Murtaghs Practice Tips 6th Ed [PDF][Tahir99] VRG - PDFCOFFEE.COM (2024)

Murtagh’s Practice Tips

To my wife, Jill, and our children, Paul, Julie, Caroline, Luke and Clare, for their patience, support and understanding.

Murtagh’s Practice Tips 6e

John Murtagh AM MBBS, MD, BSc, BEd, FRACGP, DipObstRCOG Emeritus Professor in General Practice, School of Primary Health Care, Monash University, Melbourne Professorial Fellow, Department of General Practice, University of Melbourne Adjunct Clinical Professor, Graduate School of Medicine, University of Notre Dame, Fremantle, Western Australia Guest Professor, Peking University Health Science Centre, Beijing

NOTICE Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the editors, nor the publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete. Readers are encouraged to confirm the information contained herein with other sources. For example, and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this book is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. First edition 1991 Reprinted 1992 (twice), 1993 (twice), 1994 (twice) Second edition 1995 Reprinted 1997, 1999, 2001 Third edition 2000 Reprinted 2002, 2004 Fourth edition 2004 Fifth edition 2008 Sixth edition 2013 Text © 2008 John Murtagh Illustrations and design © 2008 McGraw-Hill Australia Pty Ltd Additional owners of copyright are named in on-page credits and on the Acknowledgments page. Every effort has been made to trace and acknowledge copyright material. Should any infringement have occurred accidentally the authors and publishers tender their apologies. Reproduction and communication for educational purposes The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of the pages of this work, whichever is the greater, to be reproduced and/or communicated by any educational institution for its educational purposes provided that the institution (or the body that administers it) has sent a Statutory Educational notice to Copyright Agency Limited (CAL) and been granted a licence. For details of statutory educational and other copyright licences contact: Copyright Agency Limited, Level 15, 233 Castlereagh Street, Sydney NSW 2000. Telephone: (02) 9394 7600. Website: www. copyright.com.au Reproduction and communication for other purposes Apart from any fair dealing for the purposes of study, research, criticism or review, as permitted under the Act, no part of this publication may be reproduced, distributed or transmitted in any form or by any means, or stored in a database or retrieval system, without the written permission of McGraw-Hill Australia including, but not limited to, any network or other electronic storage. Enquiries should be made to the publisher via www.mcgraw-hill.com.au or marked for the attention of the Rights and Permissions Manager at the address below. Enquiries concerning copyright in McGraw-Hill publications should be directed to the Permissions Editor at the address below. National Library of Australia Cataloguing-in-Publication data Murtagh, John John Murtagh’s practice tips / John Murtagh 6th edition ISBN 9781743070123 (pbk.) Includes index. 1. Medicine—Practice—Handbooks, manuals, etc. 2. Medicine, Rural. 3. Surgery, Minor. 610 Published in Australia by McGraw-Hill Australia Pty Ltd Level 2, 82 Waterloo Road, North Ryde NSW 2113 Associate editor: Fiona Richardson Senior production editor: Yani Silvana Copyeditor: Nicole McKenzie Proofreader: Rosemary Moore Indexer: Shelley Barons Cover and internal design: George Creative Illustrator: Aptara Inc., New Delhi, India Typeset in 10/11 pt Joanna MT regular by Diacritech, India Printed in China on 80 gsm woodfree by China Translation and Printing Services Ltd

v

Foreword to the sixth edition It is now 21 years since I had the honour of writing the foreword to the first edition of Practice Tips. Since then, the wisdom and practical skills of John Murtagh have spread throughout the medical world through his writings. This sixth edition incorporates several new features, including the management of emergencies, the interpretation of ECGs, more injection techniques and the management of burns, scalds and smoke inhalation.

I have no doubt that this new edition of Practice Tips will find a place on the bookshelves of many practitioners in general practice and in emergency departments. GEOFF QUAIL Clinical Associate Professor Department of Surgery Monash University Melbourne

Foreword to the first edition In a recent survey of medical graduates appointed as interns to a major teaching hospital, the question was posed, ‘What does the medical course least prepare you for?’ Half the respondents selected practical procedures from seven choices. While we are aware that university courses must have a sound academic basis, it is interesting to note that many newly graduating doctors are apprehensive about their basic practical skills. Fortunately, these inadequacies are usually corrected in the first few months of intern training. Professor John Murtagh, who has been at the forefront of medical education in Australia for many years, sensed the need for ongoing practical instruction among doctors. When appointed Associate Medical Editor of Australian Family Physician in 1980 he was asked to give the journal a more practical orientation, with a wider appeal to general practitioners. He was able to draw on a collection of practical procedures from his 10 years as a country doctor that he had found useful, many of which were not described in journals or textbooks. He began publishing these tips regularly in Australian Family Physician, and this encouraged colleagues to contribute their own practical solutions to common problems.

The column has been one of the most popular in the journal, and led to an invitation to Professor Murtagh to assemble these tips in one volume. The interest in practical procedures is considerable— as witnessed by the popularity of practical skills courses, which are frequently fully booked. These have become a regular part of the Monash University Postgraduate Programme, and some of the material taught is incorporated in this book. It is particularly pleasing to see doctors carrying out their own practical procedures. Not only is this costeffective, in many cases obviating the need for referral, but it also broadens the expertise of the doctor and makes practice more enjoyable. I congratulate Professor Murtagh on the compilation of this book, which I feel certain will find a prominent place on the general practitioner’s bookshelf. GEOFF QUAIL Past Chairman Medical Education Committee Royal Australian College of General Practitioners (Victorian Faculty)

This page intentionally left blank

vii

Contents Foreword to the sixth edition v Foreword to the first edition v About the author xviii Preface xix Acknowledgments xx xxi Sterilisation guidelines for office practice 1. Emergency procedures 1 Normal values for vital signs 1 Pulse oximetry 1 Acute coronary syndromes 2 The electrocardiogram 2 Urgent intravenous cutdown 4 Intraosseous infusion 6 Acute paraphimosis 6 Diagnosing the hysterical ‘unconscious’ patient 7 Electric shock 7 Head injury 8 Sexual assault in the female victim 9 Migraine tips 10 Hyperventilation 11 Pneumothorax 11 Cricothyroidostomy 12 Choking 13 Carotid sinus massage 13 Bite wounds 13 Stings 15 Coral cuts 15 Use of the adrenaline autoinjector for anaphylaxis 15 16 Major trauma Blood loss: circulation and haemorrhage control 16 Serious injuries and clues from association 16 Roadside emergencies 17 Ionising radiation illness 18 2. Basic practical medical procedures Venepuncture and intravenous cannulation Nasogastric tube insertion Nasogastric tube insertion in children Urethral catheterisation of males Urethral catheterisation of females Catheterisation in children

20 20 21 22 22 23 24

viii

CONTENTS

Lumbar puncture Lumbar puncture in children Tapping ascites Inserting a chest drain Aspiration of pleural effusion Subcutaneous fluid infusions Continuous subcutaneous infusion of morphine 3. Injection techniques Basic injections Painless injection technique Intramuscular injections Reducing the sting from an alcohol swab Painless wound suturing Slower anaesthetic injection cuts pain Local anaesthetic infiltration technique for wounds Disposal of needles Rectal ‘injection’ Finger lancing with less pain Digital nerve block Regional nerve wrist blocks to nerves to hand Regional nerve blocks at elbow Femoral nerve block Tibial nerve block Sural nerve block Facial nerve blocks Specific facial blocks for the external ear Penile nerve block Intravenous regional anaesthesia (Bier block) Haematoma block by local infiltration anaesthetic Intercostal nerve block The caudal (trans-sacral) injection Local anaesthetic use Hormone implants Musculoskeletal injections Musculoskeletal injection guidelines Injection of trigger points in back Injection for rotator cuff lesions Injection for supraspinatus tendonopathy Injection for bicipital tendonopathy Injections for epicondylitis Injection for trigger finger Injection for trigger thumb injection for tenosynovitis of the wrist Injection for plantar fasciitis Injection for trochanteric bursalgia Injection of the carpal tunnel Injection near the carpal tunnel Injection of the tarsal tunnel Injection for Achilles paratendonopathy Injection for tibialis posterior tendonopathy

24 25 25 25 26 26 27 28 28 28 29 29 29 30 30 30 31 31 31 32 33 33 34 35 36 37 37 38 38 39 39 40 41 42 42 42 43 44 44 45 45 46 46 47 47 48 49 49 50 50

CONTENTS

Injection or aspiration of joints Acute gout in the great toe

50 53

4. Skin repair and minor plastic surgery 55 55 Principles of repair of excisional wounds Standard precautions 55 Knot tying 56 Holding the scalpel 57 Safe insertion and removal of scalpel blades 58 Debridement and dermabrasion for wound debris 59 Continuous sutures 59 The pulley suture 59 The cross-stitch 60 Planning excisions on the face 60 Elliptical excisions 60 Prevention and removal of ‘dog ears’ 61 The three-point suture 61 Inverted mattress suture for perineal skin 62 Triangular flap wounds on the lower leg 62 Excision of skin tumours with sliding flaps 63 Primary suture before excision of a small tumour 64 Multiple ragged lacerations 65 Avoiding skin tears 65 Vessel ligation 65 The transposition flap 65 The rotation flap 65 The rhomboid (Limberg) flap 66 The ‘crown’ excision for facial skin lesions 66 Z-plasty 67 Repair of cut lip 67 Wedge excision and direct suture of lip 67 Wedge resection of ear 68 Repair of lacerated eyelid 69 Repair of tongue wound 69 Avascular field in digit 70 Wedge resection of axillary sweat glands 71 Removal of skin sutures 71 Pitfalls for excision of non-melanoma skin cancer 72 W-plasty for ragged lacerations 72 Debridement of traumatic wounds 73 Debridement of skin in a hairy area 73 Wound management tips 73 When to remove non-absorbable sutures 75 5. Treatment of lumps and bumps Removal of skin tags Removal of epidermoid (sebaceous) cysts The infected sebaceous cyst Sebaceous hyperplasia

76 76 77 78 78

ix

x

CONTENTS

Dermoid cysts 78 Acne cysts 79 Biopsies 79 Treatment of ganglions 80 Olecranon and pre-patellar bursitis 80 Excision of lipomas 81 Keratoacanthoma 81 Basal cell carcinoma (BCC) 82 Squamous cell carcinoma (SCC) 82 Pyogenic granuloma 83 Seborrhoeic keratoses 83 Chondrodermatitis nodularis helicus 83 Orf 83 Milker’s nodules 83 Haemangioma of the lip 83 Aspiration of Baker cyst 83 Aspiration and injection of hydrocele 84 Epididymal cysts 84 Testicular tumours 84 Torsion of the testicle 84 Steroid injections into skin lesions 85 Steroid injections for plaques of psoriasis 85 Hypertrophic scars: multiple puncture method 86 Keloids 86 Dupuytren contracture 86 Drainage of breast abscess 86 Aspiration of breast lump 87 Marsupialisation technique for Bartholin cyst 88 Cervical polyps 88 Liquid nitrogen therapy 88 Carbon dioxide slush for skin lesions 90 Trichloroacetic acid 91 Simple removal of xanthoma/anthelasmas 91 Warts and papillomas 91 Molluscum contagiosum 92 6. Treatment of ano-rectal problems Perianal haematoma Perianal skin tags Rubber band ligation of haemorrhoids Injection of haemorrhoids Anal fissure Proctalgia fugax Perianal abscess Perianal warts Anal fibro-epithelial polyps Pruritus ani Rectal prolapse Cautionary points regarding ano-rectal disorders

93 93 94 94 95 95 97 97 97 98 98 98 98

CONTENTS

7. Foot problems Calluses, corns and warts Treatment of plantar warts Treatment of calluses Treatment of corns ‘Cracked’ heels Plantar fasciitis

99 99 99 101 101 102 102

105 8. Nail problems Splinters under nails 105 Onychogryphosis 106 Myxoid pseudocyst 106 Subungual haematoma 106 Ingrowing toenails (onychocryptosis) 108 109 Wedge resection The elliptical block dissection open method 110 Tip for post-operative pain relief 111 Paronychia 111 Excision of nail bed 111 Nail avulsion by chemolysis 112 Traumatic avulsed toenail 112 9. Common trauma

113

General 113 Essential tips for dealing with trauma 113 Other cautionary tips 113 Finger trauma 114 Finger tip loss 114 Amputated finger 114 Finger tip dressing 114 Abrasions 115 Management 115 Haematomas 115 Haematoma of the pinna (‘cauliflower ear’) 115 Haematoma of the nasal septum 115 Pretibial haematoma 116 Roller injuries to limbs 116 Fractures 116 Testing for fractures 116 Spatula test for fracture of mandible 117 First aid management of fractured mandible 117 Fractured clavicle 117 Bandage for fractured clavicle 118 Fractured rib 118 Phalangeal fractures 118 Slings for fractures 119 Important principles for fractures 121 Other trauma 122 Primary repair of severed tendon 122 Burns and scalds 122 Rapid testing of the hand for nerve injury 124

xi

xii

CONTENTS

10. Removal of foreign bodies

126

General 126 Cautionary note 126 Removal of maggots 126 Removal of leeches 127 Embedded ticks 127 Removal of ring from finger 128 Splinters under the skin 128 Removing spines of prickly pear, cactus and similar   plants from the skin 129 Detecting fine skin splinters—the soft soap method 129 Detecting skin splinters 129 Removing the Implanon rod 129 Detecting metal fragments 129 129 Embedded fish hooks Penetrating gun injuries 131 Ear, nose and throat 132 Removal of various foreign bodies 132 General principles about a foreign body in the ear 135 Insects in ears 135 Cotton wool in the ear 136 Fish bones in the throat 136 Gential and anal 136 Extricating the penis from a zipper 136 Removal of impacted vaginal tampon 137 Faecal impaction 138 Removal of vibrator from vagina or rectum 138 11. Musculoskeletal medicine Temporomandibular joint Temporomandibular dysfunction The TMJ ‘rest’ program Dislocated jaw The spine Recording spinal movements Spinal mobilisation and manipulation Cervical spine Clinical problems of cervical origin Locating tenderness in the neck Acute torticollis Traction to the neck A simple traction technique for the cervical spine Neck rolls and stretches Thoracic spine Anterior directed costovertebral gliding Thoracic spinal manipulation Thoracolumbar stretching and manipulation Lumbar spine Drawing and scale marking for back pain Reference points in the lumbar spine

139 139 139 140 140 141 141 141 141 143 143 144 144 145 145 147 147 147 149 150 150 150

CONTENTS

Tests for non-organic back pain 152 Movements of the lumbar spine 153 Nerve roots of leg and level of prolapsed disc 154 The slump test 154 Schober test (modified) 154 Manual traction for sciatica 155 Rotation mobilisation for lumbar spine 156 Lumbar stretching and manipulation technique 1 157 Lumbar stretching and manipulation technique 2 157 Exercise for the lower back 158 Shoulder 159 159 Dislocated shoulder The Mt Beauty analgesia-free method 160 Recurrent dislocation of shoulder 162 Impingement test for supraspinatus lesions 162 Elbow 163 Pulled elbow 163 Dislocated elbow 163 Tennis elbow 164 Wrist and hand 166 De Quervain tenosynovitis and Finkelstein test 166 Simple tests for carpal tunnel syndrome 166 Simple reduction of dislocated finger 167 Strapping a finger 167 Mallet finger 168 Boutonnière deformity 169 Tenpin bowler’s thumb 169 Skier’s thumb (gamekeeper’s thumb) 170 Colles fracture 170 Scaphoid fracture 171 Metacarpal fractures 171 Hip 172 Age relationship of hip disorders 172 The Ortolani and Barlow screening tests 172 Pain referred to the knee 172 Diagnosis of early osteoarthritis of hip joint 173 173 The ‘hip pocket nerve’ syndrome Ischial bursitis 174 Patrick or Fabere test 174 Snapping or clicking hip 174 Dislocated hip 175 Fractured femur 176 Knee 176 Inspection of the knees 176 Common causes of knee pain 176 Diagnosis of meniscal injuries of the knee 177 Lachman test 178 Overuse syndromes 179 Patellar tendonopathy (‘jumper’s knee’) 179 Anterior knee pain 180 Diagnosis and treatment of patellofemoral joint pain syndrome 180 Dislocated patella 181

xiii

xiv

CONTENTS

Leg Overuse syndromes in athletes Torn ‘monkey muscle’ Complete rupture of Achilles tendon Treatment of sprained ankle Mobilisation of the subtalar joint Wobble board (aeroplane) technique for ankle dysfunction Tibialis posterior tendon rupture Plastering tips Plaster of Paris Preparation of a volar arm plaster splint Leg support for plaster application Waterproofing your plaster cast A long-lasting plaster walking heel Supporting shoe for a walking plaster Use of silicone filler Prescribing crutches Walking stick advice

181 181 181 183 183 184 185 185 186 186 187 187 187 188 188 188 188 189

190 12. Orodental problems Knocked-out tooth 190 Loosening of a tooth 190 Chipped tooth 190 Bleeding tooth socket 191 Dry tooth socket 191 A simple way of numbering teeth 191 Aphthous ulcers (canker sores) 192 Geographic tongue (erythema migrans) 193 Black, green or hairy tongue 193 Calculus in Wharton duct 193 A ‘natural’ method of snaring a calculus 193 Simple removal of calculus from Wharton duct 193 Release of tongue tie (frenulotomy) 193 13. Ear, nose and throat URTIs and sinus problems Diagnosing sinus tenderness Diagnosis of unilateral sinusitis Inhalations for URTIs Nasal polyps The ear and hearing A rapid test for significant hearing loss Water- and soundproofing ears Use of tissue ‘spears’ for otitis externa and media Preventing swimmer’s otitis externa Chronic suppurative otitis media and externa Ear piercing Ear wax and syringing Recognising the ‘unsafe’ ear Air pressure pain when flying Excision of ear lobe cysts

195 195 195 195 196 197 197 197 198 198 198 198 198 198 201 201 201

CONTENTS

Infected ear lobe 201 Embedded earring stud 202 Tropical ear 202 Instilling otic ointment 202 Problems with cotton buds 202 202 The nose Treatments for epistaxis 202 Instilling nose drops 204 Offensive smell from the nose 204 Stuffy, running nose 204 Senile rhinorrhoea 204 Nasal factures 205 Miscellaneous ENT pearls 205 Hands-free headlight 205 Self-propelled antral and nasal washout 205 Use of FLO sinus care 205 Hiccoughs (hiccups) 205 Snoring 206 Tinnitus 206 Swallowing with a sore throat 206 Glue ears 206 Auriscope as an alternative to nasal specula 206 Chronic anosmia following URTI 206 Ticklish throat 206 Doctor-assisted treatment for benign paroxysmal   positional vertigo 206 14. The eyes 209 Basic kit for eye examination 209 Eversion of the eyelid 209 Blepharitis 210 Flash burns 210 Wood’s light and fluorescein 210 Simple topical antiseptics for mild conjunctivitis 210 Removing ‘glitter’ from the eye 210 Dry eyes 210 Eyelash disorders 211 Removal of corneal foreign body 211 Corneal abrasion and ulceration 212 Excision of meibomian cyst 212 Local anaesthetic for the eyelid 213 Non-surgical treatment for meibomian cysts 213 Padding the eye 214 Managing styes 214 Application of drops 214 Visual acuity 214 The pinhole test for blurred vision 214 Relief of ocular pain by heat 214 Chemical burns to the eye 216 Protective industrial spectacles 216 Effective topical treatment of eye infections 216 Hyphaema 216

xv

xvi

CONTENTS

15. Tips on treating children 217 Making friends 217 Distracting children 217 Management of painful procedures 218 ‘Bite the bullet’ strategy 218 Using pacifiers (dummies) to ease pain 218 Deep breath with blowing distraction 218 Taking medicine 218 Swallowing a tablet 218 Administration of fluids 218 How to open the mouth 218 Spatula sketches for children 219 Instilling nose drops 219 Instilling eye drops in cooperative children 219 219 Intravenous cannula insertion Difficult vein access 220 Easier access to a child’s arm 220 Swallowed foreign objects 220 Wound repair 220 Scalp lacerations 220 Lacerated lip or gums 221 Glue for children’s wounds 221 Topical local anaesthesia for children’s lacerations 222 Improvised topical ‘anaesthesia’ 222 Wound infiltration 222 Fractures 222 Splints for minor greenstick-type fractures 223 Removing plaster casts from children 223 The crying infant 223 Cleaning a child’s ‘snotty’ nose 224 Test for lactose intolerance 224 Breath-holding attacks 224 Itching and swollen skin rashes 225 Traumatic forehead lump 225 Suprapubic aspiration of urine 225 The ‘draw a dream’ technique 225 Assessing anxious children and school refusal 226 Surgery 226 16. The skin 228 Rules for prescribing creams and ointments 228 Topical corticosteroids for sunburn 228 Skin exposure to the sun 228 Acne 229 Nappy rash 230 Atopic dermatitis (eczema) 230 Psoriasis 230 Skin scrapings for dermatophyte diagnosis 231 Spider naevi 231 Wood’s light examination 231 Applying topicals with a ‘dish mop’ 232

CONTENTS

Glove over hand to enhance topical efficacy 232 Chilblains 232 Herpes simplex: treatment options 232 Herpes zoster (shingles) 233 Unusual causes of contact dermatitis 233 17. Varicose veins Percutaneous ligation for the isolated vein Avulsion of the isolated varicose vein Treatment of superficial thrombophlebitis Management of deep venous thrombosis Ruptured varicose vein Venous ulcers Applying a compression stocking

234 234 234 235 236 236 236 237

18. Miscellaneous 238 Measurement of temperature 238 Infrared aural (ear drum) use 239 Obtaining reflexes 239 Restless legs syndrome 240 Nightmares 240 Nocturnal cramps 240 Special uses for vasodilators 241 Nocturnal bladder dysfunction 241 Facilitating a view of the cervix 242 Condom on the speculum 242 Optimal timing and precautions for Pap smears 242 Priapism 242 Premature ejaculation 242 Indomethacin for renal/ureteric colic 242 Record keeping for after-hours calls 242 Sticking labels in the patient notes 242 Uses of a fine cataract knife 242 Cool cabbages for hot breasts 243 Makeshift spacing chambers for asthmatics 243 Coping with tablets 243 Patient education techniques in the consulting room 243 Improvised suppository inserter 244 The many uses of petroleum jelly (Vaseline) 245 The many uses of paper clips 245 The uses of fine crystalline sugar 245 Sea sickness 245 Honey as a wound healer 245 Snapping the top off a glass ampoule 245 Medico-legal tips 245 Tips for aged care 246 Bibliography 247 Index 249

xvii

xviii

About the author John Murtagh AM MBBS, MD, BSc, BEd, FRACGP, DipObstRCOG Emeritus Professor in General Practice, School of Primary Health Care, Monash University, Melbourne Professorial Fellow, Department of General Practice, University of Melbourne Adjunct Clinical Professor, Graduate School of Medicine, University of Notre Dame, Fremantle, Western Australia Guest Professor, Peking University Health Science Centre, Beijing

John Murtagh was a science master teaching chemistry, biology and physics in Victorian secondary schools when he was admitted to the first intake of the newly established Medical School at Monash University, graduating in 1966. Following a comprehensive postgraduate training program, which included surgical registrarship, he practised in partnership with his medical wife, Dr Jill Rosenblatt, for 10 years in the rural community of Neerim South, Victoria. Dr Murtagh was appointed Senior Lecturer (parttime) in the Department of Community Medicine at Monash University and eventually returned to Melbourne as a full-time Senior Lecturer. He was appointed to a professorial chair in Community Medicine at Box Hill Hospital in 1988 and subsequently as chairman of the extended department and Emeritus Professor of General Practice in 1993 until retirement from this position in 2000. He now holds teaching positions as Professor in General Practice at Monash University, Adjunct Clinical Professor, University of Notre Dame and Professorial Fellow, University of Melbourne. He combines these positions with parttime general practice, including a special interest in musculoskeletal medicine. He achieved the Doctor of Medicine degree in 1988 for his thesis ‘The management of back pain in general practice’.

Dr Murtagh was appointed Associate Medical Editor of Australian Family Physician in 1980 and Medical Editorin1986, a position held until 1995. In 1995 he was awarded the Member of the Order of Australia for services to medicine, particularly in the areas of medical education, research and publishing. Practice Tips, one of Dr Murtagh’s numerous publications, was named as the British Medical Association’s Best Primary Care Book Award in 2005. In the same year, he was named as one of the most influential people in general practice by the publication Australian Doctor. John Murtagh was awarded the inaugural David de Kretser medal from Monash University for his exceptional contribution to the Faculty of Medicine, Nursing and Health Sciences over a significant period of time. Members of the Royal Australian College of General Practitioners may know that he was bestowed the honour of the namesake of the College library. Today John Murtagh continues to enjoy active participation with the diverse spectrum of general practitioners—whether they are students or experienced practitioners, rural- or urban-based, local or international medical graduates, clinicians or researchers. His vast experience with all of these groups has provided him with tremendous insights into their needs, which is reflected in the culminated experience and wisdom of John Murtagh’s General Practice.

xix

Preface Practice Tips is a collection of basic diagnostic and therapeutic skills that can be used in the offices of general practitioners throughout the world. The application of these simple skills makes the art of our profession more interesting and challenging, in addition to providing rapid relief and cost-effective therapy to our patients. It has been written with the relatively isolated practitioner, doctor or nurse practitioner in mind. The art of medicine appears to have been neglected in modern times and, with the advent of super-specialisation, general practice is gradually being deskilled. I have been very concerned about this process, and believe that the advice in this book could add an important dimension to the art of medicine and represent a practical strategy to reverse this trend.The tips have been compiled by drawing on my own experience, often through improvisation, in coping with a country practice for many years, and by requesting contributions from my colleagues. Doctors from all over Australia have contributed freely to this collection, and sharing each other’s expertise has been a learning experience for all of us. I have travelled widely around Australia and overseas running workshops on practical procedures for the general practitioner. Many practitioners have proposed the tips that apparently work very well for them. These were included in the text if they seemed simple, safe and worth trying. The critical evidence base may be lacking but the strategy is to promote ‘the art of medicine’ by being resourceful and original and thinking laterally. Most of the tips have previously been published in Australian Family Physician, the official journal of the Royal

Australian College of General Practitioners, over the past decade or so. The series has proved immensely popular with general practitioners, especially with younger graduates commencing practice. The tips are most suitable for doctors working in accident and emergency departments. There is an emphasis on minor surgical procedures for skin problems and musculoskeletal disorders. A key feature of these tips is that they are simple and safe to perform, requiring minimal equipment and technical knowhow. Regular practice of such skills leads to more creativity in learning techniques to cope with new and unexpected problems in the surgery. Several different methods to manage a particular problem, such as the treatment of ingrowing toenails and removal of fish hooks, have been submitted. These have been revised and some of the more appropriate methods have been selected. The reader thus has a choice of methods for some conditions. Some specific procedures are more complex and perhaps more relevant to practitioners such as those in remote areas who have acquired a wide variety of skills, often through necessity. This sixth edition has a greater emphasis on emergency procedures, particularly for acute coronary syndromes. It must be emphasised that some of the procedures are unorthodox but have been found to work in an empirical sense by the author and other practitioners where other treatments failed. The book offers ideas, alternatives and encouragement when faced with the everyday nittygritty problems of family practice, particularly in rural and remote practice.

xx

Acknowledgments I would like to acknowledge the many general practitioners throughout Australia who have contributed to this book, mainly in response to the invitation through the pages of Australian Family Physician to forward their various practice tips to share with colleagues. Many of these tips have appeared over the past decade as a regular series in the official publication of the Royal Australian College of General Practitioners.The RACGP has supported my efforts and this project over a long period, and continues to promote the concept of good-quality care and assurance in general practice. I am indebted to the RACGP for giving permission to publish the material that has appeared in the journal. My colleagues in the Department of Community Medicine at Monash University have provided invaluable assistance: Professor Neil Carson encouraged the concept some 30 years ago, and more recently my senior lecturers provided considerable input into skin repair and plastic surgery (Dr Michael Burke) and expertise with orodental problems and facial nerve blocks (Professor Geoff Quail). Special thanks go also to Dr John Colvin, Co-Director of Medical Education at the Victorian Eye and Ear Hospital, for advice on eye disorders; Dr Ed Brentnall, Director of Accident and Emergency Department, Box Hill Hospital; Dr Alfredo Mori, Emergency Physician,The Alfred Hospital (femoral nerve block); Dr Mike Moynihan and the editorial staff of Australian Family Physician; Mr Chris Sorrell, graphic designer with Australian Family Physician; and in particular to Dr Clive Kenna, co-author of Back Pain and Spinal Manipulation (Butterworths), for his considerable assistance with musculoskeletal medicine, especially on spinal disorders. Medical practitioners who contributed to this book are: Lisa Amir, Tony Andrew, Philip Arber, Khin Maung Aye, Neville Babbage, Peter Barker, Royce Baxter, Andrew Beischer, Ashley Berry, Peter Bourke, Peter Bowles, Tony Boyd, James Breheny, Ed Brentnall, Charles Bridges-Webb, John Buckley, Michael Burke, Marg Campbell, Hugh Carpenter, Peter Carroll, Ray Carroll, Neil Carson, Robert Carson, John Colvin, Peter Crooke, Graham Cumming, Joan Curtis, Hal Day, Tony Dicker, Clarrie Dietman, Robert J. Douglas, Mary Doyle, Graeme Edwards, Humphrey Esser, Iain Esslemont, Howard Farrow, Peter Fox, Michael

Freeman, John Gambrill, John Garner, Jack Gerschman, Colin Gleeson, Peter Graham, Neil Grayson, Attila Györy, John Hanrahan, Geoff Hansen, Warren Hastings, Clive Heath, Tim Hegarty, Chris Hogan, Ebrahim Hosseini, Damian Ireland, Anton Iseli, Rob James, Fred Jensen, Stuart Johnson, Dorothy Jones, Roderick Jones, Dennis Joyce, Max Kamien, Trevor Kay, Tim Kenealy, Clive Kenna, Peter Kennedy, Hilton Koppe, Rod Kruger, Sanaa Labib, Chris Lampel, Bray Lewis, Ralph Lewis, Greg Malcher, Karen Martens, Jim Marwood, John Masterton, Jim McDonald, Sally McDonald, Peter McKain, A. Breck McKay, Peter Mellor, Thomas Middlemiss, Philip Millard, Les Miller, Geoff Mitchell, Andrew Montanari, David Moore, Michael Moynihan, Clare Murtagh, Alister Neil, Rowland Noakes, Colin Officer, Helene Owzinsky, Michael Page, Dominic Pak, Geoff Pearce, Simon Pilbrow, Alexander Pollack, Vernon Powell, Cameron Profitt, Andrew Protassow, Geoff Quail, Farooq Qureshi, Anthony Radford, Peter Radford, Suresh Rananavare, Jan Reddy, Sandy Reid, Jill Rosenblatt, David Ross, Harvey Rotstein, Jackie Rounsevell, Carl Rubis, Sharnee Rutherford, Avni Sali, Paul Scott, Adrian Sheen, Jack Shepherd, Clive Stack, Peter Stone, Helen Sutcliffe, Royston Taylor, Alex Thomson, Jim Thomson, John Togno, Bruce Tonge, John Trollor, Ian Tulloch, Talina Vizard, Peter Wallace, Olga Ward, Vilas Wavde, David White, David Wilson, Ian Wilson, John Wong, Ian Wood, Freda Wraight, David Young, Mark Zagorski. In reference to part of the text and figures in spinal disorders, permission from the copyright owners, Butterworths, of Back Pain and Spinal Manipulation (1989), by C. Kenna and J. Murtagh, is gratefully acknowledged. Many of the images in this book are based on those from other publications. Acknowledgment is given to the World Health Organization, publishers of J. Cook et al., General Surgery at the District Hospital, for figures 1.9, 3.7, 3.19, 4.33, 4.37, 9.13 and 14.4b,c and to Dr Leveat Efe for figures 1.3, 3.39, 3.42, 15.4 and 15.5. Permission to use many drawings from Australian Family Physician is also gratefully acknowledged. Finally, my thanks to Nicki Constable, Kris Berntsen and Caroline Menara for secretarial help in the preparation of this material.

xxi

Sterilisation guidelines for office practice The strict control of infection, especially control of the lethal HIV virus, is fundamental to the surgical procedures outlined in this book. Summarised guidelines include: •• All doctors and staff need to be taught and demonstrate competency in hand hygiene, dealing with blood and body fluid spills, standard precautions and the principles of environmental cleaning and reprocessing of medical equipment. •• Use single-use pre-sterilised instruments and injections wherever possible. •• The use of single-use sterile equipment minimises the risk of cross-infection. Items such as suturing needles, injecting needles, syringes, scalpel blades and pins or needles used for neurological sensory testing should be single-use. •• Assume that any patient may be a carrier of hepatitis B and C, HIV and the human papilloma virus. •• Hand washing is the single most important element of any infection control policy: hands must be washed before and after direct contact with the patient. For non-high-risk procedures, disinfect by washing with soap under a running tap and dry with a paper towel, which is discarded. •• Antiseptic handwash (e.g. 2% chlorhexidine) or alcohol hand rubs or wipes have also proven to be effective in reducing the spread of infection. •• Alcohol-based hand rubs, used according to product directions, are appropriate where hand hygiene facilities are not available (e.g. home visits).

