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3 General Surgery
3.3 Soft Tissues & General Orthopaedics
Reviewed by TB Hassan
July 2005
3.3.1 Local Anaesthesia
The only local anaesthetic used routinely in the department is lidocaine (lignocaine). It can be used in a variety of ways:
1. Field block. This is infiltration of local anaesthetic around the wound and ideal choice is 1% Lidocaine, without epinephrine.
2. Bilateral digital nerve block. Ideal for manipulation of fractures or dislocations in the finger or for suturing. Achieved by anaesthetising the digital nerves via the dorsum of the hand through the web space on either side of the digit, again use 1% lidocaine.
NEVER USE LA WITH EPINEPHRINE FOR DIGITAL BLOCKS
3. Local nerve blocks (e.g. femoral, plantar, median, ulna), or supra clavicular block for dislocated shoulder.
4. Local infiltration of 10ml 1% Lidocaine into fracture site ("haematoma block").
Intravenous regional anaesthetic (IVRA) such as a Bier’s block (see below) can also be perfomed with prilocaine. Lignocaine or bupivicaine should never be used in this situation.
Lidocaine can be a very toxic drug and close attention must be paid to maximum safe levels.
3mg / kg of lidocaine without epinephrine
5mg / kg of lidocaine with epinephrine
1ml of 1% lidocaine contains 10mg. Thus the maximum safe volume of 1% lidocaine for a 70kg person is 70 x 3 / 10 = 21mls
Blood levels of lidocaine usually peak about 10–25 minutes after injection and consequently toxicity is most likely to occur at this point, although the onset of symptoms will be faster if accidental intravascular injection occurs. The first symptoms and signs are usually numbness of the mouth and tongue. Followed by the onset of tinnitus, confusion, seizures, and potentially coma.
Cardiovascular toxicity consists of tachycardia and hypertension but with increasing toxicity bradycardia and hypotension occur. Ventricular arrythmias and cardiac arrest may occur (see below).
The treatment of local anaesthetic toxicity is primarily supportive following an ABC approach with full monitoring. If convulsions occur they should be controlled with benzodiazepines as per usual. Bradycardia is usually self limiting, but if persistent and associated with hypotension, atropine and / or cardiac pacing may be necessary. The symptoms of toxicity persist as long as the plasma concentrations remain above the therapeutic index. The toxicity from lidocaine is of shorter duration than from other agents with a longer half life, for example, bupivicaine.
Recent research has suggested a role for lipid infusion in cardiac arrest secondary to lidocaine toxicity. A quantity of 20% intralipid is kept in Jubilee theatres for such an eventuality and should be accessed ASAP in this situation. The treatment protocol is kept with the intraplipid.
3.3.2 Bier’s Block procedure
1. Assess the patient's weight.
2. Use a cannula in each hand (a flexible cannula is necessary in the "normal" limb)
3. Draw up 40mls of 0.5% prilocaine ("Citanest") for a 70Kg adult. Reduce the volume accordingly if the weight is less than 70Kg. Do not exceed 40mls.
4. Check the systolic blood pressure.
5. Elevate the limb to be anaesthetised and inflate the cuff to 250mm Hg (or 50mm Hg above the systolic if this is higher)
6. Inject the prilocaine into this limb over 2 minutes.
7. Start the clock.
8. A doctor and a trained nurse should now stay with the patient, and the cuff should not be deflated UNDER ANY CIRCUMSTANCES for 20 minutes.
9. Diazemuls or midazolam must be readily available.
10. Anaesthesia will begin at 5 minutes and will last until the cuff is released (max time 60 mins).
11. Perform the check X ray in the plaster room to enable re-manipulation if necessary.
3.3.3 Nerve injury
• Like tendon injury, suspect it in all palmar hand/wrist injuries.
• When examining, look for quality of sensation rather than absolute presence of sensation. Therefore don't test with a pin, but stroke the skin and ask if it feels normal. If definitely feels different compared to the other side refer Hands St James's.
