by David Page
Master Injury List For the Arm
Minor injuries
■ Shoulder: bursitis, first-degree AC (acromioclavicular) shoulder separation, muscle strain, arthritis, shoulder bruise
■ Arm: biceps or triceps strain, muscle contusion (bruise)
■ Forearm: "tennis elbow," bursitis of the elbow
■ Wrist: sprain, cyst, tendonitis
■ Hand: minor abrasions, laceration, nail injuries, arthritis, trigger finger
Major injuries
■ Shoulder: fracture of neck of humerus, dislocation, third-degree AC shoulder separation, sternoclavicular separation, rotator cuff tear, injury to nerves to the arm and shoulder
■ Arm: fracture of shaft of humerus, fractures at elbow with artery damage, injury to radial nerve at midarm, tear of biceps tendon
■ Forearm: fracture of one or both bones, fracture of one with dislocation of the other at the elbow, severe "tennis elbow"
■ Wrist: Colles' fracture of wrist, dislocated navicular bone, fracture of scaphoid bone, dislocation of carpal (wrist) bone, fracture of carpal bone(s)
■ Hand: severe infections, lacerations, "degloving" (stripping off of skin) injuries, crush injuries, amputation of fingers, broken fingers
2. The radial nerve may be damaged by direct pressure or a smack on the back of the arm by a club. For example: A drunk falls asleep on a park bench (be warned, this is a time-told tale in the halls of academic medicine, so alter the telling) and compresses his radial nerve against the back of the bench as he flops his arm over the bench. It's called Saturday night palsy, and it may become chronic.
In both situations, the injury produces radial nerve damage and what is called "wrist drop." The victim can't extend the wrist or hand, and varying degrees of paralysis are possible. The acute injury may disappear quickly; the more chronic problem may become permanent.
Elbow
It seems there's nothing in-between about the elbow. Either you break it and risk catastrophic damage to the nerves and blood vessels to the forearm and hand or you just cause all sorts of pain and annoyance for yourself. Not much else happens at this dingy hinge joint.
Take the minor problem of "tennis elbow," not so minor if you've ever had it and certainly not restricted to racquet enthusiasts. Inflammation of the origin (from the bone) of the extensor muscles of the forearm, tennis elbow occurs because of repetitive pronation and supination of the hand and wrist. Place your palm facedown: That's pronation. Now rotate your hand until it's facing up, as if you're holding a bowl of soup in your palm: That's supination. Tennis elbow often becomes chronic and may require steroid injections or the application of an external compression band.
Bursitis of the elbow can occur in the pocket of fluid located posteriorly over the bone. It's diagnosed as an acute inflammation or infection when the bursa becomes red, hot and tender. It may need to be drained by an incision or by needle aspiration, and antibiotics are often required. At times, it must be removed if the inflammation becomes chronic.
Kids can easily dislocate the radial head (the end of the forearm bone at the elbow) because the flare part of the bone doesn't develop until later in life. An adult could cause this injury by yanking a child by the arm.
As with the knee, the most terrible injury to the elbow is a dislocation or fracture-dislocation. The artery and nerves are at risk because they hug the bones, and major hand complications can follow these injuries. At times, the neurovascular bundle (as the blood vessels and nerves are called when considered together) is severely injured despite the orthopedic surgeon's best efforts.
Forearm
Two bones form the framework of the forearm where a galaxy of muscles weaves its way to the wrist and fingers. Complicated beyond reason, forearm anatomy may be summed up by thinking of it as two groups of muscles: flexors on the inside and extensors on the outside. Well, there are a few more muscles that rotate the forearm (that pronation and supination thing). And a couple of outcropping muscles that control the thumb.
Imagine the forces exerted against the muscles and bones of the forearm when a blow is deflected by the raised forearm. Anything from a muscle contusion, bone bruise or fracture of the ulna (the ulna bone is directly beneath the forearm skin; check it out on your own forearm), fracture of the radius or both. A stab wound to the forearm may cut nerves, muscles and large blood vessels.
