Non-articular Rheumatism
326 Musculoskeletal and Soft-tissue Emergencies
4 Deep palmar and web space infections
(i) These cause pain, swelling and loss of function with localized
tenderness and the development of a ‘flipper’ hand, from
pronounced swelling on to the dorsum of the hand.
(ii) Refer the patient directly to the orthopaedic team.Pre-tibial laceration
DIAGNOSIS
1 These are most common in elderly patients, often from trivial trauma tearing
a f lap of skin.MANAGEMENT1 Clean the wound, remove blood clots, trim obviously necrotic tissue and
unfurl the rolled edges of the wound to determine actual skin loss.
2 Refer the patient immediately to the surgical team if there is significant skin
loss or marked skin retraction preventing alignment of the skin edges, for
consideration of early skin grafting.
3 Otherwise, lay the f lap back over the wound and hold it in place with
adhesive skin-closure strips (Steristrip™). Cover the wound with a single
layer of paraffin-impregnated gauze and a cotton-wool and gauze combine
pad.
4 Then apply a firm crêpe bandage and instruct the patient to keep the leg
elevated whenever possible.
5 Enquire about tetanus immunization status.
6 Review the patient after 5 days, removing the dressing but leaving the
Steri-strips™ in place.
(i) Refer the patient to the surgical team for skin grafting if the skin
is now obviously non-viable.
(ii) Otherwise, review the patient weekly if healing is taking place, or
discharge to the care of the GP and community nurse.NON-ARTICULAR RHEUMATISM
Joint pain, swelling and tenderness that mimics arthritis may be due to
inf lammation of periarticular structures. Most patients can be treated with
non-steroidal anti-inf lammatory analgesics such as ibuprofen 200–400 mg orally
t.d.s. or naproxen 250 mg orally t.d.s. and then be referred to outpatients or back
to their GP.
Leave joint aspiration and steroid injection to the experts, as it can be tricky and
complications such as septic arthritis and joint destruction do occur.