• Tendon or nerve injuries are best treated primarily. Therefore, look for them, and if in doubt consult the senior on call in the department.
• If not sure, either refer to ED senior immediately or bring back to A&E RC in 2 days.
3.3.4 Sports injuries
Some patients present special problems, and they may need specific advice on duration of symptoms, period of rest, complications etc. Send to Returns Clinic if specific help is needed, though most GPs are able to deal with many simple problems. Discuss case with ED senior if you wish to bring the patient back to Review Clinic giving the reason.
3.3.5 Stress fracture
• Common sites are the 2nd metatarsal (March fracture), and fractures into bone cysts
• If sure of diagnosis, immobilize in a POP, and refer to ED RC in 2 weeks
• If not sure, treat according to pain, consult with a senior and bring back to ED RC in 1 week. X-rays may take many weeks to identify definitely, and sometimes a bone scan is required.
3.3.6 Suturing
• Generally, take care to use a no-touch technique.
• You can suture in the cubicles or major treatment rooms
• A significant amount of simple suturing is done by the clinical support workers (ask nicely)
• Sutures: Catgut for scalps and finger-tips. Nylon (Ethilon / Novafil) for the rest.
• Use 4.0 for most areas, 5.0 on the face, and occasionally 3.0 on the extensor aspects of the limbs.
• Arrange for facial sutures to be removed on the 4/5th day (own GP), other areas on the 7th day, though areas subject to stretch may be left 10-14 days eg front of the knee.
• Severe scalp and facial lacerations may require to be sutured by the Max Fax Dr’s ask a senior to see the problem first if possible.
• If the patient is a child of under 5 years, sedation will almost certainly be required, and we routinely prescribe Midazolam syrup for this purpose or intranasal diamorphine. There are more specific guidelines available in the Paeds area. You should suture such a child yourself (or ask a senior to do it).
• Consider using histo-acryl glue.
• Penetrating wounds: If a knife wound (or a wound with glass) think about deep structures. Ask a senior A&E Dr. to see if there is any doubt in your mind regarding an abdominal, chest, neck or groin wound.
3.3.7 Foreign bodies:
• Always think about the possibility of retained foreign bodies.
• Glass is usually radio-opaque.
• Never hunt for foreign bodies under local anaesthesia unless you can feel them through the skin. If you can't, a tourniquet (and therefore a G.A. or regional anaesthesia) is required and you should probably ask a senior member of staff to help.
• Always X-ray if a deep wound has been caused by glass, using a metal skin marker to highlight the wound.
• Do not waste X-rays on wood/thorn injuries, but keep such patients under follow up if they feel there is a retained FB; they are almost always right!
3.3.8 Dislocations
• They are always painful until reduced.
• If obvious dislocation causing distal vascular compromise or threatening the skin the reduce immediately
• Most can be reduced using local anaesthetic blocks.
• If not refer to the conscious sedation guidelines
• Shoulder dislocations are more difficult. Alawys involve a senior doctor. Use the Milch (least traumatic) technique or another technique you are familiar with. A GA may be required, so keep starved from the outset. Always document there is no neuro vascular injury before and after reduction.
• Pre and post reduction films should always be obtained.
3.3.9 Soft tissue infection (see alsoAbcesses)
Cellulitis is a common cause of presentation in A&E.
History & Examination
• There may be history of minor injury or sting or bite followed by swelling pain and erythma to a limb.
• General features of sepsis should be elicited e.g rigors, sweating etc. It is important to know the past medical history particularly if the patient is diabetic, alcoholic or immunocompromised.
• Examination will show red, hot painful area most commonly on a distal aspect of a limb. The patient may be pyrexial and tachycardic. Look for lymphangitis or lymphadenopathy.
