Body Trauma

by David Page

  Seemingly innocent bumps on the belly can damage major intraabdominal structures, and the appearance of pain, bloating or other symptoms may be delayed. You can use this subtle type of traumatic injury to create a ticking clock, leaving a trail of small clues.

  Kidney: The kidney is partly solid (the urine-forming, water- and salt-saving part) and partly hollow (the collecting system to transport urine to the bladder). Injuries include bleeding from a solid part laceration or urine leakage from a tear in the collecting tubes.

  Penetrating Trauma to the Abdomen

  The result of penetrating abdominal injury is similar to that produced by a blunt impact. For the uninitiated, a thrust with a butcher knife into the gut seems more ghastly than the by-product of slipping and falling on the ice. Sometimes it's the penetrating wound that's trivial.

  Instead of listing each organ system again, we'll outline wounds, which will permit you to create an injury time line to suit your plot. Much of it has already been described above. Penetrating trauma may lacerate solid organs, causing bleeding and loss of function, or put a hole in a hollow tube which then leaks its contents. Remember, with a penetrating wound you need only trace the normal anatomy in your mind, decide what will be injured, then write about the ghastly visible results of that injury.

  A stiletto stab wound in the right upper abdomen may hit the liver, causing trivial bleeding, which your villain survives in his room on the fifth floor of an abandoned building in the barrio. Or it might slice

  Symptoms and Signs of Peritonitis

  Subtle physical findings on exam with minimum complaints

  ■Elevated pulse rate

  ■ Low-grade fever (99° or more)

  ■ Mild swelling of the belly Obvious symptoms

  ■ Complaints of severe abdominal pain made worse by moving, coughing, jumping up and down, hitting a bump in car (on the way to the hospital)

  ■ Nausea, vomiting, bloating Obvious signs

  ■ Severe pain during doctor's examination when abdomen is pushed, then quickly released; location suggests the organ injured

  ■ Mass or lump in the belly

  ■ Bowel sounds (via stethoscope) absent

  ■ Major abdominal swelling

  ■ External markings suggesting injury, such as tire marks, cuts, bruises, abrasions; evidence of a knife wound or gunshot entry or exit wound

  through the hepatic artery and throw the fellow into hemorrhagic shock. Sure, he can survive. Aren't you at the controls of that novel?

  This is where cross-sectional anatomy comes in handy. A knife's path is direct, short and predictable. Some stab wound victims don't require surgery, just careful observation. A bullet wound, on the other hand, may ricochet anywhere in the belly, bounce off ribs, vertebrae or pelvic bones and shatter everything in its path. Refer to Figure 15 on page 106 and imagine a bullet nicking the liver, ripping through the stomach, smashing a rib and becoming redirected into the spleen or intestines.

  Suppose your character, carelessly playing with a gun, accidentally drills his kid brother in the buttocks. Buttocks? Probably a trivial wound, right? The ER doctor cleans out the wound and sends the patient home on antibiotics and a rubber donut.

  Or did the .38 hollow point tear into the kid's gluteus maximus,

  smash his hip joint, nick his rectum and then lodge in his flank muscles? The time line of this more involved injury includes transport to a hospital, emergency surgery complicated by the need for a colostomy and extensive tissue loss from an infected hip wound. Eventually, he'll need either extensive home care with visiting nurses or management in a chronic care facility. At the writer's discretion, this tale may be followed by months of further care, including a total hip replacement, which may become infected requiring removal of the hardware and . . .

  Anything can happen with a gunshot wound.

  You decide.

  The trauma surgeon handles small and large intestine injuries differently. Injured small intestine may be removed, a segment cut out, and the ends sewn or stapled together. However, in cases other than minor nicks or tears, the victim with a major perforation of the colon or rectum needs a temporary colostomy. This procedure (Figure 16) involves bringing the working end of the colon out through an opening in the belly wall to which it is sewn. A colostomy bag or appliance is worn for months until the intestine can be safely and electively prepared (cleaned of stool) and put back together.

