bodies below diaphragm eg button battery, very long foreign bodies, sharp foreign bodies, heavy metals (lead) – urgent specialist referral (paediatric surgeon if available) for close observation/gastroscopy

Pharyngeal foreign body in adult • To ENT specialist

ACC Treatment Proﬁles – 2001 Ingested Foreign Body SG5.. Toxic Ingestions (Activated Charcoal) – Treatment Protocol Read Code: SL...

The Management of Toxic Ingestions with Activated Charcoal • Identify the poison • Contact National Poisons Centre - Telephone 03 474 7000 • If toxic dose taken, give activated charcoal as detailed below Available as CARDSORB (see New Ethicals) • If Activated Charcoal given, refer patient to local Emergency Department • Don’t use Ipecacuana

Activated charcoal is the primary method for the gastrointestinal decontamination of the majority of toxic ingestions. Chemical processes increase its surface area and enable Activated Charcoal to adsorb a wide range of toxic compounds preventing or reducing their absorption by the gastrointestinal tract.

Activated Charcoal is effective for a wide range of compounds, and it is easier to list those for which it is not effective. The following is a list of compounds for which activated charcoal is not indicated: • Acids/alkalis • Hydrocarbon compounds (eg alcohols, glycols, petroleum distillates) • Ionised compounds (eg iron, fluoride, potassium, lithium)

Activated charcoal is administered orally, and while it may be instilled via a nasogastric tube, this should be performed following consultation with the National Poisons Centre or a local Emergency Physician.

Contraindications • Activated charcoal is contraindicated when: Bowel sounds are absent The toxic compound is not effectively bound by Activated Charcoal

It is recommended that the National Poisons Centre (NPC), or its guidelines, be consulted prior to the use of Activated Charcoal to ensure its effectiveness for the substance involved.

Dosage Recommendations for the Treatment of Toxic Ingestions Dosage Guide: • The usual recommendation for single-dose Activated Charcoal is: Children – 1g/kg Adults – 50g

Use of Activated Charcoal solutions with cathartics (eg sorbitol) is not recommended.

Activated Charcoal is most effective if administered while a toxic ingestant is still in the stomach. As liquids transit more quickly than solids, the window of opportunity for administering Activated Charcoal is smaller for liquids. It is therefore recommended that for: continued overleaf...

ACC Treatment Proﬁles – 2001 Toxic Ingestions (Activated Charcoal) SL... Toxic Ingestions (Activated Charcoal) – Treatment Protocol

Liquids: Activated Charcoal should be administered within half an hour of ingestion, if indicated.

Solids: Activated Charcoal may be administered up to 4 hours after ingestion, and for some compounds, longer.

Method Activated Charcoal is administered orally. Children may object to drinking the black and gritty solution. It is therefore recommended: • children be encouraged in a firm, friendly manner, preferably in the presence of a caregiver • use of a straw with an opaque, covered container to increase acceptance

As a last resort a flavouring agent (eg a flavoured drink) may be added to increase palatability but this will decrease the effectiveness of the Activated Charcoal.

If a child will not accept Activated Charcoal, nasogastric intubation to instil Activated Charcoal should not be routinely attempted.

Nasogastric Intubation Instillation of activated charcoal via nasogastric intubation is only recommended for highly toxic compounds which meet all of the following requirements: • are readily absorbed to Activated Charcoal • have no antidotes • the time-frame is acceptable • symptomatic and supportive care alone is unlikely to lead to a satisfactory outcome

All cases should be discussed with the NPC or a local emergency physician prior to attempting the procedure.

Adverse Effects The major adverse effect of single-dose Activated Charcoal is inadvertent aspiration of charcoal that may lead to asphyxia or bronchiolitis obliterans.

National Poisons Centre The National Poisons Centre is available to give advice 24 hours a day, seven days a week. Telephone 03 474 7000.