Forearm injuries occur in folks who tumble and try to break the fall as well as in those attempting to defend themselves. Chronic forearm muscle strain may occur in people performing repetitive occupational tasks. More commonly, the forearm is spared and the wrist (carpal tunnel syndrome) and elbow (tennis elbow) take the brunt of the insult.
Wrist
Fractures and sprains occur commonly at the wrist. The classic wrist fracture, perhaps the best-known bone break in the body, is the Colles' fracture. These injuries meld with those of the carpal bones, those eight stone-size bone lumps between your forearm struts (radius and ulna bones) and the delicate finger bones that elongate to form your hand. The proper diagnosis can only be made with an x-ray.
A couple of other traumatic injuries characterize the wrist area and provide you with methods of sidelining a character with a pesky problem for weeks or months.
The scaphoid bone in the wrist is subject to fracture from direct violence, such as a fall on the outstretched hand, or by direct impact. Because of the unique blood supply to this funny little ossicle, one of the broken fragments may die, and thus begins an oft-protracted tale of orthopedic surgical care. Whether pinned, screwed or casted, the broken bone stone may eventually need to be removed and replaced with a plastic implant.
The other more or less common wristbone injury involves the scaphoid's next-door neighbor, the navicular bone. For reasons of ligament design, this baby doesn't break easily; it dislocates. Squirted out of alignment, the bone creates acute and chronic pain and may ruin the plans of the professional athlete and concert pianist alike.
Carpal tunnel syndrome is a well-known chronic wrist problem. Many people, particularly folks such as writers who use their hands in repetitive tasks, develop numbness, tingling and aching of the hands. Trapped in a tight tunnel at the wrist, the median nerve becomes compressed and often surgery is needed to release the carpal ligament. This may be done with a special scope (closed surgery) or with open surgery.
Hand
Some orthopedic and plastic surgeons do nothing but hand surgery. And though palm reading is intriguing, what Flaubert accomplished in the passage quoted at the start of this chapter represents more clearly what we are seeking to emulate creatively. On the parchment of a character's fingers and palms, you may write a life history. What can the hand tell you about your character?
Lots.
Scars, knobby arthritis, missing digits, crooked fingers that won't straighten, flushed palms and splintered fingernails all imprint the individual with a unique back story. Arthritis and scar tissue contractures may distort the tissues until the hand becomes a gnarled knot, a contorted, impotent fist.
A number of hand infections may put your character out of action for days or weeks. Treatment may include antibiotics, elevation and rest and, in some conditions, surgery. Often in a story, the writer wishes to take someone out of the action for a short while, someone who needs their hands, such as a musician, artist or surgeon. These hand infections can do the trick.
If someone gets stuck in the hand or finger with a sharp object— look at the story's environment and pick something appropriate, e.g., garden tool, rose bush, hunting knife, exposed nail in a barn—an infection may result called cellulitis. It means a red, tender swollen body part with a diffuse infection with bacteria. A simple cellulitis may turn into a deep hand space abscess. The hand cellulitis may be accompanied by streaks of red traveling up the arm and is often mislabeled blood poisoning. Actually, the red marks represent lymphangitis, more infection running up the lymphatics of the arm, and mean things are definitely out of control. Treat
ment at this stage includes intravenous antibiotics, rest and elevation in the hospital. If a specific swelling occurs, say, in the palm, then surgical drainage of the abscess becomes an emergency.
From the humdrum cellulitis your pianist picked up trimming her Presidential roses a day before the big concert, there evolves a nasty swollen index finger full of pus. The tendon sheath abscess becomes a ticking clock.
Other hand injuries include:
• Ruptured tendons: require surgical repair; may be from wear and
tear or sharp trauma
• Ruptured ligaments: tearing of ligaments that hold the finger bones together; may need surgery
• Dislocated fingers: painful; short term (two to four weeks) disability; may require surgical reduction if closed reduction takes too much force
Degloving injury of the hand refers to the traumatic stripping off of full-thickness skin from the top (dorsum) of the hand where it is less well fixed than in the palm. Ripped from its attachments, the curled skin flap remains attached at one end. It must be replaced surgically, although if the blood supply is severely damaged, the flap may not survive. Then a skin graft is needed.
