Emergency Medicine

SOFT-TISSUE INJURIES

Musculoskeletal and Soft-tissue Emergencies 323

(c) give non-immune patients an initial dose of tetanus toxoid

combined-vaccine followed by a full course of the tetanus

vaccine.

(ii) Tetanus-prone wound

(a) administer tetanus immunoglobulin to patients who are non-

immune, have not completed a full tetanus immunization

programme, or are uncertain

(b) also give non-immune patients an initial dose of tetanus

toxoid combined-vaccine followed by a full course of the

tetanus vaccine.

2 Tetanus itself is rare, but worldwide it is a frequent cause of death in parts of
Asia, Africa and South America.
(i) The incubation time from injury to first symptoms ranges from 3
to 21 days (usually about 10 days).
(ii) The most common symptoms are jaw stiffness (trismus),
dysphagia, neck stiffness and abdominal and back pain.
Hypertonia is found on examination.
(iii) Localized or generalized painful spasms follow within 24–72 h,
becoming more severe and prolonged from minimal stimuli.
(iv) Death may occur from laryngospasm, respiratory failure or
autonomic dysfunction.
(v) There is no rapid diagnostic test to prove the diagnosis, therefore
admit a suspected case immediately to the intensive care unit (ICU).

Crush injury and compartment syndrome

DIAGNOSIS

1 Crush injuries may be caused by a roller or wringer injury, a direct blow or a
vehicle wheel passing over a limb.

2 Even with severe soft-tissue injury there may be little to see initially.

3 Always test for tendon, nerve or vessel damage.
(i) Loss of skin blanching on digital pressure indicates shearing of
capillaries, which may subsequently lead to extensive soft-tissue
necrosis.

4 Compartment syndrome
(i) Tissue capillary perfusion pressure is compromised due to raised
pressures locally within closed anatomic spaces or compartments:
(a) this is most commonly seen associated with the lower leg, and
forearm volar compartments.
(ii) Causes include crush injury, external compression from a tight
plaster, fractures (especially tibial), constricting burns, local
haemorrhage, vigorous exercise and prolonged immobilization in
coma, e.g. following acute poisoning.