•• Sterile gloves and goggles should be worn for any surgical procedure involving penetration of the skin, mucous membrane and/or other tissue. •• Avoid using multi-dose vials of local anaesthetic. The rule is ‘one vial—one patient’. •• Safe disposal of sharp articles and instruments such as needles and scalpel blades is necessary. Needles must not be recapped. •• Instruments cannot be sterilised until they have been cleaned. They should be washed as soon after use as possible. •• Autoclaving is the most reliable and preferred way to sterilise instruments and equipment. Bench-top autoclaves should conform to Australian standard AS2182. •• Chemical disinfection is not a reliable system for routine processing of instruments, although it may be necessary for heat-sensitive apparatus. It should definitely not be used for instruments categorised as high risk. •• Boiling is not reliable as it will not kill bacterial spores and, unless timing is strictly monitored, may not be effective against bacteria and viruses. •• Masks may be used by unimmunised staff and also by patients to prevent the spread of disease (suspected or known) by droplets. Note: For skin antisepsis for surgical procedures, swab with povidone-iodine 10% solution in preference to alcoholic preparations. Reference: RACGP Infection control standards for office based procedures (4th Edn).

This page intentionally left blank

Chapter 1

Emergency procedures Normal values for vital signs Two standard tables are shown for comparsion. Vital signs (average) Pulse (beats/min) Respiration rate (breaths/min) BP (mmHg)

40% (2000 mL) loss

no significant change tachycardia, postural hypotension, slightly anxious progressive hypotension, anxious, confused, pale, weak pulse circulatory failure, ashen, confused, lethargic

Potential concealed loss with fractures Tibia and fibula Neck of femur Shaft of femur Pelvis

750 mL 1000–1500 mL 1500–2000 mL up to 5000 mL

Note: Blood donation is 450 mL

Chapter 1 | Emergency procedures

Table 1.7  Associated injuries related to specific fractures Fracture

Associated injuries to consider

Ribs

Pneumothorax Haemothorax Ruptured spleen (lower left 10–11) Ruptured diaphragm (lower left 10–11)

Sternum

Ruptured base of heart with tamponade Ruptured aorta

Lumbar vertebra

Ruptured kidney (L1, L2) and other viscera (e.g. pancreas–L2)

Pelvis

Heavy blood loss Ruptured bladder Ruptured urethra Fractured femur

Temporal bone of skull

Cerebral contusion Extradural haematoma Subdural haematoma

Femur

Blood loss, possible > 1 L

Table 1.8 Associated serious injuries and typical clinical features Physical sign or symptom

Associated serious injury

Subconjunctival haematoma with no posterior limit

Fractured base of skull

Sublingual haematoma

Fracture of mandible

Surgical emphysema

Pneumothorax with pleural tear Ruptured trachea

Unequal pupils

Cerebral compression (e.g. extradural haematoma) Trauma to cranial nerves II and III Eye injuries, including traumatic mydriasis Brain-stem injuries

a vehicle, warning people not to smoke, moving victims and workers out of danger of other traffic. Attention should be given to: • the airway and breathing • the cervical spine: protect the spine • circulation: arrest bleeding • fractured limbs (gentle manipulation and splintage) • open wounds, especially open chest wounds, should be covered by a firm dressing. Major haemorrhage is a common cause of death in the first few hours. Lacerated organs and multiple fractures can lose 250 mL of blood a minute; pressure should be applied to control haemorrhage where possible. Colloids that can be administered intravenously for blood loss include Haemaccel and Gelofusine. Intramuscular narcotic injections (morphine, pethidine) and alcohol ‘to settle the victim’s nerves’ must be avoided. Consider inhalational analgesia with the Pentrox Inhaler. It can be used with oxygen or air. It provides pain relief after 8 to 10 breaths and it continues for several minutes. When the patient is under control, he or she should be shifted into the coma position (Fig. 1.20).

Fig. 1.20 The coma position

Shoulder tip pain without local injury

Intra-abdominal bleeding (e.g. ruptured spleen) Intra-abdominal perforation or rupture (e.g. perforated bowel)

Bluish-coloured umbilicus

Intra-abdominal bleeding (e.g. ruptured ectopic pregnancy)

Roadside emergencies The first two hours after injury can be vital: proper care can be lifesaving, inappropriate care can be damaging. The first step is for someone to notify the police and ambulance or appropriate emergency service. The site of an accident should be rendered safe by eliminating as many hazards as possible, e.g. turning off the ignition of

Administration of first aid to the injured at the roadside A simple guide is as follows: 1. Check airway and breathing (being mindful of cervical spine) a. Check oral cavity • tongue fallen back • dentures or other foreign matter in mouth Clear with finger and place in oral airway if available, or hold chin forward. b. Check breathing If absent, commence artificial respiration if feasible. 2. Check circulation If pulse absent, commence external cardiac massage if possible. 3. Check for haemorrhage, especially bleeding from superficial wounds. Apply a pressure bandage directly to the site. 4. Check for fractures, especially those of the cervical spine.

17

18

Practice Tips

Rules to remember • Immobilise all serious fractures and large wounds before shifting. • Always apply traction to the suspected fracture site. • Splint any fractured limbs with an air splint, wooden splint or to body, e.g. arm to chest, leg to leg. • For a suspected or actual fractured neck, apply a cervical collar, even if made out of newspaper; or keep the head held firmly in a neutral position with gentle traction (avoid flexion and torsion). • Lay the patient on his or her back with head supported on either side. 5. Shifting the patient • Immobilise all fractures. • Lift the casualty without any movement taking place at the fracture site, using as much help as possible. • Always support the natural curves of the spine. • Protect all numb areas of skin (e.g. remove objects such as keys from the pockets). 6. The unconscious patient • Transport the casualty lying on the back if a clear airway can be maintained. • If not, gently move into the coma position. 7. Reassure the patient (if possible) • Reassurance of the casualty is most important. • Conduct yourself with calmness and efficiency. 8. Help the medical team Take notes of your observations at the accident, e.g. record times, colour of casualty, conscious level, respiration, pulse, blood pressure.

Roadside emergency ‘tricks of the trade’ • Emergency split towel: The inner sterile paper envelope of sterile surgical gloves can be used as a split towel to cover the wound and the inner sterile side of the outer paper envelope as a sterile sheet for instruments. • Emergency sterilisation: The tip of forceps, knives, needles and other instruments can be sterilised by passing through the flame of a gas lighter. • Emergency flushing fluid: One can use the water jet stream from the hole punctuated at the neck of the purified water bottle.

Ionising radiation illness The clinical consequences of radioactive fallout

The nuclear disasters in Eastern Europe and Japan have highlighted the clinical effects of the radioactive elements (mainly iodine and caesium) that are discharged into the atmosphere.

Apart from nuclear accidents, the effects of excessive ionising radiation can follow accidental exposure in hospitals and industry, and in the use of atomic weaponry. Ionising radiation can be either penetrating (X-rays, gamma rays, neutrons) or non-penetrating (alpha or beta particles). The revised Système International (SI) nomenclature uses the sievert (SV) as the unit of radiation dose to body tissue. It is the absorbed dose weighted for the damaging effect of the radiation. As a guideline, the annual background radiation is approximately 2.5 millisievert and a typical X-ray is 0.5 millisievert. The general principles of radiation exposure are: • The closer to the focus of radiation, the more devastating the injury. • Radiation illness can vary from mild vomiting to acute leukaemia. • The most sensitive tissues are the brain, the gastro­ intestinal mucosa and bone marrow. • The dividing (mitotic) cells of blood, the gastrointestinal tract, skin, eye lenses and gonads are especially vulnerable.

Severe acute radiation sickness The extent of the radiation damage depends on the dose of radiation. The typical clinical effects are presented in Table 1.9. The acute effects include the cerebral or CNS syndrome, haemopoietic syndrome, gastrointestinal syndrome and the skin and mucous membrane syndrome (radiation dermatitis). Management Acute radiation sickness is a medical emergency and arrangements must be made for immediate referral to hospital. Contaminated clothing should be removed and substituted with protective clothing. The response to treatment is obviously dependent on the extent, degree and localisation of tissue damage. For distressing nausea and vomiting use: • suppositories or injection or • metoclopramide 10 mg IM or IV (slowly) injections or • chlorpromazine 25–50 mg IM 4 to 6 hourly or • ondansetron 8 mg 12 hourly or 4 mg IV or IM. Treatment might include: • fluid and electrolyte replacement • ultra isolation techniques to prevent infection • antibiotics are necessary • bone marrow transplantation • platelet or granulocyte transfusion.

Chapter 1 | Emergency procedures

Table 1.9  Clinical effects of radioactive fallout from a nuclear accident (using Chernobyl as a reference) Radiation dose expressed in sieverts*

Distance from focus (approximate)

Typical clinical effects (variable time of onset)

Mortality risk

10–50

1 km

Nausea, vomiting, diarrhoea Cerebral syndrome Fever Fluid and electrolyte imbalance Acute leukaemia

100% Rapidly fatal

6–10

2–3 km

Nausea, vomiting, diarrhoea Rash Acute leukaemia/agranulocytosis

80–100%

2–6

4–6 km

Nausea, vomiting Rash Leukaemia/agranulocytosis Alopecia Cataracts

50%

1–2

7–8 km

Nausea, vomiting Agranulocytosis (mild)

Not immediate Long-term cancer risk

0–1

9 km and over

Nausea, vomiting

Not fatal

* 1 sievert = 10 REM (older unit) typical X-ray = 0.5 millisievert

19

Chapter 2

Basic practical medical procedures Venepuncture and intravenous cannulation Basic venepuncture Purpose Collection of blood, including large volume collection for transfusion. The ideal site is the basilic vein or median cubital vein, otherwise the dorsum of the hand or others according to availability (Fig. 2.1). Use local anaesthetic for large volume blood collection.

Method 1. Explain the method to the patient. Ensure the patient is warm and comfortable. 2. Dilate the vein by means of a tourniquet applied to occlude venous return. 3. Place a padded block under the arm to keep it straight. 4. After using a sterile swab to prepare the site, place the needle with attached syringe on the skin. Using downwards oblique pressure, puncture the vein firmly, ensuring the needle lies well within the vein. Remove the tourniquet.

Venepuncture in children cephalic vein basilic vein and median cubital vein (most suitable for venepuncture and long catheters)

The same process for adults applies to adolescents and older children, but in infants and small children a 23-gauge butterfly needle provides more stability. A palpable vein is more likely to be successful than a visible but non-palpable vein. An assistant is necessary to support the limb and provide a tourniquet in small children. For analgesia consider topical anaesthesia, sucrose in infants < 3 months or sedation with midazolam (oral, intranasal or buccal).

Tips to aid dilation of veins Fig. 2.1  Main veins of arm for venepuncture

There are several ways in which peripheral veins can be dilated to facilitate venepuncture. The following are some of the methods used.

Chapter 2 | Basic practical medical procedures

Vasodilation methods • Apply a warm flannel for 60 seconds, or • Rub glyceryl trinitrate ointment over the vein, or • Give the patient half a glyceryl trinitrate tablet (if no contraindications). Sphygmomanometer methods • Dilate the vein by means of the sphygmomanometer to keep BP at about 80–90 mmHg (veins will stand out). or • Using the sphygmomanometer, inflate it to a pressure around 30 mmHg above systolic arterial pressure for 1to 2 minutes while the patient opens and closes their hand. Thereafter it is deflated to around 80 mmHg and the resulting reactive hyperaemia is effective in filling even the shyest of veins. According to Wishaw this is the method par excellence. Venesection tourniquet method Apply the tourniquet tightly and then release. After a reactive hyperaemia occurs reapply it and the veins should stand out well.

Intravenous cannulation Use sterile gloves for this procedure. Best site • Choose a suitable prominent vein in the non-dominant forearm (not over a joint), e.g. dorsum of hand, cephalic vein just above wrist (dorsolateral position). • Use elbow veins as last resort. • Choose a relatively fixed vein, e.g. where it penetrates the fascia. • Choose a vein running parallel to the long axis of the arm. Method 1. Apply a small bleb, e.g. 0.2–0.5 mL of local anaesthetic, over or adjacent to the vein (keep very superficial)andwait 5minutes, or apply EMLA cream at least 60 to 90 minutes beforehand (note that all cannulae hurt). 2. Insert the needle and catheter unit (6-gauge is suitable) through the skin beyond the shoulder of the plastic part. 3. Pierce the vein and ensure that the unit lies flatasitisguided along the vein lumen for a short distance. 4. When blood enters the chamber, put a finger over the vein to stop backflow. Remove the tourniquet and guide the plastic catheter into the vein. 5. Fix the cannulae in position, e.g. use transparent ‘Tegaderm’.

Cannulation in children The preferred site is the dorsum of the non-dominant hand and consider the need for subsequent splinting. The same rules of local anaesthesia apply with an injection of LA considered for older children (see p. 219).

Note the advisory grasp if using the dorsum of the hand for infants (Fig. 2.2).

Fig. 2.2 Intravenous cannula insertion in children Reproduced from Thomson, K., Tey, D. and Marks, M. (eds), Paediatric Handbook (8th Edn), 2009, Wiley-Blackwell, Sydney, p. 32.

Nasogastric tube insertion Indications • Intestinal obstruction—to drain stomach. • Diagnostic—aspiration of stomach contents. • Administer enteral nutrition. Equipment • Radio-opaque nasogastric tube e.g. 16 FG for aspiration, fine bore for feeding (more comfortable). • Assess correct length of tube—measure from the end of the nose to the earlobe and then 5 cm below the end of the xiphisternum. • Lignocaine spray and lubricating jelly (consider lignocaine). • 50–60 mL syringe for aspiration. Method 1. Explain the procedure to the patient including anticipated times of discomfort. 2. Sit the patient upright. Inspect the nose for any deformity and the best possible passage. 3. Use a local anaesthetic spray to anaesthetise the nasal passage. Consider also lubrication with lignocaine jelly. Wait 5 minutes. 4. Lubricate the tube and pass it backwards along the floor of the nasal passage (Fig 2.3). Resistance will be felt when the tube passes from the nasopharynx to the oropharynx. Warn the patient that a retching sensation may be experienced. 5. The patient is now asked to swallow (with the assistance of a ‘feeder’ of water if not contraindicated) as the tube continues to advance with each swallow. 6. The tube should pass down the oesophagus without resistance (never force it down. If retching, take itslowly and only advance with each act of swallowing).

21

22

Practice Tips

• Tube size: 8 FG neonates, 10–12 FG 1–2 years, 14–16 FG adolescents. • Correct length: Place distal end of tube at end of nose, run it to the ear and 3.5 cm beyond the xiphisternum. • If the child coughs and gaps, or gets a hoarse voice or the tube appears in the mouth, pull the tube back into the nasopharynx and retry.

Urethral catheterisation of males yes no

Fig. 2.3  Nasogatric intubation: note the correct direction for inserting the tube

7. Ideally 10–15 cm of tube should be placed in the stomach. Confirmation of its presence in the stomach is confirmed by free aspiration of gastric contents and testing for acidity with litmus paper. 8. Once in place, the tube is fixed to the nose with adhesive tape.

Nasogastric tube insertion in children See Fig. 2.4. Indications • Decompression of stomach, e.g. intestinal obstruction • Administration of medication, e.g. charcoal • Oral rehydration/enteral nutrition Method • Same principles as for adults, including topical anaesthetic spray.

Fig. 2.4  Nasogastric tube insertion in children Reproduced from Thomson, K., Tey, D. and Marks, M. (eds), Paediatric Handbook (8th Edn), 2009, Wiley-Blackwell, Sydney, p. 32.

‘To start catheterising before the anaesthetic works is barbarous’—C.G. Fowler, British Medical Journal. The adult male urethra is 18–20 cm long. Preliminary questions 1. What is the aim of this procedure and can it be achieved without urethral catheterisation? 2. How long must the catheter remain in situ? 3. Can I avoid introducing urinary infection? 4. Do I have the skill to perform the procedure safely? Equipment You will need: • prepackaged set including swabs • aqueous (not alcoholic) skin antiseptic • one or two pairs of forceps • sterile kidney dish to collect urine • suitable catheter—usually medium size • sterile lubricant, e.g. lignocaine jelly in syringe • sterile syringe • suitable catheter drainage bag • catheter dressing • sterile gown and mask. Technique essentials 1. Explain the procedure to the patient, who is best placed in the heel-to-heel position. 2. Sterile preparation/clean suprapubic area and glans penis. A sterile drape is placed over the scrotum and thighs and the penis is lowered onto this. 3. A small amount of lignocaine jelly (2%) is put aside onto a sterile bowl to lubricate the tip of the catheter. Fit nozzle to the syringe of lignocaine jelly and insert gently into the penile meatus (warn the patient that this brief introduction is very uncomfortable)—instil the 10–20 mL jelly slowly: massage the gel carefully down the urethra to the sphincter; compress the glans and leave for a minimum of 5 minutes. 4. Grasp the catheter a few centimetres from its tip with forceps (the funnel end rests in the kidney dish). Apply lignocaine jelly to the tip of the catheter. 5. Hold the penis upwards and straight with one hand and gently insert and slowly advance the catheter.

Chapter 2 | Basic practical medical procedures

penis held firmly

forceps

catheter prostate

sphincter

Fig. 2.5 Urethral catheterisation: initial phase of the procedure where the catheter is gently guided with forceps

Askthe patient to slowly take deep breaths in and out. Do not rush or use force (Fig. 2.5). 6. When the catheter reaches the penoscrotal junction (it now rests against the external sphincter), pull the penis downwards between the patient’s thighs. 7. Continue insertion through the sphincter or prostatic urethra until the entire length is inserted, even if urine emerges before then. 8. Non-retaining catheter: Ensure urine is flowing, then withdraw a few centimetres. Eventually press on the abdomen to ensure the bladder is empty. Retaining catheter: Inflate balloon (usually 5 mL of water) and gently withdraw until the balloon impinges on the bladder neck. Note: Ensure the catheter is in the bladder with urine coming out (get the patient to cough to confirm this) before inflating the balloon. 9. Replace the retracted prepuce over the glans (to prevent paraphimosis).

Urethral catheterisation of females Anatomical considerations The female urethra is comparatively short and straight— being 3–4 cm long and 6 mm in diameter. The urethral orifice lies approximately halfway between the clitoris and the vaginal opening and may be partly obscured by a fringe of soft tissue (Fig. 2.6). Explanation Despite the size of the urethra the procedure is most uncomfortable and local anaesthesia is important. Explain the procedure to the patient with appropriate reassurance. Indicate that the introduction of the nozzle and anaesthetic jelly is uncomfortable and advise about slow deep breathing during introduction of the jelly and subsequently the catheter.

clitoris labia minora labia majora

clitoral frenulum urethral orifice vagina

Fig. 2.6 Anatomy of the female perineum

Technique 1. Lie the patient down with the thighs apart and the knees comfortably flexed. 2. The pubic region, groin, vulva and perineum are initially cleaned with antiseptic solution (after washing your hands). 3. The labia minora are separated with the thumb and forefinger of the non-dominant hand to expose the vaginal orifice and the urethral opening. T   wo swabs are used with each sweeping from anterior to posterior across this area and then discarded. 4. A sterile split sheet is applied to expose the vagina and urethral opening and the hands rewashed and sterile gloves donned. The urethral orifice is again exposed and lightly swabbed.

23

24

Practice Tips

5. A small amount of lignocaine jelly is put aside for lubrication of the tip of the catheter and then the nozzle, which is attached to the tube of the jelly, is introduced into the urethra and approximately 10 mL slowly introduced. The labia should be kept apart with the V-shaped arrangement of the fingers. Wait at least 5 minutes for local anaesthesia to develop. 6. Expose the tip of the catheter (e.g. 16 FG) from its envelope, dip it in the gel in the sterile bowl and, using a ‘no touch’ technique, insert the catheter into the urethral opening and guide it in smoothly. It should pass directly without difficulty. 7. Inflate the balloon and connect the catheter to a sterile closed drainage system (if required).

Catheterisation in children The female child should lie with legs apart in the frog leg position. Catheter size guidelines: • 5 FG for diagnostic purposes • for indwelling 0–6 months: 6 FG • 2 years: 8 FG • 5 years: 10 FG • 6–12 years: 12 FG.

Lumbar puncture Main indications • Diagnostic purposes, e.g. meningitis, MS, Guillain–Barre syndrome, SAH, CNS syphilis. • Introducing contrast media. • Introducing chemotherapeutic agents. In children: • Febrile, sick infant with no focus of infection. • Fever with meningism. • Prolonged seizure with fever. neck flexed

Contraindications • Absolute: Local skin infection, bleeding diathesis. • Relative: Raised intracranial pressure. Depressed conscious state, focal neurological signs. Essentials of lumbar puncture 1: Preparation 1. Explain the procedure to the patient. 2. The patient should be in the lateral recumbent position, with the back maximally flexed and vertical to the table (Fig. 2.7). The shoulders and hips must be perpendicular to the bed. 3. The patient should be well immobilised. Avoid slumping. 4. Open the spinal pack, if required, and have 3 plain sterile tubes and 1 fluoride tube (for glucose) ready. 5. Adopt the sterile procedure (wash hands, mask, gloves, antiseptic prep). 6. Apply 1% lignocaine to skin and subcutaneous tissue (not necessary in infants). Inject 0.5–1 mL and wait 2 minutes. Surface anatomy Imaginary line between tops of iliac crests lies at spinous process of L4 or between L3 and L4. Insert the needle at L4–L5 or L3–L4 (the conus medullaris of the spinal cord ends at L1–L2 but finishes near L3 at birth). Essentials of lumbar puncture 2: Procedure 1. Use a 21- to 22-gauge LP needle (9 cm) for an average adult; 22–23 gauge × 4 cm for infants, × 5 cm for 4to 10 years, × 6 cm for older children. 2. Insert the needle at right angles to the skin. 3. Slowly advance slightly cephalad (about 10°: aim for the umbilicus), otherwise perfectly parallel. knees pulled up towards abdomen

Fig. 2.7 Lumbar puncture: the patient is placed in the fetal position with the back perpendicular to the bed. A line along the top of the iliac crests will intersect the midline at approximately the interspinous space between L3 and L4 (or the L4 spinous process)

Chapter 2 | Basic practical medical procedures

4. Keeping the bevel of the needle facing up, advance 1mm at a time.You will feel a ‘give’ when the dura is pierced (about 4–7 cm in adults, 2–3 cm in children). 5. Withdraw the stylus, and wait 30 seconds for CSF flow. Rotating the needle through 90–180° may allow CSF to flow. Measure CSF opening pressure with manometer. 6. If CFS is blood stained, get three samples. 7. Remove the needle with one quick motion. Recordings • CSF pressure with manometer (N < 180 mm). • CSF biochemistry, microbiology, immunology (oligoclonal bands). Note: Don’t aspirate CSF. Post-care Lie flat for at least 1 hour. Careful observation and bed rest (8 to 12 hours).

Lumbar puncture in children The same principles apply: use the L3–L4 or L4–L5 space for insertion. Have an assistant restrain the child, who should have the spine maximally flexed, in the lateral position on the edge of a flat surface.

Tapping ascites Abdominal paracentesis is often required as a therapeutic procedure to drain ascitic fluid in patients with terminal malignancy. The method is very simple. Select a site where there is shifting dullness and under which there are no solid organs (including an enlarged spleen). Theideal site is in the left iliac fossa (the LHS equivalent of McBurney’s point) and lateral to the line of the inferior epigastric artery (Fig. 2.8). Method 1. After the bladder is emptied, ask the patient to lie supine. 2. Put on a mask and sterile gloves. 3. Swab the skin with antiseptic.

inferior epigastric artery

4. Infiltrate 5 mL of 1% or 2% Xylocaine into the anterior abdominal wall down to the parietal peritoneum at the chosen site. 5. Insert a 19-gauge intravenous cannula on a 20 mL syringe. Aspirate gently. 6. When ascitic fluid is obtained, remove the stilette and syringe and connect the plastic indwelling catheter via intravenous tubing to a sterile drainage bag, so that drainage occurs by gravity into a sterile closed drainage system. 7. The rate of flow can be regulated by the control on the IV tubing.

Inserting a chest drain The main indications for this are: • pneumothorax, e.g. large spontaneous, ventilated, tension (p. 11) • malignant pleural effusion • traumatic haemopneumothorax • postoperative e.g. thoracotomy. Location The majority of drains and chest aspirations are performed in the ‘triangle of safety’ (Fig. 2.9), which is a triangle situated in the anterior half of axilla above the level of the 5th intercostal spaces. It contains no important or dangerous structures in the chest wall.The boundaries are: • anteriorly: the anterior axillary line • posteriorly: the mid-axilllary line

anterior axillary line

point of insertion

midaxillary line

anterior superior iliac spine femoral artery

Fig. 2.8 Ideal site to tap ascites

Fig. 2.9 The ‘triangle of safety’

25

26

Practice Tips

• inferiorly: a horizontal line drawn posteriorly from the level of the nipple in a man or the 4th intercostal space in a woman. Methods The method of aspiration of a pneumothorax via the ‘triangle of safety’ is outlined on page 11 under ‘Pneumothorax’, and for a pleural effusion, which is performed where it is located in the pleural cavity, follows.

Aspiration of pleural effusion Use a recent chest X-ray to aid the clinical examination in order to select the best site for aspiration. A common site for a malignant effusion is on the posterior chest wall medial to the angle of the scapula, in the intercostal space below the upper limit of dullness to percussion. Avoid going too low. Beware of pneumothorax either from puncture of the visceral pleura or from air entry via the chest wall or apparatus. Method 1. Explain the procedure to the patient, who sits on a chair facing the bed and leaning slightly forwards with the arms folded in front resting on a pillow on the bed. 2. Using a sterile procedure with gloves and gown, swab the skin with antiseptic. 3. Infiltrate the overlying skin with 1% lignocaine with adrenaline (25-gauge needle) and change to a 21-gauge needle and two-way or three-way tap with Leur connectors. Slowly infiltrate the chest wall down to pleura. Fluid appears in the syringe on aspiration (apply steady suction as you advance carefully) after the pleura is penetrated.

Fig. 2.10 Pleural aspiration with three-way Leur-Lok tap

4. Aspirate the fluid and by turning the tap, direct the fluid into the collecting container. To aspirate large volumes of fluid insert an intravenous catheter and connect to a three-way tap. This is repeated until all the fluid is tapped. It is normally recommended that no more than 1 to 1.5 litres of fluid be removed at any one time. Caution: Ensure that air does not enter the pleural space at any stage. Reposition or withdraw the cannula or needle if pain on aspiration or coughing. 5. Upon withdrawing the catheter, immediately apply a sterile collodion dressing. Order a follow-up chest X-ray. A simpler technique This technique is useful for tapping recurrent malignant effusions and can be performed at home. Insert a size 18 intravenous cannula. Withdraw the stilette and connect the plastic cannula to an intravenous tubing set with the end draining into a drainage bag by gravity.

Subcutaneous fluid infusions Subcutaneous fluids are useful when: • relatively small amounts of crystalloid are needed (15 mL/kg per 12 hours) • intravenous access is not required for systemic therapy. This method of administering fluid has been used for more than 30 years. It can be sited and supervised by the nursing staff. Complications are rare and usually relate to local oedema, which settles spontaneously once the infusion has been ceased. Practical aspects • Access to the subcutaneous space is via a 21-gauge butterfly needle, which is replaced daily. • One ampoule of hyaluronidase (hyalase) is given prior to infusion and before subsequent bags of crystalloid. (This is necessary when skin elasticity is high, as in children.) • Crystalloid solution (normal saline or 4% dextrose and 1/5 normal saline) with infusion set is then connected to the butterfly needle. • The infusion is usually run at a maximum of 15 mL per kg over 4 to 12 hours per 24 hours. (This enables the patient to move about.) • Most regions are suitable. The more convenient aretheabdomen, the anterior thigh and the shoulder. • The drip rate can be reduced if any discomfort is produced.

Chapter 2 | Basic practical medical procedures

Continuous subcutaneous infusion of morphine When the oral and/or rectal routes are not possible or are ineffective, a subcutaneous infusion of morphine (for terminal pain) with a syringe pump can be used. It is also useful for symptom control when there is a need for a combination of drugs, e.g. for pain, nausea and agitation. It may avoid bolus peak effects (sedation, nausea or vomiting) or trough effects (breakthrough pain) with intermittent parenteral morphine injections. Practical aspects • Access to the deep subcutaneous space is via a 21-gauge butterfly needle, which is replaced regularly (1, 2, 3 or 4 days).

• Most regions are suitable. The more convenient are the abdomen, the anterior thigh and the anterior upper arm. (Usually the anterior abdominal wall is used.) • The infusion can be managed at home. • About one-half to two-thirds of the 24-hour oral morphine requirement is placed in the syringe. • The syringe is placed into the pump driver, which is set for 24-hour delivery. • Areas of oedema are not suitable.

27

Chapter 3

Injection techniques Basic injections Painless injection technique Method 1 The essence of this technique is to ensure good muscle relaxation. The patient should be as comfortable as possible. For injections into the deltoid region, the patient should be sitting down with hand on the hip and with the muscle as relaxed as possible. For deep intramuscular injections the buttock is preferred, but care must be taken to inject in the upper outer quadrant.These patients should be lying face down. The buttock should be exposed and the patient encouraged to relax. 1. Massage for muscular relaxation: The injection site should be well massaged for 20 to 30 seconds. This is a traditional preparation of the injection site, but it is probably more important for achieving relaxation than for ensuring that the skin is cleaned. It is easy to ensure that the underlying muscle is fully relaxed if firm, gentle pressure is applied with the left hand. When the muscle is relaxed, hold the syringe like a dart between the thumb and forefinger of the right or dominant hand. 2. Sharp tap over site: Before giving the injection, use the side of the back of the right (or dominant) hand to give a smart tap over the injection site (Fig. 3.1). A sharp flick with a finger can also be effective, but not as much as a tap. 3. The injection: Follow this immediately by injecting the needle using the dart technique.

Fig. 3.1  Sharp tap with side of hand

Note: These steps follow in very rapid succession. Many patients will tell you with surprise that they did not feel the needle but were conscious of the sting of the injection material going into the tissues. Method 2: Almost painless injections A subcutaneous or intramuscular injection is almost always painless if the skin is stretched firmly before inserting the needle. If injecting the arm, for example, the third, fourth and fifth fingers should go medial to the arm while the thumb and index finger stretch the skin on the lateral surface (Fig. 3.2). The needle should be inserted quickly into the stretched skin.

Chapter 3 | Injection techniques

iliac crest superiorly, posterior superior iliac spine (PSIS) superomedially, the ischial tuberosity inferomedially, and the greater trochanter laterally. The sciatic nerve lies inferior to an imaginary line from PSIS to the greater trochanter. After emerging from the pelvis, it follows a quarter circle course to a point halfway along the line drawn from the ischial tuberosity to the greater trochanter. posterior superior iliac spine iliac crest safe area for injection

Fig. 3.2  Stretching the skin with thumb and index finger

greater trochanter

Method 3: Muscle contraction–relaxation method Use the muscle energy method by asking the patient to push their elbow against their hip as an isometric contraction for 7 seconds. Then quickly give the injection into the deltoid muscle (now relaxed). Method 4: Needle gauge The discomfort from an IM or SC injection can be minimised by using a smaller gauge needle, e.g. 30-gauge, especially for vaccinations in children. Method 5: Alcohol swab massage Rub the injection site firmly with an alcohol swab for about 20 seconds while distracting the patient with appropriate conversation. After about 4 to 5 seconds give the injection into the (by now) erythematous site.