Finally, there are congenital deformities of the hand that are quite striking. A claw hand, for example, occurs when a huge cleft develops between the third and fourth fingers, leaving a truly clawlike (lobster) appearance. Two or more fingers may fuse together before birth. Or six fingers may develop.
These types of injuries will be echoed in the discussion of lower limb injuries.
The Lower Extremity Hip
In a young person, the hip is a sensual signal of firmness, physical health and allure. In the elderly, the hip strains to carry the load of accumulated poundage that overloads an already crooked back. The youthful woman's hips rock as she walks and suggest a generous pelvic cavity friendly to new life and birth. The old woman's hip shatters when she tumbles to the floor, her foot caught on a rug, her eyesight dim. There is an insidious degeneration that the hip joint endures as age creeps into our bones.
It does not respect gender. Hips do not age well. Falls and fractured hips in the elderly and hip "pointers," or contusions, with skin abrasion in younger people make up the lion's share of acute hip pain. Bursitis and degenerative arthritis play a role in chronic suffering in middle and old age. A lifetime of bearing the body's weight wears down the hip joint and thins out the cartilage designed to keep the joint running smoothly. Thin bones break at or near the angle between the vertical thigh bone (femur) and the short neck of the bone that supports the head (ball of the ball-and-socket joint). Limping may result
Extremity Trauma: Crunched Arms and Legs / 121
Master Injury List For the Lower Extremity
Minor Injuries
■ Hip: acute pain from bursitis; a "hip pointer" or skin abrasion from scraping injury; chronic degenerative osteoarthritis resulting from "wear and tear"
■ Thigh: acute and chronic groin pull or adductor muscle tear (minor or major), quadriceps (anterior thigh muscles) contusion, abrasions, hamstring pull (posterior muscles)
■ Knee: acute minor sprains or strains involving the four major ligaments with localized pain: medial collateral, lateral collateral, anterior cruciate, posterior cruciate; minor meniscus cartilage tear; fluid in knee (joint effusion); chronic osteoarthritis
■ Leg: minor acute "shin splints" and minor anterior compartment syndrome, bone contusion ("bone bruise"), simple fracture of the fibula, abrasions and lacerations, chronic tendon or muscle strains
■ Ankle: minor acute sprained ankle, acute partial tear or tendonitis of the Achilles tendon (may become chronic), chronic degenerative arthritis, tendonitis of long tendons to toes
■ Foot: fallen arches (flat feet), bunions, fracture of metatarsal bone (so-called "stress" or "march" fracture), Morton's neuroma (painful swelling of a nerve to the toes), gouty arthritis of great toe, hammer toe, plantar warts—all chronic
Major injuries
These injuries are acute but may have chronic, painful complications.
■ Hip: fractured hip, posterior dislocation of hip, pelvic fracture through hip joint
■ Thigh: fractured femur with major blood loss, major torn quad-raceps muscle, major hamstring tear, major soft tissue injury or crush injury (direct trauma), traumatic amputation of leg through thigh
■ Knee: fractured patella (kneecap), complete tear of one of the four ligaments, complete tear of two ligaments, dislocation of the knee with damage to artery supplying the lower leg, fracture of femur or tibia through knee joint
■ Leg: compound (open) or comminuted (many broken bone fragments) fracture of tibia with or without a fibular fracture, major soft tissue trauma with vascular or nerve damage, crush injury to leg
■ Ankle: trimalleolar fracture (all three bones making up the ankle are broken), complete rupture of the Achilles tendon, open (compound) fracture of the ankle, major laceration of tendons, nerves or arteries to foot, traumatic amputation of the foot
■ Foot: traumatic amputation of part of the foot, severe lacerations with tissue loss ("degloving" injury), major crush injury
from any of these lower extremity injuries.
With a hip dislocation the thigh bone (femur), positioned horizontally in a seated driver, is driven posteriorly with direct impact of the knee against the dashboard (or by any major force against the flexed hip). The weak posterior hip joint capsule ruptures, and the head of the femur dislocates backward. Surgical correction is required.