Toxic Ingestions (Activated Charcoal) SL... ACC Treatment Proﬁles – 2001 Toxic Reaction Bee Sting Read Code: TE532

KEY POINTS • Reaction may be local, urticarial without systemic reaction or generalised/systemic reaction • Sting to cornea may cause more serious damage • Oxygen, adrenaline, fluids for anaphylaxis • Generalised toxic reaction – observe closely, usually admit to hospital • Stings to throat or mouth may cause airway obstruction

Complications Local: • Erythema, infection • Impaired circulation in distal extremity from secondary oedema • Corneal ulceration (from corneal sting) • Retained FB (stinger), granuloma, skin necrosis

Generalised: • Serum sickness-like illness at 10-21 days • Unusual complications include encephalopathy, neuritis, vasculitis, nephrosis, coagulopathy, renal failure • Anaphylaxis

History • Time/number of stings (>30 stings more likely to be fatal) • Past history of stings (most fatalities occur in patients with a history of recent sting causing severe/generalised reaction) • Identify insect • Position of sting (face/body) • Past history of anaphylaxis • Tetanus immunisation status • Current medication and allergies • Symptoms of itching, sneezing, tongue swelling, shortness of breath

Examination • Vital signs: pulse rate, blood pressure, respiratory rate and level of consciousness • Skin rash • Presence of stings – number and site • Site/s of sting/s for erythema and swelling, check if sting still in place • Circulation distally • Signs of shock: poor tissue perfusion, confusion, hypotension • Signs of anaphylaxis: see treatment protocol in this section

If Generalised: • Pharyngeal, facial, neck oedema • Hypotension • Airway obstruction • Arrhythmias • Abdominal signs continued overleaf...

ACC Treatment Proﬁles – 2001 Toxic Reaction Bee Sting TE532 Toxic Reaction Bee Sting

Differential Diagnosis • Urticaria • Other invertebrate bite especially ants, wasps, spiders • Localised infection • Other causes of anaphylaxis, circulatory collapse • Corneal abrasion/laceration – if corneal sting

Investigation If generalised reaction: • Pulse oximetry • Cardiac monitor

Treatment • Remove stinger – don’t squeeze • Resuscitation, treat as appropriate

Local: • 20% aluminium sulphate cream/spray (Stingose) – denatures venom • RICE and paracetamol

• Localised reaction: Large local reaction may benefit from systemic steroids for 2-3 days Sting to eye – refer for assessment Sting to mouth or pharynx – observe closely for airway obstruction Antihistamine • Generalised toxic reaction (due to multiple stings): Supportive care May require adrenaline if features of anaphylaxis (bronchospasm or hypotension) Usually hospitalise for more prolonged observation as other organ dysfunction may develop Anaphylaxis (see Treatment Protocol this section): • Adrenaline • Oxygen, antihistamine, steroid, fluid resuscitation

Other: • Mouth or throat sting be prepared for intubation • If generalised symptoms continue for 2-4 hours refer • Consider prescription of Anakit for subsequent emergency treatment • Consider medicalert bracelet • Tetanus prophylaxis if indicated – see Lacerations/Abrasions section

Referral to Specialist • Consider emergency paediatric transfer if <14 years • If anaphylaxis, generalised toxic reaction, or airway obstruction – to local emergency department • Sting to eye – discuss with ophthalmologist or refer directly • Delayed referral to allergy specialist if severe – life-threatening anaphylaxis for assessment • Slow response to treatment or relapse (systemic reaction) • Pregnant with systemic reaction • Immunocompromised/other serious medical problems

Toxic Reaction Bee Sting TE532 ACC Treatment Proﬁles – 2001 Dog Bite/Human Bite/Cat Bite Read Code: TE60./U120.

KEY POINTS • Infection risk with all bites (cat bites 75%; human and dog bites 5-20%) • Human bite risk factors MCP joints => ascending tendon infection Tooth vs head in child => subgaleal (scalp) infection Finger => deep tendon infection

• Animal bite risk factors: High risk: Hand, wrist or foot Scalp in infants (risk of skull penetration) Over joint Punctures and heavily crushed injuries Age >50 years Co-morbidities (asplenia, chronic alcoholic, diabetic, immunocompromise, peripheral vascular disease) Low risk: Face Large, minimally contaminated wound, easily irrigated Superficial wounds and abrasions

• Adrenaline in local anaesthetic and deep sutures increase infection rate • Critical treatment strategy is thorough wound cleansing • Teeth fragments may be in wounds • Erythromycin is not an appropriate antibiotic for bite wounds • Consider rabies exposure if bite occurs in rabies endemic country • Close follow-up at 24-48 hours advisable especially with cat bites • Check tetanus status