Intramuscular injections Deltoid injection A good site to inject but avoid striking the humerus as injury can occur to the anterior branch of the axillary (circumflex) nerve. This nerve winds posteriorly around the surgical neck of the humerus, below the capsule of the joint, approximately 6–8 cm below the bony prominence of the acromion. Thigh injection The safest area for injection is into the anterolateral aspect of the thigh, into the vastus lateralis or rectus femoris (two of the four components of quadriceps femoris). Buttock injection The sciatic nerve may be readily injured in a poorly placed deep intramuscular injection. The only safe area is the true upper outer quadrant (Fig. 3.3). The landmarks are the

sciatic nerve

ischial tuberosity

Fig. 3.3  Safest site for intramuscular injection into the left buttock

Reducing the sting from an alcohol swab The sting from alcohol on the skin can be reduced by drying the skin with a piece of sterile gauze or cotton wool after swabbing. Alternatively, one can blow onto the preparation site or rapidly wave your hand over it to achieve drying.

Painless wound suturing The objective is to administer local anaesthetic (LA) as painlessly as possible when treating a wound that requires suturing. The method applies to non-contaminated wounds only. Method 1. Irrigate the wound with a small volume of LA. 2. Rather than inserting the needle into the skin, insert it into the subcutaneous tissue through the open wound (Fig. 3.4). 3. Infiltrate for the length of the wound on both sides. This method is relatively painless.

29

30

Practice Tips

Disposal of needles Recapping of used needles should be avoided, to eliminate as far as possible the risk of accidental puncture of the medical practitioner or practice nurse. The risk of contracting such infections as hepatitis B, C and HIV from a sharps injury is ever-present. Needles should be disposed of directly into a sharps container, which should be above child height and attached to the wall. There are many types of sharps containers available for use in the surgery and even in the doctor’s bag. The ‘take it with you’ needle disposal unit consists of a plastic bottle 2.5 cm in diameter and 8 cm in depth. The lid has an opening with a plastic flap on the underside. This opening is designed to allow introduction of the needle attached to its syringe and then withdrawal of the syringe to ‘trap’ the needle in the container. After the needle is introduced into the centre of the opening, it is tilted to the side. The syringe is then pulled sharply upwards to disconnect the needle (Fig. 3.6). (In Australia the unit is available from Go Medical Industries Pty Ltd.)

Fig. 3.4 A relatively painless method of administering local anaesthetic at a wound site requiring suturing

Slower anaesthetic injection cuts pain A study has shown that subcutaneous infiltration of local anaesthetic causes only half the pain if injected slowly over 30 seconds rather than rapidly over 5 seconds.

Local anaesthetic infiltration technique for wounds This technique is applicable to larger wounds, contaminated wounds and planned excision of lumps. The anaesthetic should allow for adequate debridement and skin excision and suturing. Marking the boundaries and injection entry points will facilitate the procedure. Infiltrate both the dermis and underlying subcutaneous tissue. Figure 3.5 indicates the four entry points and eight needle positions required to cover the operative area.

1

Fig. 3.6 The doctor’s bag needle disposal bottle

2

8 7 3

area of infiltration

4

6 5 limb

Four sites of infiltration cover the outlined region completely. The lines represent the eight needle positions required to achieve this.

Fig. 3.5  Wide multiple infiltration to completely cover the outlined region

Chapter 3 | Injection techniques

Recapping of needles

Finger lancing with less pain

Although the recapping of needles should be avoided, probably the safest way, if it really must be done, is to scoop up the needle guard with the used needle and syringe unit, using the dominant hand only.This reinforces the principle of always staying ‘behind the needle’, and keeps the thumb and forefinger of the non-dominant hand out of danger.

A method of minimising the pain of lancing fingers for blood samples, especially for diabetics, is outlined.

‘Hole in one’ method This is a common method in developing countries where more sophisticated disposal methods are unavailable. Holes that are slightly larger than the size of the needle guard but smaller than the collar of it are drilled at an angle of 15° through the edge of the injection preparation table. The needle guard is placed into the hole while you give the injection. After the injection, the needle with used syringe is simply inserted into the guard. The whole unit is then placed in an old used drinking bottle.

Rectal ‘injection’ When no veins can readily be found for intravenous injections, in some emergency situations the use of the rectal route is effective.

Diabetic hypoglycaemia In some unconscious patients it may not be possible to administer the ‘difficult’ intravenous injection of 50% glucose, due to such factors as vasoconstriction and obesity in the patient. However, the glucose can be given simply by pressing the nozzle of the syringe (usually a 20 mL syringe) gently but firmly into the rectum and slowly injecting the solution.

Convulsions In children with a persistent febrile convulsion or in patients with status epilepticus, the rectal route can be used for administering a diazepam or paraldehyde solution with amazing success. Example Consider a 2-year-old child (weight 12 kg) with a persistent febrile convulsion. The dose of diazepam injectable is 0.4 mg/kg, so 5 mg (1 mL) of diazepam is diluted with isotonic saline (up to 5–10 mL of solution) and introduced into the rectum, preferably with a plastic fluid-drawing-up nozzle attached to the syringe.

Theory The sides of the fingers are less painful than the pad or the base of the nailbed of the thumb or index finger (as traditionally used for bleeding). The thumb and index finger have heightened sensitivity, as presented in Penfield and Boldrey’s homunculus. Method • Clean the finger with a non-alcohol swab. • Insert the lancet into the medial or lateral aspect of the third or fourth finger of either hand. • Provide firm pressure on the pad of the lanced finger with the opposing thumb on the pad of the finger. This ensures an adequate blood flow for the test strips.

Other viewpoints Side of thumb According to a randomised controlled trial published in The Lancet (1999, 354, pp. 921–2), the least painful area to lance for blood sugar testing was the side of the thumb. It would be worth conducting our own trial—the side of the thumb or the third or fourth finger! Earlobe A UK study of diabetic patients in 2003 found that the average pain score for finger pricking was 4 to 5 times higher than pricking the earlobe.

Digital nerve block The digital nerve block is indicated for simple procedures on the fingers and toes. (A more proximal block, such as the brachial plexus block, is indicated for extensive injury.) Each digit is supplied by four nerve branches, two dorsal and two palmar (or plantar). These nerves run forward adjacent to the respective metacarpal or metatarsal bone. The nerves to the fingers and toes are blocked at the base of the digit. Method 1. Perform the block at the level of the respective metacarpal or metatarsal from the dorsal aspect. 2. Introduce the 25- or 23-gauge needle distal or adjacent to the metacarpal head (for the hand) immediately alongside the bone (at the level where a ring would be worn).

31

32

Practice Tips

3. Insert at right angles to the skin and proceed as far as the palmar or plantar skin. 4. Inject 1–1.5 mL of LA without adrenaline (plain LA) on each side of the digit as the needle is slowly being withdrawn, so that the solution is spread evenly superficially and deeply (Fig. 3.7).

Alternatively, a wheal can be raised on the dorsal surface and the needle advanced as the injection is given. Dosage This is 2–3 mL of lignocaine or prilocaine 1% without adrenaline. Note: Never use a vasoconstrictor in the injection. Allow sufficient time for anaesthesia (5 to 20 minutes). Adrenaline antidote If adrenaline is injected into a digit and causes vasoconstriction, inject 1 mL phentolamine (Regitine) directly into the same area.

The thumb The thumb requires only one injection in the midline of the palmar surface at the base of the thumb.

Regional nerve wrist blocks to nerves to hand Partial or complete wrist block is very valuable for minor surgery or wound repair of the hand. The distribution of the cutaneous nerves to both surfaces of the hand is shown in Fig. 3.8.

Fig. 3.7 The digital nerve block blocks both palmar (or plantar) and dorsal nerve branches

median nerve distribution

ulnar nerve distribution

radial nerve distribution injection site —ulnar nerve

radial artery

ulnar artery FCR injection site —median nerve

Fig. 3.8  Illustration of median and ulnar nerve blocks

PL FCU

Chapter 3 | Injection techniques

Median nerve block Area supplied • Palmar surface on radial (lateral) side involving fingers 1, 2, 3 and the radial half of 4. • Dorsal distal aspect of same fingers. Technique of block • Identify palmaris longus (PL) tendon (flex wrist against resistance). • Insert 25-gauge needle between tendons flexor carpi radialis (FCR) and just lateral to PL. • The point is almost exactly in the middle of the anterior surface of the wrist or a few millimetres to the radial site of the midline. • Insert at level of proximal skin crease. • Inject 1 mL 1% lignocaine superficially and 1–2 mL deep, angling the needle at about 60°. • Cease the injection if median nerve symptoms such as tingling or pain develop. Note: If PL is absent, inject midway between the flexor tendons and FCR.

Ulnar nerve block Area supplied • Ulnar (medial) aspect of hand (fingers 5 and half 4). Technique of block • Identify flexor carpi ulnaris (FCU) tendon and styloid process of ulna. • Insert 25-gauge needle between FCU and the ulnar artery on radial side FCU just medial to the artery at the level of the styloid process of ulna (similar level as for median nerve block). Beware of entering the ulnar artery. • Inject 4 mL 1% lignocaine, preferably when paraesthesia has been induced by the needle.

Radial nerve block Area supplied • Radial half of dorsal aspect of hand. • Base of thenar eminence. Technique Because of the anatomical variations in the divisions of the radial nerve near the wrist joint, it is preferable to raise a subcutaneous ring of 10 mL 1% lignocaine radially (from level with the FCR tendons), then around the radial border of the wrist dorsally (about 4cm proximal to the wrist) to just lateral to the styloid process of the ulna.

Regional nerve blocks at elbow Median nerve block Extend the elbow and draw a line between the medial and lateral epicondyles, which is about 3 cm proximal to the flexion crease. Palpate the brachial artery and insert a 25-gauge 38 mm needle on the epicondylar line, about 0.5cm medial to the artery, and elicit paraesthesia deep to the artery. Inject 5 mL of plain LA.

Ulnar nerve block Flex the elbow to 30° and identify the ulnar nerve in the sulcus (groove) behind the medial epicondyle (‘funny bone’). Inject 2 mL of lignocaine 1% with adrenaline 1–2 cm proximal to this position and elicit paraesthesia. The nerve can also be blocked with the needle outside the nerve using 5–10 mL plain LA.

Radial nerve block Extend the elbow and draw a line between the two condyles (as above). Insert a 25-gauge 38 mm needle just lateral to the biceps tendon in the groove between it and the brachioradialis muscle on the epicondylar line. Direct the needle slightly cephalad and medial to contact the lateral epicondyle. Inject 2–4 mL of plain LA while the needle is withdrawn.

Femoral nerve block In a general practice setting, and especially in rural and remote areas, a femoral nerve block may prove useful in providing emergency analgesia for the transported patient with a fractured neck of femur or shaft of femur and in reducing the need for systemic opioids. It is indicated in the analgesia of a fractured femur, especially the femoral shaft. Occasionally it may be used for anaesthesia of the anterior thigh for exploration of soft tissue injuries. Patients with effective blocks cannot mobilise since the quadriceps is weakened, so all patients must be appropriately splinted for transfer. Femoral nerve block is a safe, easy to learn and minimally invasive procedure that can be repeated. Specific training with nerve stimulator guidance or ultrasound will reduce the incidence of arterial puncture. Anatomy of the femoral nerve The femoral nerve (L2, L3, L4) enters the anterior thigh about one finger’s breadth lateral to the femoral artery immediately below the inguinal ligament. The femoral

33

34

Practice Tips

artery lies at the midpoint of the symphysis pubis and anterior superior iliac spine (ASIS). The femoral nerve lies at the midpoint of the pubic tubercle and the ASIS. The nerve is covered by two layers of fascia, the fascia lata and iliopectineal fascia (Fig. 3.9). Two ‘pops’ are therefore felt when piercing each of these layers.

anterior superior iliac spine inguinal ligament

site of injection femoral nerve femoral artery femoral vein

injection onto nerve

x

pubic tubercle

inguinal crease

skin fascia lata fascia iliaca

femoral vein

iliopsoas muscle

femoral artery

Fig. 3.9 Anatomical position of the femoral nerve in the femoral triangle with illustration of the position of the needle during nerve blockade Fig. 3.10  Femoral nerve block (right side)

Materials Alcohol swab, an appropriate needle is a 2.5 to 4 or 5cm 22- or 21-gauge. A St Vincent’s needle is ideal as it ends in a point. When introduced up to the hilt, a 2.5 cm should be sufficient to reach the appropriate area. Otherwise, especially in obese subjects, a 4–5 cm needle can be used. An appropriate local anaesthetic is 20 mL of 1% lignocaine, or 10 mL ropivacaine or 0.5% bupivacaine (preferred if available because it lasts up to 8 hours). Method Identify and mark the site for injection, which should be adjacent to (one finger breadth away) the femoral artery and over the femoral nerve at the level of the inguinal crease (Fig. 3.10). This crease is a skin fold 2 to 3 cm below, and parallel to, the inguinal ligament. Insert the needle and aim it slightly rostral or headwards at about 35° to the skin. As you slowly inject, aspirate for blood and check for pain and paraesthesia. If paraesthesia is elicited, withdraw the needle by 1–2mm and try again. If no blood is aspirated, fan out all the local anaesthetic as you move in and out eg. ¼ of dose medial, ¼ lateral, ¼ over nerve and ¼ during withdrawal. It should take about 5 minutes for the anaesthesia to start developing. You should be about 3–4 cm deep to the skin surface.

If attempting to provide anaesthesia for a fractured neck of femur, massage the anaesthetic upwards towards the groin. Precautions The only real complication is striking the femoral artery or some small vessel, causing either systemic absorption or false aneurysm formation and local bleeding. Note time of procedure and doses of anaesthetic. The block is contraindicated in patients with severe scarring, infection or necrosis over the femoral triangle. In children Raise a bleb of LA just lateral to the femoral artery, below the inguinal ligament. Introduce a 23-gauge or lumbar puncture needle and advance it perpendicular to the skin. Fascia insertion ‘pops’ will then be heard.

Tibial nerve block The tibial (posterior tibial) nerve can be blocked as it passes behind the medial malleolus, in front of the Achilles tendon, usually midway between these structures. It innervates most of the sole of the foot (Fig. 3.11).

Chapter 3 | Injection techniques

saphenous nerve sural nerve

medial plantar nerve lateral plantar nerve

tibial nerve

3. At about a depth of 1 cm, paraesthesia may be elicited, indicating the ideal location for injection. The depth of injection varies from 0.5 to 2 cm. 4. Inject 6–10 mL of 1% plain lignocaine, taking care not to puncture a blood vessel. The block should induce an area of anaesthesia around the sole of the foot, making it ideal for the procedures listed. It usually does not anaesthetise the most proximal and lateral parts.The anaesthesia develops over 10 minutes and lasts for up to 2 hours. Note: Avoid bilateral nerve blocks at the same visit. Bilateral anaesthesia may cause falls due to loss of balance. To obtain almost full anaesthesia of the plantar aspect of the foot a sural nerve block is necessary, as well as the tibial block. Caution: Ensure that the injection is not given into the nerve.

Sural nerve block Fig. 3.11  Innervation of the heel and sole of the foot

Indications • Operations on the foot • Removal of plantar warts • Injecting the plantar fascia • Foreign bodies in sole Method 1. Palpate the posterior tibial artery behind the medial malleolus. The tibial nerve lies immediately behind the artery. 2. Insert a fine-gauge needle just posterior to the artery, either at the level of the medial malleolus or just below it, pointing in an anterolateral direction (Fig. 3.12). Alternatively, insert the needle anterior to the artery.

tibial nerve tibial artery

possible blocking sites

Fig. 3.12 Tibial nerve block

The sural nerve, which runs behind the lateral malleolus, innervates most of the back of the heel and the lateral border of the sole, is blocked by a subcutaneous infiltration of up to 5–8 mL of 1% plain lignocaine in a fanwise fashion from the Achilles tendon to the outer and upper border of the lateral malleolus (Fig. 3.13). Another landmark is the groove midway between the posterior border of the lateral malleolus and the calcaneus bone. You can inject LA between the skin and malleolar surface 1 cm behind and proximal to the tip of the lateral malleolus. This procedure anaesthetises the most proximal and lateral aspects of the sole of the foot. If combined with a tibial nerve block, most of the heel and sole of the foot will be covered.

lateral malleolus

Achilles tendon

medial malleolus

Fig. 3.13  Sural nerve block (infiltrate between the Achilles tendon and lateral malleolus)

35

36

Practice Tips

Facial nerve blocks

Infraorbital nerve block

Regional nerve blocks have advantages over infiltration for facial and oral anaesthesia because there is less tissue swelling at the operative site, a wider area is anaesthetised, and they are less painful.

Indications Surgery to: • lower eyelid • cheek • side of nose and upper lip • gingival tissues from midline to first molar.

General points • Use 2% lignocaine with adrenaline. 1:2 000 000 forfacial injections and 1:80 000 for intra-oral injections. • Allow 5 to 10 minutes before commencing the procedure. • Always aspirate to check for blood before injecting.

Indications Surgery to forehead, upper eyelids and scalp to vertex.

Method 1: Intraoral approach (preferred to the extraoral route) The infraorbital foramen lies above and in line with the second premolar, 1 cm below the infraorbital margin. 1. Elevate the upper lip and align the syringe along the long axis of the tooth. 2. Enter the mucosa at its reflection from the gum and advance a 23- or 25-gauge needle to just short of the foramen (until the bone is just contacted). 3. Inject 2–3 mL of LA.

Method 1. Insert a 23- or 25-gauge 3.5 cm needle in a horizontal plane over the supraorbital foramen, at the upper border of the orbit, under the eyebrow, 2.5 cm from the midline (Fig. 3.14). 2. Inject 3–4 mL of LA.

Method 2: Extraoral approach 1. Instruct the patient to look straight ahead. 2. Insert the needle 1 cm below the infraorbital margin in line with the pupil, directing the needle towards the infraorbital foramen. Do not attempt to enter it. 3. Inject 2 mL of LA.

Supraorbital nerve block

supraorbital nerve block

infraorbital nerve block corresponding areas of anaesthesia

mental nerve block

Fig. 3.14  Facial nerve blocks

Chapter 3 | Injection techniques

Mental nerve block Indications • Excision of oral and skin lesions • Suturing lacerations: from midline to lower border of mandible (Fig. 3.14) to include lower lip and chin Method (intraoral approach) 1. Palpate the mental foramen, which lies at the apex of the lower second premolar tooth. 2. Lift the lip forward and align the syringe with the long axis of this tooth. 3. Penetrate the mucosa and advance the needle to just short of the foramen. This is about half-way between the gum margin and the lower border of the mandible. 4. Aspirate and inject 2 mL of LA. If the patient is edentulous, use as a reference a vertical line from the midpoint of the pupil.

Specific facial blocks for the external ear For minor surgery and repair of lesions of the external ear, widespread infiltration can be used (Fig. 3.15). However, more specific blocks using 3 mL of 1% plain lignocaine for each nerve can be used. Care should be taken because of the proximity of branches of the carotid artery.The skin of the external ear is mainly supplied by three branches of the trigeminal nerve, namely: • Auriculotemporal nerve—innervates upper anterior quadrant of lateral surface including tragus, crux of helix and adjacent helix. Blockage: Insert needle immediately posterior-inferior to temporomandibular joint. auriculotemporal nerve supply

greater auricular nerve supply

• Greater auricular nerve—innervates remainder of lateral surface, including anti-helix and earlobe and most of medial (cranial) surface. Blockage: Insert needle just behind and inferior to the earlobe at the anterior border of the sternomastoid muscle. • Lesser occipital nerve—innervates upper part of medial (cranial) surface. Blockage: Insert needle about 1 cm posterior to the ear at its midpoint.

Penile nerve block The penis can be anaesthetised for procedures such as circumcision, wound repair and paraphimosis reduction by injecting local anaesthetic (without adrenaline) into the dorsal and ventral surfaces. Method 1. Inject a ring of 5 mL of plain LA subcutaneously around the base of the penis, with the needle resting against the corpus cavernosum (Fig. 3.16a). 2. Inject 2 mL of LA into each of the grooves on the ventral surface (between the corpus cavernosum and spongiosum) (Fig. 3.16b). (a)

(b)

Infiltration of base of penis to block dorsal nerves auriculotemporal nerve block

lesser occipital nerve block Injections of block para-urethral branches

greater auricular nerve block

Fig. 3.15 Nerve supply to the ear and sites for the three nerve blocks

Fig. 3.16  Penile nerve block: (a) infiltration of base of penis; (b) three injection approaches

37

38

Practice Tips

Intravenous regional anaesthesia (Bier block) This technique uses an intravenous injection of local anaesthetic into an arm or leg that is isolated from the circulation by an arterial tourniquet. It produces excellent anaesthesia, muscle relaxation and (if desired) a bloodless operating field. Ideally, two doctors are required. It is also used in children over 5 years of age. Indications • Minor surgery, especially to upper arm (e.g. release of trigger finger, removal of foreign bodies) • Reduction of limb fractures (e.g. Colles fracture) Precautions • The patient should be fasted as for a GA. • Exclude patients with unstable epilepsy, second- or third-degree heart block, liver disease, severe vascular disease, allergy to LA agents or a condition precluding the use of a tourniquet. • Obtain informed consent. • Ensure patient fasting—at least 4 hours. • Avoid sudden release of LA (e.g. escaping beneath tourniquet). • Maintain IV access with a needle in the vein of the opposite arm. • Check the pressure of the tourniquet throughout. • Have resuscitation equipment available, including a positive pressure oxygen system. • Ideally, monitor with an ECG and SaO 2 (pulse oximetry). • Maintain inflation for at least 20 minutes. • Maximum inflation 45 minutes. Method (for arm) 1. Cannulate vein (e.g. plastic 22 G IV cannula of IV set) and tape on. 2. Drain blood by simple elevation for 3 minutes or (for bloodless field) by an Esmarch bandage. This exsanguination is very important. 3. Apply a sphygmomanometer cuff or (better still) arterial pneumatic tourniquet. 4. Inflate to 100 mmHg above the patient’s systolic blood pressure (50 mmHg in children). Check for absence of the brachial or radial pulse. Remove the Esmarch and lower the arm. 5. Slowly inject 2.5 mg/kg of 0.5% plain lignocaine or prilocaine (preferred) (without adrenaline) into the indwelling needle (Fig. 3.17). Note: Usual adult dose is 30 mL of 0.5% prilocaine (maximum 40mL). 6. The onset of anaesthesia is reasonably rapid (5 to 10minutes). Confirm its adequacy. Remove the cannula in the arm being treated.

7. Watch carefully for side effects, e.g. restlessness, dizziness, tinnitus, seizures, bradycardia or hypotension. 8. Use a second doctor (if available) to perform the procedure. 9. On completion, ensure very slow release of the tourniquet. As soon as it is deflated, pump it up again rapidly then slowly deflate. (Repeat this three times at the rate of once per minute if inflated for only 20 to 25 minutes. Serial deflation/inflation is considered to reinforce safety. Some do not use it.) Ideally, the tourniquet should not be released before 20 minutes after the infusion and left on no longer than 40 minutes. 10. Observe the patient carefully for at least 15 minutes. Note: More sophisticated double cuff tourniquets are available.

Haematoma block by localinfiltration anaesthetic In this procedure, local anaesthetic is injected directly into the haematoma surrounding the fracture. It usually employs the barbotage method of alternately injecting small amounts of anaesthetic and withdrawing small amounts of haematoma. A full aseptic technique is essential and caution is required for possible complications including infection. Ideally, ECG monitoring is recommended. Its use is not favoured because of the potential for adverse effects but it remains an option when no other anaesthetic methods, including the preferred Bier’s block, are available or practical. Indications This method has a place in the emergency reduction of fractures of the distal radius (notably Colles fracture), sometimes for distal ankle fractures and fractures of the upper extremity in children. Method • Use sterile gloves and prepare the overlying skin with a bactericidal agent. • Use a 21-gauge needle and 1% plain lignocaine with a volume less than 10 mL. • Localise the haematoma by aspirating blood into the syringe. • Slowly inject the anaesthetic (up to no more than half the quantity) into the haematoma (Fig. 3.18). • Withdraw an equivalent amount of the bloody fluid. • Repeat injection and aspiration until the anaesthetic is dispersed. • Wait 10–15 minutes and gently manipulate the displaced fracture to achieve satisfactory reduction.

Chapter 3 | Injection techniques

arterial tourniquet (keep 80–100 mmHg above systolic BP at all times)

needle and syringe in situ

Fig. 3.17  Intravenous regional anaesthesia

Fig. 3.18 Haematoma block: Illustration of injecting anaesthetic into the site of a Colles fracture

Complications • Infection, since a closed wound is converted to an open wound. • For the distal radius—compartment syndrome, temporary paralysis of the interosseous nerve and carpal tunnel syndrome. • Introduction of anaesthetic agent into the circulation with potential arrhythmias and seizures.

Intercostal nerve block Indications • Relief from severe pain of fractured rib • Malignant pain • Other painful chest conditions, e.g. post-thoracotomy pain

Method 1. The patient sits up, bending slightly forwards, hugging a pillow. 2. Apply antiseptic over the paravertebral area, corresponding to the posterior end of the fractured rib and the two adjacent ribs. 3. Insert a smaller-gauge needle (25 or 23) into the lower border of the neck of the fractured rib about four finger-breadths from the spinous process—that is, at about the angle of the rib or 8 to 10 cm from the midline (Fig. 3.19a). 4. Advance the needle forward until it reaches the rib and inject a small amount of plain LA (1% lignocaine). 5. Now ‘walk’ the needle slowly downward to allow itto slip below the inferior border of the rib (Fig.3.19b). 6. Advance the needle anteriorly a further 2–3 mm only (take care not to puncture the pleura) and inject 3–5mL of LA (Fig. 3.19c). Note: Perform this block with great care. Pleural puncture is indicated by coughing, pleuritic pain or aspiration of air into the syringe.

The caudal (trans-sacral) injection An epidural injection is the appropriate way to treat persistent painful sciatica without neurological signs in a patient who is not a candidate for surgery but is making slow progress. The lumbar epidural is technically more difficult than the caudal epidural and requires hospital day care. The caudal epidural is safer and within the skill of any medical practitioner. It can be performed in a general practice procedure treatment room with resuscitation facilities. The key to success is to identify the sacral hiatus and insert a needle

39

40

Practice Tips

(usually a 21- or 22-gauge, 36 mm needle is sufficient for most patients) at the appropriate angle in a cranial direction.

(a)

Identifying the sacral hiatus

X = site(s) of infiltration

(b)

The sacral hiatus can be identified in the following ways: • Palpate the two sacral cornua and mark the hiatus at the top end of the hollow formed by the cornua. • It lies directly beneath the upper limit of the intergluteal fold. • It tends to correspond to the proximal interphalangeal (PIP) joint with the tip of the index finger resting on the tip of the coccyx. • It lies at the caudal apex of an equilateral triangle drawn with the horizontal base between the posterior superior iliac spines (PSIS) (opposite S2). This apex is usually situated over the sacral hiatus (Fig. 3.20).

Local anaesthetic use vein

artery nerve

Use 15–20 mL of half-strength solution (without adrenaline) of any of the local anaesthetics, such as plain lignocaine, procaine or bupivacaine. Corticosteroid is not necessary.

Injection procedure Method 1. Inform the patient that the procedure is surprisingly comfortable but that some heaviness will be felt in the back of the legs and that pain may be initially exacerbated. 2. Mark the sacral hiatus after its identification. PSIS equilateral triangle

(c)

PIP joint index finger

sacral hiatus (injection site) sacral cornua intergluteal fold coccyx

Fig. 3.19  (a) Shows sites of infiltration (X); (b) ‘walking’ the needle; (c) final position

Fig. 3.20  Identify the sacral hiatus by four methods: 1. Palpating the sacral cornua. 2. Noting the upper limit of the intergluteal fold. 3. Measuring the tip of the coccyx to the PIP of the index finger. 4. D rawing an equilateral triangle with the base being the line between the postero-superior iliac spines. Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Chapter 3 | Injection techniques

Hormone implants Suitable sites for the subcutaneous insertion of crystalline pellets of the hormones oestradiol and testosterone into the abdominal wall are shown in Figure 3.22a. The preferred sites are in the anterior abdominal wall above and parallel to the inguinal ligament. A site just superolateral to the pubic hair is ideal. The procedure is performed under local anaesthesia using a wide-bore trocar and cannula. It is simple and effective, and takes a few minutes only.

Fig. 3.21 The caudal epidural: the appearance of the procedure

3. Lie the patient prone with a pillow under the symphysis pubis to slightly flex the hips (or with the operating table ‘broken’). 4. Relax the glutei by inversion of the ankles (feet in pigeon-toe position). 5. Clean and drape the area, avoiding spirit running onto the anus. Using a 23- or 25-gauge needle, anaesthetise the skin and subcutaneous tissue. 6. Select a spinal tap cannula: 21-, 22- or 23-gauge 50 mm or a 21-gauge 38 mm standard single-use needle (preferred). 7. Insert the needle upwards (cranially) keeping strictly to the midline. The angle to the skin should be about 25–30° (Fig. 3.21); if too superficial, the needle will pass above the hiatus. When the ligament is pierced there is a sensation of ‘giving’. 8. Angle the needle slightly downwards as you insert it for about 2 cm. Avoid proceeding any further because of the risk of piercing the dura. 9. The needle is rotated through 90° twice—check for a back flow of cerebrospinal fluid (CSF) or blood. If blood is obtained, partly withdraw the needle and reinsert it, keeping as far posterior as possible to avoid the greater concentration of veins anteriorly. If CSF is withdrawn, abandon the procedure. 10. Inject the fluid carefully and slowly over a 5-minute period (at least) with at least three aspiration checks for blood. The plunger of the syringe should move with relative ease. 11. Ask the patient to report any unusual symptoms such as giddiness or light-headedness, which is reasonablycommon but indicates a need for caution. Monitor the pulse and blood pressure during the procedure and stop the injection if an adverse reaction develops. The injection can be repeated if the patient experiences a good, albeit temporary, result.

Equipment You will need: • 2–5 mL of 1% lignocaine with syringe • povidone-iodine 10% antiseptic • wide-bore trocar and cannula (use an expellor if available) • scalpel with no. 11 (or similar) blade • crystalline pellets (that will fit into the cannula) • sterile gauze or suitable container, for ‘catching’ a dropped pellet • sterile adhesive strips. Method To insert the hormone implants: 1. Choose the implantation site. 2. Infiltrate the sterilised skin with LA so that a small bleb is raised. 3. Make a small incision 5–10 mm long with the scalpel blade. 4. Insert the trocar and cannula through the incised skin at a shallow angle (Fig. 3.22b) for at least 2 cm.The end of the cannula now rests in a pocket in the subcutaneous tissue (care should be taken to avoid the rectus sheath). 5. Remove the trocar. 6. Grasp a pellet with sterile forceps and place it in the cannula. Note: This part of the procedure is the most delicate because the pellet is likely to be accidentally dropped. Have an assistant standing by with a sterile receptacle or gauze to catch it. 7. Reinsert the trocar or expellor (ideally the expellor should extend 5 mm beyond the end of the cannula) and push the pellet into the subcutaneous ‘pocket’ (Fig. 3.22c). 8. The cannula and trocar (or expellor) are removed while maintaining pressure over the site for 1 minute to minimise bruising. 9. Apply sterile adhesive strips (or a suture) over the wound and then a light dressing. Precaution: Ensure that you have the correct hormone for the correct patient and record the batch number.

