Accident and Emergency
Missed Fractures
Scaphoid (wrist/hand) Fracture
Spinal Injuries
Lacerations to the Hand and Wrist
Flexor Tendons
Partial Division of a Tendon
Glass and Other Foreign Bodies
Eye Injuries
Head Injuries
Subarachnoid Haemorrhage
Ectopic Pregnancy
Missed Fractures
See also Fractures
It is important that:-
- A history of the mechanism of injury is obtained because this will indicate the force and direction of injury, and this will suggest likely patterns of injury
- An adequate examination is carried out.
- If a fracture is suspected, relevant x-ray films are taken.
Scaphoid (wrist/hand) Fracture
The scaphoid is a small bone which forms part of the wrist joint. A painful wrist following a fall on the out-stretched hand may be due to a scaphoid fracture. Often the x-rays do not show a fracture. In the early stages patients with a suspected scaphoid fracture should be instructed to return to hospital for repeat scaphoid x-rays 10 to 14 days after the injury. It is not sufficient to tell a patient to come back if the pain continues.
Scaphoid fractures can have significant complications:-
- Part of the bone can die because of an interruption in the blood supply to that end
- The bone fails to unite early on, requiring treatment with internal fixation or bone graft
- The bone fails to unite
- Osteoarthritis (a form of arthritis in the joint which undergoes degenerative changes)
Spinal Injuries
See also Spinal Surgery
All patients with an altered level of consciousness who have any evidence of any injury above the level of the shoulder must be suspected of having an injury to the cervical spine (neck) and be managed appropriately. A patient who is concussed will not be able to explain to the doctors that they have a painful neck. For this reason, the cervical spine should always be x-rayed in all cases of head injury.
One of the x-rays taken when a cervical spine injury is suspected must always show the top of the first thoracic (upper back) vertebra and all 7 cervical vertebrae. This is to detect a possible fracture or dislocation at that level. If the x-rays are not adequate they may not show any fracture or dislocation at that level even though one is there. It is not appropriate to say that the patient was in a lot of pain or unconscious
Failure to x-ray, or to properly x-ray, the cervical spine can lead to very serious consequences. If a fracture or dislocation of the cervical vertebra has occurred it can be unstable. If left untreated further displacement can take place causing damage to the spinal cord and/or the nerve roots. This damage can result in limb and bladder paralysis not present when the injury occurred.
The other area of the spine that is especially at risk from trauma is the thoraco-lumbar (upper and lower back) junction. A thorough “head to toe” examination of the patient with multiply injuries must be carried out and documented including examination of the whole length of the spine.
Lacerations to the Hand and Wrist
Nerves and tendons in the hand and wrist are very vulnerable to partial or complete division from lacerations (cuts), especially those caused by glass. The doctor must exclude damage to underlying structures by careful clinical examination and thorough exploration of the wound before it is sutured
Sensory loss (nerve injury) may be difficult to detect during the first 48 hours even if a nerve has been completely divided (severed) because some sensation may be retained if the cut ends of the nerve remain positioned together. It is necessary to compare quality of sensation between the injured and uninjured sides. If there is any suspicion of altered sensation and nerve damage, then the patient must be referred immediately either to senior A & E staff or to the duty orthopaedic team.
Flexor Tendons
Injury to flexor tendons is easily overlooked. The doctor must exclude injury by individually testing the function of each finger.
Divided flexor tendons of the hand can cause severe problems. They must always be referred immediately to the duty hand, orthopaedic or plastic surgery team.
Partial Division of a Tendon
A partially divided tendon can snap later on. This is possible if more than half of the tendon is divided. The doctor should test movement because it will be painful if there is a partial division. If there is any suspicion of tendon (or nerve damage) the patient must be reassessed on the next working day.
Glass and Other Foreign Bodies
Virtually all glass, except certain types of fluorescent tubing, is radio-opaque (will show up on x-rays). The hospital staff should take an x-ray to exclude glass foreign bodies if a patient has an injury involving broken pieces of glass. If there is a suspicion of more than one fragment of glass further x-rays must be taken after removal of pieces of glass to ensure that no glass remains.
Eye Injuries
See also Eye Surgery
The eye is vulnerable to devastating damage by chemical and physical trauma (which may take the form of blunt or perforating injury).
Management Errors include:-
• Failure to provide emergency and satisfactory irrigation of the eye
• Failure to remove all foreign particles from the eye
• Failure to document history and examination on arrival
• Failure to institute the correct drug regime
Perforating injuries of the eye, especially with high speed pieces of metal, are easily overlooked. Injuries sustained whilst using a hammer and chisel, or when using a drill bit which suddenly breaks, are likely to be associated with small fragments of flying metal. The history should alert the doctor to this possibility, and a careful examination needs to be carried out.
Even if a foreign body is not seen, the patient must be referred to an ophthalmologist. This is because of the very serious consequences that can arise due to contamination from any piece of debris, such as wood or metal, no matter how small, being left within the eyeball for any length of time.
Head Injuries
See also Brain Injury
Drunkenness can mask the symptoms of a head injury so that it is not diagnosed in time to prevent death or serious injury resulting from the delay.
The initial management of a patient with a serious head injury in the A & E department should be to assess the patient as a whole.
The A & E doctor must ensure that there are no other injuries to the patient, which may not be detected initially because attention is being focused on the often dramatic head injury.
The injury to the patient may be relatively minor and the initial brain injury may also appear to be insignificant. Delay in diagnosing a haematoma (a swelling containing blood) leads to increasing cerebral compression and can lead to irreversible brain damage over a few hours or days. Careful clinical observation is necessary. Delay in the diagnosis and treatment of haematoma is an important factor in the complications of head injury.
Scalp wounds have to be cleaned and treated carefully because a fracture or penetration of the skull by a shape object may lead to dangerous infection.
Subarachnoid Haemorrhage
A haemorrhage is the loss of a large amount of blood in a short period of time.
A subarachnoid haemorrhage is a haemorrhage into the subarachnoid space between the layers covering the brain.
A subarachnoid haemorrhage may be caused by a rupture of a major vessel. The prospects are poor without treatment.
A large haemorrhage will result in the patient suffering the sudden onset of very severe head pain with vomiting and loss of consciousness. Smaller bleeds are less dramatic, with a severe headache that is again often of sudden onset and unusual for that patient. This may be followed by vomiting and later by some neck stiffness.
It is generally not acceptable to ignore the possibility of the diagnosis of subarachnoid haemorrhage if the headache is of sudden onset and unlike other headaches that the patient has had in the past. The patient should be referred for more senior or specialist advice and further investigation.
Delay in diagnosis of subarachnoid haemorrhage can result in serious or fatal consequences.
Ectopic Pregnancy
An ectopic pregnancy occurs when the fertilised egg develops outside the uterus (womb), most often in the fallopian tube.
Patients complain of cramp-like, colicky pain, usually on one side of the abdomen. It can be confused with appendicitis. The pain is severe and is worse when moving. Ectopic pregnancy should be considered if a patient has vaginal bleeding and is possibly in the early stages of pregnancy with abdominal pain.
Undiagnosed and untreated, the natural history of the ectopic pregnancy with acute rupture of the Fallopian tube is death. The safe rule for doctors to remember is: lower abdominal pain in female patients of reproductive age is due to the presence of an ectopic pregnancy until proved otherwise. Doctors must not discount the possibility until it is known that a pregnancy test is negative.
Summary
This is only a very short summary of what is a complicated medico-legal topic. All claims for medical negligence require a detailed assessment of the factual, medical and legal issues surrounding the circumstances of the treatment. Raleys can help you find a way through this maze.