Complications • Infection – fulminant sepsis, DIC, renal failure in those immunocompromised • Cat scratch fever (Bartonella henselae) • Nerve, vessel, muscle, bone and joint injury • Septic arthritis

History • Mechanism of injury • Time since injury • Age of patient • Affected body part • Medical history: Asplenia or liver disease Metabolic or circulatory problems Immunocompromised • Tetanus immunisation status • Species of mammal • Associated injuries • History of possible exposure to rabies (bite in foreign country with incidence of rabies) • Consider child/domestic abuse continued overleaf...

ACC Treatment Proﬁles – 2001 Dog Bite/Human Bite/Cat Bite TE6o./U12o. Dog Bite/Human Bite/Cat Bite

Examination • Site (check for multiple sites) – consider injuries to dorsum of MCP joint as human bite wounds until proven otherwise • Nature of wounds, depth, foreign body, tissue loss • Explore wounds over nerve, bone, tendon, joint, artery • Assess movement, circulation, nerve supply • Palpate for evidence of gas in tissues • Extent of bleeding • Penetration/injury to joint • Evidence of active infection • Cellulitis or systemic toxicity if delayed presentation

Differential Diagnosis • Other causes of lacerations/puncture wounds • Cellulitis

Investigation • Usually none • If evidence of active infection – swab for culture and sensitivity • If concern about bony involvement/penetration of joint or teeth in wound – X-ray • Blood culture if toxic • Consider CT for skull bites in children

Treatment • Stop bleeding • Infiltrate local anaesthetic (plain) as needed to ensure well-anaesthetised area • Remove foreign material and obviously necrotic material, NB meticulous debridement with as much tissue preservation as possible • Copious irrigation with saline or povidone-iodine 10% solution (diluted with saline to 1 part povidone-iodine and 10-20 parts saline). Irrigation through a 19-20 gauge needle, 50 ml syringe. The amount necessary – 100-250mls, or more depending on degree of contamination • Closure (avoid deep sutures, may need delayed primary closure at 3-4 days if high-risk wound – see Key Points) • Suspicion of exposure to rabies – discuss with infectious disease specialist • Tetanus prophylaxis if indicated – see Lacerations/Abrasions section • Pressure bandage dressing • Immobilise and elevate if appropriate • Review daily for 3-5 days • Treat associated injuries as appropriate

Dog bites: • Usually primary closure unless: >12 hours old Puncture wounds Hand lacerations High-risk wound, see Key Points Almost always close bites on face continued overleaf...

Dog Bite/Human Bite/Cat Bite TE6o./U12o. ACC Treatment Proﬁles – 2001 Dog Bite/Human Bite/Cat Bite

• Antibiotic prophylaxis – controversial. Usually not necessary unless high risk factors, see Key Points. Amoxycillin with clauvulanate. If penicillin allergic, cotrimoxazole or doxycycline +/- metronidazole or clindamycin 3-5 day course

Human bites: • Primary closure usually avoided unless cosmetic concerns (eg facial bite) • Prophylactic antibiotics usually indicated except for the most superficial human bite wounds – see above. • The common punch injury with wound over dorsum of MCP joint is notoriously prone to infection and septic arthritis – urgent specialist referral advised

Cat bites: • Usually puncture wounds with deep penetration • Avoid closure • High infection incidence • Prophylactic antibiotics usually indicated unless minor scratch – see above • Close follow-up

Referral to Specialist • Spreading cellulitis if not responding to treatment • Nerve damage • Penetration of joint • Significant ear/nose damage • Asplenia or liver disease if infected • Hand and foot wounds if infected • Facial bite wounds (especially children) where optimal cosmetic result imperative – to plastic surgeon • Extensive wound/s requiring considerable time/debridement/exploration – orthopaedic or plastic surgeon • Associated fracture • Infected wound requiring extensive debridement • Wound with significant tissue loss • Many young children who may require sedation or general anaesthetic to facilitate wound care • Punch injuries to dorsum of MCP joint – to orthopaedic (hand) specialist. • Concern about rabies exposure – to infectious disease specialist

ACC Treatment Proﬁles – 2001 Dog Bite/Human Bite/Cat Bite TE6o./U12o. Electrical Injury Read Code TLO1.