41

42

Practice Tips

(a)

(b)

skin

trocar

cannula

subcutaneous fat

(c)

Fig. 3.22  (a) Suitable sites for insertion of pellets; (b) trocar and cannula are angulated into subcutaneous tissue after initial, more upright entry; (c) shows pellet in cannula pushed gently into place with expellor

Musculoskeletal Injections Musculoskeletal injection guidelines Conditions that are considerably relieved by injections include: • rotator cuff tendonopathy, especially supraspinatus tendonopathy • subacromial bursitis • bicipital tendonopathy • lateral and medial epicondylitis • trigger finger and thumb • trochanteric bursalgia and gluteus medius tendonopathy • tendonopathy around the wrist, e.g. de Quervain’s tenosynovitis • plantar fasciitis • knee conditions—anserinus tendonopathy/bursitis, biceps femoris tendonopathy. Rules and guidelines • Use any one of the depot (long acting) corticosteroid formulations: betamethasone (Celestone Chronodose), triamcinolone (Kenocort–A10 or A40) or methylprednisolone (Depo-Medrol, Depo-Nisolone). • Use the more soluble formulation (Celestone Chrondose) for tendon sheath injection. • Use a mixture of 1 mL of LA corticosteroid (CS) with 1% Xylocaine (0.5–8 mL) for most injections. • Conditions not very responsive and best avoided include patellar tendonopathy and Achilles tendonopathy. • Conditions responsive for about 3 weeks only include epicondylitis and plantar fasciitis. • Trochanteric bursalgia or gluteus medius tendonopathy is common, misdiagnosed often and responds exceptionally well to 1 mL CS + 8 mL Xylocaine 1%.

• All injections of local anaesthetic use plain preparations (without adrenaline) unless otherwise specified. • Corticosteroids are not very effective for trigger spots of the back. • A subacromial space injection (posterior approach) will be effective for most rotator cuff problems. • Use corticosteroid alone for carpal tunnel injections and small joints. • Intra-articular injections for arthritic joints have limited use: perhaps 2 to 3 times for osteoarthritis—best for monarticular rheumatoid arthritis. • For soft tissue injections, avoid repeating under 6 weeks and use a maximum of four in 12 months. • Tendons should never be injected; inject tendon sheaths but with caution because of the danger of rupture. • Always aspirate before injecting into soft tissue to avoid injecting into a blood vessel. • Contraindications include local and systemic infection, bleeding disorders and lack of informed consent. • Warn the patient about potential adverse effects of corticosteroids, including tendon rupture and skin atrophy. • Maintain a strict aseptic technique.

Injection of trigger points inback The injecton of painful myofascial trigger points of the back and neck (Fig. 3.23) is relatively easy and may give excellent results. A trigger point is one characterised by: • circumscribed local tenderness • localised twitching with stimulation of juxtaposed muscle • pain referred elsewhere when subjected to pressure.

Chapter 3 | Injection techniques

Injection for rotator cufflesions Injections of local anaesthetic and corticosteroid produce excellent results for inflammatory disorders around the shoulder joint, especially for supraspinatus tendonopathy. The best results are obtained with precise localisation of the area of inflammation, although injections into the subacromial space are all that is necessary to reach inflammatory lesions of the tendons comprising the rotator cuff and the subacromial bursa. Preliminary ultrasound diagnosis for shoulder lesions is recommended.

The subacromial space injection for rotator cuff lesions (especially with impingement) The recommended approach is from the posterolateral aspect of the shoulder, with the patient sitting upright. Method 1. Draw up 1 mL of corticosteroid and 5–6 mL of 1% LA. 2. Sit the patient upright and explain the procedure in general terms. 3. Identify the soft gap between the acromion and the humeral head with the palpating finger or thumb. 4. Mark this spot, about 2 cm below and 1 cm medial to the edge of the acromion. 5. Swab the area with antiseptic. 6. Place the needle (23-gauge, 32 or 38 mm long) into this gap, 2 cm inferior to the acromion (Fig. 3.24).

Fig. 3.23 Typical trigger points of the back Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Don’t: use large volumes of LA; use corticosteroids; cause bleeding. Do: use a moderate amount of LA (only). Method 1. Identify and mark the trigger point, which must be the maximal point of pain. 2. Select a 21-, 22- or 23-gauge needle of a length compatible with the injection site. (A 38 mm needle will cover most areas of the back and neck.) 3. Insert the needle into the point until the patient complains of reproduction of pain, which may be referred distally. 4. At this point, introduce 5–8 mL of plain LA of your choice. (Lignocaine/lidocaine, procaine or bupivacaine 1% or 0.5% can be used.) 5. Recommend post-injection exercises and local massage for the affected segment.

direction of needle

Fig. 3.24  Posterior view of the subacromial bursa injection site (2 cm inferior and 1 cm medial to lower extent of acromion)

43

44

Practice Tips

7. Aim the needle slightly medially and anteriorly so that it is felt passing beneath the acromion. 8. Insert for a distance of about 30 mm. The solution should flow into the subacromial space without resistance. Tip: Place a weight (0.5–1 kg) in the hand nearest to the affected side to facilitate opening the subacromial space. It also distracts the patient!

The subacromial space injection for subacromial bursitis

acromion

bicipital groove

coracoid process

XX palpate for (1) tenderness (2) site of injections

The lateral approach is used for localised bursitis when there is localised tenderness over the subacromial space. It is important to angle the needle into the appropriate anatomical plane. Method 1. Identify the lateral edge of the acromion and select the midpoint. 2. Insert the needle 10 mm below the edge of the acromion and angle it upwards at about 10° between the head of the humerus and the acromion. 3. Inject 1 mL of corticosteriod and 5–6 mL of 1% LA.

Injection for supraspinatus tendonopathy An injection directed onto the inflamed tendon of supraspinatus is so effective that it is preferable to administer a specific injection rather than a general infiltration into the subacromial space. The tendon can be readily palpated as a tender cord anterolaterally as it emerges from beneath the acromion to attach to the greater tuberosity of the humerus. This identification is assisted by depressing the shoulder via a downward pull on the arm and then externally and internally rotating the humerus. This manoeuvre allows the examiner to locate the tendon readily. Method 1. Identify and mark the tendon. 2. Place the patient’s arm behind the back, with the back of the hand touching the far waistline. This locates the arm in the desired internal rotation and forces the humeral head anteriorly. 3. Insert a 23-gauge 32 mm needle under the acromion along the line of the tendon, and inject around the tendon just under the acromion (Fig. 3.25). If the gritty resistance of the tendon is encountered, slightly withdraw the needle to ensure that it lies in the tendon sheath and not the tendon. 4. The recommended injection is 1 mL of long-acting corticosteroid with 2 mL of LA.

Fig. 3.25  Injection placement for supraspinatus tendonopathy

Injection for bicipital tendonopathy Bicipital tendonopathy is diagnosed by finding an abnormal tenderness over the tendon when the arm is externally rotated. The usual site is the bicipital groove of the humeral head. Method 1. The patient sits with the arm hanging by the side and the palm facing forwards. 2. Find and mark the site of maximal tenderness. This is usually in the bicipital groove and more proximal than expected. 3. Insert a 23-gauge needle at the proximal end of the bicipital groove above the tender area. 4. Slide the needle down the groove to reach the tender area (Fig. 3.26). 5. Inject 1 mL of long-acting corticosteroid and 2 mL of LA around this site.

Fig. 3.26  Injection placement for bicipital tendonopathy

Chapter 3 | Injection techniques

Injections for epicondylitis Lateral epicondylitis (tennis elbow) The key to successful injections is to have the tender lesion pinpointed precisely. The point of maximal tenderness is usually on or just distal to the lateral epicondyle, which coincides with 1–2 square cm of degenerate tendon. Warn the patient about the risk of skin thinning. Equipment You will need: • an antiseptic swab • a 25- or 23-gauge needle • 1 mL of long-acting corticosteroid and 2 mL of LA (e.g. 1% lignocaine). Use a mixed solution (LA drawn last) in a 5 mL syringe. Method 1. The patient sits with the elbow resting on a table, flexed to a right angle and fully supinated. 2. Using an anterior approach, palpate the tender area and mark it with a pen. 3. With the thumb (of the non-dominant hand) over the patient’s lateral epicondyle and the fingers spread out around the elbow to steady it, insert the needle vertically downward to touch the periosteum of the tender point (Fig. 3.27). 4. After introducing about 0.5 mL of the mixed solution, partly withdraw the needle and reinsert it to ensure that the tender area is covered both deeply and superficially. Inject over at least two sites. A deeper injection minimises the risk of skin atrophy. Post-injection 1. Ask the patient to ‘work it in’ during the next few hours with repeated extensions of the elbow joint and pronation of the wrist.

vertical approach for injection

supinated forearm tender lateral epicondyle thumb stretches skin around epicondyle

Fig. 3.27  Injection technique for tennis elbow

2. Warn the patient that the area will be very painful for the next 24 hours and recommend moderately strong analgesics. 3. Repeat the injection in 2 to 4 weeks unless all the symptoms have been abolished. 4. A maximum of two injections only is recommended.

Medial epicondylitis (golfer’s elbow) A similar method is used to that for lateral epicondylitis. The elbow is flexed to about 45° and supinated with full external rotation of the shoulder of the affected arm. The anterior approach is used, and the tender area of the medial epicondyle injected as for lateral epicondylitis. Take care not to inject the ulnar nerve, which lies posterior and close to the medial epicondyle. It can be felt to move with flexion and extension of the elbow. Keep your finger over the nerve as you inject the usual 3 mL of mixed solution.

Injection for trigger finger Treatment of trigger finger or thumb by injection is often very successful, and usually relieves symptoms for a considerable period of time. The injection is made under the tendon sheath and not into the tendon or its nodular swelling. The fourth (ring) and middle fingers are most commonly affected. There are three possible injection approaches: proximal, distal and mid-lateral. Distal is preferred. Method (distal palmar approach) 1. The patient sits facing the doctor with the palm of the affected hand facing upward. 2. Draw 1 mL of long-acting corticosteroid solution and 0.5–1 mL LA into a syringe and attach a 23- or 25-gauge needle for the injection. 3. Insert the needle at an angle distal to the nodule and direct it proximally within the tendon sheath (Fig.3.28). This requires tension on the skin with free fingers. To avoid injecting into the tendon, flex and extend the finger and ensure that the needle does not move. 4. By palpating the tendon sheath, you can (usually) feel when the fluid has entered the tendon sheath. 5. Inject 0.5–1 mL of the solution, withdraw the needle and ask the patient to exercise the fingers for 1 minute. Method (proximal palmar approach) Insert the needle about 1 cm proximal to the nodule and angle it to lie in the tendon sheath over the nodule. Flexthe finger to confirm that it is the correct position. If the needle is in the tendon, withdraw it a fraction before injecting the solution. Method (mid-lateral approach) This approach uses a lateral approach at the level of the proximal phalanx and about 1 cm lateral to the anterior

45

46

Practice Tips

injection distal to nodule

nodular swelling of tendon (site of triggering)

Fig. 3.28  Injection site for trigger finger

surface of the finger. Direct the needle towards the nodule and inject over the tendon. The fourth and fifth fingers are approached from the ulnar side and the second and third fingers from the radial side. Post-injection Improvement usually occurs after 48 hours and may be permanent. The injection can be repeated after 6 to 8weeks if the triggering is not completely relieved. If triggering recurs, surgery is indicated. This involves division of the thickened tendon sheath only.

Injection for trigger thumb The injection for the trigger thumb follows a similar principle to the trigger finger but it is more difficult.With the hand rotated radially and the thumb extended, approach the nodule from the palmar (volar) aspect and inject into the tendon sheath just proximal to the nodule (Fig. 3.29).

injection for tenosynovitis of the wrist Tenosynovitis of the wrist, especially that of the thumb abductors (de Quervains stenosing tenosynovitis), is a common problem that can readily be identified by tenderness, swelling and palpable crepitus over the tendon. It may respond to an injection of a long-acting corticosteroid, but care should be taken to inject the suspension into the tendon sheath rather than into the tendon. Warn the patient about the risk of skin atrophy.

Fig. 3.29 Trigger thumb showing site of injection

Method for de Quervains tenosynovitis 1. Identify and mark the most tender site of the tendon and the line of the tendon. Draw up 1 mL each of LA and cortiocosteroid. 2. Thoroughly cleanse the skin with an antiseptic, such as povidone-iodine 10% solution. 3. Insert the tip of the needle (21-gauge) about 1 cm distal to the point of maximal tenderness and about 1cm proximal to the radial styloid (Fig. 3.30). 4. Advance the needle almost parallel to the skin along the line of the tendon. 5. Inject about 0.5 mL of the corticosteroid suspension into the tendon sheath. If the needle is in the sheath, very little resistance to the plunger should be felt and the injection will cause the tendon sheath to billow out. Complete the injection of 2 mL. Alternative method 1. Advance the needle into the tendon, where there will be resistance to the attempted injection in addition to a firm, gritty feel to the needle. 2. Slowly withdraw the needle until the resistance to depressing the plunger disappears. 3. Inject the corticosteroid. The ideal site for this injection is into the sheath of the abductor tendons to the thumb just above the radial styloid. It is important, therefore, to avoid injecting

Chapter 3 | Injection techniques

into the radial artery, which should always be identified beforehand. Note: It should be emphasised that the common problem of de Quervains disease (also known as ‘washerwoman’s sprain’) is best treated by resting and avoiding the causative stresses and strains on the thumb abductors.

Injection for plantar fasciitis Plantar fasciitis can be treated by injecting local anaesthetic and long-acting corticosteroid into the site of maximal tenderness in the heel. An alternative is to inject the corticosteroid into the anaesthetised heel. On the other hand, to minimise the pain of injecting through the heel, apply liquid nitrogen beforehand and immediately inject through that spot.

maximal tenderness over abductor pollicus longus tendon injection site 1 cm distal

wrist crease

Fig. 3.30 Tendon sheath injection

Method 1. Perform a tibial nerve block. (The area of maximal tenderness should be marked prior to the nerve block.) Refer to Figure 3.12 (p. 35). 2. When anaesthesia of the heel is present (about 10 minutes after the tibial nerve block), insert a 23-gauge needle with 1 mL of long-acting corticosteroid perpendicular to the sole of the foot at the premarked site (Fig. 3.31). Insert the needle until a ‘give’ is felt as the plantar fascia is pierced. 3. Inject half the steroid against the periosteum in the space between the fascia and the calcaneus. 4. Reposition the needle to infiltrate into the fascial attachments over a wider area. Alternative approach For the non-anaesthetised heel, introduce the needle containing 3 to 4 mL of LA with steroid into the softer part of the heel medially and guide it to the most tender site. Tip for plantar fasciitis: Massage the sole of the foot over a wooden foot massager or glass bottle filled with water for 5 minutes daily to help prevent recurrence (refer to Chapter 7).

Injection for trochanteric bursalgia Pain around the greater trochanter Pain around the lateral aspect of the hip is a common disorder, and is usually seen as lateral hip pain radiating down the lateral aspect of the thigh in older people engaged in walking exercises, tennis and similar activities. It is analogous in a way to the shoulder girdle, where

calcaneus

plantar fascia site of plantar fasciitis injection into this area

Fig. 3.31  Injection approach in plantar fascitis

47

48

Practice Tips

supraspinatus tendonopathy and subacromial bursitis are common wear-and-tear injuries. The two presumed common causes are tendonopathy of the gluteus medius tendon, where it inserts into the lateral surface of the greater trochanter of the femur, and bursitis of one or both of the trochanteric bursae. Distinction between these two conditions is difficult, and it is possible that, as with the shoulder, both are related. The pain of bursitis tends to occur at night; that of tendonopathy occurs with such activity as long walks and gardening. Treatment method Treatment for both is similar. 1. Determine the points of maximal tenderness over the trochanteric region and mark them. (For tendonopathy, this point is immediately above the superior aspect of the greater trochanter; see Fig. 3.32.) 2. Inject aliquots of a mixture of 1 mL of long-acting corticosteroid with 8–9 mL of LA into the tender area, which usually occupies an area similar to that of a standard marble. The injection is invariably very effective. Follow-up management includes sleeping with a small pillow under the involved buttock, and stretching the gluteal muscles with knee–chest exercises. One or two repeat

gluteus medius tendonopathy

trochanteric bursitis

Fig. 3.32  Injection technique for gluteus medius tendonopathy (into area of maximal tenderness)

injections over 6 or 12 months may be required. Surgical intervention may be necessary for a severe persistent problem. Extra tips to alleviate • Local application of cold pack if acute. • Perform straight-leg stretching in dependent adduction (see Fig. 11.63, p. 175). • Develop a ‘Charlie Chaplin’ gait—legs in external rotation for walking. • Massage lateral thigh for 2 to 5 minutes daily using a glass or plastic (preferably grooved) bottle, full of water, as a rolling pin.

Injection of the carpal tunnel An injection of long-acting corticosteroid into the carpal tunnel may relieve symptoms permanently or, more commonly, temporarily. It may therefore be useful as a diagnostic test and also to provide symptomatic relief while awaiting surgery. Note: The injections may be repeated. Do not use local anaesthetic in the injection. Method 1. The patient sits by the side of the doctor with the hand palm upward, the wrist slightly extended (acrepe bandage under the wrist helps this extension). 2. Identify the palmaris longus tendon, which lies above the median nerve (best done by flexing the wrist against resistance or opposing the thumb with the little finger) and the ulnar artery. 3. Insert the needle (23-gauge) at a point about 2 cm proximal to the main transverse crease of the wrist and midway between the palmaris longus tendon andthe flexor carpi ulnaris or the ulnar artery (Fig. 3.33). Take care to avoid the superficial veins. 4. Advance the needle distally, parallel to the tendons and nerve at about 25° to the horizontal. It should pass under the transverse carpal ligament (flexorretinaculum) and come to lie in the carpal tunnel. Note: The needle can be slightly bent to facilitate entry. 5. Inject 1 mL of corticosteroid.This is usually painless and runs freely. Place the free thumb proximal to the needle and apply pressure to facilitate flow of fluid distally. Ensure that the patient feels no severe pain or paraesthesia during the injection. If so, immediately withdraw the needle. The medial nerve lies below and between the palmaris longus and the flexor carpi radialis tendons. 6. Withdraw the needle and ask the patient to flex and extend the fingers for 2 minutes. Remind the patient that there may be pain for up to 48 hours and to rest the arm for 24 hours.

Chapter 3 | Injection techniques

posterior tibial nerve

(a)

flexor hallicus longus flexor digitorum longus Achilles tendon flexor retinaculum

transverse crease of wrist median nerve palmaris longus

2.5 cm ulnar artery

Fig. 3.34  Sites of injection for tarsal tunnel syndrome (above or below the flexor retinaculum that roofs the ‘tunnel’). This medial view of the right foot shows the relationship of the posterior tibial nerve to the tendons.

needle introduced into carpal tunnel

(b)

needle position ulnar artery and nerve

which is uncommon, is due to dislocation or fracture around the ankle or tenosynovitis of tendons in the tunnel from injury, rheumatoid arthritis and other inflammations.

PL transverse carpal ligament median nerve tendons

Medial

FCU

FCR

Lateral

Fig. 3.33 Needle introduced into carpal tunnel: (a) anterior view; (b) section

Injection near the carpal tunnel A study reported in the BMJ (1999, 319, pp. 884–6) recommended giving a single injection of corticosteroid, e.g. 40 mg methylprednisolone with lignocaine 1%, close to but not into the tunnel (to avoid potential damage to the median nerve). The results were considered to be as good as giving it into the tunnel.

Injection of the tarsal tunnel Tarsal tunnel syndrome is caused by an entrapment neuropathy of the posterior tibial nerve in the tarsal tunnel beneath the flexor retinaculum on the medialside of the ankle (Fig. 3.34). The condition,

Symptoms and signs • A burning or tingling pain in the toes and sole of the foot, occasionally the heel. • Retrograde radiation to the calf. • Discomfort often in bed at night and worse after standing. • Removal of the shoe may give relief. • Sensory nerve loss is variable (may be no loss). • The Tinel test (finger or reflex hammer tap over the nerve below and behind the medial malleolus) may be positive. • A tourniquet applied above the ankle may reproduce symptoms. The diagnosis is confirmed by electrodiagnosis. Treatment • Relief of abnormal foot posture with orthotics. • Corticosteroid injection. • Decompression surgery if other measures fail. Injection method Using a 23-gauge 32 mm needle, inject a mixture of corticosteroid in 1% xylocaine or procaine into the tunnel either from above or below the flexor retinaculum. The sites of injection are shown in Figure 3.34. Be careful not to inject the nerve.

49

50

Practice Tips

Injection for Achilles paratendonopathy Management Inflammation of and around the tendon can be a resistant problem, and conservative measures such as rest, a heel raise and NSAIDs should be adopted. As a rule, injections around the Achilles tendon should be avoided but for resistant painful problems an injection of corticosteroid can be helpful. The inflammation must be localised, such as a tender 2 cm area. Avoid giving the corticosteroid injection in the acute stages and never lodge it in the tendon. Method 1. Mark the area of paratendonopathy, which usually lies immediately anterior and deep to the tendon just above the calcaneus. 2. Infiltrate this tender area adjacent to the tendon with 1 mL of plain local anaesthetic (e.g. 1% lignocaine) and 1 mL of long-acting corticosteroid (Fig. 3.35). The solution should run freely, and care should be taken to avoid the tendon.

Achilles tendon

site of maximal tenderness

Fig. 3.35 Usual approach for the injection of Achilles paratendonopathy

Injection for tibialis posterior tendonopathy This is a common and under-diagnosed condition in people presenting with foot and ankle pain, especially on the medial side. It is usually found in middle-aged females, in ballet dancers, and in those with flat feet with a valgus deformity. Pain is reproduced on: • palpation anterior and inferior to the medial malleolus • stretching by passive inversion of the foot • resisted inversion of the foot. Tibialis posterior tendonopathy can cause the tarsal tunnel syndrome. The diagnosis can be confirmed by ultrasound imaging.

Preferred treatment • Conservative with inversion/eversion exercises • Orthotics Method of injection Reserved for painful recalcitrant cases. 1. Mark the tender area of the tendon. 2. Use a lower-gauge needle with a syringe containing 0.5–1 mL LA corticosteroid with 0.5–1 mL local anaesthetic. 3. Approach the tendon at a very shallow angle, either proximally or distally, and inject into the sheath, taking care to avoid injecting the tendon (Fig. 3.36). Note: The tibialis posterior tendon is prone to rupture.

tibialis posterior tendon tibialis anterior tendon

Fig. 3.36  Method of injecting the tendon sheath of tibialis posterior

Injection or aspiration of joints Intra-articular injections of corticosteroids can be very therapeutic for some acute inflammatory conditions, particularly severe synovitis caused by rheumatoid arthritis (especially monarticular rheumatoid arthritis). The common indication for the glenohumeral joint of the shoulder is adhesive capsulitis, although hydrodilatation under imaging is the preferred method. This use is limited in osteoarthritis but can be very effective for a particularly severe flare-up of osteoarthritis such as in the knee or the acromioclavicular joint. (Corticosteroids can cause degeneration of articular cartilage and hence restricted usage is important.) Strict asepsis is essential, using disposable equipment.

Acromioclavicular joint Method 1. The patient sits with the arm hanging loosely by the side and externally rotated. The joint space is palpable just distal (lateral) to the bony enlargement of the clavicle. It is about 2 cm medial to the lateral edge of the acromion. 2. Palpate the ‘gap’ for maximal tenderness. 3. Insert a 25-gauge needle, which should be angled according to the different surfaces encountered

Chapter 3 | Injection techniques

acromioclavicular joint clavicle

coracoid process

injection approach for the glenohumeral joint

Fig. 3.37 Approaches for injections into the acromioclavicular joint and the glenohumeral joint of the shoulder

(Fig.3.37). It may be helpful to ‘walk’ the needle along the acromion to get the feel of the joint. It should reach a depth of about 0.5–1 cm when it is certainly intra-articular. 4. Inject a mixture of 0.25–0.5 mL of corticosteroid with 0.25–0.5 mL of 1% lignocaine.

Shoulder (glenohumeral) joint Method 1: Anterior approach 1. The patient sits in the same position as for the acromioclavicular joint injection. 2. Use an anterior approach and insert a 21- to 23-gauge needle just medial to the head of the humerus. Feel for the space between the head of the humerus and the glenoid cap. (If in doubt, feel for it by rotating the humerus externally or alternating external and internal rotation.) 3. This insertion should also be 1 cm below and just lateral to the coracoid process (Fig. 3.37). Then aim the needle posteriorly towards the glenoid fossa. 4. Inject a mixture of 1 mL of corticosteroid and 1 mL of 1% lignocaine. Method 2: Posterior approach This uses the same approach as for the posterior injection into the subacromial space, that is, into the ‘soft spot’ 2 cm inferior to and 1 cm medial to the edge of the acromion. Aim the needle to the tip of the coronoid process and inject when the joint space is reached.

Elbow joint Intra-articular injections may alleviate synovitis, either arthritic or post-traumatic. The objective is to inject the solution into the middle of the joint by identifying the soft entry point near the

Fig. 3.38  Illustration of injection into the centre of triangular space of the elbow joint

middle of the isosceles triangle formed by the lateral epicondyle, the radial head and the tip of the olecranon (Fig. 3.38). Method 1. The patient sits with the elbow flexed to 70–90° and the wrist pronated. 2. Mark the three key points of the triangle and palpate the soft entry point. 3. Using a posterolateral approach, insert a 23-gauge needle with 1 mL of steroid and 2 mL of local anaesthetic into the space. 4. The needle should easily enter the joint. Aim for the middle of the joint and to a depth of about 2 cm. Aslight readjustment of the needle may be necessary.

Wrist joint Method Inject on the dorsal surface in the space just distal to the ulnar head at its midpoint. 1. Palpate the space between the ulnar head and the lunate. 2. Insert the needle at right angles to the skin between the extensor tendons of the fourth and fifth fingers. 3. Insert to a depth of about 1 cm. 4. Inject 0.5 mL of corticosteroid and 0.5 mL of 1% lignocaine.

First carpometacarpal joint of thumb Method 1. Palpate the proximal margin of the first metacarpal in the anatomical snuffbox. 2. Insert the needle to a depth of about 1 cm between the long extensor and long abductor tendons into the joint space. 3. Inject 0.5 mL of corticosteroid.

Finger joint The technique for injections of the metacarpophalangeal and interphalangeal joints is similar.

51

52

Practice Tips

Method It is important to have an assistant for this injection. 1. The joint is flexed to an angle of 30°, and this position is maintained by the assistant who simultaneously applies longitudinal traction to ‘gap’ the dorsal aspect of the joint. 2. Insert the needle, which is kept at right angles to the base of the more distal phalanx, from the dorsal aspect in the midline. 3. Direct the needle through the tendon of extensor digitorum just distal to the head of the more proximal bone (phalanx or metacarpal) to a depth of 3–5 mm (Fig. 3.39).

joint capsule extensor tendon

Fig. 3.40  Injection approach for the hip joint

Fig. 3.39  Injection of the proximal interphalangeal joint

Hip joint Method 1. The patient lies supine with the hip in extension and internal rotation. 2. Use an anterior approach, with the insertion point being 2.5 cm below the inguinal ligament and 2 cm lateral to the femoral artery. 3. Use a 20-gauge 6–7 cm needle and insert it at about 60° to the skin. 4. Introduce the needle downwards and medially until bone is reached (Fig. 3.40). 5. Withdraw it slightly and inject the mixture of 1 mL of corticosteroid and 2 mL of 1% lignocaine.

2. A 21-gauge needle can be inserted either medially (preferably) or laterally. 3. Insert the needle in the triangular space bounded by the femoral condyle, the tibial condyle and the patellar ligament (Fig. 3.41). 4. Direct the needle inwards and slightly posteriorly in a plane pointing slightly upwards to the horizontal (to avoid the infrapatellar fat pad).

ligamentum patella

femoral condyle

tibial plateau

Knee joint Injections can be given into one of four ‘safe’ zones at the four corners of the patella. Method for infrapatellar route (inferior safe zone) 1. The patient flexes the knee to a right angle. (The patient can sit on the couch with the leg over the side.) Alternatively, the knee can be extended with the quadriceps relaxed.

Fig. 3.41  Injection of the knee joint (note the needle angled into the triangular space)

Chapter 3 | Injection techniques

2. Palpate the joint line anterior to the tragus of theear.This is confirmed by opening and closing the jaw. 3. Insert a 25-gauge needle into the depression above the condyle of the mandible, below the zygomatic arch and one finger breadth (2 cm) anterior to the tragus. 4. Direct the needle inwards and slightly upwards so that it is free within the joint cavity (Fig. 3.42). 5. Inject the 1 mL solution containing 0.5 mL of local anaesthetic and 0.5 mL of corticosteroid, which should flow freely.

Fig. 3.42  Injection of the temporomandibular joint

5. Inject 1 mL of LA corticosteroid (an anaesthetic agent isn’t necessary).

Temporomandibular joint This injection is useful in the treatment of painful rheumatoid arthritis, osteoarthritis or temporomandibular joint dysfunction that is not responding to conservative measures. Method 1. The patient sits on a chair, facing away from the doctor. The mouth is opened to at least 4 cm.

Acute gout in the great toe Injection technique Acute gouty arthritis invariably presents with exquisite pain in the great toe and the diagnosis and relief of pain is a special challenge to the general practitioner. An effective and caring, albeit invasive, treatment is as follows: • Perform a modified digital block using 1% plain local anaesthetic to the affected toe. • When anaesthesia has been obtained, use a 19-gauge needle to aspirate fluid from the joint or the periarticular region.

1. aspiration for microscopic diagnosis 2. infiltration of cortiscosteroid

gouty arthritis of metatarsophalangeal joint

nerve blocks to toe

Fig. 3.43  Management of acute gout of the great toe, illustrating nerve blocks and joint injection

53

54

Practice Tips

• Examine the fluid under polarised light microscopy. The presence of long, needle-shaped urate crystalis is diagnostic. • If sepsis is eliminated, inject corticosteroids, e.g. 0.5–1.0 mL of triamcinolone, into the joint (Fig. 3.43).

Drug treatment Two NSAIDs options are usually employed, one a heavier dosage than the other. Indomethacin is the preferred one but others can be used. Conventional method Indomethacin 50 mg (o) 8 hourly for 24 hours, then 25mg (o) 6 hourly until resolution. ‘Shock’ method Indomethacin 100 mg (o) statim, 75 mg 2 hours later,then 50 mg (o) 8 hourly (relief is usual within 48 hours)

plus Metoclopramide (Maxolon) 10 mg (o) 8 hourly (or other anti-emetic). Other corticosteroids • Prednisolone 40 mg/day for 3 to 5 days then taper by 5 mg over 10 days or Corticotrophin (ACTH) IM • Colchicine Consider if NSAIDs are not tolerated. 0.5–1.0 mg statim, then 0.5 mg every 2 hours until pain disappears or GIT side effects develop.

Chapter 4

Skin repair and minor plastic surgery PRINCIPLES OF REPAIR OF EXCISIONAL WOUNDS It is important to keep the following in mind: 1. Plan all excisions carefully. 2. Check previous scars for healing properties. 3. Aim to keep incision lines parallel to natural skin lines. 4. Take care in poor healing areas, such as backs, calves and knees; and in areas prone to hypertrophic scarring, such as over the sternum of the chest, and the shoulder. 5. Use atraumatic tissue-handling techniques. 6. Practise minimal handling of wound edges. 7. Use Steri-strips after the sutures are removed.

• warfarin—3 days • aspirin—10 days • NSAIDs—2 to 5 days (check half life).

Suture material (Table 4.1) • Monofilament nylon sutures are generally preferred for skin repair. • Use the smallest calibre compatible with required strains. • The synthetic, absorbable polyglycolic acid or polyglactin sutures (Dexon, Vicryl) are stronger than catgut of the same gauge, but do not use these (use catgut instead) on the face or subcuticularly.

Standard precautions Mandatory safety measures • Goggles • Gloves • Protective gown

Table 4.1  Selection of suture material (guidelines) Skin

nylon 6/0

face, eyelids

nylon 5/0

elsewhere

nylon 4/0

hands, forearms

nylon 3/0

back, scalp

nylon 2/0

knees

Deeper tissue

catgut 4/0

face

(dead space)

Dexon/Vicryl 3/0 or 4/0

elsewhere

Subcuticular

catgut 4/0

Small-vessel ties

plain catgut 4/0

Large-vessel ties

chromic catgut 4/0

Common mistakes for excisional surgery • • • • • • •

Skimping (inadequate margins) Tension on skin edges Knots too strongly tied Stitches too thick Too large a bite Stitches in too long Inadequate early compression

Minimising bleeding in the elderly Stop anticoagulants (if possible) before a significant procedure. Examples:

56

Practice Tips

Instruments Examples of good-quality instruments: • locking needle holder (e.g. Crile-Wood 12 cm) • skin hooks • iris scissors. Holding the needle The needle should be held in its middle because this will help to avoid breakage and distortion, which tends to occur if the needle is held near its end (Fig. 4.1a). Incisions Incisions should be made perpendicular to the skin (not angled) (Fig. 4.1b).

