Closed soft tissue injuries

Closed injuries are mechanical injuries to the soft tissues (contusions, crushes, strains and ruptures) without defects in the skin covering.

Contusion. Contusion is a closed mechanical injury to the soft tissues and organs without apparent damage to their anatomical structures, in contrast to subcutaneous ruptures.

Contusions occur as a result of a fall or a blow from a blunt object with minimum kinetic energy (e.g. stones, parts of an object, instrument). Soft tissue contusions can be encountered alone or in combination with bone fractures resulting from severe blows, contused wounds. Most common are external (superficial) contusions of the limbs and head; they can also accompany contusions and other injuries (concussion, rupture) of internal chest, abdominal, cerebral organs. Clinical signs of contusion are signs, swelling, haemorrhage and functional disorder.

Pain is the first symptom of contusion, it appears immediately at the moment of injury and can be rather severe. Pain is especially intensive in contusion to the periosteum. Later the pain may reduce in intensity, and in 1-3 hours after injury reappears or even intensifies. The change in pain character, an increase in its intensity result from the traumatic oedema, haemorrhage (infiltration of tissues with blood) or from growing haematoma.

In limb contusions, movements in the joints are initially intact; progression of oedema and bleeding, however, make movements impossible, especially in haemarthrosis. It is the functional disorder that differentiates contusion from fractures and displacements when immediately after the injury both active and passive movements become impossible.

Swelling at the site of contusion appears fast. On inspection it appears as a painful induration without sharp borders with the intact tissues. Pain is more intensive on palpation when there is contusion of the periosteum, with subperiosteal haematoma. Swelling as a rule increases in the first hours or days after injury, which is as a result of the development of posttraumatic oedema and inflammatory changes.

Contusion is normally associated with bruises, which result from bleeding into (impregnation of) the skin and subcutaneous tissues. The time of appearance of bruises depends on how deep the damaged vessels are situated. In skin and subcutaneous contusions they appear within the immediate minutes or hours. In contusions of the muscle and periosteum, they appear within the 2-3 days and occasionally far from the contused area. The appearance of late bruises that are situated far away from the contused sites is a serious sign that requires extra investigations (e.g. X-ray to rule out bone fractures and cracks). An example is the sign of «spectacles» - bruises around the eyes, which occur in several hours or even two days after contusion of the head. This sign is strongly suggestive of a severe head injury, i.e. skull base fracture.

The colour of bruises changes as a result of disintegration of haemoglobin. Fresh bruise is of red colour, after 5-6 days it turns green, and then yellow. The colour of the bruise can be used to determine the duration of trauma.

When giving the first aid at the accident site a pressure bandage is applied on the contused site. During the first few days, ice packs are applied to the contused site to reduce bleeding into tissues. A break in the application of icepacks is done every 2 hours for 30-40 minutes. In contusion of the extremities with formation of haemarthrosis, the limb has to be put to rest in a raised position, with a pressure bandage applied to the joint. Starting from day 2-3 following trauma, to enhance the resolution of small haematomas, heat is applied (e.g. hot water bottles). In contrast, large haematomas are punctured after 5-7 days, blood is evacuated and pressure dressing applied.

In examining a patient with soft tissue contusion of the extremities, pulsation of the peripheral arteries must be checked; skin temperature on both limbs should be compared, peripheral nerve sensations should also be checked since contusions can be accompanied by nerve damage or the compression of nerve bundles by haematoma. If damage to the bone (e.g. fracture, crack) is suspected, an X-ray film should be obtained.

Crush syndrome. Crush syndrome (traumatic toxicosis; the syndrome of prolonged compression) is a condition typically caused by prolonged compression of the soft tissues of the limb, resulting in ischaemic necrosis of muscles, intoxication with the products of necrotic disintegration with subsequent hepatic and renal failures. The condition occurs after the limb has been freed from the compression. The following are the major factors of crush syndrome.

• Pain irritation.

• Traumatic toxaemia resulting from absorption of tissue disintegration products.

• Plasma and blood loss.

Clinically, the three periods of traumatic toxicosis are distinguished:

1. Oedema and vascular insufficiency (days 1-3).

2. Acute renal failure (days 3-12).

3. Recovery.

In the first period immediately after freeing the limb from compression, there is severe pain in the leg, which cannot be moved by the patient, weakness, and nausea. The limb is found to be pale, with multiple abrasions and bruises. The general condition of the patient can be satisfactory, skin colour is pale, slight tachycardia is observed and blood pressure is within normal limits. However, within a few hours the affected leg gets rapidly swollen. The limb size increases, the skin assumes an uneven bluish-purple colour with haemorrhages, blisters with serous or serosanguinous contents form. The pulse rate rises, blood pressure falls, body temperature increases, skin becomes very pale and the patient gets weaker, i.e. develops the clinical picture of shock.