  Abdominal Trauma: Beware of Hidden Damage / 107

  A colostomy may create dread, depression and disillusionment. Many patients think the stool collection bag is forever, and sometimes, the colostomy cannot be reversed. For transient distress and a test of deep character, a colostomy appliance full of feces in your heroine's lap could be distressing indeed.

  A summary of what happens with penetrating abdominal trauma is listed below:

  • Solid organs bleed.

  • Hollow organs perforate and leak irritating body fluids.

  • Virtually all gunshot wounds to the abdomen must be explored: The victim must go to surgery and have the trauma surgeon search for any and all possible injuries in the bullet's path.

  • Some stab wound victims may be observed in the ICU if the wound is superficial and there are no signs of peritonitis.

  • Deep stab wounds of the belly are usually explored (exploratory surgery).

  • A stab or gunshot wound of the lower chest may cause damage in the belly.

  Diagnosing a Major Abdominal Injury

  The injured belly (one of the causes of what is called an acute abdomen) can be a diagnostic snake pit for the trauma surgeon. Notice how many of the problems listed above have similar symptoms and pain location? Twenty percent of major abdominal injuries are not associated with significant symptoms or physical findings. A lot of blood may hide in the belly without detection. The trauma surgeon's job is to always suspect a missed injury, particularly if surgery isn't performed immediately.

  The victim's history may be helpful in blunt trauma. Information about the injuring object, weapon, speed of the car on impact or details from the scene of the accident all help to determine the likelihood of certain injuries. Skin abrasions, bruises or cuts may suggest deeper injury. In penetrating trauma, the availability of the weapon is useful in gauging depth of penetration. Any obvious external findings, such as a knife wound or gunpowder burns, will help direct further special tests.

  When the surgeon examines the victim, she looks for tenderness, particularly increased soreness when she presses in on the belly wall, then releases suddenly. The sudden movement of the underlying peritoneal lining will hurt terribly if there is peritonitis. Severe pain produced by this maneuver ("rebound" tenderness) leads to emergency surgery. A belly that is swelling before the surgeon's eyes means massive bleeding and immediate surgery.

  Clinical Picture of Abdominal Injuries

  Minor abdominal injuries

  ■ Bruised kidney: blood in urine, flank pain

  ■ Small liver laceration: skin abrasion over upper right abdominal skin with deeply located pain

  ■ Small spleen laceration: left lower rib pain or upper left abdominal pain

  ■ Mildly bruised pancreas: central abdominal pain that may radiate into the back

  ■ Minor tear of bowel: abdominal pain Major abdominal injuries

  Usually associated with shock; any of these injuries may be heralded by diffuse or generalized abdominal pain.

  ■ Massively bleeding liver lacerations: upper right or diffuse abdominal pain

  ■ Shattered spleen with extensive bleeding: left rib or abdominal pain or diffuse abdominal pain associated with shock

  ■ Leaking small intestine (perforation): diffuse abdominal pain

  ■ Leaking colon or rectum (perforation): diffuse lower abdominal pain

  ■ Shattered kidney with bleeding or urine leakage

  ■ Ruptured urinary bladder (perforation): lower abdominal pain

  ■ Torn, bleeding aorta or vena ca
va: massive abdominal swelling, hemorrhage in belly, shock

  Two special tests may lead the trauma surgeon to recommend an emergency operation:

  1. Peritoneal lavage, a "washing out" of the abdominal cavity with saline solution, looking for blood, stool, bile or urine

  2. CT scan of the abdomen to look for leaking fluid, gas outside the gut, a mass or a lacerated solid organ

  Armed with information derived from the clinical examination, multiple tests and x-rays, the surgeon decides whether to explore the patient's

  abdomen or observe the patient for further clarification of the clinical picture. Also, the surgeon searches for the appearance of new findings.

  The Outcome of Abdominal Injury

  Abdominal injuries, with or without exploratory surgery, usually heal without major complications, permitting a complete recovery and return to one's usual diet and activities. If a colostomy was needed, it will be closed at a later date. Drains may be left in for a prolonged period of time and removed in the surgeon's office or in the clinic. Wound infections occur sometimes.