Everted wounds Eversion is achieved by making the ‘bite’ in the dermis wider than the bite in the epidermis (skin surface) and making the suture deeper than it is wide. Shown is: • a simple suture (Fig. 4.3a) • a vertical mattress suture (Fig. 4.3b). The mattress suture is the ideal way to evert a wound. Number of sutures Aim to use a minimum number of sutures to achieve closure without gaps, but sufficient sutures to avoid tension. Place the sutures as close to the wound edge as possible. (a)

Dead space Dead space should be eliminated, to reduce tension on skin sutures. Use buried absorbable sutures to approximate underlying tissue. This is done by starting suture insertion from the fat to pick up the fat/dermis interface so as to bury the knot (Fig. 4.2). (a)

(b)

(b) epidermis Fig. 4.3 Everted wounds: (a) correct and incorrect methods of making a simple suture; (b) making a vertical mattress

dermis subcutaneous fat

Knot tying

Fig. 4.1 Correct and incorrect methods of (a) holding the needle; (b) making incisions

Special techniques of knot tying are necessary to achieve a secure knot. Insecure knots leading to slippage of a tie may result in catastrophic blood loss or at least revisiting the surgery. The ability to tie a secure knot should be a reflex action based on practice for the proceduralist. The friction between threads of the suture material is also a factor in avoiding slippage of the knot. The monofilament braided synthetics, particularly nylon and polyesters, are more supple and easier to handle so that knots are easier to tie securely.

Reef knot buried knot introduce needle here

Fig. 4.2 Eliminating dead space

The traditional secure knot is the reef knot, which is a firm interlocking knot. It is also referred to as the ‘square knot’. In this knot, one thread is looped around the other and the knot is completed by a mirror image of

Chapter 4 | Skin repair and minor plastic surgery

the first throw. The two free ends of one suture emerge from either above or below the loop created by the other suture (Fig. 4.4).

(a)

(a) both below

both above

(b)

(b)

Fig. 4.4 Two views of typing a reef knot (a) and (b) Fig. 4.6 Two views of tying a surgeon's knot (a) and (b)

Granny knot A granny knot is formed when the reverse of this mirror image throw is formed. The free ends emerge one above and one below each loop (Fig. 4.5). It is best to avoid this knot in surgical practice. below

above

above

below

Fig. 4.5 The granny knot

The surgeon’s knot This involves the same pattern as the reef knot, except that there are two throws on each side of the knot instead of one (Fig. 4.6). The ends of the thread should be pulled at 180º to each other.

The instrument knot The instrument knot, which is the most common knot, uses the principle of the reef knot. Initially, the thread is

wound twice around the needle holder (say in a clockwise direction) to create the double loop of a surgeon’s knot and then firmly tied (Fig. 4.7a). On the reverse side, the thread is wound around the needle holder in the opposite direction (an anti-clockwise spiral), thus creating the double loop of a surgeon’s knot.The knot is finally secured by pulling the ends at 180º to each other (Fig. 4.7b).

Ligatures on vessels Every precaution must be undertaken to avoid the ligature slipping. The first tie should be very tight, and the second slacker than the first. For deep ties on vessels it is best to tie with the hands and keep the ties parallel to the wound. Do not pull upwards on the tie. Leave an adequate cuff of tissue past the tie (see Fig. 4.27).

Holding the scalpel The two common methods of holding a scalpel are: • the pen grip, and • the underhand grip. The pen grip, which is the one most commonly used in minor surgery, is used for fine incisions or excisions and for dissection with the scalpel. Most of the movement imparted to the blade comes from the hand and fingers (Fig. 4.8). The underhand or table-knife grip (Fig. 4.9) is traditionally used for long incisions, such as in abdominal surgery. A larger handle and blade are used.

57

58

Practice Tips

(a)

Safe insertion and removal of scalpel blades While many part-time surgeons prefer the use of disposable scalpels, it is appropriate to use firm twopiece metal scalpel holders and blades. For safe handling it is important to become deft at using forceps to insert scalpel blades onto the scalpel handle (Fig. 4.10), and also to remove the blade. In the latter the thumb can be used to facilitate unloading by steadily pressing against the forceps (haemostat clamp) in an extension movement (Fig. 4.11). Another blade unloading method is to grasp the blade with the forceps and rotate the forceps to lift the end of the blade, which is then pushed off the handle.

(b)

Fig. 4.7 Two steps in tying an instrument knot (a) and (b) Fig. 4.10  Loading the blade onto the scalpel holder

Fig. 4.8 The pen grip

Fig. 4.9 The underhand grip

Fig. 4.11 Unloading the scalpel blade

Chapter 4 | Skin repair and minor plastic surgery

Debridement and dermabrasion for wound debris

The suturing shouldnot be too tight nor too widely spaced (Fig. 4.12b).

If grit and other foreign material such as oil is left in the wound, an unacceptable tattoo effect will occur in the healed wound. This can be avoided by meticulous exploration of the wound to remove debris and dermabrasion for superficial grit (see p. 73).

Blanket stitch

Continuous sutures Continuous subcuticular (intradermal) suture

The pulley suture

This is ideal for the repair of episiotomy wounds with catgut after the dead space has been closed. It does have a limited place in skin repair where monofilament nylon material is best, especially for removal of the suture. Supplementary interrupted skin sutures may be necessary for accurate skin-edge apposition. Method This suture picks up dermis only (picking up the epidermis and fat is not acceptable), and should be inserted uniformly at the same level without gaps in the linear direction (Fig. 4.12a).

The blanket or ‘running lock’ stitch does not tend to bunch the wound up. A double turn at each stitch converts it into a locked suture (Fig. 4.12c).

The pulley suture, also called the ‘near–far, far–near’ suture, is a very useful technique for the closure of difficult wounds, especially those on the lower leg. It permits approximation of the wound when an extra 2–3 mm of space needs closing and the normal method falls short of adequate closure.

This is a useful time saver, especially where a meticulous cosmetic result is not required. One disadvantageisthetendency to bunch the wound up.

Method 1. Introduce the needle 3–4 mm from the edge of the wound. 2. Let the needle emerge about 8–10 mm from the wound edge on the opposite side. 3. Reintroduce the needle at 8–10 mm on the original side. 4. Finally, let the needle emerge at 3–4 mm on the opposite side (Fig. 4.12d). After the suture is in place, normal interrupted sutures can close the wound. However, the pulley suture may create too much tension and, if it does, it should be removed and replaced with a simple suture.

(a)

(b)

‘Over-and-over’ suture

continuous subcuticular suture

(c)

(d)

} pulley suture 2

4

1

the pulley suture

3

the final view of wound from above

Fig. 4.12  (a) Subcuticular suture; (b) ‘over-and-over’ suture; (c) blanket stitch; (d) pulley suture. (A), (B) and (C) Reproduced from I. Mcgregor, Fundamental Techniques of Plastic Surgery, Churchill Livingstone, Edinburgh, 1989, with permission

59

60

Practice Tips

The cross-stitch The cross-stitch, which is a type of pulley suture, is an excellent method for closing difficult wounds where there is likely to be some tension across the wound. The cross-stitch is ideal for small circular wounds left after a 3–5 mm punch biopsy. It will shorten the scar and avoid the placement of two sutures. It gives a neater result than the vertical mattress or the horizontal mattress. Circular wounds up to 10 mm in diameter in areas of thicker skin can be closed with one such figure-of-eight suture. Method Consider a punch biopsy wound of 5 mm in diameter. Using a 5/0 or 6/0 nylon atraumatic suture insert the needle from right of centre across the wound to left of centre, then from left of centre to right of centre on the next pass (or the other way, i.e. from left to right and back). Thus four strands cross the wound and when tied create a pulley effect (Fig. 4.13). Fig. 4.14 Recommended lines for excisions on the face Adapted from J.S. Brown, Minor Surgery, a Text and Atlas, Chapman and Hall, London, 1986

Elliptical excisions final view

Fig. 4.13 The cross-stitch: a type of pulley suture

Planning excisions on the face It is important to select optimal sites for elliptical excisions of tumours of the face. As a rule, it is best for incisions to follow wrinkle lines and the direction of hair follicles in the beard area. Therefore, follow the natural wrinkles in the glabella area, the ‘crows feet’ around the eye, and the nasolabial folds (Fig. 4.14). To determine non-obvious wrinkles, gently compress the relaxed skin in different directions to demonstrate the lines. For tumours of the forehead, make horizontal incisions, although vertical incisions may be used for large tumours of the forehead. Ensure that you keep your incisions in the temporal area quite superficial, as the frontal branch of the facial nerve is easily cut.

Small lesions are best excised as an ellipse. Generally, the long axis of the ellipse should be along the skin tension lines identified by natural wrinkles. The intended ellipse should be drawn on the skin (Fig.4.15). The placement will depend on such factors as the size and shape of the lesion, the margin required (usually 2–3 mm) and the skin tension lines.

Excision margin rules • 1–2 mm: moles and benign lesions • 3–4 mm: BCCs • 4–10 mm: SCCs

3x

x

lesion

excision line

Fig. 4.15 Elliptical excision

Chapter 4 | Skin repair and minor plastic surgery

General points • The length of the ellipse should be 3 times the width (usually for head and neck). • This length should be increased (say, to 4 times) in areas with little subcutaneous tissue (dorsum of hand) and high skin tension (upper back). • Incisions should meet, rather than overlap, at the ends of the ellipse. • A good rule is to obtain an angle at the end of 30° or less. • These rules should achieve closure without ‘dog ears’.

Prevention and removal of ‘dog ears’

(a)

fish-tail cuts

final appearance of wound

(b)

‘Dog ears’ are best avoided by using a long axis (at least 3 to 1) for an elliptical excision.

The fish-tail cut However, if this axis turns out too short after excision, performing a fish-tail cut (Fig. 4.16a) will avoid the necessity of later correction.

Correction of ‘dog ear’ If a ‘dog ear’ results in the suture line after elliptical defect closure, it can be dealt with by limited further excision and closure.

(1)

(2)

Fig. 4.16  Prevention of  ‘dog ears’: (a) the fish-tail cut; (b) correction of defect 4.16b Reproduced from I. Mcgregor, Fundamental Techniques of Plastic Surgery, Churchill Livingstone, Edinburgh, 1989, with permission.

Method 1. Place a hook in the end of the wound, which is elevated; this defines the extent of the ‘dog ear’ (Fig. 4.16b). 2. Incise the skin around the base (1). 3. Stretch the resultant flap across the wound so that excess skin is defined and removed (2). 4. Complete the suturing of the wound, which will have a slight curve (3).

The three-point suture In wounds with a triangular flap component, it is often difficult to place the apex of the flap accurately. The three-point suture is the best way to achieve this while minimising the chance of strangulation necrosis at the tip of the flap. Method 1. Pass the needle through the skin of the non-flap side of the wound. 2. Pass it then through the subcuticular layer of the flap tip at exactly the same level as the reception side. 3. Finally, pass the needle back through the reception side so that it emerges well back from the V flap (Fig. 4.17).

(3)

Fig. 4.17 The three-point suture

61

62

Practice Tips

Inverted mattress suture for perineal skin This method of repair of the perineum is suitable either for an episiotomy or a simple tear, and uses a technique of inverted vertical mattress sutures. It is a simple method that provides a sound and comfortable repair. Because it is an interrupted suture wound, drainage is not sacrificed for the sake of comfort. Method 1. Suture the vaginal tissue with a normal, continuous absorbable suture tied subcutaneously. 2. If the wound is very deep, a second internal layer of sutures should be inserted initially. 3. Close the perineal skin with the inverted mattress sutures (Fig. 4.18) using an absorbable suture. It is preferable to commence anteriorly, as this provides accurate opposition of the skin edges.

Triangular flap wounds on the lower leg Triangular flap wounds below the knee are a common injury and are often treated incorrectly. Similar wounds in the upper limb heal rapidly when sutured properly, but lower limb injury usually will not heal by first intention unless the apex of the flap is excised and a small donor graft implanted. Also think twice about suturing a pretibial laceration in an elderly person.

Proximally based flap A fall through a gap in flooring boards will produce a proximally based flap; a heavy object (such as the tailboard of a trailer) striking the shin will result in a distally based flap. Usually the apex of the flap is crushed and poorly vascularised; it will not survive to heal after suture.

Fig. 4.18 Inverted mattress suture

Treatment method 1. Infiltrate a wide area around the wound with LA. 2. Excise the apex of the skin flap back to healthy tissue. 3. Loosely suture the angles at the base of the flap. 4. With a no. 24 scalpel, shave a small, split-thickness graft from the anaesthetised area proximal to the wound; place it on the raw area (Fig. 4.19). 5. Cover both the wound and donor site with petroleum jelly gauze, a non-stick dressing and a combine pad; strap firmly with a crêpe bandage. The patient should rest with the leg elevated for 3 days. Re-dress the wound on the fourth day. donor site (within anaesthetised area)

excised apex of skin flap and graft site

Fig. 4.19 Triangular flap wound suture

Chapter 4 | Skin repair and minor plastic surgery

Alternative (preferred) method It may be possible to save the distal avascular flap, especially in younger patients, by scraping away the subcutaneous tissue on the flap and using it as a full-thickness graft.

Distally based flap This flap, which is quite avascular, has a poorer prognosis. The same methods as for the proximally based flap can be used (Fig. 4.20).

vulnerable distal flap

elliptical wound creates tension at the centre. A split skin graft or Wolfe graft will solve the problem but all too often leaves a depressed, unsightly scar. A rotation flap will cover the deficiency nicely but requires the undermining of a large area of skin and time-consuming suturing.

Double Y on V advancement flap method Tumours up to 2.5 cm in diameter can be excised and the deficiency repaired without tension by means of a double advancement flap fashioned from the ‘wings’ of the ellipse after the lesion has been excised. As the viability of the flaps relies on a blood supply from the subcutaneous tissue, do not undermine the flaps. Incise the skin and subcutaneous tissue vertically to the fascia. The elasticity of the subcutaneous tissues will permit the flaps to be advanced to the midline to be united by sutures (Fig. 4.21).

Alternative flap technique Fig. 4.20 Triangular flap wound repair: distally based flap

Excision of skin tumours with sliding flaps General practitioners, in both city and country, not uncommonly excise small skin tumours under local anaesthesia using an elliptical incision. Where the skin is tight, as on the trunk or thigh, suture of an

More flexibility of the flaps can be obtained by undermining the flaps above and below the incision lines (Fig. 4.22). Viability of the flaps is not a problem.

The Y on V (or Island) advancement flap This flap, which maintains a good blood supply, is ideal to close the end of an amputated finger tip in a child, or to use as an excision procedure on the face in the area of the nasolabial fold and lip where it conforms to skin creases.

(b) (a) skin lesion

(c) planned flaps (marked with fine marking pen)

Fig. 4.21 Methods of excising skin tumour: (a) planned flaps marked; (b) triangular flaps advanced to midline; (c) flaps sutured to repair defect

Fig. 4.22 Undermining of subcutaneous tissue (alternative variation)

63

64

Practice Tips

Method 1. Mark the excision lines carefully before excising (Fig.4.23a). 2. Excise the lesion as a square or rectangle. 3. Fashion the flap as a triangle about 2 to 2½ times the length of the defect. Carefully free the flap so that the skin remains on its subcutaneous tissue pedicle. This flap is referred to as an ‘island’. 4. Using skin hooks, advance the base of the flap to the far edge of the defect with the help of blunt dissection and avoiding excessive tension (Fig. 4.23b). 5. Use three-point sutures at the two edges and at the apex. 6. Suture the sides of the wound (Fig. 4.23c). Thus the V ‘island’ is converted to a Y-shaped scar.

Method 1. Excise the tumour with a square excision. 2. Extend the excision lines to about 1½ times the length of the defect (Fig. 4.24a). 3. Excise the skin and subcutaneous tissue with care vertically to the fascia. 4. Dissect the skin flaps from the subcutaneous tissue and advance them towards each other (preferably with skin hooks) to meet in the middle (Fig. 4.24b). 5. Use three-point sutures to anchor the corners of the flaps and then suture the wound as shown in Figure4.24c.

H double advancement flap

Before excising a small tumour, such as a dermatofibroma, skin tag or similar benign tumour, a primary suture can be inserted. The advantages include better initial haemostasis and ability to operate singlehandedly.

Like the double Y on V flap this is suitable for areas with a good pad of subcutaneous tissue (e.g. re-excision of a melanoma on the arm). It is useful in places such as the forehead where the scars conform to skin creases. It is used where skin closure is impossible for a large ellipse. It can be tested, aborted or grafted. (a)

Primary suture before excision of a small tumour

Method 1. Infiltrate around the lesion with local anaesthetic. 2. Insert an appropriate suture (you may choose to insert more than one) to straddle the tumour (Fig. 4.25). 3. Excise the tumour. (Take care not to cut the suture.) 4. Secure the suture. 5. Add more sutures if necessary.

(a) (b)

(b)

(c) (c)

Fig. 4.23 The single Y on V method: (a) planned flaps marked; (b) ‘Island’ flap advanced to midline; (c) flaps sutured to repair defect

Fig. 4.24 The H double advancement flap: (a) excision of tumour with planned flaps; (b) pulling the flaps together; (c) flaps sutured to repair defect

Chapter 4 | Skin repair and minor plastic surgery

excision line tumour

a properly placed ligature. A ligature applied too close to the cut end may subsequently slip and cause unexpected bleeding (Fig. 4.27).

suture insertion

correct

Fig. 4.25 Insertion of primary suture before excision of small tumour

Multiple ragged lacerations Lacerations in a cosmetically important place, such as the face, that have ragged edges or multiple components should be trimmed and/or excised (Fig. 4.26). This will provide vertical edges and an organised wound, which can then be sutured meticulously. For the face, use 6/0 nylon. Sacrifice of small amounts of facial skin is justified in the interest of a linear and less obvious scar. Sometimes Z-plasty is required. ragged lacerations

incorrect

Fig. 4.27 Method of ligating a vessel to avoid slippage of the tie

The transposition flap In the transposition flap, the flap moves sideways into the primary defect. The flap has a donor site that usually runs radial to the defect. The flap crosses over intervening normal skin to slot into the defect. The point at the base of the flap opposite the defect does not move, and this is the pivot point that is marked with an asterisk in Figure 4.28. The distance from the pivot point to the top of the flap should be the same as the distance from the pivot point to the far side of the defect. The donor site is closed directly. The transposition flap has widespread use, especially on the face and scalp. flap

final appearance planned elliptical excision

Fig. 4.26 Example of managing a group of multiple lacerations

Avoiding skin tears Avoid using adhesive tapes on friable skin or dehydrated skin. Instead, use a cohesive bandage such as Easifix or Tubigrip. When a flap moves laterally into the primary defect it is called a transposition flap, and when rotated into the defect it is called a rotation flap. With these flaps, be careful to avoid a vascular disaster.

Vessel ligation It is imperative to pay close attention to safe ligation of any bleeding vessels in the wound by clamping and using

defect pivot point

Fig. 4.28 The transposition flap Adapted from A. Pennington, Local Flap Reconstruction, McGraw-Hill, with permission.

The rotation flap The local rotation flap is a most useful procedure in general practice for the excision of skin lesions such as basal cell carcinomas (BCCs). The excision is semicircular and the pivot point is at the end of the releasing incision.The larger the flap, the more skin becomes available. This method is favoured for the excision of BCCs greater than 12 to 20 mm and other tumours, especially on shoulders and backs.

65

66

Practice Tips

Method 1. Excise the tumour using a triangular excision, which, ideally, should be equilateral. Extend the excision beyond subcutaneous fat to the deep fascia-covering muscle (Fig. 4.29a). 2. Extend the excision in a curve to a length about 3 times that of the length of a side of the original triangular excision. (a)

pivot point

A extended excision skin tumour

B

C

(b)

D

A

flap undercut to this line defect

B C

(c)

D

A

B C

Fig. 4.29 Rotation flap: (a) triangular area of excision with extended excision; (b) resultant skin defect; (c) appearance after suturing

3. Now undercut the skin flap to the line AD (Fig. 4.29b). 4. Rotate this flap so that AC corresponds to AB without excessive tension. 5. Use simple sutures to close the wound (Fig. 4.29c). Note: Blood is supplied to the skin on the back by the lateral cutaneous branch of each posterior intercostal artery and hence follows the line of the ribs. Make sure that the extended incision allows a blood supply to the flap—that is, that AD faces medially and not laterally.

The rhomboid (Limberg) flap The rhomboid flap is very useful for repairing defects that are difficult to suture directly or where the tension is in the wrong direction. It is most useful for removing lesions on the forehead, temple and scalp. Method 1. Draw out the rhomboid and the relief extensions, making sure that the angles, lengths and directions are correct. The short diagonal of the rhomboid equals the length of the sides, giving the appearance of two equilateral triangles placed side by side. The direction of the relief extensions (theoretically four options) depends on the availability of skin. 2. Extend the diagonal for an equal distance in the desired direction and then draw a back line parallel to one of the sides of the rhomboid (Fig. 4.30a). 3. Remove the lesion and free the flaps by back-cutting. 4. Ensure that the ‘x’ lengths are equal. 5. Rotate the flap so that A moves to A1, B to B1 and C to B. This should fill the defect perfectly (Fig. 4.30b). 6. Care is required in suturing the corners—especially A and B, where subcutaneous three-point sutures are appropriate (Fig. 4.30c). 7. The resultant tension from the example illustrated is transverse (¬®). This contrasts with longitudinal tension if sutured directly.

The ‘crown’ excision for facial skin lesions When the standard elliptical skin excision is unworkable or inappropriate, a crown-shaped excision provides an excellent alternative. This applies particularly to skin lesions adjacent to key facial structures such as the nose, lips, ears and eyes. The shape of the crown excision can vary—it does not always have to be curved. Method (Using a basal cell carcinoma adjacent to the nose as an example.) 1. Mark out the lines of excision around the lesion in a circle. 2. Extend the axis of the excision in the free skin (Fig. 4.31a). 3. On the ‘obstacle’ side, excise two small curved flaps as illustrated.

Chapter 4 | Skin repair and minor plastic surgery

(a) A1 X A

60° X

120°

Repair of cut lip

B1

B

Indications • Treatment of contractures (to lengthen). • Facial scars (to change direction).

While small lacerations of the buccal mucosa of the lip can be left safely, more extensive cuts require careful repair. Local anaesthetic infiltration may be adequate, although a mental nerve block is ideal for larger lacerations of the lower lip. For wounds that cross the vermilion border, meticulous alignment is essential. It may be advisable to premark the vermilion border with gentian violet or a marker pen. It is desirable to have an assistant.

C

(b) A B C

(c)

Method 1. Close the deeper muscular layer of the wound using 4/0 CCG. The first suture should carefully appose the mucosal area of the lip, followed by one or two sutures in the remaining layer (Fig. 4.33). 2. Next, insert a 6/0 monofilament nylon suture to bring both ends of the vermilion border together. The slightest step is unacceptable. 3. Close the inner buccal mucosa with interrupted 4/0 plain catgut sutures. 4. Close the outer skin of the lip (above and below the vermilion border) with interrupted nylon sutures. Post-repair 1. Apply a moisturising lotion along the lines of the wound. 2. Remove nylon sutures in 3 to 4 days (in a young person) and 5 to 6 days (in an older person).

Fig. 4.30 The rhomboid flap Reproduced from I. Mcgregor, Fundamental Techniques of Plastic Surgery, Churchill Livingstone, Edinburgh, 1989, with permission.

4. Suture the defect so that a Y-shaped wound is eventually produced (Fig. 4.31b).

Z-plasty The Z-plasty is a procedure that redistributes wound tension by transposing two interdigitating triangular flaps. It brings in tissue from the sides to lengthen the wound and break up the tension across it. All arms of the Z are equal in length. Method (scheme for a longitudinal contracture) 1. Mark out the Z so that the angles are 60° and the arms are of equal length. 2. Incise along the lines to produce two flaps and free the flaps by dissection. 3. Transpose the flaps and suture (Fig. 4.32).

Wedge excision and direct suture of lip Indications Small, invasive squamous cell carcinomas leading to a defect on less than one-third of the lip. Alternativeprocedures are required for larger defects and for tumours close to the angles of the mouth. An assistant is necessary to help achieve haemostasis, due to the copious bleeding from the inferior labial artery in the posterior third of the lip. Method 1. Provide anaesthesia with a mental nerve block. 2. Carefully mark the excision outline, with special attention to the vermilion border (allow a 2–3 mm margin from the lesion). A small marker ‘nick’ or a stay suture at the border can be used as a guide. 3. Have the assistant hold the lip firmly on either side of the excision lines with gauze for a good grip, and slightly evert the lip.

67

68

Practice Tips

(a)

(b)

curved excisions

initial circular excision line extended excision

Fig. 4.31  (a) The ‘crown’ excision; (b) final appearance

a

a

b b

b a

Fig. 4.32 Z-plasty

4. Excise a clean, full-thickness wedge, with the apex extending almost to the mental fold (Fig. 4.34a). 5. Identify the labial arteries and either use diathermy or clamp and tie these bleeders. 6. Close the dead space of the muscular layer with interrupted 4/0 CCG sutures, starting with accurate apposition of the main lip area (Fig. 4.34b). 7. Insert a 6/0 nylon suture precisely at the vermilion border (the slightest step is unacceptable) and one at the apex of the wound. 8. Close the buccal mucosa with interrupted plain catgut sutures. 9. Finally, insert nylon sutures to the vermilion border and skin.

Wedge resection of ear This procedure is ideal for small tumours on the superior surface of the helix. The requirements are the same as for wedge excision of the lip.

Method 1. Provide LA by infiltrating subcutaneously around the appropriate margin of the ear. The area for infiltration (to cover all the ear) is shown in Figure 4.34a. This V infiltration method is the simplest way to block the ear completely. Specific nerve blocks are outlined on page 37. 2. Cleanse with antiseptic. 3. Mark an outline of the area of excision with the back of the scalpel and, with a marker, the margins for the first suture (e.g. the rim of the helix). 4. With tension applied by the assistant, excise a wedge, cutting cleanly through the skin and cartilage (Fig. 4.35b). The anterior skin is incised with a scalpel and then surgical scissors or the scalpel cuts through the cartilage and posterior ear skin so that the posterior and anterior aspects of the wedge are an exact match. 5. Brisk bleeding should soon cease with direct pressure.

Chapter 4 | Skin repair and minor plastic surgery

6. Place the first suture to achieve meticulous alignment. Place a nonabsorbable mattress suture to ensure hypereversion. 7. Suture the skin on the anterior surface with 6/0 nylon. 8. When the assistant folds the ear over, place and bury a few interrupted CCG sutures in the cartilage (Fig.4.35c). This step is optional, as granuloma formation may complicate buried sutures. 9. Suture the skin of the posterior surface with nylon. The dressing A single layer of paraffin gauze is used, then a double layer of gauze folded around the ear, so that it sits back in its normal position. The dressing is firmly fastened with tape. The dressing is changed in 3 days and the sutures removed in 6 days.

Repair of lacerated eyelid Fig. 4.33 Repair of cut lip (a)

General points • Ensure that the tear duct is not involved. • Preserve as much tissue as possible. • Do not shave the eyebrow. • Do not invert hair-bearing skin into the wound. • Ensure precise alignment of the wound margins. • Tie suture knots away from the eyeball. Method 1. Place an intermarginal suture behind the eye lashes if the margin is involved (Fig. 4.36a). 2. Repair conjunctiva and tarsus with 6/0 catgut (Fig.4.36b). 3. Then repair the skin and muscle (orbicularis oculi) with 6/0 nylon (Fig. 4.36c).

(b)

Fig. 4.34  Wedge excision of lip: (a) wedge of lip removed; (b)precise initial suture

Repair of tongue wound Wherever possible, it is best to avoid repair to wounds of the tongue because these heal rapidly. However, large flap wounds to the tongue on the dorsum or the lateral border may require suturing. The best method is to use buried catgut sutures. Method 1. Infiltrate with 1% lignocaine LA and leave for 5 to 10 minutes. (Sucking ice may provide adequate analgesia.) 2. Use 4/0 or 3/0 catgut sutures to suture the flap to its bed, and bury the sutures (Fig. 4.37). It should not be necessary to use surface sutures. If it is, 4/0 silk sutures will suffice. The patient should be instructed to rinse themouthregularly with salt water until healing is satisfactory.

69

70

Practice Tips

(a)

(a) (a)

(b) (b)

(b)

(c) (c)

(c)

Fig. 4.36 Repair of lacerated eyelid: (a) initial suture; (b)repair of deeper layer; (c) outer skin sutured last

Avascular field in digit Fig. 4.35  Wedge resection of ear: (a) method of ear block with local anaesthesia Infiltrated subcutaneously; (b) wedge of ear removed; (c) suturing in layers

A bloodless field in the anaesthetised digit (after a digital block) can be achieved by using a rubber band as a simple tourniquet.

Chapter 4 | Skin repair and minor plastic surgery

(a)

3. Mark the area requiring wedge resection, which is usually elliptical. 4. Swab with antiseptic and infiltrate with local anaesthetic. 5. Perform a wedge resection to remove the sweat glands, which lie in the layer immediately below the dermis. Clearing the undersurface of the flap of subcutaneous fat will remove these sweat glands. 6. Close the wound, which may be sutured directly or by employing a flap if extensive.

Removal of skin sutures

(b)

Fig. 4.37 Repair of tongue wound

Method 1. Elevate the hand vertically (or the leg) for 2 minutesandwrap tape from the tip of the digit to its base. 2. Wrap a rubber band around the base of the digit to block circulation, and unwrap the tape. 3. Now place the limb on the table and complete the procedure (e.g. removing a foreign body or repairing a wound). 4. When completed, apply a dressing and snip the rubber band with a scalpel or scissors.

Wedge resection of axillary sweat glands

Suture marks are related to the time of retention of the suture, its tension and position. The objective is to remove the sutures as early as possible, as soon as their purpose is achieved. The timing of removal is based on commonsense and individual cases. Nylon sutures are less reactive and can be left for longer periods. After suture removal it is advisable to support the wound with micropore skin tape (e.g. Steri-strips) for 1 to 2 weeks, especially in areas of skin tension. Method 1. Use good light and have the patient lying comfortably. 2. Use fine, sharp scissors that cut to the point or the tip of a scalpel blade, and a pair of fine, non-toothed dissecting forceps that grip firmly. 3. Cut the suture close to the skin below the knot with scissors or a scalpel tip (Fig. 4.38a). 4. Gently pull the suture out towards the side on which it was divided—that is, always towards the wound (Fig. 4.38b). Note: In children, cut all sutures before removal. (a)

(b)

Indication Profuse sweating of axillary hyperhydrosis, especially with body odour, unresponsive to antiperspirants. Method 1. Shave the axilla. 2. Apply iodine starch powder to the axilla. This produces a dark blue/purple response in the area of highest sweat production.

Fig. 4.38 Removal of skin sutures: (a) cutting suture; (b) removal by pulling towards wound

71

72

Practice Tips

Pitfalls for excision of non-melanoma skin cancer There are several anatomical pitfalls awaiting surgical excision. The following summarises potential or real problem areas. • The face—for cosmetic reasons. • The face—for potential nerve damage, e.g. temporal branch of facial nerve (Fig. 4.39). • The lips and helix of the ear—because of malignant potential. • The eyelids. • The inner-canthus of the eye with close proximity to the nasolacrimal duct. • Mid-sternomastoid muscle areas where the accessory nerve is superficial. • Fingers where functional impairment may be a concern. • Lower limb below the knee where healing, especially in the elderly, will be a problem.