•
• If there is crepitus in the site suspect gas-forming organism (or on x-ray). This is a serious sign. If there is any doubt or if the patient presents with PAIN OUT OF ALL PROPORTION AROUND THE CELLULITIC / DISCOLORED AREA – SUSPECT NECROTISING FASCITIS. INVOLVE A SENIOR!
Treatment
Treatment should generally consist of elevation and oral antibiotics.
Those who require admission to CDU for IV therapy are patients who are:
• failing to improve on oral therapy, or
• those with a pyrexia >38.5, with ascending lymphangitis,
• those who have had a rigor, or
• Those who have difficult social circumstances.
Discuss these patients with the CDU fellow – Please make sure if the patient is being admitted to CDU that you complete a CDU protocol with a COMPLETE admission CELLULITIS SCORE. This will be done on CDU as well.
When starting antibiotics try and curb your enthusiasm, if the patient is going home we would suggest Flucloxicillin +/- Pen v, or oxytetracycline (or cephradine elixir in children) if they are ? Penicillin sensitive. Second line treatment (on ward 1) should be with iv cefotaxime (if large doses of iv fluclox/benzylpen have failed) or iv clindomycin if they are definitely penicillin sensitive. Do not treat abscesses with antibiotics, but use them if there is a significant cellulitic component.
Key points
- If the patient is septic discuss the case with a senior. Do not admit to CDU. Septic shock can occur rapidly
- If there is evidence of abscess either drain or discuss with senior for referral to the RSO.
- Although rare, necrotising fasciitis can present as cellulitis. Be aware – patients present with pain out of all proportion to what you can see!!
- Sometimes difficult to differentiate between gout and osteomyelitis or bursitis
- Urate may not necessarily be raised
- The gold standard test is joint aspirate
- Best treated in the acute phase with a non-steroidal anti-inflammatory drug .
- If this is contraindicated use Colchicine - probably as effective as a non-steroidal but its use is limited by its toxicity in high doses, (diarrhoea). Its very useful for patients on anticoagulants. The dosing regime is 500microg tds for 5 days. This regime causes less diarrhoea than traditional ones.
- Do not start allopurinol in the acute phase as this may worsen the condition
- Uncomplicated gout can be referred back to the GP with a management plan.
3.3.11 Open fractures
This is when the fracture is open to the air via a skin wound.
All are at high risk of infection.
Treat as contaminated and orthopaedic emergencies
Classification - Gustillo:
• Type 1-the wound is less than 1 cm long and appears clean
• Type II- the wound is >1 cm long but is not associated with tissue loss or extensive damage
• Type IIIA either a open fracture with adequate soft tissue coverage of bone, despite extensive soft tissue damage or flap laceration or any fracture involving high energy trauma or bone shattering regardless of wound size.
• Type IIIB open fracture with extensive soft tissue loss, periosteal stripping or exposure of bone
• Type IIIc open fracture involving vascular injury requiring repair.
Management: Remember treat life threatening injuries before limb threatening ones.
Use ATLS principles and start with A with C spine control, B, & C with haemorrhage control
Open fractures require immediately
• adequate analgesia
• Dressing and splintage
• fluid replacement
• antibiotics (cefotaxime & metronidasole or flucox and Ben pen.)
• tetanus status
• Record presence or absence of pulses and recheck often.
3.3.12 Acute Compartment syndrome
This can occur in any osteofascial compartment . The commonest is in the lower leg and the forearm but it also may occur in the foot hand ,buttock, upper leg etc.
Maintain a high index of suspicion. It can lead to irreversible muscle damage leading to excision or amputation. It may also lead to myoglobinuria and acute renal failure
The following is suggestive of compartment syndrome
• Increasing pain
• Pain on passive stretching the muscles of that compartment
• Parastheisa of the nerve from that compartment
• Tense swelling in the compartment.
• The presence of a pulse does not exclude compartment syndrome
If you suspect compartment syndrome involve a snr dr and refer immediately to orthopaedics.