Hip fractures occur almost exclusively in the elderly and require hospitalization and surgical fixation with special orthopedic prosthetics, plates, and screws or "superglue." Often the patient must wait a few days after the accident for operating room time to become available. The big postoperative risk is phlebitis (blood clots forming in the legs) because of the patient's immobility. After surgery, prolonged rehabilitation is needed to help the patient regain muscle strength, balance and maneuverability.
Thigh
Fractures lead the list of severe thigh injuries, and although a hip fracture technically occurs in the neck of the femur bone, it is a shaft fracture that we refer to in the thigh. Two common patterns may be seen, each with a different impact on the patient. Besides the disability experienced because a major bone has been broken, a bone that ordinarily supports much of the body's weight, these two fractures carry additional ominous complications:
1. A midshaft fracture of the femur may be associated with major blood loss—up to one or two units of blood lost into each thigh. Bilateral (on both sides) thigh bone fractures can cause shock from blood loss.
2. A fracture of the femur above the knee (called a supracondylar fracture) may cause disruption of the artery to the leg, producing a cold foot. This is a vascular emergency, and the fracture often requires surgical fixation (with pins, plates or screws).
The basic principles of emergency treatment for fractures of the femur include:
• Clean and bandage any open wound and cover with a dry sterile dressing
• Place a traction splint, manipulating the fracture only enough to straighten severely angulated bones
• Transport to a hospital with an orthopedic surgeon
Crush injuries to the lower extremity are especially devastating when the meaty thigh muscles are smashed, creating increased IV fluid volume requirements as well as releasing toxins. Major lacerations require extensive debridement (surgical cleaning up) and suturing of torn tissue. Major tissue loss must sometimes be filled in by rotation flaps from elsewhere (done later when the threat of infection is less). Other plastic surgery techniques may also be required, but that would be much later in the hospital course.
Lesser thigh injuries include contusions (bruises), groin pulls (a tear of the adductor muscles) and strains or major injury to the quadriceps tendon at the kneecap (patella). Chronic "quad" contusions seen in football, lacrosse, soccer and hockey players occasionally will become calcified and mimic a chunk o
f bone within the muscle. And, of course, your character can get shot or knifed in the leg.
In John Sandford's novel Mind Prey, the cops find bad guy John Mail's house and attempt to corner him as he runs out of the cellar. Police officer Sherrill jumps out from around the corner of the house, and Mail shoots her in the thigh with a shotgun.
Del was kneeling over her, had ripped open her pants leg. Sherrill had taken a solid hit on the inside of her left leg between her knee and her hip; bright red arterial blood was pulsing into the wound.
"Bleeding bad," Del said, his voice was cool, distant.
Mail nailed Sherrill's superficial femoral artery, and the subsequent description of the cop applying pressure, then whisking her off on a helicopter rings true. And there's no mention of the artery, but Sandford knew it was there.
Knee
Acute knee injuries, ligament strains or tears, or torn cartilage often occur during strenuous sports activity. Each supporting structure may be mildly or severely injured. The damage may occur during vigorous activity in the highly trained person as well as in the untrained weekend athlete. Tissue tears are partial or complete. Any of these injuries may become chronic.
The following acute knee injuries may be the result of a direct or indirect impact on the knee:
• Medial collateral ligament strain/sprain/tear
• Lateral collateral ligament strain/sprain/tear
• Medial meniscus tear
• Lateral meniscus tear
• Anterior cruciate ligament tear
• Posterior cruciate ligament tear
• Patellar (kneecap) ligament strain
When a knee structure is repeatedly strained or torn, a chronic knee problem results. This is often seen in athletes who strain or tear the aforementioned ligaments or cartilage that then may wear out and snap or tear. Like old rope, the ligaments may become frayed and weak and often must be replaced by prosthetic material or other ligamentous tissue from the patient's body. With time, the cartilage lining the knee joint becomes worn because joint mechanics are thrown off by ligament imbalance. Traumatic arthritis results.