• anticipation of difficulty with technique or anatomy where an appropriate specialist should be consulted • squamous cell carcinomas on the lips and ears • infiltrating or scar-like morphoeic BCCs—particularly those on the nose or around the nasal labial fold, as there may be a problem in determining the tumour’s extent and depth • cosmetic concerns such as lesions of the upper chest and upper arms where keloid scarring is a potential problem • areas where palpable regional lymph nodes suggestive of metastatic spread of squamous cell carcinoma exist, namely head and neck, axilla and groin.

W-plasty for ragged lacerations Jagged lacerations are usually best debrided with a small elliptical excision following wrinkle lines, when possible. As a rule it is better to close a ragged wound without tension than to trim it and close it with considerable tension. There is no rule that dictates that a laceration has to be closed as a straight line. One procedure that debrides the sides of a ragged wound (too large for simple elliptical debridement) in a saw-toothed fashion is W-plasty. The sides of the wound have to match each other (Fig. 4.40a). With W-plasty, care should be taken to ensure that adequate blood supply is maintained. Select the pattern of debridement and, using a scalpel with a no. 15 blade, make the initial incisions through the dermis, avoiding full-length incisions, which tend to result in rolled skin edges. Apply simple sutures using three-point sutures at the apices of the triangular components (Fig.4.40b).

(a)

laceration

Fig. 4.39 The course of the temporal branch of the facial nerve

Referral to a specialist Referral should be considered when one or more of the following is involved: • uncertainty of diagnosis • any doubts about appropriate treatment • tumours larger than 1 cm • multiple tumours • recurrent tumours, despite treatment • incompletely excised tumours, especially when complete excision may be difficult • recommended treatment beyond the skills of the practitioner

trimmed excised wound

(b)

final ‘saw-tooth’ appearance

Fig. 4.40 Technique of W-plasty

Chapter 4 | Skin repair and minor plastic surgery

Debridement of traumatic wounds The fundamental principle of debridement is to prevent infection and facilitate healing of open wounds by the manual removal of foreign, dead and contaminated material. It may vary from simple irrigation with saline to a major clean up under general anaesthetic. Basic equipment will include (sterlised) scrubbing brush, saline solution, scalpel and tissue forceps, artery forceps and a 20 mL syringe for irrigation. The principles and process are summarised in Table 4.2.

Debridement of skin in a hairy area When debriding skin in a hairy area, it is important to realise that hair shafts grow obliquely to the skin. In order to avoid creating a hairless path along the length of the scar, try to debride the skin edges at the same angle as the hair shafts (Fig. 4.41). This avoids damage to the hair follicles. Natural lacerations (such as from a blunt blow) to hairy areas such as the eyebrow do not leave a hairless patch of scar when sutured correctly.

Keeping hairs out of wounds for suturing While suturing in a hair-bearing area such as the scalp, it is important to keep hair out of the wound. This can be done by smoothing the hair down with K-Y gel, hair gel such as Brylcream, or adhesive tape.

incision lines

Table 4.2  Principles of traumatic wound debridement  1.

Remove foreign bodies and gross contamination.

 2.

Irrigate and scrub to remove surface debris.

 3.

Wide prep and drape.

 4.

Avoid tourniquets unless vital.

 5.

Excise all dead tissue.

 6.

Excise crushed or dubiously viable tissue if primary closure is planned or leave it to declare itself and plan a second-look debridement.

 7.

Cut skin edges and deep surfaces back to bleeding tissue. Debride in the line of any longitudinal structures (e.g. limb arteries, veins or nerves) to avoid transection or damage.

 8.

Further irrigate the wound to wash out bacteria, residual foreign bodies and small non-viable tissue fragments. Use normal saline, not povidone-iodine solution, antibiotics or other antiseptics as they may be tissue-toxic.

 9.

Obtain haemostasis prior to completing the debridement.

10.

Decide whether a second-look debridement or formal closure is required.

Reproduced from Royal Australasian College of Surgeons, Fundamental Skills for Surgery, McGraw-Hill, Sydney, 2008, with permission.

Clearing shaved areas An effective way to clean up a shaved area such as a scalp prior to surgical repair is to use strips of adhesive tape such a Micropore to pick up loose hairs.

Wound management tips Traumatic wounds Primary wound closure rules • Traditional rule—within 4 to 6 hours • Facial wounds (uncontaminated)—within 12 to 24 hours • Other wounds (uncontaminated)—8 to 12 hours Delayed primary closure • Wounds too old • Heavy contamination Rule: observe 72 hours then repair if not infected.

Dressings Fig. 4.41  Direction of trimmed incision lines in a hair-bearing area

Table 4.3 indicates examples of the most appropriate dressing materials for the exudate level of the wound being treated.

73

74

Practice Tips

Healing cavities of incised cysts and abscesses

Table 4.3 Appropriate dressing materials for various exudate levels Dressing type

Exudate level

Film dressings e.g. Tegaderm

Nil/minimal

Hydrocolloid e.g. Duoderm

Low/moderate

Alginate e.g. Algisite

Moderate/high

Foam e.g. Allevyn

Moderate/high

Hydrogel e.g. Solosite

Dry/sloughy

This practice tip outlines a simple method of promoting the healing of cavities resulting from drained abscesses or removed sebaceous cysts, especially infected cysts. The concept originally came from veterinary management of cysts in animals. Method 1. For deep cavities resulting from surgical incision it is best to pack them first with sterile non-adherent gauze while the patient is anaesthetised. This controls haemostasis and maintains drainage. 2. The following day infiltrate the cavity with intrasite gel. 3. Cover the wound with opsite or appropriate waterproof dressing. 4. Change this every day or every second day until the wound heals.

Post-operative wound care Useful guidelines are: • Use non-adherent dressings over excision wounds. Leave for 24 to 48 hours. Place an occlusive dressing over this for protection and when showering. • After removal of dressing clean daily with saline to remove crusting and to minimise infection. • If concerned about infection use thin application of chloramphenicol (or similar ointment). For healing by secondary intention (such as after curette or diathermy): • Use hydrocolloidal dressings (e.g. Intrasite, Duoderm, Rapid Healing Band Aids). • Leave in situ for up to 7 days.

Advantages • The gel infuses to all recesses of the cavity that packing cannot reach. • Patients can continue management themselves. • More convenient for patients who have a considerable distance to travel. • Less pain and discomfort compared with other dressings. • Rapid healing.

Table 4.4 Time after insertion for removal of sutures Area

Days later

Scalp

6

Face

3 (or alternate at 2, rest 3–4)

Ear

5

Neck

4 (or alternate at 3, rest 4)

Chest

8

Arm (including hand and fingers)

8–10

Abdomen

8–10 (tension 12–14)

Back

12–14

Inguinal and scrotal

7

Perineum

2

Legs

10

Knees and calf

12

Foot (including toes)

10–12

Chapter 4 | Skin repair and minor plastic surgery

When to remove non-absorbable sutures For removal of sutures after non-complicated wound closure in adults, see Table 4.4. Note: Decisions need to be individualised according to the nature of the wound and health of the patient and healing. In general, remove sutures as soon as possible. One way of achieving this is to remove alternate sutures a day or two earlier and remove the rest at the usual time. Steri-strips can then be used to maintain closure and healing.

Additional aspects In children, usually remove 1 to 2 days earlier. Allow additional time for backs and legs, especially the calf. Nylon sutures can be left longer because they are less reactive. Alternate sutures may be removed earlier (e.g. from the face in women).

75

Chapter 5

Treatment of lumps and bumps

Removal of skin tags Skin tags (fibroepithelial polyps) are very benign tumours, and can safely be left. However, patients often request their removal for cosmetic reasons. There are several ways to remove skin tags. These include: • simple excision (see also Perianal skin tags for elliptical excision) • cutting with scissors • electrocautery (to base); a very effective method • tying a fine thread around the base • crushing with bone forceps • liquid nitrogen therapy.

Liquid nitrogen therapy 1. Use a pair of forceps (dissecting or artery) to grasp the skin tag, preferably on the base or stalk. 2. Holding the skin tag upright and taut, apply a liquidnitrogen-soaked cotton bud to the forceps close to the tumour (Fig. 5.1). 3. Apply for several seconds to freeze the tumour. It can be left or cut off with scissors. A variation The tips of the forceps can be dipped directly into the liquid nitrogen and then clamped onto the base of the skin tag. Multiple tags can be frozen rapidly in this way.

Fig. 5.1  Removal of skin tag by liquid nitrogen

Bone forceps method A simple procedure is to crush the base of the skin tag flush with the skin using bone forceps (Fig. 5.2a). The advantages are that: • no local anaesthetic is required • the procedure is relatively painless • the procedure is very quick • immediate haemostasis is achieved (Fig. 5.2b).

Chapter 5 | Treatment of lumps and bumps

(a)

(a)

skin tag

base is crushed flush with the skin until the tag ‘gives way’

cyst outline bone forceps

excised ellipse of skin

(b)

‘bandaid’ is applied to wound

(b) forceps defect (usually bloodless)

Fig. 5.2  Removal of skin tag using bone forceps method

ellipse of skin scissors

Removal of epidermoid (sebaceous) cysts There are several methods for removal of sebaceous cysts after infiltration of local anaesthetic over and around the cyst. These include the following methods.

cyst

Incision into cyst Make an incision into the cyst to bisect it, squeeze the contents out with a gauze swab and then avulse the lining of the cyst with a pair of artery forceps or remove with a small curette.

Punch biopsy method Use a 5 mm punch biopsy to punch a hole into the apex of the cyst. Squeeze vigorously to express the contents. Look for the cyst wall, grasp it with forceps and carefully enucleate it. A suture is not necessary.

Incision over cyst and blunt dissection Make a careful skin incision over the cyst, taking care not to puncture its wall. Free the skin carefully from the cyst by blunt dissection.When it is free from adherent subcutaneous tissue, digital pressure will cause the cyst to ‘pop out’.

Fig. 5.3 Standard dissection of sebaceous cyst

a problem. When the cyst is removed, obliterate the space with subcutaneous catgut. The skin is sutured with a vertical mattress suture to avoid a tendency to inversion of the skin edges into the slack wound. Send the cyst for histopathology.

Electrocautery method On the first visit, inject LA into the overlying skin. Insert a heated electrocautery needle in the cyst and cauterise the contents for several seconds (Fig. 5.4). On the second visit, 7 to 10 days later, inject LA, then

sebaceous cyst

hot wire of electrocautery unit

Standard dissection Incise a small ellipse of skin to include the central punctum over the cyst (Fig. 5.3a). Apply forceps to this skin to provide traction for dissection of the cyst from the adherent dermis and subcutaneous tissue. Ideally, forceps should be applied at either end. The objective is to avoid rupture of the cyst. Insert curved scissors (e.g. McIndoe’s scissors) and free the cyst by gently opening and closing the blades (Fig. 5.3b). Bleeding is not usually

Fig. 5.4 Electrocautery to sebaceous cyst

skin

77

78

Practice Tips

make a small incision in the cyst and express the contents.

Sebaceous hyperplasia

Treatment of infected cysts Incise the cyst to drain purulent material. When the inflammation has resolved completely, the cyst should be excised as outlined above.

Sebaceous hyperplasia presents as a single or multiple nodules on the face, especially in older persons. The nodules are small, yellow-pink, slightly umbilicated andare found in a similar distribution to basal cell carcinoma, for which they may be mistaken. There is no need for surgical excision.

Simple deroofing method This method simply unroofs the cyst and allows healing by dressings over an open area. It should be avoided on the face or other areas where a puckered scar is unacceptable. It is very useful for an infected cyst. Method 1. Infiltrate the skin over the cyst with local anaesthetic. 2. Unroof the cyst by removing a disc of skin with scalpel or scissors. This disc should be slightly smaller than the diameter of the cyst (Fig. 5.5). 3. Evacuate the contents of the cyst and pack with paraffin gauze. 4. Apply pressure if bleeding is a problem. 5. Apply non-adherent dressings daily.

Dermoid cysts Subcutaneous dermoid cysts arise from a nest of epidermal cells in the subcutaneous tissues. There are two forms.

Developmental (inclusion) dermoid cyst The most common is the external angular dermoid, which lies at the junction of the outer and upper margins of the orbit, in the line of fusion of the maxilla and frontal bones (Fig. 5.6). It is usually fluctuant and transilluminable. It should not be treated in the office as an excision of a simple cyst, but referred for expert dissection under general anaesthetic, as it can extend into the cranium.

The infected sebaceous cyst When an infected cyst is encountered, it is appropriate to open it and drain the pus through a cruciate incision or a 4–6 mm punch biopsy (under local anaesthetic). Evacute the contents with sterile gauze and determine if it is possible to avulse the cyst wall. Usually it heals, often definitively, through open healing.

(a)

external angular dermoid

cut about here

sebaceous cyst

subcutaneous cyst

Fig. 5.6 External angular dermoid

(b)

cyst outline

line of excision

Fig. 5.5 A simple deroofing method: (a) cross-sectional view; (b) surface view

Traumatic (implantation) dermoid cyst This is a common lesion of the fingers and palms in adults. It is lined by squamous epithelium and contains sebum, degenerate cells, mucus and occasionally hair. It is caused by implantation of epithelial cells from repeated occupational trauma (puncture wounds) and may be seen in seamstresses, wire workers and hairdressers. It initially presents as a small (< 1 cm) cystic nodular swelling

Chapter 5 | Treatment of lumps and bumps

beneath the skin surface, and attached to it, commonly on the finger pulp (Fig. 5.7). There may be an overlying puncture wound or scar. It is often painful and tender and should be removed by a simple incision removal under local anaesthetic (deroof the cyst and enucleate its contents by curette or scraping). If asymptomatic, it can be left.

scar

(a)

(b)

Fig. 5.7 Implantation cyst of finger

Acne cysts Acne cysts can be treated by an injection of a long-acting corticosteroid preparation in such a way as to flush out the follicular contents and subdue the sterile inflammation. The treatment is suitable for small numbers of cysts. Equipment You will need: • 25-gauge needles • small syringe • 1 mL long-acting corticosteroid (e.g. triamcinalone acetonide, methylprednisolone acetate) Method 1. Introduce a 25-gauge needle into one side of the cyst and inject a small quantity of steroid. Remove the needle (Fig. 5.8a). 2. Introduce a needle into the opposite side of the cyst. Inject steroid so that material is flushed out through the initial entry point (Fig. 5.8b). This removes the follicular material and leaves residual amounts of steroids in a depot form.

Biopsies There are various methods for taking biopsies from skin lesions. These include scraping, shaving and punch biopsies, which are useful but not as effective or safe as excisional biopsies.

Shave biopsies This simple technique is generally used for the tissue diagnosis of premalignant lesions and some malignant tumours, but not melanoma.

Fig. 5.8  Treatment of acne cyst

Method 1. Infiltrate with LA. 2. Holding a no. 10 or 15 scalpel blade horizontally, shave off the tumour just into the dermis (Fig. 5.9). 3. Diathermy may be required for haemostasis. The biopsy site usually heals with minimal scarring.

Punch biopsy This biopsy has considerable use in general practice, where full-thickness skin specimens are required for histological diagnosis. (Good-quality disposable punch biopsies are available from Dermatech.) Method 1. Clean the skin. 2. Infiltrate with LA.

79

80

Practice Tips

Treatment of ganglions excision scalpel held horizontally

Fig. 5.9 Shave biopsy

3. Gently stretch the skin between the finger and thumb to limit rotational movement. 4. Select the punch (4 mm is the most useful size) and hold it vertically to the skin. 5. Rotate (in a clockwise, screwing motion) with firm pressure to cut a plug about 3 mm in depth (Fig.5.10). Remove the punch. 6. Use fine-toothed forceps or a tissue hook to grip the outer rim of the plug. 7. Exert gentle traction and undercut the base of the plug parallel to the skin surface using fine-pointed scissors or a scalpel. 8. Place the specimen in fixative. 9. Secure haemostasis by firm pressure or by diathermy. 10. Apply a dry dressing or a single suture to the defect.

punch held perpendicularly and rotated

Ganglions have a high recurrence rate after treatment, with a relapse of 30% after surgery. Most ganglions are around the dorsal area of the wrist and associated with the scapulolunate joint, while about 25% are volar (palmar). A simple, relatively painless and more effective method is to use intralesional injections of long-acting corticosteroid, such as methylprednisolone acetate. Method 1 1. Insert a 19- or 21-gauge needle attached to a 2 mL or 5 mL syringe into the cavity of the ganglion. 2. Aspirate some (not all) of its jelly-like contents, mainly to ensure that the needle is in situ. 3. Keeping the needle exactly in place, swap the syringe for an insulin syringe containing up to 0.5 mL of steroid. 4. Inject 0.25–0.5 mL (Fig. 5.11). 5. Rapidly withdraw the needle, pinch the overlying skin for 1 to 2 minutes and then apply a firm dressing. 6. Review in 7 days and, if still present, repeat the injection using 0.25 mL of steroid. Up to six injections can be given over a period of time, but 70% of ganglions will disperse with only one or two injections. Method 2 Insert a larger gauge catgut suture through the middle of the ganglion and firmly tie it over the ganglion. Side pressure may express the contents through the needle holes. Remove the knot 12 days later.

Olecranon and pre-patellar bursitis Simple aspiration–injection technique Chronic recurrent traumatic olecranon or pre-patellar bursitis with a synovial effusion may require surgery,

ganglion

tendon

lesion

Fig. 5.10 Punch biopsy

Fig. 5.11 Injection treatment of ganglion

Chapter 5 | Treatment of lumps and bumps

but most cases can resolve with partial aspiration of the fluid and then injection of LA corticosteroid through the same needle.

(a)

Excision of lipomas Lipomas are benign fatty tumours situated in subcutaneous tissue. They are common on the back, but can occur anywhere. Ultrasound imaging is useful for gauging the depth of a lipoma. Lipomas rarely require removal, but removal may be desired for cosmetic reasons or to relieve discomfort from pressure. Many lipomas can be simply enucleated using a gloved finger, but there are a few traps: some are deeper than anticipated, and some are adjacent to important structures such as large nerves and blood vessels. Others are tethered by fibrous bands, and recurrence can occur if excision is incomplete. Beware of lipomas on the back that can be difficult to remove and in the axilla and supraclavicular areas where they can be misleadingly extensive. Larger lipomas (> 5 cm) may require referral. Method The principle is CUT, SQUEEZE, POP. 1. Outline the extent of the lipoma and mark it with a ballpoint pen. Note its anatomical relationships. 2. Infiltrate the area with 1% lignocaine with adrenaline. (Include the deepest part of the lipoma.) 3. Make a linear incision (Fig. 5.12a) in the overlying skin, preferably in a natural crease line, for about three-quarters of its length. The lipoma should bulge through the wound. For large lipomas, incise an ellipse of skin (Fig. 5.12b). 4. Deepen the incision until the lipoma can be seen. 5. Insert a gloved finger between the skin and fatty tumour to find a plane of dissection and to determine whether it will shell out. 6. It is important to seek the outer edge of each lobule, dissect it and bring it to the wound surface (Fig.5.12c). If necessary, insert curved scissors and use a blunt opening action to free any fibrous bands tethering the lipoma (Fig. 5.12d). Note: The best way to prevent bleeding is not to dissect around the fatty tissue but to incise it, invert the tumour through the wound and then remove it. 7. Ensure that all the fatty tissue is removed. Send it for histological examination. Clipping and ligation of persistent bleeding vessels may be required. Haemostasis should be meticulous. 8. Use a gauze swab to control bleeding and remove debris from the dead space. 9. Close the dead space with interrupted catgut sutures. Consider a small suction drain tube if oozing persists in an extensive dissection area. 10. Close the skin with interrupted or subcuticular sutures.

(b)

(c)

(d)

Fig. 5.12  (a) Linear incision for small lipomas; (b) elliptical incision for large lipomas; (c) gloved finger dissection to bring lipoma to the surface; (d) blunt scissors dissection to free lipoma from tethering fibrous bands

Keratoacanthoma Most keratoacanthomas (KAs) occur singly on lightexposed areas. They are regarded as a variant of squamous cell carcinoma and should be treated as such.

81

Practice Tips

Although KAs can be treated by curettage and cautery, the recommended treatment is surgical excision and histological examination. Ensure a 2–3 mm margin for excision. Most patients will not tolerate a tumour on an exposed area such as the face for 6 months while waiting for a spontaneous remission to confirm the clinical diagnosis. Note: SCCs on the ear metastasise 15 times more rapidly than elsewhere. The relative growth rates of SCC, KAs and basal cell carcinomas (BCCs) are shown in Figure 5.13.

Basal cell carcinoma (BCC) BCCs are the most common type of skin cancer. They can occur on any part of the body, but the most common site is on the face, especially next to the eyes or nose. It is useful to think of it as the area covered by an eye mask (Fig. 5.14). Another common area is the neck, and the upper back and chest are becoming more common sites. Increased risk occurs with: • age over 50 years • exposure to excessive sunlight

• fair complexion • lack of sun protection. Treatment guidelines • Surgery is the primary treatment: use a simple ellipse (where possible) under local anaesthetic with a 3 mm margin (in most cases). • Cryotherapy is suitable for primary, well-defined, histologically confirmed superficial tumours, at sites away from the head and neck. Contraindicated for morphoeic or ill-defined tumours. Good results are obtained for small BCCs (< 1 cm) with sharply demarcated borders. • Superficial X-ray therapy is an option in larger tumours in older people. Use with discretion and infrequently. • Imiquimod: Suitable for biopsy-proven superficial BCC, but not on nose or around eyes. Treatment Monday to Friday, 5 times weekly for 6 weeks. • Curettage and electrodissection: A curette is first used to remove friable tumour tissue, leaving firm normal tissue. Electrodesiccation of the margins of the defect is then performed. Careful follow-up is essential.

Squamous cell carcinoma (SCC) SCC Size of tumour

82

KA

clinically apparent

time

BCC

10 weeks

SCCs usually develop in skin exposed to the sun, in particular the face (especially the lower lip), ears, neck, forearm, back of the hands and lower legs (Fig. 5.15). A special trap is on the scalps of men who are bald or have thin scalp hair. Increased risk occurs with: • age over 60 years • fair complexion • outdoor occupations • development of sunspots (solar keratoses).

Fig. 5.13  Relative growth rates of three types of skin tumours scalp, especially in bald men

helix of ear

lower lip

Fig. 5.14  Typical sites of basal cell carcinoma: the ‘mask’ area of the face

Fig. 5.15 Important common sites of squamous cell carcinoma on the head and face

Chapter 5 | Treatment of lumps and bumps

Treatment guidelines • Surgery is the treatment of choice—use a simple ellipse under LA with a 4 mm margin (in most cases). • Superficial X-ray therapy is an option in a primary untreated tumour when surgery is not feasible. Cryotherapy and curettage are not treatments of choice.

helix

antehelix

Pyogenic granuloma These solitary, raised, bright red tumours (granuloma telangiectaticum) tend to bleed profusely. The most effective treatment is curettage and electrocautery under local anaesthesia. However, it must be stressed that histological confirmation of the diagnosis is essential to exclude anaplastic squamous cell carcinoma or amelanotic melanoma. Thus, after the tumour has been shaved off or curetted it should be sent for examination.

Seborrhoeic keratoses Regular applications of liquid nitrogen may remove these benign skin tumours, or at least decolourise them. Immediately after freezing you can use a scalpel (e.g. size 15 blade) to scrape off the lesion at skin level. Another method is to apply carefully concentrated phenol solution. Repeat in 3 weeks if necessary. Yet another method is to apply trichloroacetic acid to the surface and instil it in gently by multiple pricks with a fine gauge needle. Perform twice weekly for 2 weeks.

Stucco keratoses This subtype of seborrhoeic keratoses are multiple nonpigmented small friable keratoses over the lower legs. They can be treated with a topical keratolytic such as 3–5% salicyclic acid in sorbolene.

Chondrodermatitis nodularis helicus This lump, which is not an SCC or other neoplasm, presents as a painful nodule on the most prominent part of the helix or antehelix of the ear (Fig. 5.16). It is seen more often on the helix in men, while it is found more often on the antehelix in women. It is caused by sun damage and pressure degeneration from excessive sleeping on the affected side. It causes pain at night. Histologically, a thickened epidermis overlies inflamed cartilage. It looks like a small corn, is tender, and affects sleep if that side of the head lies on the pillow. The first line treatment is cryotherapy. If that fails, wedge resection (p. 68) with a minimal border under local anaesthesia is an effective treatment. Send the specimen for histological examination.

Fig. 5.16  Typical sites of chondrodermatitis nodularis helicus

Orf Rapid healing of the skin lesion orf can be achieved by injecting corticosteroids into the pustular nodule. Precautions • Ensure that the diagnosis of orf is correct. • Warn the patient of likely increased discomfort for 24 hours. Method • Mix 0.5 mL of 1% plain lignocaine with 0.5 mL of long-acting corticosteroid, e.g. triamcinolone. Use more solution for a larger lesion. • Infiltrate the solution into the lesion, around its margins and into its base. • The lesion is left to heal without dressings. Rapid healing occurs within 5 to 10 days. Otherwise it takes 3 to 4 weeks.

Milker’s nodules These nodules can heal more rapidly if the same intralesional corticosteroid injection is given as for orf.

Haemangioma of the lip Attempted excision of these common lesions should be avoided because of bleeding. Perform a mental nerve block (preferable to local infiltration) and insert the needle of the electrocautery or hyfrecator into the centre of the haemangioma. More than one treatment may be necessary.

Aspiration of Baker cyst A distended tender popliteal cyst (Baker cyst) of the knee is really a bursa that communicates with the knee joint. It may be associated with rheumatoid arthritis, osteoarthritis, traumatic knee disruption or a normal joint.

83

84

Practice Tips

Aspiration and injection may alleviate the symptoms of swelling and tenderness. Method 1. The patient should be prone, with a small pillow under the knee to produce slight hyperextension of the joint and obvious distension of the bursa. 2. Using a sterile, no-touch technique, insert a 21-gauge 38 mm needle attached to a 20 mL syringe into the bursa. 3. Completely aspirate the fluid, which is usually a clear yellow. 4. Leave the needle in situ and exchange the 20 mL syringe for a 2 mL syringe containing 1 mL of longacting corticosteroid, which is then injected (Fig. 5.17). 5. Recurrence is common. An alternative treatment is to inject 5 mL of 2.5–3% aqueous phenol or 3% STD (sodium tetradecyl sulfate) solution instead of corticosteroid.

Aspiration and injection of hydrocele Aspiration, followed by an injection of dilute aqueous phenol or STD, can be a very useful treatment technique for primary hydroceles—especially where definitive surgery is inappropriate. Aspiration alone rarely corrects a hydrocele, but the aspiration/injection combination performed 2 or 3 times can often cure the problem. Method 1. Inject LA into the scrotal skin down to the sac. 2. Insert an 18- or 19-gauge intravenous cannula through

this site into the sac and remove the stilette, leaving the soft cannula in the sac (Fig. 5.18). 3. Remove the serous fluid initially by free drainage, possibly aided by manual compression on the sac and then by aspiration with a 20 mL syringe. 4. Record the volume. 5. Inject 2.5–3% sterile aqueous phenol into the empty sac (10 mL for 200 mL of fluid removed, 15 mL for 200– 400 mL and 20 mL for over 400 mL). An alternative and simpler solution is to use 3% STD. Use 2–5 mL. Phenol: Ivn Australia phenol can be ordered from Briggate Medical Company (www.briggate.com.au). The procedure can be repeated after 6 weeks.

testis catheter hydrocele

Fig. 5.18 Aspiration of hydrocele

Epididymal cysts The same method as for hydroceles can be used. Aspirate and then inject sclerosant.

Testicular tumours popliteal (Baker) cyst

It has been shown that scrotal needling such as for needle biopsy of testicular tumours has the potential risk of implanting malignant cells in the scrotal wall. The same applies to a scrotal incision to remove testicular cancer. For this reason, incisions to remove testicular cancer are made in the inguinal area.Testicular cancer is spread by the lymphatics to the para-aortic nodes, and not to the inguinal nodes.

Torsion of the testicle

Fig. 5.17 Aspiration of Baker’s cyst

• Follow the 4 to 6 hour intervention rule. • Don’t waste time with investigations, such as ultrasound. • Consider manipulation from the horizontal position, although it is painful.

Chapter 5 | Treatment of lumps and bumps

Steroid injections into skin lesions Indications Suitable lesions for steroid injections are: • granuloma annulare • hypertrophic scars (early development) • keloid scars (early development) • alopecia areata • lichen simplex chronicus • necrobiosis lipoidica • hypertrophic lichen planus • plaque psoriasis.

Triamcinolone is the appropriate long-acting corticosteroid (10 mg/mL). It may be diluted in equal quantities of saline. Method 1. The steroid should be injected into the lesion (not below it). 2. Insert a 25- or (preferably) 27-gauge needle, firmly locked to a small insulin-type 1 mL syringe, into the lesion at the level of the middle of the dermis (Fig.5.19). 3. High pressure is required with some lesions (e.g. keloid). 4. Inject sufficient steroid to make the lesion blanch. 5. Several sites will be needed for larger lesions, so preceding LA may be required in some instances. Avoid infiltration of steroid in larger lesions: use multiple injections.

Steroid injections for plaques of psoriasis An excellent method of effective treatment of small to moderately sized plaques of psoriasis is by intralesional infiltration using a long-acting corticosteroid. hypertrophic scar

Fig. 5.19 Injection of corticosteroid into mid-dermis

Requirements • Triamcinolone 10 mg/mL solution (or other corticosteroid) • 1% (plain) lignocaine (or similar local anaesthetic) • 25-gauge needle (or 23-gauge if larger plaque) Method 1. Mix equal parts of corticosteroid and local anaesthetic. 2. Swab the lesion. 3. Insert the needle at the margin of the plaque and infiltrate the lesion at an intradermal level, avoiding going deep into the subcutaneous tissue. 4. Infiltrate the whole plaque. 5. A larger plaque may require needle insertion at two sites (Fig. 5.20).

needle infiltrates all areas of plaque

long-acting corticosteroid

Fig. 5.20 Intralesional corticosteroid injection technique for psoriatic plaque (requiring double injection; small plaques cope with one infiltration)

85

86

Practice Tips

This treatment, which is ideal for a persistent elbow or knee plaque, is rapidly effective and tends to induce a long remission.

Hypertrophic scars: Multiple puncture method Hypertrophic scars are usually treated by multiple intradermal injections of long-acting corticosteroids. The injections are not normally painful, but the procedure can be distressing, particularly to children. It is possible to achieve the same results without ‘an injection’, delivering the steroid by the multiple-pressure technique used for smallpox vaccinations. Method 1. The patient is positioned so that the scar to be treated is in the horizontal plane. 2. Cleanse the skin thoroughly with an alcohol swab and allow it to dry. 3. Draw injectable corticosteroid up into a syringe, preferably before the patient enters the treatment room. 4. Spread a film or layer of the steroid aseptically over the scar. 5. Make multiple pressures through the solution into the scar, using a 21-gauge needle held tangentially to the skin.The point of the needle should just penetrate the epidermis and not be deep enough to cause bleeding. 6. There should be approximately 20 pressures per cm2. 7. Allow the steroid to dry and cover the area with a dressing if desired. Treatment can be repeated every 6 weeks if necessary; most simple hypertrophic scars, however, settle after one treatment.

Silicon adhesive gel/dressings Silicon sheet dressings (e.g. Cica-Care) worn continuously over a wound may prevent hypertrophy of the wound. An adhesive gel sheet can be purchased and a piece cut out to fit the wound. The gel sheet should be re-applied daily for 12 weeks. Alternatively, silicon gels massaged firmly into the wound each day after the wound has re-epithelialised may help.

Fig. 5.21 Injecting corticosteroid into wound

Elastoplast Scar Reduction Patch These patches can be used to treat or prevent hypertrophic scars.The patch is applied over the scar and changed every 24 hours. It should not be applied to open wounds or burns.

Keloids Methods • Multiple puncture method. • Inject long-acting corticosteroid, e.g. triamcinolone 10 mg/mL (usually three treatments, 6 weeks apart). • Apply liquid nitrogen, then inject with corticosteroid about 5 to 15 minutes later—the softer oedematous tissue is easier to inject. • Radiotherapy.

Prevention of keloids (in susceptible patients) • Apply high-potency topical corticosteroid with occlusive dressing for 2 to 3 days. • Inject long-acting corticosteroid into the recess of the wound immediately following suture of the wound (Fig. 5.21). • Inject long-acting corticosteroid immediately following suture removal.