KEY POINTS • Electrical injuries can be divided into high voltage (>1000V) and low voltage (<1000V) • Lethal cardiac dysrhythmias occur at the time of exposure • Exposure to electricity depolarises electrically active tissue (cardiovascular and nervous systems) AND burns tissue due to heat generated • Other injuries may result from subsequent trauma eg fall • Individuals suffering high voltage electrical injury should be hospitalised • Individuals suffering low voltage electrical injury may be safely managed in the community providing certain criteria are met – see Treatment section

Complications • Compartment syndrome • Rhabdomyolysis and myoglobinuria • Neurological impairment • Scarring from burns

History • Mechanism of injury: Domestic Industrial Activity involved • Voltage exposure: Low <1000v High >1000v • Time of injury • First aid administered • Pattern of injury • Co-morbidities especially ischaemic heart disease • Medications and allergies • Tetanus immunisation status

Examination • Initial focus on airway, breathing, circulation and neurological state if appropriate • Assess and record vital signs • Assess associated injuries eg if subsequent fall • Secondary survey: Thermal burns (entry/exit wounds) Muscle tenderness Presence of fractures Evidence of neurological impairment Assess for evidence of compartment syndrome

Differential Diagnosis • Other causes of thermal injury continued overleaf...

ACC Treatment Proﬁles – 2001 Electrical Injury TLo1. Electrical Injury

Investigation • 12 lead ECG

Treatment • Resuscitation as necessary • Treat associated injuries as indicated • Analgesia as indicated (opiates may be necessary) • Tetanus prophylaxis as indicated – see Lacerations/Abrasions section

High voltage: • Burns should be cooled for 15 minutes – see Burns section • Then cover with sterile drape • Refer to hospital for admission – close observation, cardiac monitoring • Analgesia as above

Low voltage: • If no loss of consciousness, no evidence of neurovascular or muscle injury, a normal ECG and no history of ischaemic heart disease – patient can be safely discharged • If any of the following are present, the patient should be referred to hospital for further assessment and observation: History of loss of consciousness Neurological injury (motor weakness/sensory deficit) Muscle injury (muscle tenderness/pain/swelling) Vascular injury (acute ischaemia or loss of pulses) Abnormal ECG or history of ischaemic heart disease • Associated injuries may necessitate admission to hospital • Burns should be treated as per Burns section

Referral to Specialist To local Emergency Department: • All high voltage electrical injuries • Some low voltage injuries – see Treatment section

Electrical Injury TLo1. ACC Treatment Proﬁles – 2001 Management of Sexual Assault/ Abuse in General Practice Read Code: SN571

KEY POINTS • Sexual assault/abuse is a crime • A history of sexual assault/abuse is very common in general practice (up to 30% of patients) and such patients are at more risk of both short and long-term negative impact on physical and psychological health • Management commonly (always with children) requires a multi-disciplinary approach with involvement of judicial, child-protective and other social agencies • Management may be forensic as well as therapeutic • Doctors should act within the limits of their training and experience and refer appropriately, particularly if untrained in doing or assessing the need for a forensic examination • ACC has contracted with accredited DSAC doctors to provide free medical assessment of sexual assault • Document carefully – may have medico-legal significance. If first person told of the assault – document verbatim questions and response • Do not ask leading questions and do not seek information beyond that required to attend to the immediate emotional and medical needs of the patient ie do not attempt to take a full and detailed history of the assault

Therapeutic Role of GP • Recognise and treat physical injury • Attend to the emotional impact on patient and family/intimates with non- judgmental supportive approach and provision of appropriate counselling • In New Zealand under the Contraception, Sterilisation and Abortion Act 1977, it is a legal requirement to provide protection against pregnancy after rape • Screen for STDs and/or provide prophylaxis and/or treatment when indicated • Attend to patient safety with appropriate referral to police/child protection agencies/women's refuge/family and friends • Arrange medical follow up to ensure adequate progress in all of the above

Forensic Considerations • A forensic medical examination is a specialised examination undertaken by a forensic medical examiner who is specially trained • It involves taking a detailed history of the assault, a comprehensive physical and genital examination, the collection of samples for a forensic science laboratory and recording of all findings using the protocol and kit supplied by the police • The procedure may take up to 3 hours • The examining doctor is required to give expert opinion for the police and later to a court of law on the significance of any findings in relation to allegations of sexual assault continued overleaf...

