Emergency Medicine

SOFT-TISSUE INJURIES

324 Musculoskeletal and Soft-tissue Emergencies

(iii) Always consider the possibility of a compartment syndrome

if there is marked pain, particularly on passive stretching of

muscles, associated with paraesthesiae and loss of motor and

sensory nerve function.

(iv) The entire area within the closed fascial compartment feels tense.

(v) However, arterial pulses and even skin perfusion may initially

remain deceptively normal.

5 Send blood for full blood count (FBC), electrolyte and liver function tests

(ELFTs), creatine kinase (CK) and dipstick the urine for evidence of

myoglobinuria (positive for blood, yet negative for red cells on microscopy).

6 Perform an electrocardiogram (ECG) particularly if hyperkalaemia is

suspected.

7 Request X-rays to exclude an underlying fracture.

MANAGEMENT

1 Gain i.v. access and give normal saline 20–40 mL/kg i.v. to improve any

hypoperfusion, and give morphine 0.1 mg/kg i.v. and metoclopramide 10 mg

i.v.

2 Place the affected limb at the level of the heart. Excessive elevation reduces

arterial f low and may worsen the ischaemia.

3 Eliminate any external constricting factors such as a tight bandage or plaster

by cutting, or bivalving a cast.

4 Refer every severe crush injury involving a limb, hand or foot to the ortho-

paedic team, including patients suspected of having a compartment

syndrome.

(i) Management will include consideration of compartment pressure

monitoring, the use of vasodilator agents, mannitol and sodium

bicarbonate, or operative fasciotomy.

5 Otherwise, clean and debride an isolated finger or toe injury without

suturing, elevate the limb to the level of the heart, and give the patient

analgesics.

(i) Review within 3 days for consideration of delayed primary

suture.

Puncture injuries

DIAGNOSIS

1 This type of injury is caused by treading on a nail or pin, by penetration of a

sewing-machine needle, or through industrial accidents including nailguns

or high-pressure guns for grease, paint, water or oil.

2 Needlestick and sharps incidents are covered on page 151.