318 Musculoskeletal and Soft-tissue Emergencies
SOFT-TISSUE INJURIES
The so-called ‘minor injury’ is of major importance to the patient and may lead to
serious problems if managed incorrectly. Therefore, adopt a consistent, careful
approach to every patient presenting with a soft-tissue injury.
GENERAL MANAGEMENT OF A SOFT-TISSUE INJURY
1 Assessment
(i) Obtain a history of:
(a) the nature of the injury, and when and where it was sustained
(b) the possibility of a foreign body, wound contamination, and
damage to deeper structures
(c) any crushing injury
(d) current medical conditions and drug therapy
(e) antibiotic allergy and tetanus immunization status.
(ii) Examine nerves and tendons for evidence of damage, before
infiltrating with local anaesthetic.
(iii) Send the patient for X-rays before exploring the wound, if a
radio-opaque foreign body (metal or glass) is suspected. Inform
the radiographer of the nature of the foreign body.
2 Wound preparation
(i) When assessing and preparing the wound:
(a) always lie the patient down on a trolley
(b) wash hands thoroughly before and after wound review
(c) wear sterile gloves and prepare a sterile field.
(ii) Remove all the dirt and debris from around the edges of the
wound prior to anaesthetic infiltration, using normal saline or a
disinfectant, e.g. chlorhexidine with gentle swabbing.
(iii) Only trim adjacent hair for 3–5 mm if absolutely necessary, but
never shave the eyebrows or eyelashes.
3 Local anaesthetic infiltration
(i) Simple laceration. Infiltrate 1% lignocaine (lidocaine) along the
edge of the wound using a 25-gauge orange needle.
(ii) Digital nerve ring block
Use 2% plain lignocaine (lidocaine) without adrenaline (epinephrine)
to ring block wounds around the nail, fingertip, distal finger and toes
(see p. 491).
(iii) The maximum safe dose of lignocaine (lidocaine) is 3 mg/kg. A
1% solution contains 10 mg/mL. Therefore, the maximum safe
amounts allowed in a 67 kg patient are:
(a) 20 mL of a 1% solution containing 200 mg lignocaine
(lidocaine), or