ACC Treatment Proﬁles – 2001 Management of Sexual Assault/Abuse SN571 Management of Sexual Assault/ Abuse in General Practice

Practical Advice for Provision of Supportive Approach • Allow patients to tell their story, acknowledge their trauma and that a crime has been committed • Reassure patients that what they are feeling is part of a post-traumatic response. Immediate crisis reactions include numbness, shock, disbelief and anxiety that may last for days to weeks. Subsequent emotional reactions include continued feelings of helplessness, depression, sleep disturbances, nightmares, flashbacks, guilt, self-blame and shame • Patients often feel guilty for not struggling. Reinforce the fact that this may have helped them survive the assault

Three statements that should be part of consultation: YOU ARE SAFE NOW (but don't say this if it is not true) I AM SORRY THIS HAPPENED TO YOU (or in your own words convey empathy and your belief in the worth of this patient) IT'S NOT YOUR FAULT (gently draw attention to how patient is blaming her/himself eg "sounds as if you are blaming yourself for that?")

Management of Sexual Assault/Abuse SN571 ACC Treatment Proﬁles – 2001 Adult Survivors of Abuse or Previous Undisclosed Assault Presentation

KEY POINTS • Spontaneous disclosure by a patient • Disclosure by patient in response to doctor asking “Has anyone ever made you have sex that you didn’t want to and didn’t agree to?” in one of the following situations: A routine question as part of a sexual health history ECP request following non-use of condom Patient has strong negative reaction to genital examination Some chronic or unexplained pain conditions – especially pelvic, gastrointestinal. Patients presenting with mental health problems Significant behavioural, drug or alcohol problems, high grade CIN or pregnancy in adolescent

Management Guidelines • Affirm the patient for having told you. Do not push for full details of the abuse or attempt to deal with all the issues • Inform patient of widespread incidence of sexual abuse to reduce patient feelings of isolation • Ask the patient how the abuse has affected or still is affecting their life and what they want to do about this (if anything). Respect the patient’s decision • Check if the patient (and other family members) is safe now – including in current relationship • Enquire whether a sexual health check – STD screen and/or smear etc – has been done since the assault/abuse. Offer an examination to check physical injuries, scars or medical conditions related to the abuse. Normal findings may address the patient’s unspoken concerns and reassure • When performing a physical examination request permission for even minor procedures – be gentle, take time, give encouragement. Involve the patient (eg to insert the speculum herself), ensure the patient understands that consent to the examination is flexible (not final) and can be withdrawn at any stage in the procedure • On some occasions it may be appropriate to advise the patient on making a complaint to the police, for instance if injuries, STI or concerns about patient safety are present

Stress Symptoms • For most patients a routine enquiry about past abuse does not precipitate crisis. Some patients may require extra medical care following disclosure because of the emergence of post-traumatic stress symptoms. Assess for and advise about: Anxiety or sleep disturbances (short-term medication may help) Depression – SSRIs may be helpful for PTSD Exercise and general stress management Work/financial needs – patients previously employed and not coping may need time off work (some occupations make recovery from sexual abuse more difficult), or additional support. Alcohol/eating problems Problems in current relationship(s) • For a minority of patients the issue of recovered memory may arise. These cases are complex and referral to an appropriate expert (a mental health professional who is a member of a recognised college or equivalent body with clinical expertise in this area)is advised continued overleaf...

ACC Treatment Proﬁles – 2001 Adult Survivors of Abuse SN571 Adult Survivors of Abuse or Previous Undisclosed Assault Presentation

• Advise the patient that many people find it helpful to talk things over with a trained sexual abuse counsellor. • Be guided by the severity and nature of the patient’s symptoms, the patient’s wishes and culture, in deciding where to refer. • Refer to a therapist (psychologist, psychotherapist or counsellor) who has a balanced, well-informed approach to sexual abuse, memories and family dynamics. • Fill out ACC 45 where appropriate. • Know your own limits. If you have not had in-depth training in counselling or psychotherapy, do not attempt to be a sexual abuse counsellor for your patient

Adult Survivors of Abuse SN571 ACC Treatment Proﬁles – 2001 Adolescent Sexual Abuse

KEY POINTS Certain issues are specific to adolescents. Always consider suicide risk after disclosure of sexual assault in this age group.