Dupuytren contracture If the palmar nodule is growing rapidly, an injection of long-acting corticosteroid or collagenase (e.g. Xiaflex) into the cord or nodule may be very effective. It can be repeated in 6 weeks, but surgical intervention is indicated for a significant flexion deformity.

Drainage of breast abscess Acute bacterial mastitis Resolution without progression to an abscess will usually be prevented by antibiotics (e.g. flucloxacillin 500 mg 4 times a day orally or cephalexin 500 mg 4times a day orally). In addition, therapeutic ultrasound (2 W/cm2 for 6 minutes) daily for 2 to 3 days will assist resolution.

Chapter 5 | Treatment of lumps and bumps

The breast abscess

(a)

If an abscess develops, repeated aspiration or occasionally incision and drainage will be required. Aspiration drainage This is the preferred treatment and best performed under ultrasound guidance. However, if US is unavailable it can be drained with an 18- to 21-gauge needle under local anaesthetic every second day until resolution. Surgical drainage under general anaesthesia The surgical incision should be placed as far away from the areola and nipple as possible and the dressings kept clear of the areola to allow breastfeeding to continue. The incision is best placed in a radial orientation (like the spoke of a wheel) to minimise the risk of severing breast ducts or sensory nerves to the nipple. Method 1. Make an incision over the point of maximal tenderness, preferably in a dependent area of the breast (Fig. 5.22a). 2. Use artery forceps to separate breast tissue to reach the pus. 3. Take a swab for culture. 4. Introduce a gloved finger to break down the septa that separate the cavity into loculations (Fig. 5.22b). Flush the cavity with sterile saline solution. 5. Insert a corrugated drainage tube into the cavity. Fix it to the skin edge with a single suture (Fig. 5.22c). Remove the tube 2 days after the operation. Change the dressings daily until the wound has healed. Continue antibiotics until resolution of the inflammation. Continue breastfeeding from both breasts, but if breastfeeding is not possible because of the location of the incisions and drains, milk should be expressed from that breast.

Aspiration of breast lump This simple technique is very helpful, especially if the lump is a cyst, and will have no adverse effects if the lump is malignant. If so, the needle biopsy will help with the pre-operative cytological diagnosis. Clues to diagnosis of breast cysts • Sudden onset; past history at surgery • Discrete breast mass, firm, rarely fluctuant, relatively mobile Method of aspiration and needle biopsy 1. Avoid LA; use an aqueous skin preparation. 2. Use a 21-gauge needle and a 5 mL sterile syringe. 3. Identify the mass accurately and fix it by placing three fingers of the dominant hand firmly on three sides of the mass (Fig. 5.23a).

(b)

(c)

Fig. 5.22 Drainage of breast abscess: (a) linear incision; (b) exploring abscess cavity; (c) drainage tube in situ

4. Introduce the needle directly into the area of the swelling, and once in subcutaneous tissue apply gentle suction as the needle is being advanced (Fig. 5.23b). 5. If fluid is obtained (usually yellowish green), aspirate as much as possible. 6. If no fluid is obtained, try and get a core of cells from several areas of the lump in the bore of the needle. 7. Make several passes through the lump at different angles, without exit from the skin and maintaining suction. 8. Release suction before exit from the skin so as to keep the cells in the needle (not in the syringe). 9. After withdrawal, remove the syringe from the needle, fill with 2 mL of air, reattach the needle and produce a fine spray on two prepared slides. 10. Fix one slide (in Cytofix) and allow one to air dry, and forward to a reputable pathology laboratory.

87

88

Practice Tips

(a)

fourth finger

direction of syringe

third finger

second finger

(b) third finger

second finger thumb

Fig. 5.23 Fixation of the cyst: (a) lateral view; (b) position of other hand: second (index) finger and thumb steady the syringe while the third (middle) finger slides out the plunger to create suction

Indications for biopsy of lump • The cyst fluid is bloodstained • The lump does not disappear completely with aspiration • The swelling recurs within 1 month

Recurrent cysts After aspiration, leave the needle in situ and inject 2–5 mL of air. This method reduces the recurrence rate.

Marsupialisation technique for Bartholin cyst Bartholin cyst presents as a swelling at the posterior end of the labium majus, close to the fourchette. The correct treatment of both cyst and abscess is marsupialisation, not excision (which is difficult, bloody and leads to scarring) or incision (which is usually followed by recurrence). The procedure can be carried out on an outpatient, preferably using local anaesthesia. Method 1. With the patient in the lithotomy position, swab and drape the vulva. 2. Infiltrate the skin over the medial part of the cyst with 1% lignocaine with adrenaline, using a fine needle and a slow injection.

3. Make a narrow elliptical incision over the medial part of the cyst, at least 3 cm in length (Fig. 5.24a). (As this ostium later contracts, it is a fault to make it too small.) 4. Excise the ellipse of skin, then open the wall of the cyst in the same line, and carefully grasp its edges with mosquito forceps. 5. After the contents of the cyst escape, wash out the cavity with saline, and inspect it then dry it carefully. Any deep loculi must be opened widely. On the posteroinferior cyst wall it is usual to find a punctum leading into the proximal remnant of the duct. 6. Suture the cyst wall to the skin edge at four points using fine catgut, thus creating a pouch (Fig. 5.24b). No dressing is applied and the patient is instructed to take a sitting bath twice a day for a week. Healing is rapid, without pain, and the result is a permanent ostium close to the hymen which delivers free-draining secretion close to the normal site (Fig. 5.24c). If this ostium is too lateral, the woman may complain of discharge and wetness of the skin. With this technique, even the inexperienced operator will have no difficulty achieving good results with Bartholin’s cysts. Abscesses can be more difficult if the lining is friable or necrotic. For this reason, early operation should be advised in the presence of inflammation.

Cervical polyps Women presenting with small cervical polyps can be readily and simply treated in the office with spongeholding forceps and a silver nitrate stick. Patients with large polyps require a different approach and referral may be appropriate. Method 1. Grasp the polyp with sponge-holding forceps and gently twist the polyp until it separates (Fig. 5.25a). 2. Place the polyp in a specimen bottle and send it for histological examination. 3. Cauterise the base of the polyp at the cervical os (Fig.5.25b) with silver nitrate or by electrocautery.

Liquid nitrogen therapy Ideally, liquid nitrogen is stored in a special, large container and decanted when required into a small thermos flask or a spray device.The temperature is –193°C. The easiest method of application to superficial skin tumours (see Table 5.1) is via a ball of cotton wool rolled rather loosely on the tip of a wooden applicator stick. This should be slightly smaller than the lesion, to prevent freezing of the surrounding skin.

Chapter 5 | Treatment of lumps and bumps

(b)

(a)

(c)

lining of cyst skin vaginal epithelium

Fig. 5.24 Marsupialisation technique: (a) start of operation; (b) final suture; (c) post-operative appearance

(a)

• eyelids • nails (do not freeze over nail matrix).

cervix twisted polyp cervical os

removal of polyp by twisting

(b)(b)

Cotton wool application method (basic steps) 1. Inform the patient what to expect. 2. Pare excess keratin with a scalpel. 3. Use a cotton wool applicator slightly smaller (not larger—see Fig. 5.26a) than the lesion. 4. Immerse it in nitrogen until bubbling ceases. 5. Gently tap it on the side of the container to remove excess liquid. 6. Hold the lesion firmly between thumb and forefinger. 7. Place the applicator vertically (Fig. 5.26b, c) on the tumour surface. 8. Apply with firm pressure: do not dab. 9. Redip the applicator every 5 to 10 seconds. 10. Freeze until a 2–5 mm white halo appears around the lesion. The appropriate length of application varies (see Table 5.2). Explain likely reactions to the patient, such as the appearance of blisters (possibly blood blisters). The optimal time for retreatment of warts is at or soon after 3 weeks. Table 5.1 Superficial skin tumours suitable for cryotherapy

Fig. 5.25  Cervical polyp excision: (a) removal by twisting; (b) cauterising base with silver nitrate

Warts (plane, periungual, plantar, anogenital)

Beware of application to the following: • dark skin • upper lips • nerves

Seborrhoeic keratoses

Skin tags

Molluscum contagiosum Solar keratoses

89

90

Practice Tips

(b) (a)

(b) X

(c)

Fig. 5.26 Shows (a) applicator too large; (b) correct size and approach of applicator; (c) correct size but wrong position of applicator Table 5.2  Recommended treatment times for cryotherapy Solar keratoses, solar lentigos

< 3 seconds

Seborrhoeic keratoses

single cycle 5–10 seconds

Skin tags

5–10 seconds

Warts—hands

single cycle 30 seconds

Warts—feet

two cycles 30 seconds with complete thaw in between

Molluscum contagiosum

5 seconds

Spray ‘gun’ method Spraying liquid nitrogen under high pressure is by far quicker and more effective than the topical method. It produces sufficient intense cold to treat deeper lesions. Spray until the white halo forms. If the spray is too diffuse for the lesion, you can place the opening of an otoscope earpiece over the lesion—then spray into the opening of the earpiece, but wear thick gloves for this manoeuvre. Another strategy is to apply a thick film of petroleum jelly or spray ‘plastic skin’ such as Op Site to protect the surrounding skin.

Carbon dioxide slush for skin lesions Carbon dioxide (CO2), also known as dry ice, is an effective cryotherapy (freezing) agent for the treatment of warts and keratoses. The CO2 snow is obtained by the rapid release of CO2 gas from a cylinder. Equipment You will need: • one sparklet cylinder of CO2 • a chamois bag with a purse string around the edge • a bottle of acetone • a cotton wool bud (preferably on a long stick).

Chapter 5 | Treatment of lumps and bumps

Method 1. Invert the cylinder and connect the chamois bag around the nozzle to collect a small amount of dry ice (snow). The CO2 snow can be made into a slush by adding a few drops of acetone immediately before use. Alternatively, the cotton bud can be dipped in acetone and then introduced into the snow. 2. Roll the cotton wool bud firmly in this slush to collect an ‘ice ball’, which must be used immediately as it melts very rapidly. The ‘ice ball’ should be marginally smaller than the lesion to be treated. 3. Apply this ‘ice ball’ to the skin lesion for 10 to 15 seconds.

Trichloroacetic acid Trichloroacetic acid, which should be readily available from pharmacies, has good use as a chemical ablative agent, but it requires careful application on skin lesions. It is usually applied twice weekly, and can be introduced into the lesions, e.g. seborrhoeic keratoses, with fine needle pricks. Suggested uses • Seborrhoeic keratoses • Xanthelasma • Other flat hyperpigmented lesions

Simple removal of xanthoma/ xanthelasmas General practitioners receive many requests to remove cosmetically unacceptable xanthomas (xanthelasmas) of the eyelid. A simple method of removal is described. It is suitable for most sizes, but works best for smaller nodular xanthomas that are bulging and ‘ripe’ for removal. Equipment • A 21-gauge sterile disposable needle • Manicure tweezers (flat or slanted, not pointed) Method 1. Explain the method to the patient, indicating that there is slight discomfort only. 2. Although it is not necessary for all patients, apply some ice or other surface ‘anaesthetic’ to the xanthoma to lessen the discomfort. 3. Stretch the overlying skin and make a small incision in the skin with the tip of the needle (or a fine scalpel) (Fig. 5.27a). 4. Compress the xanthoma along its axis with the tweezers. It is invariably easily expelled (Fig. 5.27b).

Infiltrative xanthelasmas The flat yellowish xanthelasma around the eyes is difficult to treat surgically. The simplest method is to use ablative therapy, such as laser or careful application of trichloracetic acid.

(a)

tip of needle skin deroofed from xanthoma

tweezers

(b) lateral squeeze by tweezers expels xanthoma

Fig. 5.27  Removal of nodular xanthoma

Warts and papillomas Warts are skin tumours caused by the human papilloma virus that are transmitted by direct or fomite contact and may be autoinnoculated from one area to another. The various types include common warts, plantar warts, filiform warts (fine elongated growths usually on the face and neck), digitate warts (finger-like projections, usually on scalp), genital and plantar warts.We should keep in mind the fact that about 25% of warts resolve spontaneously in 6 months and 70% in 2 years.

Treatment options Topical applications • Salicylic acid, e.g. salicylic acid 5–20% in flexible collodion (apply daily or bd), salicylic acid 16–17% + 16–17% lactic acid (apply once daily) • Formaldehyde 2–4% alone or in combination • Podophyllotoxin 0–5%, for warts on mucosal surfaces, e.g. anogenital warts • Cytotoxic agents, e.g. 5-fluorouracil, very good for resistant warts such as plantar warts and periungual warts • The immunomodulator, imiquimod Cryotherapy • Carbon dioxide (–56.5°C) or liquid nitrogen (–195.8°C) • Excessive keratin must be pared before freezing Curettage A most common treatment, some plantar warts can be removed under LA with a sharp spoon curette. The problem is a tendency to scar.

91

92

Practice Tips

Electrodissection A high-frequency spark under LA is useful for small or digitate warts. A combination of curettage and electrodissection is suitable for large and persistent warts. Vitamin A and the retinoids • Topical retinoic acid (e.g. tretinoin 0.1% creamRetin-A) for plane warts • Systemic oral retinoid, acitretin (Neotogason) for recalictrant warts (with care) Medication Consider cimetidine for a large crop of warts. Specialised treatments Bleomycin, cantharidin, immunotherapy (e.g. topical diphencyprone-DPCP).

Specific wart treatment The method chosen depends on the type of wart, its site and the patient’s age. • Plane warts: liquid nitrogen (after paring) to each wart every 2–4 weeks; consider tretinoin 0.05% cream (once daily for face) or 5-fluorouracil cream • Filiform or digitate warts: liquid nitrogen or electrodissection • Plantar warts: refer to pages 99–101 • Periungual warts (fingernails): consider 5-fluorouracil or liquid nitrogen with care. Always use a paint rather than ointment or paste on fingers • Common warts (see below) Topical options for common warts: helpful hints 1. Soak the wart/s in warm soapy water. 2. Rub back the wart surface with a pumice stone. 3. Apply the anti-wart agent—options: • Adults: 17% salicylic acid, 17% lactic acid in collodion paint (Dermatec, Duofilm), apply daily. • Children: 8% salicylic acid, 8% lactic acid in collodion. • Formulated paint: formalin 5%, salicylic acid 12%, acetone 25%, collodion to 100%; apply daily or every second day. • Salicylic 70% paste in linseed oil: leave 1 week then freeze with liquid nitrogen. 4. Consider protecting the surrounding skin with nail polish or Vaseline. 5. Remove dead skin between applications. Maverick tip (from personal communications): Apply Superglue weekly to stubborn common warts.

Molluscum contagiosum Individual lesions usually involute spontaneously over several months. There are several simple treatments available for this viral tumour of the skin, the choice being influenced by the person’s age. The great range of possible treatments reflects the difficulty of achieving rapid resolution. Treatment choices are: • liquid nitrogen (a few seconds) • pricking the lesion with a pointed stick soaked in 1% or 3% phenol • application of 15% podophyllin in Friar’s Balsam (compound benzoin tincture) • application of 30% trichloroacetic acid • application of 5% benzoyl peroxide • application of 17% salicylic acid + 17% lactic acid in collodion (Dermatech or Duofilm) • application of wheatgrass topical cream or spray (a wheatgrain extract—see www.drwheatgrass.com.au) • destruction by electrocautery or diathermy • ether soap and friction method • lifting open the tip with a sterile needle inserted from the side (parallel to the skin) and applying 10% povidone-iodine (Betadine) solution or 2.5% benzoyl peroxide (parents can be shown this method and continue it at home for multiple tumours) • paint with clear nail polish • cover with a piece of duct tape or Micropore (or similar paper-based tape) and change every day (may take a few months) • inject a larger single lesion with corticosteroid, e.g. triamcinolone 10 mg/mL solution. Most effective method Extract the core with a curette or large needle, then apply 10% povidone-iodine solution. Ether soap method Soak the tumour or tumours for 1 to 2 nights in ether soap (now difficult to obtain), with a plastic covering over the soap-soaked swab. The tumours are then obliterated by rubbing with another damp swab. For large areas of multiple molluscum contagiosum Apply aluminum acetate (Burrow’s solution 1:30) twice a day. New alternative treatments • Extract of the Cantharis beetle (prepared as Canthrone) is reportedly very effective (if available). • Imiquimod (Aldara) cream, thrice weekly for 3 weeks.

Chapter 6

Treatment of ano-rectal problems Perianal haematoma This painful condition usually develops with straining to pass stool. Surgical intervention is recommended, especially in the presence of severe discomfort. The treatment depends on the time of presentation after appearance of the haematoma.

Stage 1 treatment: Within 24 hours ofonset While the haematoma is still fluid, the treatment is by simple aspiration of the blood (Fig. 6.1). No local anaesthetic is necessary. If this is unsuccessful, surgical drainage is recommended. Equipment You will need a: • 2 mL or 5 mL syringe • 19-gauge needle

blood

Fig. 6.1  Aspiration of blood for perianal haematoma

Stage 2 treatment: Within 24 hours to 5days of onset By now the blood has clotted, and a simple incision over the haematoma to remove the thrombosis followed by deroofing is the most appropriate treatment. Equipment You will need: • 1% lignocaine with adrenaline (1–2 mL) • a 25-gauge needle and 2 mL syringe • a no. 15 scalpel blade • 1 plain-toothed dissecting forceps (not essential). Method 1. Swab the perianal area with povidone iodine, then inject 1–2 mL of LA into the pedicle of the skin around the base of the haematoma (Fig. 6.2a). An alternative is to apply a liberal amount of local anaesthetic ointment and wait 20 to 30 minutes. 2. Make a stab incision with the scalpel blade into the skin over the haematoma. 3. Extend the incision along the main axis of the haematoma (Fig. 6.2b). 4. Evacuate the thrombus with gentle, lateral pressure (Fig. 6.2c) or lift out with forceps. 5. An alternative and perhaps better method is to deroof the haematoma with scissors (like taking the top off a boiled egg). Squeeze out the clot. 6. Apply pressure to the incised area with a plain gauze swab to achieve haemostasis.

94

Practice Tips

(a)

(b)

25-gauge needle

(c)

thrombus

no. 15 scalpel blade

Fig. 6.2 Treatment of perianal haematoma: (a) local anaesthetic; (b) incision over haematoma; (c) thrombus expressed by digital pressure

7. When bleeding has stopped, apply a small dressing of gauze, then a combine (5 cm × 5 cm) folded in half. 8. Retain the dressing with well-fitting underpants (not adhesive), apply an ice pack and rest in bed. Remove the next day. 9. No stitch is required unless haemostasis is a problem.

Stage 3 treatment: Day 6 onwards The haematoma is best left alone unless it is very painful or (rarely) infected. Resolution is evidenced by the appearance of wrinkles in the previously stretched skin. The haematoma will ultimately become a skin tag. Note: A gangrenous haematoma or a very large thrombosed pile should be surgically excised. The patient should have analgesics and Sitz baths.

Follow-up The patient should be reviewed in 4 weeks for rectal examination and proctoscopy, to examine for any underlying internal haemorrhoid that may predispose to further recurrence. Prevention includes an increased intake of dietary fibre and avoidance of straining at stool.

Perianal skin tags The skin tag is usually the legacy of an untreated perianal haematoma. It may require excision for aesthetic reasons, for hygiene, or because it is a source of pruritus ani or irritation. Method 1. Make a simple elliptical excision at the base of the skin under LA (Fig. 6.3). Suturing of the defect is usually not necessary. 2. Apply a light gauze dressing for about 24 hours. The patient is advised to have twice-daily salt baths until healing is complete.

elliptical incision flush with base skin tag

Fig. 6.3 Excision of perianal skin tag

Rubber band ligation of haemorrhoids Before the procedure • Two glycerine suppositories (to empty rectum) • Paracetamol and codeine oral analgesics Rubber band ligation of haemorrhoids (best for stages 2 and 3) is a simple technique performed through a lubricated proctoscope which can be held by the patient after insertion (Fig. 6.4a). One or two rubber bands are stretched over the loading cone onto the metal drum of the banding instrument. Method 1. Thread the long grasping forceps through the drum of the banding instrument and grasp the haemorrhoid about 1 cm above the dentate line (Fig. 6.4b). (It is important to keep above the dentate line.) 2. Apply gentle traction to the haemorrhoid to indent its base. 3. Snap the band or bands onto the haemorrhoid by pushing the trigger mechanism (Fig. 6.4c). Post-procedure • If possible, avoid a bowel action on day 1. • Take simple analgesics as necessary. • Don’t drive home (prone to get vasovagal attacks).

Chapter 6 | Treatment of ano-rectal problems

(a)

(b)

dentate (pectinate) line

haemorrhoid suitable for rubber band ligature

proctoscope

rubber band drum

haemorrhoid grasped by forceps

(c) outer cylinder which pushes rubber band on to haemorrhoid when desired

inner cylinder on to which rubber band is stretched

Fig. 6.4 Rubber band ligation of haemorrhoids: (a) proctoscope; (b) haemorrhoid grasped by forceps; (c) operational end of applicator

Injection of haemorrhoids Aims • To exclude associated tumours (? colonoscopy) • To produce fibrosis in the submucous layer • To avoid injection into haemorrhoidal vessels The procedure is best for small haemorrhoids that bleed frequently. Equipment You will need: • a proctoscope with illumination and lubricant • a haemorrhoid (Gabriel) injection syringe and needle, or a 10 mL disposable syringe with a 21-gauge needle • a 5 mL ampoule of 5% phenol in almond oil • a 19-gauge drawing-up needle • forceps and cotton wool to wipe away faeces. Method 1. The patient lies in the left lateral position. 2. Insert the lubricated proctoscope to visualise the haemorrhoids.

3. Draw up 5 mL of oily phenol. 4. Aim the injection at the upper end (base) of the haemorrhoid, which should be above the anorectalring (injections given below this are very painful). Pierce the mucosa with a quick stab. 5. Inject up to 3 mL into the submucous plane. The bevel of the needle should be directed towards the mucosa rather than towards the lumen of the rectum. The injection should be painless (Fig. 6.5). Inject the phenol slowly until an opalescent swelling (blanching) is seen, displaying the vessels in the mucosa more superficially (the ‘striate’ sign). 6. The amount of phenol injected varies from 1 mL to 5 mL (usually 3 mL).

Anal fissure The acute fissure Treatment is with warm saline Sitz baths, analgesics and 15 g bran or psyllium fibre orally each day for 3 months.

95

96

Practice Tips

Method 3: Lateral sphincterotomy The anal sphincter mechanism comprises internal and external sphincters. The spasm of the internal sphincter that occurs because of an anal fissure is relieved by the procedure of lateral sphincterotomy, allowing the fissure to heal in about 2 weeks. The procedure gives dramatic relief; however, the rare complication of permanent faecal incontinence has to be considered. Procedure under local anaesthetic 1. The patient lies on the side. 2. Palpate the ridge between the internal and external sphincter, and infiltrate local anaesthetic (1% lignocaine with adrenaline) (Fig. 6.6a). 3. Introduce a no. 11 scalpel blade (or fine cataract knife) on a handle through the skin at a tangent to the internal sphincter fibres. 4. Rotate the blade through 90° to face the fibres, with the examining finger in the anal canal. Fig. 6.5  Position of needle for the injection of haemorrhoids

Milder cases

(a)

In a milder case of anal fissure the discomfort is slight, anal spasm is a minor feature and the onset is acute. Conservative management • Xyloproct suppositories or ointment • High-residue diet (consider the addition of unprocessed bran) • Avoidance of constipation with hard stools (aim for soft bulky stools) • Glyceryl trinitrate ointment (Nitro-bid 2%) diluted 1 part with 9 parts white soft paraffin applied to the lower anal canal 2 to 3 times daily. A commercial preparation is Rectogesic ointment—apply 3 times daily for 6 weeks or until healed

More severe chronic fissures

internal sphincter external sphincter

fissure sentinel pile

ridge between sphincters infiltrated with 1% lignocaine with adrenaline

(b)

The feature here is a hyperactive anal sphincter, and a practical procedure is necessary to solve this painful problem. Method 1: Digital anal dilatation Under general anaesthesia (or even adequate local anaesthesia), undertake four-finger (maximum) anal dilatation for 4 minutes. This is effective, but is usually followed by a brief period of incontinence. Anal dilatation under general anaesthesia is a most appropriate treatment for children with anal fissures. Method 2: Inject botulinum toxin into the sphincter Several studies indicate excellent results when botulinum toxin is injected into the surrounding internal sphincter. Its availability and cost are limiting factors.

gloved finger in anal canal

no. 11 scalpel blade

Fig. 6.6  Anal fissure: (a) basic anatomy of the anal canal; (b)direction of cutting through the internal sphincter with a scalpel blade

Chapter 6 | Treatment of ano-rectal problems

5. Careful, slow advancement and withdrawal of the blade will cut through the sphincter muscles, the sensation akin to cutting through many rubber bands around a finger (Fig. 6.6b). 6. When the spasm is felt to subside, cease cutting. 7. Rotate the blade 90° again and withdraw. Firm pressure on the wound will stop any bleeding.

(a)

Procedure under general anaesthetic A qualified surgeon performs an open lateral sphincterotomy. Post-procedure The patient is instructed to take 20 mL of Agarol atnight or 12 hourly to achieve loose bowel motions for the next 5 days.

(b)

Proctalgia fugax Main features • Fleeting rectal pain in adults • Varies from mild discomfort to severe spasm • Lasts 3 to 30 minutes • Often wakes patient at night • Can occur at any time of day • A functional bowel disorder Management • Explanation and reassurance • Salbutamol inhaler (2 puffs statim) worth a trial Alternatives include glyceryl trinitrate spray forthesymptom or prophylactic quinine bisulphate at night.

Perianal abscess Clinical features • Severe, constant throbbing pain • Fever and toxicity • Hot, red, tender swelling adjacent to anal margin • Non-fluctuant swelling Careful examination is necessary to make the diagnosis. Look for evidence of a fistula-in-ano and an ischio-rectal abscess. Treatment Drainage via a cruciate incision over the point of maximal induration (Fig. 6.7a). Method 1. Infiltrate 10 mL of 1% lignocaine with adrenaline in and around the skin overlying the abscess (in some people a general anaesthetic may be preferable).

Fig. 6.7  Perianal abscess: (a) cruciate incision over abscess; (b) extension of cruciate incision

2. Make a cruciate incision. 3. Insert artery forceps to open the abscess cavity and evacuate the pus. 4. Excise the corners of the cruciate incision to produce a circular skin defect (about 2 cm in diameter) (Fig.6.7b). 5. Dress the wound with gauze soaked in a mild antiseptic. Post-procedure • Change gauze dressings twice daily. • Have warm saline Sitz baths prior to new dressing. • If undue bleeding occurs, pack the cavity for 24 hours and add covering dressings. Antibiotics If a perianal or perirectal abscess is recalcitrant or spreading with cellulitis, use metronidazole 400 mg (o) 12 hourly for 5–7 days plus cephalexin 500 mg (o)6hourly for 5–7 days.

Perianal warts It is important to distinguish the common viral warts from the condylomata lata of secondary syphilis. Counselling and support are necessary. Not all warts are sexually transmitted.

97

98

Practice Tips

Treatment The warts may be removed by chemical or physical means. The simplest and most effective treatment for readily accessible warts is: • podophyllotoxin 5% paint (a more stable preparation) –– Apply bd with plastic applicator for 3 days. –– Repeat in 4 days if necessary (may need four treatments). or • podophyllin 25% solution in tinct benz co –– Apply with a cotton wool swab to each wart. –– Wash off in 4 hours, then dust with talcum powder. –– Repeat once weekly until warts disappear. or • imiquimod (Aldara) cream –– Apply 3 times weekly until resolved.

Anal fibro-epithelial polyps These polyps are usually overgrown anal papillae which present as an irritating prolapse. They are removed by infiltrating the base with local anaesthetic, crushing it with artery forceps and applying a ligature. They are benign but the removed lesion should undergo histological examination if there is any doubt.

Pruritus ani In addition to the usual measures, consider cleaning the anus (after defaecation) with cotton wool dampened in warm water. Cotton wool is less abrasive than paper, and soap also irritates the problem. General measures • Stop scratching. • Bathe carefully: avoid hot water, excessive scrubbing and soaps.

• Use bland aqueous cream, Cetaphil lotion or Neutrogena soap. • Keep the area dry and cool. • Keep bowels regular and wipe with cotton wool soaked in water. • Wear loose-fitting clothing and underwear. • Avoid local anaesthetics and antiseptics. If still problematic and a dermatosis is probably involved, use: • hydrocortisone 1% cream, or • hydrocortisone 1% cream with clioquinol 5% to 3% (most effective). If an isolated area and resistant, infiltrate 0.5 mL of triamcinolone intradermally. If desperate, use fractionated X-ray therapy.

Rectal prolapse In the emergency situation it may be possible to reduce the swelling and thence the prolapse by covering the prolapse with a liberal sprinkling of fine crystalline sugar (common table sugar).

Cautionary points regarding ano-rectal disorders • Every patient who presents with ano-rectal problems should undergo a digital rectal examination for anorectal cancers. • Practitioners need to be properly trained in techniques such as sclerosant injections and rubber band ligation in order to reduce the likelihood of complications.

Chapter 7

Foot problems

Calluses, corns and warts The diagnosis of localised, tender lumps on the sole of the foot can be difficult. The differential diagnosis ofcallus, corn and wart is aided by an understanding of their morphology and the effect of paring these lumps (Table 7.1). A callus (Fig. 7.1) is simply a localised area of hyperkeratosis related to some form of pressure and friction. A corn (Fig. 7.2) is a small, localised, conical thickening, which may resemble a plantar wart but which gives a different appearance on paring. A wart (Fig. 7.3) is more invasive, and paring reveals multiple small, pinpoint bleeding spots.

Fig. 7.3 Wart

Treatment of plantar warts There are many treatments for this common and at times frustrating problem. A good rule is to avoid scalpel excision, diathermy or electrocautery because of the problem of scarring. One of the problems with the removal of plantar warts is the ‘iceberg’ configuration (Fig. 7.4) and not all may be removed. Pare the wart with a scalpel or file with a pumice stone or emery board prior to treatment.

Fig. 7.1 Callus

Fig. 7.2 Corn

Fig. 7.4  ‘Iceberg’ configuration of plantar wart

100

Practice Tips

Table 7.1  Comparison of the main causes of a lump on the sole of the foot Typical site Callus

Corn

Wart

Nature

where skin is normally thick: beneath heads of metatarsals, heels, inframedial side of great toe

hard, thickened skin

where skin is normally thin: on soles, fifthtoe, dorsal projections of hammertoes

white, conical mass of keratin, flattened by pressure

anywhere, mainly over metatarsal heads, base of toes and heels; has bleeding points

viral infection, with abrupt change from skin at edge

Effect of paring

normal skin

exposes white, avascular corn with concave surface

exposes bleeding points

Liquid nitrogen

Occlusion with topical chemotherapy

1. Pare wart. 2. Apply liquid nitrogen (use double freeze–thaw cycle). 3. Repeat every 2 weeks until resolved. Can be painful and results are often disappointing.

A method of using salicylic acid in a paste for the treatment of plantar warts is described here.

Topical chemotherapy 1. Pare wart (particularly in children). 2. Apply Upton’s paste to wart each night and cover. 3. Review as necessary. (Upton’s paste comprises trichloroacetic acid 1 part, salicylic acid 6 parts, glycerine to a stiff paste.)

Topical chemotherapy and liquid nitrogen 1. Pare wart (a 21-gauge blade is recommended). 2. Apply paste of 70% salicylic acid in raw linseed oil. This can be done by placing a corn pad over the wart and filling the central hole with the paste. Protect the surrounding skin with nail polish (acetone) or Sleek tape. 3. Occlude for 1 week. 4. Pare on review, then curette or apply liquid nitrogen and review.

Curettage under local anaesthetic 1. Pare the wart vigorously to reveal the extent of the wart. 2. Thoroughly curette the entire wart with a dermal curette. 3. Hold the foot dependent over a kidney dish until the bleeding stops (this always stops spontaneously and avoids a bleed later on the way home). 4. Apply 50% trichloroacetic acid to the base.

