Emergency Medicine

SOFT-TISSUE INJURIES

Musculoskeletal and Soft-tissue Emergencies 325

MANAGEMENT

1 Refer all high-pressure gun injuries immediately to the orthopaedic team,
even if no apparent damage is seen initially. They will require extensive
surgical debridement.

2 Otherwise, clean the wound with antiseptic, give tetanus prophylaxis, and
consider the need for antibiotics.

3 Treat a rusty nail injury to the foot by soaking in Betadine for 30 minutes and
give amoxicillin 875 mg and clavulanic acid 125 mg one tablet orally b.d. for
5 days.

4 Instruct the patient to return immediately if signs of infection or gross
oedema supervene.

Hand infections

DIAGNOSIS AND MANAGEMENT

1 Paronychia
(i) This is pus formation adjacent to the nail, with throbbing pain.
(ii) Make a longitudinal incision parallel to the nail edge across the
nail fold to release the pus, under a ring- block anaesthetic (see p.
491). Mop out the cavity with pledgets of cotton-wool.
(iii) Dress the finger with paraffin-impregnated gauze tucked into
the cavity, and apply a plain viscose stockinet tubular bandage
without tension. Use a high-arm sling for 24 h, and review the
dressing after 2 days.

2 Pulp space infection
(i) This is pus formation in the distal fat pad of the finger.
(ii) Make a central longitudinal incision using a ring block, over the
middle of the abscess. Take care not to cross the flexion crease of
the distal interphalangeal joint, and mop out the cavity of pus.
(iii) Dress and review as for paronychia.
(iv) The flexor tendon sheath is in danger in more extensive
infections when swelling approaches the distal interphalangeal
joint. Refer the patient directly to the orthopaedic team, after an
X-ray to exclude osteomyelitis.

3 Suppurative tenosynovitis of the flexor tendons
(i) The original wound may have been forgotten, but intense
discomfort, swelling and tenderness develop along the line of the
flexor tendon, with characteristically severe pain on all passive
finger movements.
(ii) Refer the patient directly to the orthopaedic team for operative
debridement and i.v. antibiotics.