Adolescent Development • Adolescents are no longer children but do not have the independence or full self-determination of adults. An adolescent is capable of varying degrees of self-determination. Respect for their developing identity is essential to recovery from abuse

Confidentiality and Legal Issues • There is a dichotomy between the adolescent’s need for self-determination and basic human rights and their requirements for protection as specified in child protection and criminal laws. This poses difficulties for health professionals in relation to confidentiality • Clarify your position on confidentiality of information – don’t make promises you cannot keep. The requirement to share information does not necessarily preclude confidentiality about the adolescent's needs that may or may not be related to the sexual abuse eg consenting intercourse with peer, drug use etc • The limits on confidentiality can be explained as “Everything you tell me is confidential – except I will have to talk to someone else if I think you may be at risk of serious harm” AND “I would not do this behind your back. I would discuss it with you first”

Safety and Protection Issues • Because adolescents are not yet independent adults, especially in aspects of power, they may require intervention for protection, safety and education. This may be needed regardless of what the adolescent and/or their caregivers or family wish. Consider CYFS or Police referral for all young people 14 and under, and consultation on all between 14 and 17 years with a senior colleague or CYFS social worker

Sexual Health Needs • For adolescents who are victims of sexual abuse it is essential to assist in normalising their developing sexuality and present sexual behaviour. They need help to identify themselves as sexually healthy individuals separate from their sexual abuse. They need the usual adolescent contraceptive and STI advice

General Health Care • Any contact with an adolescent should be used opportunistically to attend to wider aspects of health care including suicide prevention, and drug and alcohol use

ACC Treatment Proﬁles – 2001 Adolescent Sexual AbuseSN571 Adolescent Sexual Abuse

Follow-up at 1 & 3 months • Is victim safe? • Check physical health/concerns • Rule out /manage pregnancy • Check STI symptoms/concerns • Arrange STI blood tests @ 3/6 months – Hep.B. HIV, VDRL • Assess psychological state • Consider medication (SSRI?) • Offer counselling referral again • Review ACC entitlements–if cover has been granted • Check progress if Police case • Consider public safety. • Request permission to report assault without identifying victim • Counsel patient re police report • Enlist crisis counsellor • Refer for forensic medical examination (if within 7 days of assault) to keep reporting options open • Discuss informing police “for intelligence purposes with no view to prosecution” • Treat urgent medical conditions • Document verbatim • Preserve forensic evidence (no food /drink/cleansing/wiping/nail biting)

Adolescent Sexual AbuseSN571 ACC Treatment Proﬁles – 2001 GP Management of Child (or Adolescent Under 17) Sexual Abuse

KEY POINTS • Child sexual abuse (suspected or disclosed) requires specialist referral and multi-disciplinary management.

Consider the possibility of the diagnosis if: Disclosure by a child Pregnancy in a young adolescent Vaginal bleeding or other signs of injury Vaginal discharge Significant behavioural disturbance – running away, phobias, sexual acting out etc

Do Not: Attempt to manage or investigate a suspicion of sexual abuse on your own Attempt to interview the child beyond a gentle inquiry about possibility of abuse if indicated Promise to keep what you are told a secret Conduct a forensic medical examination unless you are adequately trained. Perform only a limited external medical examination to ascertain the urgency of a referral when there is acute trauma or vaginal bleeding or if other conditions such as vulvitis are suspected Show child you are shocked or angry by what they say Criticise the alleged abuse in front of the child Try to determine if abuse has occurred by confronting the parents

Management Document: The child’s history and clinical symptoms (note verbatim child’s words) Explanation of symptoms and injuries given by either parents or child

• Consult If in doubt about the basis of your concern or how you should proceed consult: A doctor experienced in management of sexual abuse (GP or paediatrician) or CYFS senior social worker

• Refer Promptly: If there is reasonable suspicion that abuse has occurred and/or the child is at risk of further abuse: Refer to CYFS or Police Section 16 of CYP and F Act protects a doctor who reports suspicion of child abuse from any criminal or civil litigation provided the report is made in good faith

Immediate specialist medical referral is indicated and admission should be considered if: Assault/rape within 7 days especially for young child, ill or unsafe Obvious external physical trauma or suspected internal trauma Systemic signs or symptoms of illness, local signs and symptoms – especially significant genital discharge or bleeding or ano-genital pain continued overleaf...