  Unlike the residual limps, lapses and language deficits seen after neurological damage, recovery from abdominal surgery is quite uncomplicated. Nonetheless, the major focus of the abdominal surgeon remains fixed on deciding whether to explore the trauma victim's abdomen at all. The surgeon cultivates a high degree of suspicion even if there is no obvious belly injury.

  Some diagnoses are difficult to make, particularly when other injuries, such as coma, complicate the picture. The trauma surgeon will return to the bedside over and over to reevaluate the patient until he is certain no injury exists.

  Some belly injuries are subtle. Some diagnoses are delayed.

  After major torso trauma, there may be heard inside the victim's belly, without the assistance of a stethoscope, a loudly ticking clock.

  Most writers have suffered a painful impact at some juncture in their lives. Perhaps an awkward stumble resulted in a twisted knee, or a slam in the thigh produced a painful muscle knot. The injuries discussed in this chapter—lumps, bumps, abrasions, twisted ankles, broken bones and dislocations—are undoubtedly familiar maladies.

  In some ways, arm and leg injuries are more useful than catastrophic injuries of the trunk as subjects for characterization. All sorts of potential characters come to mind. Think of Uncle Wheezer with his gimpy leg. Or Cousin Billy's annoying trigger finger, the one he snaps incessantly. What about Grandma's hammer toe? Or Martha's unresolved sciatica?

  In Madame Bovary, Charles is about to splint a man's broken leg; the scene occurs in a small farmhouse. Gustave Flaubert describes Charles observing Mademoiselle Emma's hands as she prepares strips of sheets for the splint:

  Charles was surprised at the whiteness of her nails. They were

  shiny, delicate at the tips, more polished than the ivory at Dieppe,

  and almond-shaped. Yet her hand was not beautiful, perhaps not white enough, and a little hard at the knuckles, besides, it was too long, with no soft inflections in the outlines.

  Perfect nails, imperfect fingers. A reflection of the young woman's work on the farm? Flaubert carved intrigue into her knuckles to be read by the perplexed Charles, subtle indications of deep character, polished by repetitive minor trauma.

  We are known by our hands and feet.

  Engineers often build a prototype when working on something new, a model of the real thing. The prototype is really a physical scheme with essential elements crafted and enjoined. Thus, a prototype arm or leg could be represented as a cylinder of concentric layers of tissue through which course a variety of tubes and cables, all supported by a central rod with joints. Figure 17 demonstrates all of the elements of a human limb. With this model in mind, you'll easily understand the effects of common injuries. For a particular scene, you may choose an isolated injury or a combination of afflictions. These elements represent the trauma prescription for an injured arm or leg. Or both.

  For both extremities, we'll discuss acute impact injuries first. At the end of the chapter, you'll discover ways to employ chronic injuries from repetitive motion, often occupational, to create back story and establish character verisimilitude. For example, envision the cracked, grease-filled fingernails of a mechanic or the stained fingers of the ever-suffering woman working in a dingy print shop. Sometimes old injuries, for example, loss of a fingertip from frostbite, reflect a forgotten passion for adventure. Arm and leg injuries may be major or minor, and the time line of each injury determines how each plays out in the plot.

  The Upper Extremity

  Shoulder

  Several direct and indirect impacts create problems in the shoulder. Lesser shoulder injuries include contusion (bruise); tendonitis, e.g., inflammation or damage to the rotator cuff; or bursitis (inflammation of the tiny bags of fluid around any joint, which act as cushions for tendons). Repetitive motion as in swimming, in throwing a baseball or in various occupations produces diseases of wear and tear—the arthritis-bursitis-worn-out-old-tendon syndromes.

  The most common acute shoulder injuries are fractures and disloca-

  tions. Fractures occur in the neck of the upper arm bone (humerus) or in different parts of the shoulder blade (scapula), part of which forms the shoulder socket. A bone-shattering impact may result from a fall directly on the shoulder, from force transmitted to the shoulder from a fall on the outstretched arm or from direct trauma, e.g., a club strike.

