Needless to say, people hurt themselves in uncountable ways, and this is a frequent reason people must decide, should I go to the hospital or not? Do I need x-rays? Do I need stitches or a tetanus shot? Could I be seriously injured?
From the head and neck, to the extremities and fingers and toes, there are lots of things to think about, and I will make some attempt to address at least the more common situations people get themselves into, and some basic concepts as to what to do and when. It is quite the industry, accounting for a significant percentage of the conditions that constitute a minor and sometimes major injury. On the other hand, we see a lot of stuff that probably don’t need medical attention, but never forget, we’re here for what YOU think is an emergency, not what WE think is an emergency. If it’s nothing it’s nothing.
LACERATIONS: Here’s a brief anatomy lesson: The skin is a dead layer (epidermis) on top of a live layer (dermis), and at the bottom of the dermis is a tough, white and shiny layer of tissue called the superficial fascia. The blood vessels and nerves travel through here to innervate and supply life-giving blood to this very circulated and active tissue. Below this is a layer of fat that looks like little globs of tannish tissue. Below that is the “deep fascia”, the bottom layer of the skin. And under that, in most places, is muscle.
To lacerate into the dermis at all generally hits a small blood vessel and you bleed. But it is when you have violated the superficial fascia that it all sags open (“gaps”), and the fat is visible, and you’re best off getting it sutured together, so it will heal faster, and with a more narrow scar. If you cut into the fat far enough you have gotten all the way through the skin and exposed the muscular layer, where things become dangerous in a hurry, and pretty much everyone would agree that you’re going to need to go to the hospital. And with hand injuries especially, they can be disabling and can require sophisticated intervention.
All wounds heal by scarring, which takes a year or more, so the wound is purple and somewhat wide until the process is finally over, leaving, ideally, a thin white line. In areas where there is constant movement (by the mouth, front of the knee), the scar will usually end up wider, and less cosmetically good.
Pretty simple, right? Sewing up a cut is about the first thing they’ll allow a young doctor in training or a medical student to do. But there are a number of things to be alert to. Was a tendon involved? A nerve? Is there anything in the wound, like a rock or a piece of wood? What about a bite, like a dog or a cat or (Gasp!) a human? So we explore all wounds for foreign bodies, aggressively irrigate bite wounds and antibiotic them, and always be alert to signs of deep involvement with tendons and nerves, where you should be able to tell if something isn’t working.
It’s important to note that there was no suturing in cave man days, so wounds will all eventually heal together with scarring. Therefore it depends a little on the lacerated, the location, the age of the patient. Can I duct tape this? Well, if you sew the wound, it’ll be about 7% healed when the stitches come out, so anything that is cleaned and held together long enough to start the healing process will work, so duct tape instead of stitches is a reasonable concept. In fact my last duct-taping I needed for myself was 3 days ago.
Stitches themselves become a foreign body problem after a few weeks, so we have them removed by then. The face, such a fast healer, will leave stitch mark scars (“tram track lines”) if left in that long so they are recommended to be removed within 5 days, and no later.
What about glue? I don’t like it, and I’m sure if done right, especially for small wounds in non-cosmetic places, the result is good. But for me, if there is deep enough of a wound to violate the superficial fascia, I like to sew them. Staples work well, but are often hard to “install” properly, and I reserve them for scalp wounds. And you may notice that essentially all surgical wounds now are stapled together. Stapling definitely “bunches” the edges of the wounds as they “staple”, and this allows for good healing.
There are fancy stitches like mattressing and running stitches, and if your doctor went to a good training program you may see this. Most wounds can be sewn with “simple, interrupted” stitches, for sure. But here’s an interesting issue: tissue fibers run in the direction of underlying muscle, so when a sharp object cuts across them, they retract a little, and pull in the dead layer some. If simply sutured, often the dead layers on either side of the wound are pulled together, and they will not stick together, and may fall apart when the stitches are removed. With a mattress stitch, you turn the needle around when the initial harpooning is done, going back in near where the needle came out, and then back out the other side where the needle went in to start with, when you tie the knot (now on just one side of the wound), it nicely everts the edges, putting dermis to dermis which is what you want. When the stitch comes out, it flattens out no problem.
