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Toronto Notes 2019
Traumatology
Emergency Medicine ER17
LATERAL VIEW
A. Posterior edge or tip
of lateral malleolus
MEDIAL VIEW
Malleolar Zone Midfoot Zone
Figure 10. Ottawa ankle and foot rules
Adapted from: Stiell IG, et al. JAMA 1994;271:827-832.
Malleolar Zone Midfoot Zone
An ankle radiographic series is required only if there is any pain in malleolar zone and any of these findings:
1. Bony tenderness at A or
2. Bony tenderness at B or
3. Inability to bear weight both immediately and in ED
A radiographic series is required only if there is any pain in midfoot zone and any of these findings:
1. Bony tenderness at C or
2. Bony tenderness at D or
3. Inability to bear weight both immediately and in ED
©Natalie Cormier 2016
6 cm
C. Base of 5th metatarsal
B. Posterior edge or tip
of medial malleolus
D. Navicular
• identifyinjuriesandstopanyactivebleeding–directpressure • managepain
• woundexaminationandexploration(historyandphysical)
• cleansing±antibioticandtetanusprophylaxis
• closureanddressing
Tetanus Prophylaxis
• bothtetanustoxoid(Td)andimmunoglobulin(TIG)aresafeinpregnancy
6 cm
Wound Management
Goals of ED Treatment
Acute Treatment of Contusions
RICE
Rest
Ice Compression Elevation
High Risk Factors for Infection Wound Factors
• Puncture wounds
• Crush injuries
• Wounds >12 h old • Hand or foot wounds Patient Factors
• Age >50 yr
• Prosthetic joints or valves (risk of
endocarditis)
• Immunocompromised
Suture Use and Duration
Table 11. Guidelines for Tetanus Prophylaxis for Wounds
Vaccination History
Unknown or fewer than 3 doses
3 or more doses
Clean, Minor Wounds
Tdap or Td† TIG Yes No No§ No
All Other Wounds*
Tdap or Td† Yes
No¶
TIG Yes No
*Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite
†Tdap is preferred to Td for adults who have never received Tdap. Single antigen tetanus toxoid (TT) is no longer available in the United States
§Yes, if more than ten years since the last tetanus toxoid-containing vaccine dose
¶Yes, if more than five years since the last tetanus toxoid-containing vaccine dose Source: MMWR 1991;40(No. RR-10):1-28
Bruises
• non-palpable=ecchymosis
• palpablecollection(notswelling)=hematomafollowingblunttrauma • assessforcoagulopathy(e.g.liverdisease),anticoagulantuse
Abrasions
• partialtofullthicknessbreakinskin • management
■ clean thoroughly with brush to prevent foreign body impregnation ± local anesthetic antiseptic ointment (Polysporin® or Vaseline®) for 7 d for facial and complex abrasions tetanus prophylaxis
Lacerations
• seePlasticSurgery,PL23
• considereverystructuredeeptoalacerationinjureduntilprovenotherwise
• inhandinjurypatients,includethefollowinginhistory:handedness,occupation,mechanismofinjury,
Suture to:
Face
Not Joint
Joint
Scalp
Mucous Membrane
Close with
Nylon or Other Non-absorbable (days) Suture
6-O 5
4-O 7
3-O 10
4-O 7
absorbable N/A (vicryl)
Approx. Duration
previous history of injury
N.B. Patients on steroid therapy may need sutures for longer periods of time