On palpation, the limb is of wood-hard consistency, and pressing with the finger does not leave a mark. Movement in the affected limb joint is not possible, and an attempt at this causes extreme pain. Peripheral arterial pulse of the peripheral arteries in their distal parts is absent, all types of sensation are lost. Urine production quickly reduces (occasionally immediately after injury) up to 50-70 ml per day. Urine colour changes to varnish-red and later to dark brown with a high protein content (600-1, 200 ml/l). Urinary sediment shows copious red cells, and casts consisting of myoglobin. Blood viscosity rises with an increase in haemoglobin level and red blood cell count, haematocrit and progressive uraemia.

The restoration of blood circulation and worsening signs of renal failure indicate transmission of the disease into the period of acute renal failure. Pain in the limb reduces, blood pressure returns to normal, moderate tachycardia persists, pulse matches the temperature of 37, 5-38, 5 °C. Despite the improvement of blood circulation, renal insufficiency worsens, oliguria progresses turning into anuria; the levels of blood urea nitrogen and creatinine are very high. Extensive tissue damage treatment may be ineffective and in such cases fatal uraemia may develop on days 5-7.

Favourable course, coupled with effective treatment, results in recovery. The patient's general condition improves, azotaemia reduces, the urine volume increases, and the casts and red blood cells disappear from the urine. With improvement in the general condition, pain in the limb that can be occasionally very intensive and burning sensation recurs, oedema resolves and sensation restores. Examination of the limb reveals a wide area of skin necrosis. Dull grey necrotised muscles that can be seen in the wound, disintegrate. The muscles progressively atrophy and movement of the limb becomes limited.

Treatment. As soon as the limb is rescued, the patient is given an injection of promedol or morphine; the injured limb is bandaged tight with either elastic or an ordinary bandage after which a transportation splint is applied. Signs of cardiovascular insufficiency evident before transportation require that the patient be first given ephedrine, norepinephrine, and an antishock blood substitute (e.g. polyglucin). On admission to hospital, adequate (to the disease's stage) treatment is given. Antishock and detoxication therapy is started immediately. Antishock blood substitutes, solutions of albumin, sodium bicarbonate and plasma are given intravenously. 3, 000-4, 000 ml of fluid have to be given within 24 hours taking into consideration the patient's diuresis.

A circular novocain block of the limb is done on admission, after which icepacks are applied. The application of icepacks is continued for 2-3 days, after each 3-5 hours the ice is removed for 1_1/2- 2 hours. Broad-spectrum antibiotics are given. The patient is closely monitored (measurement of blood pressure, pulse and the hourly diuresis).

In progressive oliguria, wide incisions of the damaged area are done. In the second period of the disease, when the patient is out of the shock, haemodialysis can be used to treat renal failure.

In the third period, treatment of the purulent wound, necrosis and gangrene is provided.

In life-threatening cases, amputation of the damaged limb is indicated.

Sprains and ruptures. Sprain is a joint injury in which some of the fibres of a supporting ligament are ruptured, the continuity of the former, however, remaining intact. If the elastic threshold is overcome, rupture occurs.

Sprain of the ankle joint most commonly occurs, mainly resulting from a twist of the foot, while the knee joint is only rarely affected. The clinical manifestations of sprain are similar to those of soft tissue contusion: local tenderness, tissue oedema and painful joint movements.

Treatment involves rest for the limb, pressure bandage, icepacks during the first few days followed by heat therapy to promote haematoma resolution.

Muscle rupture occurs in excessive muscle stress. Most commonly affected are as follows: the biceps brachii, quadriceps femoris, and gastrocnemius muscles. The clinical presentation is quiet clear: severe pain at the moment of the tear (as if struck by an electric shock), abrupt muscular paresis, local haematoma formation.

In partial muscle tear, the limb is immobilized with a plaster of Paris (POP) splint, the muscle being placed in a completely relaxed position. In biceps rupture, the upper limb is immobilized by bending it in the elbow joint at right angles. Rupture of the quadriceps requires that POP be applied with the lower limb in a straightened position; in gastrocnemius muscle rupture, the leg is bent in the knee joint. Immobilisation should last for 2-3 weeks, followed by physical therapy (massage and exercise).

In complete muscle rupture, the only treatment is by surgery, i.e. suturing the ruptured muscle with subsequent immobilisation of the limb for 2-3 weeks.

Tendon tear is accompanied by pain and joint dysfunction (inability to flex or extend depending upon the tendon affected). Most commonly it is the tendons of the fingers, hands, Achilles tendon and the tendon of the long biceps head that get affected. Examination reveals local tenderness and oedema.

Suturing the tendon is a usual therapy.

Fractures. Fracture is a break or interruption in the continuity of a bone, which is caused by mechanical exposure (trauma) or pathology (tumour or inflammation).

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