But wait doctor, my little brat child has a laceration on his FACE! Don’t I need a plastic surgeon? Usually the answer is no. Hey, if you cut yourself you’re going to make a scar and that’s all there is to that. Plastic surgeons do face lifts and boob jobs. Calling in a “specialist” sounds good and all of that, but who sews up all the cuts in the community? Right, your local ER guy. But there are times when you need that help, and you can imagine the deep gashes of trauma, and it’s not a good thing. But your ER doctor should tell you when there is something more than he feels comfortable with. Otherwise, it’s a good idea to massage wounds that are in cosmetic areas of the face, to keep the edges even and flat, and this can be very helpful at improving the cosmetic outcome. Rub it for a minute or two several times a day when you think of it, and for weeks or a few months even.
A few more thoughts. Every dog that ever bit a kid’s face (a favorite place for animals to attack each other) never bit a kid before. So I don’t like old dogs and new humans. And while I’m not a dog people type, I sure see how much they mean to their owners. But dog bites to kids faces… makes me want to blame somebody. Antibiotics for bites is routine. But only about 5 or 10% of dog bite become infected, while 80% of cat bites do. So remember: the solution to pollution is dilution, so copious flushing of all bites is a great idea.
A human bite is a rare event. You may know they’re a bad thing and they are, but it is usually a punch to the mouth, and a laceration of a knuckle by a tooth that constitutes a “human bite”. There are university hospitals that admit people for IV antibiotics for any such injury. But they can be really bad, especially on top of the hand, where there is not as good of circulation as in other places.
Tetanus? Most of us will go our entire careers and never see a case of tetanus. That’s because we vaccinate against it with an effective vaccine. And something like 80% of the 25 or 30 cases reported in the US each year are in people over 50 who’ve never even had their first vaccination. And there are less and less of those people out there. And 25 or 30 cases is an absolutely teen weeny amount. So if the question is about whether you need a tetanus shot or not, probably not.
We did have a case of tetanus at a local hospital a long time ago, and it illustrates the germ pretty well. Tetanus lives in soil, so wounds out-doors involving moist earth, and allowed to fester long enough for the germs to produce the toxin that make muscles go into spasm (“tetany”) is the scenario. This lady was around 50 and had cut her foot on something in a manure pile, and she said that when her dogs barked that her back would stiffen up so bad she couldn’t stand it. You may have heard of the term “lockjaw”, an old name for this infection. If you kill the germs with antibiotics, that’s usually it. But support of breathing may be needed until then, which is the main concern.
One last thing regarding lacerations (or “lacs” as we call them). How long can I wait to get it fixed? It varies. But as healing begins, they won’t always stick together if you try to sew them up,(dehiscence), and the rate of wound infection goes up after 6 hours or so. Any fixing after that is questionable. On the face you can go up to 24 hours, and we’ll still sew them, because of cosmetic concerns and because the face, with so much blood supply, will do OK usually. But we are wise to “freshen up” the wound by scrubbing hard enough to make it bleed some. Still, don’t wait if you can help it. (A common scenario is waking up with a wound after a wild night on the town generally involving alcohol.)
Orthopedic injuries;
Like lacerations, there are lots of options as far as what to injure, and for the most part you can always wait a few days or even longer for an orthopedist to tell you what happened and how to deal with it, as opposed to a clock ticking like in lacerations. A broken bone will start to heal at a few weeks, so you can’t wait forever, but getting your ankle x-rayed in the middle of the night doesn’t make much sense. Here are a few of the more famously injured orthopedic structures.
Hands and fingers, and forearms and wrists constitute the lion’s share of such injuries. Bent fingers and bent forearms are worth going to the hospital about because “reductions” of deformities is generally done and recommended., rather than waiting. Especially wrists and forearms. Kids are great at such injury. No one will ever argue with bringing in a kid for evaluation. If there’s one thing we’ll drag an orthopedist into the ER for, it’s bent forearms.
Elbows, especially in kids, break badly sometimes and require operative repair. So if there is much swelling and pain with movement of the elbow, especially in the growing child, going to the ER is always the right thing to do, even in the middle of the night. Nerves and arteries are in there and can be entrapped, and this is bad.
The shoulder is a very mobile joint, allowing you to raise your arm in class for example. But “stability” of the joint is sacrificed, since the only thing holding the joint together is muscle. So there are a lot of ways to “strain” these muscles, and tendinitis (where something gets overused and worn raw) is very common here. More significant injuries and cause the shoulder to come apart, where the top or the humerus comes away from the shoulder blade completely. In such dislocation usually there is a deformity and drastically reduced range of motion, and an ER visit for this is recommended.