  It's possible to dislocate the shoulder with a fall on the arm or by yanking or striking the shoulder while it's relatively unprotected. The worst position (most susceptible to dislocation) is when the arm is held away from the body and rotated backward. Most shoulder dislocations are anterior, or in front of the joint, and may be reduced in the field or in the ER with sedation. Basically, the dislocated head of the humerus (contrary to the sound of that name, there's nothing funny about a shoulder dislocation) must be replaced into the socket before the shoulder

  Mechanisms of Extremity Injuries

  Acute injuries occur by:

  ■ Direct trauma to the injured area

  ■ Indirect force transmitted up or down the arm or leg to the injured area

  Chronic injuries occur by:

  ■ Direct, repetitive low-level intensity impact

  ■ Indirect irritation associated with repetitive motion

  ■ Deterioration of the limb from an acute injury

  muscles go into spasm.

  A dislocated shoulder is diagnosed when:

  • There is a flat angular shoulder profile (loss of gentle shoulder curve)

  • Shoulder pain is severe (except in the case of a chronic dislocation, which may not be painful)

  • The elbow is bent slightly away from the body with the forearm turned in (palm down)

  There are two ways to reduce a dislocated shoulder:

  1. Place the stocking foot into the armpit and apply steady traction on the arm until the head of the humerus "clunks" back into the socket.

  2. Apply the Kocher maneuver's four moves: first, pull down on the bent elbow; second, rotate the arm out (externally); third, slide the elbow in toward the middle of the chest with the victim's hand still out; fourth, cross the hand over the body, or rotate the arm medially.

  The owner of a chronically dislocating shoulder may be able to reduce the slack joint without assistance. Some acute dislocations cannot be reduced with the two conservative methods mentioned above. Part of the joint capsule or a chunk of the rotator cuff (muscle or tendon) may become stuck between the joint surfaces. Open surgery is then needed.

  Fractures of the shoulder blade, which result from a major direct smack on the shoulder or back, are not common. It takes an impressive direct hit to break the flat part of the scapula, and other major injuries, such as damage to the arm nerves, may also occur.

  Connecting the scapula (shoulder blade) to the sternum (breastbone) is the bony strut called the clavicle (collarbone). It's a good one to break if your hero attack
s a villain using a karate chop to the root of the neck. Severe pain and deformity result from a fractured clavicle. It gets the bum out of the picture for a few weeks.

  A shoulder separation (AC, or acromioclavicular, separation) may be slight or may result in disruption of all of the complex ligaments that tie the lateral end of the collarbone to the shoulder. These injuries are seen frequently in contact sports.

  The sternoclavicular joint is where the collarbone attaches to the breastbone and rarely is the site of a dislocation. If the dislocation is anterior (in front of the sternum), it's not dangerous, but if the end of the collarbone dislocates posteriorly, it may damage blood vessels in the lower neck causing major hemorrhage.

  Any of these orthopedic problems may be associated with a significant tissue tear and disruption of the joint anatomy. Thus, some injuries become chronic. If so, open surgery may be the only solution to persistent pain or disability. Surgery is the only solution to a major fracture or dislocation.

  Arm

  Not to be confused with the forearm (below the elbow), the arm extends from the shoulder to the elbow crease and is known best for its cultivated biceps and massive triceps. Common acute injuries to the arm include fracture of the shaft of the humerus, tears of the biceps or strains of the triceps. An interesting acute injury occurs when the long head of the biceps tears away from the shoulder area where it inserts, leaving the belly of this impressive muscle to curl up like a burrowing rodent beneath the arm skin.

  Five nerves arise from a tangle of interconnections in the neck and go south to the arm, forearm and hand. Each has the task of supplying sensation to specific areas of skin as well as innervating specific arm and forearm muscles. For example, spiraling behind the middle of the arm (hugging the humerus bone) lies the radial nerve, which controls the extensor (bending backward) muscles of the wrist and fingers. These muscles form the mass below the elbow and can be knocked out of commission in two interesting circumstances:

  1. The radial nerve may be damaged acutely by a broken shard of

  bone following a fracture of the midhumerus.