ACC Treatment Proﬁles – 2001 Child Sexual Abuse SN571 GP Management of Child (or Adolescent Under 17) Sexual Abuse

• Follow Up – Maintain Liaison The GP should provide support for the child, family/whanau. Support family members who may disclose their own past abuse at this time Use community resources to refer for counselling both child and family if appropriate Provide continuing medical care and follow-up to ensure that the child remains safe, injuries heal, STDs have been recognised and treated appropriately and pregnancy recognised and assistance provided Check that ACC documentation has been provide

Child Sexual Abuse SN571 ACC Treatment Proﬁles – 2001 Presentation of Recent Sexual Assault

• Treat urgent medical conditions • Document verbatim • Preserve forensic evidence (no food/drink/cleansing/wiping/nail biting)

Does patient want to make police RED FLAG: complaint? Full medical management of an acute UNSURE: YES sexual assault, whether or not police • Counsel patient re police report are involved, requires time and • Enlist crisis counsellor experience. It is difficult to fit into a • Refer for forensic medical NB. If assault was within 7 days general practice consultation. examination (if within 7 days of URGENT report to Police required assault) to keep reporting options Consider referral to DSAC accredited open doctor for ACC-funded management. YES • Discuss informing police “for DSAC Office (09) 376 1422 intelligence purposes with no view to prosecution” Consider public safety. Request NO permission to report assault without Patient decides to make police REPORT TO POLICE identifying victim complaint Refer to Forensic Medical Examiner to examine using accepted protocol THERAPEUTIC MANAGEMENT ALWAYS CONSIDER PATIENT'S SAFETY AND SECURITY

PHYSICAL INJURIES: • Treat or refer as appropriate FOLLOW-UP AT 1 WEEK • Offer vaginal examination if not done for forensic reasons Review therapeutic and PSYCHOLOGICAL TRAUMA: counselling needs • Provide supportive approach • Offer support person or counsellor • Provide patient literature • Refer for on-going counselling FOLLOW-UP AT 1 & 3 MONTHS: PREGNANCY: • Is victim safe? • Check pre-existing pregnancy, Hx and PT • Check physical health/concerns • Discuss risk in relation to assault, menstrual cycle and other variables • Rule out/manage pregnancy • Offer prophylaxis –Postinor© 2, or Yuzpe (Nordiol© or Ovral© 2 + 2 • Check STI symptoms/concerns and anti-emetic) • Arrange STI blood tests @ 3/6 • Give written instructions months–Hep.B. HIV, VDRL • Assess psychological state STI: • Consider medication (SSRI?) • Counsel re risk • Offer counselling referral again • Offer baseline screening • Review ACC entitlements • Offer prophylaxis • Check progress if Police case Chlamydia – Azithromycin 1Gm stat (fully subsidised for sexual assault prophylaxis) – if contraindicated use erythromycin ethylsuccinate 800mg qid 7 days Gonorrhoea and incubating syphilis (with emerging resistance regime changes, check with local STI specialist). Amoxicillin 3Gm + Probenecid 1Gm orally Ciprofloxacin 500 mg orally stat (not pregnant, child, adolescent – consult STI specialist) Anti-fungal – Clotrimazole Hepatitis B – Hyperimmune globulin up to 14 days + first Hep.B vaccine. HIV – consult local STI specialist • Arrange return for screening VICTIM COMPENSATION: • Discuss role of ACC • Complete ACC45 Referral if appropriate

ACC Treatment Proﬁles – 2001 ACC5157 Cover a/w.fh8 11/12/00 1:06 PM Page 1 rne eebr20 SN0481766ACC 579 ISBN 0-478-11756-6 Printed December 2000 Treatment Proﬁles

2001 Treatment Proﬁles 2001

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