When collarbones break, like with any bone, the pain is huge. They often shatter and splinter, but for the most part heal without much intervention over a period of weeks. No treatment for them other than a sling. They are almost never repaired. In shoulder “separation”, there is injury to the only ligament of the shoulder, the one holding together to end of the collarbone and a knob on top of the shoulder blade. This is where a lump will develop with injury, usually when you land directly on the outside of the upper arm, like on the turf from a fall or a tackle in a sport. If the ligament tears completely the collarbone will wing up an inch or so, making this obvious. Can you touch the other shoulder? You probably don’t have much of an injury. If the collarbone is sticking up a lot, a visit to the bone doctor in the coming days is typically recommended, but like with collarbones, they usually just let them heal rather than offer surgical repair.
Hips: Anyone can fall hard enough to break their hip, and when it happens there is little doubt, because you can’t walk, and the leg injured will often shorten and rotate externally, making a quick diagnosis pretty simple. There are lots of repair options. Beware this: the growing child will often injure the head of the femur, which is only held on by the weak growth plate at that end of the bone. So for limping kids you need to be careful, and seeing an orthopedist is a good idea. If this cap of the bone has “slipped” off the top of the femur, there is a limited time for repair to be done before a disastrous outcome results, making it a famous emergency medicine worry.
Knees: The knee joint is a hinge, so again it is only ligaments and tendons holding them together. So with the femur on one side and the tibia on the other, these are two huge bones and they won’t break unless with major trauma, in which case a gross deformity occurs. (The word “gross” simply means all that is visible to the naked eye.) So injuries are usually internal, such as with ligament tearing.
The knee is a huge joint, and when something big happens to it, it swells and that’s how you know you need to see a bone doctor about it. Usually something “pops” in the knee when something tears, and if it’s the internal criss-cross ligaments (the “cruciates”), the joint swells almost right away, a sign of internal bleeding.
The knee joint has a little gasket type structure that sits on the bearing surfaces of the tibia, and we often “pinch” this with rotational injuries. The joint will often swell overnight, mildly a lot of times, but it becomes hard to extend the joint all the way, and it hurts to walk on it. It will improve with more limited activity for weeks, and can recur in the future with overuse.
Ankles: Remember, ligaments are tough structures that hold joints together, attaching to all the bones involved. When the range of motion (ROM) of the joint is exceeded by enough force, they tear and generally make a “pop” of a noise, and hemorrhage locally, and may swell immediately. The most classic probably is the ankle sprain. There are ligaments on the outside that tear with rollover injuries like landing on someone’s foot playing basketball, and there is a big triangular ligament on the inside of the ankle, and it’s harder to tear (but stepping in a hole is one option). So as the scarring process heals the injured ligament, walking and so forth is very difficult. Healing to normal generally takes months, and in severe injuries, half of a year recovering is typical. And yes, x-rays should be done, because often the fibula on the outside 0f the ankle, a thing bone, will break, and require casting for proper healing.
We used to splint and even cast ankle sprains but found out that the joint does poorly so now, just 3-4 days in, you should be bearing weight on a sprained ankle. And it will only allow so much, but there are a lot of reflexes in this joint, and it can literally have trouble finding the floor with too much immobilization. Wearing air splints and gel splints is helpful, and allows for weight bearing during the healing process. And a good dose of Aleve (2) or ibuprofen (800mg) can do wonders for a bad ankle, or any orthopedic injury for that matter.
Feet and toes: People drop things on their toes, step in holes, or put too much force turning and running, and the foot can sprain and of course fracture bones. While not debilitating like knee and ankle in juries, if there’s much swelling an x-ray is worthwhile.
One last description as far as fractures are concerned. Bones are hard, and they break, and this is fracture, plain and simple. So we can describe what happened when we look at the x-ray, as the various types of fracture, and there are many. They can be angulated, or displaced, or just crack and lay in good position. If there are several pieces, that’s comminuted. Through the skin, that’s compound of course. Long bones tend to fracture in a spiral. A piece of a tip can break off, and that’s “avulsion”. If there’s a cancer in the bone, that’s a pathologic fracture. Not rocket science, right? Well, orthopedists are definitely the carpenters of medicine, and their tool box includes saws and drills and screws and plates and hammers (occasionally), and orthopedists like to look at themselves as the tradesman of medicine, and they all seem to love what they do, and their residencies are very competitive to get into.