Equipment You will need: • 2.5 cm (width) elastic adhesive tape • 30% salicylic acid in Lassar’s paste. (Ask the chemist to prepare a thick paste, like plasticine.) (Lassar’s paste comprises zinc oxide, starch and salicylic acid, dispersed in white petrolatum.) Method 1. Cut two lengths of adhesive tape, one about 5 cm and the other shorter. 2. Fold the shorter length in half, sticky side out (Fig. 7.5a). 3. Cut a half circle at the folded edge to accommodate the wart. 4. Press this tape down so that the hole is over the wart. 5. Roll a small ball of the paste in the palm of the hand and then press it into the wart. 6. Cover the tape, paste and wart with the longer strip of tape (Fig. 7.5b). 7. This paste should be reapplied twice daily for 2 to 3 weeks. 8. The reapplication is achieved by peeling back the longer strip to expose the wart, adding a fresh ball of paste to the wart weekly and then recovering with the upper tape. The plantar wart invariably crumbles and vanishes. If the wart is particularly stubborn, 50% salicylic acid can be used. For finger warts use 20% salicylic acid. This method should not be used for vaginal, penile or eyelid warts.

Chapter 7 | Foot problems

(a)

(b) sticky side

wart and salicylic acid paste

long strip

short strip

Fig. 7.5  (a) ‘Window’ to fit the wart is cut out of shoulder strip of elastic adhesive tape; (b) larger strip covers the wart andshoulder strip

Alternative chemicals • Formalin: Wearing gloves, syringe a small amount out of a specimen jar and place in a test tube. Upturn the test tube on the wart and leave in place for 5 minutes. Repeat daily and pare the wart weekly. Formalin is toxic: use with caution and keep in a locked cabinet. • Salicylic acid 17%, lactic acid 17% in collodion (Dermatech Wart Treatment). • Paste of trichloroacetic acid 1 part, salicylic acid 6 parts, glycerine 20 gm (Upton’s paste). • Salicylic acid, lactic acid in collodion (Duofilm).

Poultice of aspirin and tea tree oil Method 1. Place a non-effervescent 125–300 mg soluble aspirin tablet on the centre of the wart and dampen it with 15% tea tree oil in alcohol. 2. Cover with a cotton pad and tape firmly with Micropore. Allow it to get wet to encourage dissolution. 3. After one week remove the dressing and debride or curette the friable slough. 4. Repeat if necessary.

• Proper footwear is essential—wide shoes and cushioned pads over the ball of the foot. • Provide paring with a scalpel blade (the most effective) or file with callus files. • If severe, daily applications of 10% salicylic acid in soft paraffin or Eulactol Heel Balm with regular paring. Paring method Hold a no. 10 scalpel blade with the bevel almost parallel to the skin and shave the lines of any cracks with small, swift strokes (Fig. 7.6). Scrape along the lines of any cracks, not into them. Be careful not to draw blood.

Treatment of corns Hard corns, e.g. outside of toes • Remove the cause of friction and use wide shoes. • Soften the corn with daily applications of 15% salicylic acid in collodion and then pare when soft. An alternative is to apply commercial medicated disks on a daily basis for about 4 days, then pare.

Simple (and unusual) treatments The banana skin method 1. Cut a small disk of banana skin to cover the wart. 2. Apply the inner soft surface of the banana skin to the wart and cover with tape. 3. Perform this daily for a few weeks or as long as necessary. The citric and acetic acid method Soak pieces of lemon rind in vinegar for 3 to 4 days and then apply a small piece to the wart each day and cover with tape. The crumbling slough can usually be curetted out after 2 to 3 weeks.

Treatment of calluses • No treatment is required if asymptomatic. • Remove the cause.

Fig. 7.6 Method of using a scalpel or similar knife to shaveoff a callus

Soft corns in webbing of toes For soft corns between the toes (usually the last toe-web), treat in the same way, but keep the toe-webs separated with lamb’s wool at all times, or use cigarette filter tips (these can be purchased at tobacco stores) separately and dust with a foot powder.

101

102

Practice Tips

‘Cracked’ heels Method 1 • Soak the feet for 30 minutes in warm water containing an oil such as Alpha-Keri or Derma Oil. • Pat dry, then apply a cream such as Nutraplus (10% urea) or Eulactol Heel Balm. • Apply twice daily and keep covered at night e.g. with cotton socks.

• a pad made from sponge or sorbo rubber placed inside the shoe to raise the heel about 1 cm. Ahole corresponding to the tender area can be cut out ofthepad to avoid direct contact with the sole (Fig. 7.7).

Method 2 Consider applying medical skin glue, e.g. Histoacryl or even Superglue, to neatly fill a dry crack and leave, with review in 4 days.This provides instant pain relief and often good healing.

Plantar fasciitis

Fig. 7.7 Types of insole heel pads made from sponge or sorbo rubber

Plantar fasciitis is a very common and surprisingly debilitating condition that may take 12 to 36 months (typically 2 years) to resolve spontaneously.

Hydrotherapy

Features • Pain: –– under the heel (about 5 cm from end of heel) –– can be diffuse over heel –– when first step out of bed –– relieved by walking around after shower –– increasing towards the end of the day –– worse after sitting –– felt as a severe throbbing while sitting • Minimal signs • X-ray may reveal a calcaneal spur

The following tips have proved very useful for patients. Hot and cold water treatment The patient places the affected foot in a small bath of very hot water and then a small bath of cold water for 20 to 30 seconds each time. This is continued on an alternating basis for 15 minutes—preferably twice a day and best before retiring at night. Therapeutic foot massage Commercial electrical foot hydro-massagers are available at low cost and are recommended for patients with plantar fasciitis.

Patient advice

Exercises

• • • •

Most foot surgeons now recommend regular stretching exercises as the basis of effective treatment. The aim is to allow the plantar fascia to heal at its ‘natural length’. Stretching should be performed at least 3 times a day. It is recommended to perform at least 2 of the following exercises.

Avoid standing for long periods if possible. Rest from long walks and running. Try to cope without injections. Keep the heel ‘cushioned’ by wearing comfortable shoes and/or inserts in shoes. • Surgery is rarely required and is not usually recommended. Excision of the calcaneal spur is advised against.

Footwear and insoles Obtain good, comfortable shoes with a cushioned sole (e.g. Florsheim ‘comfortech’; sporting ‘runners’). Examples of orthotic pads: • Viscospot orthotic (sold by Melbourne Orthotics) • Rose insole • an insole tailored by your podiatrist

Exercise 1: sitting position stretch 1. Sit on a bed with both legs straight out in front of you and your hands on your knees. 2. Using a rope towel or cord looped around the foot, pull the foot back and point your toes towards your head, bending the foot upwards at the ankle (Fig. 7.8a). The more effort you put into the motion, the better the stretch will be. 3. Hold the position for as long as possible (at least 30 seconds). Repeat several times.

Chapter 7 | Foot problems

Exercise 2 1. Stand on a stair, with the ball of your foot (or feet) on the edge of the stair, and keep your knees straight. 2. Holding the rails for balance, let your heels gently drop as you count to 20. Do not bounce (Fig. 7.8b). You should be relaxed, and no active muscle contraction should be necessary in your leg. 3. Lift your heels and count to 10. 4. Repeat the cycle twice. You will feel tightness both in the sole or heel of the foot, and at the back of the leg (as the Achilles tendon is also stretched).

Exercise 3 1. Stand against a solid wall with your painful foot behind you and the other foot closer to the wall (Fig. 7.8c). 2. Point the toes of the affected foot towards the heel of the front foot. Keep the knee of the painful foot straight and the painful heel on the floor. (b)

(a)

(c)

(d)

Fig. 7.8 Exercises for plantar fasciitis: (a) exercise 1; (b) exercise 2; (c) exercise 3 (right foot affected); (d) exercise 4 (left foot affected)

103

104

Practice Tips

3. Bend the front knee forward—you will feel the Achilles tendon in the painful foot grow tight. 4. Count to 20, then relax for a count of 10. 5. Repeat the cycle twice. 6. Change over the position of each foot and repeat the program to stretch the opposite Achilles tendon. Exercise 4 You must be wearing flexible sole shoes for this exercise. 1. Stand against the wall with your good foot behind you and the painful foot jammed into the juncture of the wall and floor (Fig. 7.8d). 2. Bend the knee of the front leg, which will bring it towards the wall. You will feel that both the Achilles tendon and the tissue on the sole of the foot (plantar fascia) are being stretched by this exercise. 3. Count to 20, then relax for a count of 10. 4. Repeat the cycle twice. 5. Change over the position of each foot and repeat the program to stretch the opposite side.

Injection An injection of corticosteroid mixed with local anaesthetic can be very effective during the period of severe discomfort. (See Fig. 3.26, p. 44.) The relief usually lasts for 2 to 4 weeks during this difficult period. However, injections are generally avoided. (a)

Strapping for plantar fasciitis

strapping configuration

Strapping of the affected foot can bring symptomatic relief for the pain of plantar fasciitis. A few strapping techniques can be used but the principle is to prevent excessive pronation, create a degree of inversion and reduce tension on the origin of the plantar fascia by compressing the heel. Use non-stretch sticking tape about 3–4 cm wide. Method • Start with the tape on the lateral side of the dorsum of the foot (Fig. 7.9a). • Run the tape in a figure-of-eight configuration to include the sides of the heel but squeeze the heel from the sides to make a ‘pad’ immediately before applying and fixing the tape. • Repeat twice (Fig. 7.9b). If reinforcement is desired, a U-shaped strip of tape can be applied to the sides of the foot—from the neck of the metatarsals on one side to the other. Also, a strip of holding tape can encircle the foot.

squeeze heel

(b)

Other tips Manual massage Massage the sole of the foot over a wooden foot massager, a glass bottle filled with water, or even a golf ball for 5 minutes, preferably 3 times daily.

Course of NSAIDS It is worthwhile to conduct a trial of a 3-week course of NSAIDS during the time when there is most pain (about 4 to 7 weeks after the problem commences). It can be continued if there is a good response.

Fig 7.9  Strapping for plantar fasciitis: (a) first application; (b) final appearance

Chapter 8

Nail problemS

Splinters under nails Foreign bodies, mostly wooden splinters, often become deeply wedged under fingernails and toenails (Fig.8.1a). Efforts by patients to remove the splinters often aggravate the problem. Methods of effective removal are outlined here.

that a good grip can be obtained. (A poor grip can result in fragmentation of the splinter.) 3. Obtain a good grip on the end of the splinter with the splinter or small-artery forceps, and remove with a sharp tug in the axis of the finger (Fig. 8.1c). (a)

(b)

The needle lever method Take a sterile hypodermic needle, or any household needle that can be sterilised in a gas jet flame, and insert it just underneath the splinter, parallel to the nail through the entry tract. Then push the protruding end of the needle downwards. Since the needle spears the splinter, the lever effect drags out the splinter.

(c)

The V-cut out method Equipment You will need: • needle, syringe and 1% lignocaine • small scissors • splinter forceps or small-artery forceps. Method 1. Perform a digital nerve block to anaesthetise the involved digit (may not be necessary in rugged individuals). 2. Using small but strong scissors, cut a V-shaped piece of nail from over the end of the splinter (Fig. 8.1b). It is important to leave sufficient splinter exposed so

Fig. 8.1 Shows: (a) splinter under nail; (b) V-shaped incision; (c) tug with forceps

The ‘paring’ method Use a no. 15 scalpel blade to gradually pare the nail overlying the splinter to create a window so that the splinter can be lifted out (Fig. 8.2). This is painless since the nail itself has no innervation.

106

Practice Tips

Fig. 8.2  Method of paring over a nail splinter using light shaving strokes

Onychogryphosis Onychogryphosis, or irregular thickening and overgrowth of the nail, is commonly seen in the big toenails of the elderly (Fig. 8.3). It is really a permanent condition. Simple removal of the nail by avulsion is followed by recurrence some months later. Softening and burring of the nail gives only temporary relief, although burring sometimes provides a good result. The powder from burring can be used as culture for fungal organisms. Permanent cure requires ablation of the nail bed after removal of the nail. Two methods of nail bed ablation are: • total surgical excision • cauterisation with pure phenol.

3. Paint the nail bed and germinal layer with pure phenol on a cotton bud, with special attention to the groove containing the nail matrix. Leave the phenol on for 2 to 3 minutes, flush it with alcohol to neutralise it, mop dry and apply a dressing. Pack a small piece of chlorhexidine (Bactigras) tulle into the wound and then cover with sterile gauze and a bandage. Caution: • Avoid spilling pure phenol onto normal skin. • Remember to remove the tourniquet.

Myxoid pseudocyst There are two types of digital myxoid pseudocysts(also known as mucous cysts) appearing in relation to the distal phalanx and nail in either fingers or toes (more common) (Fig. 8.4). One type occurs in relation to, and often connecting with, the distal interphalangeal joint and the other occurs at the site of the proximal nail fold. The latter (more common) is translucent and fluctuant, and contains thick clear gelatinous fluid, which is easily expressed after puncture of the cyst with a sterile needle. Osteoarthritis of the DIP is associated with leakage of myxoid fluid into the surrounding tissue to form the cyst.

Fig. 8.4  Myxoid pseudocyst: typical position of the cyst

Fig. 8.3 Onychogryphosis Adapted from A. Forrest et al., Principles and Practice of Surgery, Churchill Livingstone, Edinburgh, 1985, with permission.

Cauterisation method 1. Apply a tourniquet to the toe after administering ring block. 2. Remove the nail by lifting it away from the nail bed and then grasping the total nail or two halves (after it is cutdown the middle) with strong artery forcepsandusing a combination of rotation and traction.

Some pseudocysts resolve spontaneously. If persistent and symptomatic attempt: • repeated aspiration (aseptically) at 4–6 weekly intervals or • cryosurgery or • puncture, compression, then infiltration intralesionally with triamcinolone acetonide (or similar steroid). Pseudocysts tend to persist and recur and, if so, refer to surgery for total excision of the proximal nail fold and/or ligation of the communicating stalk to the DIP.

Subungual haematoma The small, localised haematoma There are several methods of decompressing a small, localised haematoma under the fingernail or toenail that causes considerable pain. The objective is to release the blood by drilling a hole in the overlying nail with a hot wire or a drill/needle.

Chapter 8 | Nail problemS

Method 1: The sterile needle Simply drill a hole by twisting a standard disposable hypodermic needle (21- or 23-gauge) into the selected site. Some practitioners prefer drilling two holes to facilitate the release of blood. Method 2: The hot paper clip Take a standard, large paper clip (Fig. 8.5a) and straighten it. Heat one end (until it is red hot) in the flame of a spirit lamp (Fig. 8.5b). Immediately transfer the hot wire to the nail, and press the point lightly on the nail at the centre of the haematoma. After a small puff of smoke, an acrid odour and a spurt of blood, the patient will experience immediate relief (Fig. 8.5c). (a)

(b)

Method 3: Electrocautery This is the best method. Simply apply the hot wire of the electrocautery unit to the selected site (Fig. 8.6). It is very important to keep the wire hot at all times and to be prepared to withdraw it quickly, as soon as the nail is pierced. It should be painless. hot wire of electrocautery unit

localised haematoma

Fig. 8.6 Electrocautery to subungual haematoma

(a)

Method 4: Algerbrush II A gentler method suitable for children is the Algerbrush II, used by ophthalmologists to remove rust rings from the cornea. It resembles a small dental burr, is battery operated and gently drills through the fingernail.

(c)

Important precautions • Reassure patients that the process will not cause pain; they may be alarmed by the preparations. • The hot point must quickly penetrate, and go no deeper than the nail. The blood under the nail insulates the underlying tissues from the heat and, therefore, from pain. • The procedure is effective for a recent traumatic haematoma under tension. Do not attempt this procedure on an old, dried haematoma, as it will be painful and ineffective. • Advise the patient to clean the nail with spirit or an antiseptic and cover with an adhesive strip to prevent contamination and infection. • Advise the patient that the nail will eventually separate and a normal nail will appear in 4 to 6 months.

The large haematoma Where blood occupies the total nail area, a relatively large laceration is present in the nail bed. To permit a good,long-term functional and cosmetic result it is imperative to remove the nail and repair the laceration (Fig. 8.7).

Fig. 8.5  (a) A standard paper clip; (b) the end of the paper clip is heated in the flame of a spirit lamp; (c) the point of the clip is pressed lightly on the nail at the centre of the haematoa

Method 1. Apply digital nerve block to the digit. 2. Remove the nail. 3. Repair the laceration with 4/0 plain catgut. 4. Replace the fingernail, which acts as a splint, and hold this in place with a suture for 10 days.

107

108

Practice Tips

(a)

(b)

diffuse haematoma

(c)

The spiral tape method This simple technique involves the application of adhesive tape such as Micropore to retract the skin off the ingrowing nail. The tape is then passed around the plantar surface to anchor the tape in loops around the proximal aspect of the toe (Fig. 8.9). The application of Friar’s Balsam to the distal ‘achor’ gives a better grip. This process is repeated twice weekly until the problem settles.

Fig. 8.7 Shows (a) diffuse haematomas; (b) sutures to laceration; (c) fingernail as splint

Ingrowing toenails (onychocryptosis) There are a myriad methods to treat ingrowing toenails. Some very helpful ones are presented here. Cautionary note Treatment of ingrowing toenails is a potential legal ‘minefield’, especially with wedge resection. Keep in mind the following: • Full and detailed discussion with the patient about the procedure used and its risks is recommended. • Avoid adrenaline with the local anaesthetic—use plain lignocaine or bupivacaine. • Avoid prolonged use of a tourniquet and do not forget to remove a rubber band if used. • Avoid tight circumferential dressings. • Be careful with diabetics and those with peripheral vascular diseases. • Avoid excessive use of phenol for nail bed cautery. • Give clear post-operative instructions. • It is best to treat when the infection settles.

Fig. 8.9 The spiral tape method for the ingrowing toenail

Central thinning method An interesting method for the prevention and treatment of ingrowing toenails is to thin out a central strip of the nail plate. This is usually performed with the blade of a stitch remover or a no. 15 scalpel blade. The central strip is about 5 mm wide and is thinned out on a regular basis (Fig. 8.10).

Prevention It is important to fashion the toenails so that the corners project beyond the skin (Fig. 8.8). Then each day, after a shower or bath, use the pads of both thumbs to pull the nail folds as indicated. cut nail towards centre

corners of nail project beyond skin

Fig. 8.8  Stretch nail folds with thumb daily

Fig. 8.10 Illustrating strip of nail plate to thin out

Chapter 8 | Nail problemS

Excision of ellipse of skin

Electrocautery

Figure 8.11 shows the toe in extremis. The procedure transposes the skinfold away from the nail.The skin heals, the nail grows normally and the toe retains its normal anatomy.

If the nail is severely ingrown, causing granulation tissue or infection of the skin or both, a most effective method is to use electrocautery to remove a large wedge of skin and granulation tissue so that the ingrown nail stands free of skin (Fig. 8.13). This is performed under digital block. The toe heals surprisingly quickly and well (with minimal pain). The long-term result is excellent, because the nail that is not cut in this procedure can grow (and be trimmed) free of flesh.

ingrowing toenail

Fig. 8.11 Ingrowing toenail

Method 1. An elliptical excision is made after a digital block (Fig. 8.12a). The width of the excision depends on the amount of movement of the skinfold required to fully expose the nail edge. 2. The skinfold is forced off the nail (Fig. 8.12b). Any blunt instrument can be used for this purpose. The wound closure holds the fold in its new position. 3. Any granulation tissue and debris should be removed with a curette. The toe heals well, and there are usually no recurrences of ingrowing. (b)

(a)

Fig. 8.14  Phenolisation method: lift the nail fold and apply the phenol on a stick

Wedge resection The aim is to remove about one-quarter of the nail. Excise en bloc the wedge of nail, nail fold, nail wall and nail bed. Then back cut and curette out the lateral recess to ensure that the spicule of germinal matrix is removed.

Phenolisation Fig. 8.12 Excision of ellipse of skin electrocautery needle ingrowing nail lies free

cauterised wedge of tissue

Fig. 8.13 Electrocautery to wedge of tissue

This method uses 80% phenol (pure solution) to treat the nail bed after simply removing the wedge of nail. It is not necessary to perform a standard wedge resection of the ingrown nail and nail bed. The success rate is almost 100%. Method 1. Perform a ring block with plain local anaesthetic. 2. Apply a tourniquet so that a bloodless field is obtained. 3. Using scissors, mobilise the nail on the affected side and excise the nail sliver for about one quarter of its width. 4. Curette the nail sulcus to remove any debris from the area. 5. Lift the nail fold and insert a cotton bud soaked (not saturated) in 80% phenol onto the corresponding nail bed (Fig. 8.14).

109

110

Practice Tips

6. Leave the bud in place for 1½ to 2 minutes. 7. Remove and wash out the nail fold area with an alcohol swab. 8. Apply a dressing and review as necessary. Cautionary tale Pure phenol is a cytotoxic agent that causes a chemical burn and can be destructive to skin, causing a nasty slough. Several doctors using this excellent method claim that its value has been spoilt by causing severe burns to the surrounding skin. This has occurred because the swab had excess phenol that spilt onto the surrounding skin. This must be avoided with carefully controlled application, and if spillage occurs it must be washed off immediately with alcohol.

Wedge resection of nail with delayed nail fold excision This method works very well where there is infection with swollen tissue. Method 1. Perform a digital block. 2. Cut a standard wedge of ingrown nail (as for previous method). No further tissue is removed (Fig. 8.15a). 3. Dress and leave for 2 to 3 months.

(a) (a)

wedge of nail removed

4. After this time, perform a linear elliptical excision of the nail fold skin for the length of the nail extending to almost the tip of the toe. This should be about 3–4 mm from the nail margin to ensure skin necrosis does not occur. Suture and allow to heal (Fig. 8.15b).

The elliptical block dissection open method This method, described by Chapeski, is claimed to cure all cases of ingrown toenails and the wound, if performed aseptically and dressed properly, will not get infected. The wound heals in about 4 weeks. Method 1. Perform a digital block. 2. Place an elastic band around the toe and wait 5minutes. 3. An incision is made at the base of the nail, about 3–4mm from the edge, and then continued towards theside of the nail in an elliptical sweep to end upunder the tip of the nail about 3–4 mm from the edge. 4. The ingrown skin (about 10 × 20 mm) is thus removed along with subcutaneous tissue (it is important that none of the skin remains around the edge of the nail) (Fig. 8.16). 5. Cauterise any bleeding points, e.g. with a silver nitrate stick. 6. A 3 mm thick Sofra-tulle square is then placed directly over the wound, followed by a single gauze square (to wrap the toe), then a simple 25 mm Elastoplast pressure dressing.

infected granulation tissue wide ellipse of skin and subcutaneous tissue removed

Step 1

(b)

(b)

excised thin strip of nail fold skin

Step 2: treatment when healed

Fig. 8.15  Wedge resection of nail with delayed nail fold excision

Fig. 8.16 Elliptical block dissection open method

Chapter 8 | Nail problemS

Note: Bleeding can be a problem when the patient walks, so place a small plastic bag over the foot before pulling on the shoe. The patient should elevate the foot at home for an hour or so. Follow-up • Next day, the patient should soak the foot in lukewarm water for 15 to 20 minutes, gradually peel off the old dressing and then apply several layers of fine mesh gauze and tape them into place. • Repeat the soaking procedure religiously 3 times daily for 20 minutes. • Follow up the patient weekly for 4 weeks—cauterise any granulation tissue (a sign of poor compliance) with silver nitrate and dress.

Paronychia The extent of the procedure depends on the extent of the infection (Fig. 8.18). For all methods anaesthetise the finger or toe with a digital block. pus

Fig. 8.18 Paronychia

The ‘plastic gutter’ method This simple method separates the ingrowing nail from the skin to allow healing. Method 1. Cut a length (to match the nail) of tubing from a scalp vein plastic cannula and cut it down the middle to form a hemi-cylinder. 2. Under suitable local anaesthetic lift the skin around the ingrowing toenail with forceps and insert the tubing (Fig. 8.17). Leave it in place for 1 week covered with a dressing. It can be stitched to the skin. 3. Repeat if necessary. skin

plastic insert ingrowing nail

Fig. 8.17 Illustration of the ‘plastic gutter’ method

Tip for post-operative pain relief Procedures on the toe, especially for ingrown toenails, can be very painful, especially during the night after the surgery. Plan these procedures as the final appointment for the day and use the long-acting local anaesthetic bupivacaine 0.5% (Marcaine).

Method 1: Lateral focus of pus 1. With a size 11 or 15 scalpel blade incise over the focus of pus (Fig. 8.19a). 2. Probe deeply until all pus is released. 3. Insert a small wick into the wound and allow to heal. Method 2: Central focus of pus Elevate the eponychial fold with a pair of fine artery forceps (Fig. 8.19b). This will release the pus. Method 3: Infection adjacent to nail Gently pack a fine wisp of cotton wool or gauze into the space between the paronychia and the nail and apply povidone-iodine. Dry and repeat as necessary. It should be relatively painless. Method 4: Extensive infection under nail 1. If the infection extends under the nail, this fold should be pushed back proximally with a small retractor to expose the nail base. 2. Elevate the nail base bluntly and excise the proximal end of the nail with sharp scissors (Fig. 8.19c). (Alternatively, the nail can be removed.) 3. Apply petroleum jelly gauze dressing and use a light splint for 3 days. 4. The patient should be encouraged to wear gloves to keep the area dry.

Excision of nail bed Method 1. Apply a tourniquet after digital or ring block. 2. Make skin incisions (Fig. 8.20a). 3. Avulse the nail using strong artery forceps. 4. Elevate the skin flaps (Fig. 8.20b). 5. Excise the nail bed carefully, including the undersurface of the overhanging skin (Fig. 8.20c).

111

112

Practice Tips

Equipment You will need: • 40% salicylic acid ointment • plastic ‘skin’.

(a) incision line pus

(b)

(b)

(c)

Method 1. Apply plastic ‘skin’ spray to the skin around the nail to prevent possible skin maceration. 2. Apply 40% salicylic acid ointment to the nail. Use a liberal application, but confine it to the nail. 3. Cover with plastic wrap. Post-procedure • Reapply the ointment every 2 days. • Maintain for about 4 weeks. This treatment will soften and destroy the nail.

Fig. 8.19 Treatment of paronychia: (a) incision for lateralfocus of pus; (b) elevation of eponychial fold; (c) excision ofproximal end of nail Reproduced from A. Forrest et al., Principles and Practice of Surgery, Churchill Livingstone, Edinburgh, 1985, with permission.

Traumatic avulsed toenail If a toenail, particularly of the great toe, is torn away, it is appropriate to reapply it as a splint, secure it with stay sutures (e.g. chromic catgut) and apply continuing dressings (Fig. 8.21). This provides protection and promotes healing.

6. Scrape the bone with a Volkman’s spoon to ensure that no parts of the nail root remain. 7. Apply the phenolisation method also at this stage (with caution). 8. Suture the skin flaps (Fig. 8.20d).

slot toenail under cuticle

Nail avulsion by chemolysis Indication Dystrophic toenails (e.g. from chronic fungal infection) in patients with peripheral vascular disease or other conditions where surgery is inadvisable.

stay sutures

Fig. 8.21 Traumatic avulsed toenail

(a)

(b)

(c)

(d)

Fig. 8.20 Excision of nail bed: (a) skin incisions; (b) elevation of skin flap; (c) excision of nail bed; (d) suturing of skin flaps Reproduced from A. Forrest et al., Principles and Practice of Surgery, Churchill Livingstone, Edinburgh, 1985, with permission.

Chapter 9

Common trauma General Essential tips for dealing with trauma Common traps • • • •

Failure to diagnose a foreign body Failure to diagnose a ruptured tendon Exposed joint capsule in the fist Beware of bites, high pressure guns and puncture wounds

Stab wounds Always assume (and look for) the presence of nerve, tendon or artery injury.

Jumping or falling from a substantial height onto feet Always consider a fractured calcaneum, talus, spine (especially lumbar) or pelvis and central dislocation of hip. Concussion can follow.

Cut finger or toe Always look for a peripheral nerve injury.

Finger tourniquet If using a small tourniquet such as a rubber band for haemostasis, clip on a small artery forcep so it is not forgotten when you finish.

Foreign bodies

Other cautionary tips

Buried wooden splinters, gravel and slivers of glass are old traps—if suspected and not found on simple exploration, order high-resolution ultrasound, which is good at detecting wood and glass. CT is best.

• You can get concussion from a heavy fall onto the coccyx/sacrum. • Think of a sewing needle in the knees of women and in the feet of children for unexplained pain. • Treat (evacuate) haematomas of the nasal septum and ear because they can collapse cartilage. • Beware of pressure gun injuries into soft tissue, especially those involving oil and paint. • Beware of a painful immobile elbow in a child—look for a fracture that can cause trouble later. • Beware of the scaphoid fracture after a fall onto an outstretched hand.

Falling on the outstretched hand Consider the following fractures: Colles (distal radius); scaphoid; radius and ulna shafts; head of radius; supracondylar (children); neck and shaft of humerus, clavicle and the dislocations—lunate and shoulder.

114

Practice Tips

Finger trauma Finger injuries can be treated by simple means, providing there is neither tendon nor nerve injuries complicating the lacerations or compound fractures involved.

Finger tip loss Not all finger tip loss demands an immediate graft or tidyup amputation. If there is no exposed phalanx tip and the area of exposed subdermal tissue is small, conservative management is best. Remember that a grafted finger tip is insensate. If the amputated skin tip is available it should be replaced (use Steri-strips or a couple of small sutures), as it may take as a graft or merely act as a good biological dressing.

Large skin loss Apply a split skin graft, preferably using a Goulian knife with three spacing devices.

Amputated finger

Cut a suitable length of a dressing strip. Cut through the adhesive to the dressing strip— 1–1.5 cm from the top. adhesive margins 1.5 cm (cut here)

central dressing strip Remove the backing from the lower segment and apply to the injured side of the finger. injured finger tip

In this emergency situation, instruct the patient to place the severed finger directly into a fluid-tight sterile container, such as a plastic bag or sterile specimen jar. Then place this ‘unit’ in a bag containing iced water with crushed ice. Note: Never place the amputated finger directly in ice or in fluid such as saline. Fluid makes the tissue soggy, rendering microsurgical repair difficult. Care of the finger stump Apply a simple, sterile, loose, non-sticky dressing and keep the hand elevated.

Finger tip dressing A method of applying a dressing (using an adhesive dressing strip) for an injured finger tip is described. Method 1. Cut a suitable length of the dressing strip almost as long as the finger. 2. Cut through the adhesive margins to the central non-adhesive dressing about 1–1.5 cm from the top (Fig. 9.1). 3. Remove the backing from the lower larger segment and apply to the injured side of the finger. Wrap the adhesive part around the circumference of the finger. 4. Now remove the backing from the upper segment and fold it backwards over the tip, with the adhesive margins wrapped around the finger to provide the most effective dressing.

side strips wrapped around finger

Remove the backing from the upper segment and fold it backward over the tip.

upper flap folded over finger tip and secured

Fig. 9.1 Applying a finger tip dressing

Chapter 9 | Common trauma

Abrasions Abrasions or ‘gravel rash’ vary considerably in degree and potential contamination. They are common with bicycle or motorcycle accidents and skateboard accidents. Special care is needed over joints such as the knee or elbow.

Management (see p. 73) • Clean meticulously, remove all ground-in dirt, metal, clothing and other material. • Scrub out dirt with sterile normal saline under anaesthesia (local infiltration or general anaesthesia

• • • • •

for deep wounds). Adequate local anaesthesia may also be achieved by coating the wound liberally with Xylocaine jelly 2% and leaving for 10 minutes. Treat the injury as a burn. When clean apply a protective dressing (some wounds may be left open). Use paraffin gauze and non-adhesive absorbent pads such as Melolin. Ensure adequate follow-up. Immobilise a joint that may be affected by a deep wound.

Haematomas Haematoma of the pinna (‘cauliflower ear’)

(a)

When trauma to the pinna causes a haematoma between the epidermis and the cartilage, a permanent deformity known as ‘cauliflower ear’ may result. The haematoma, if left, becomes organised and the normal contour of the ear is lost. The aim is to evacuate the haematoma as soon as practicable and then to prevent it re-forming. One can achieve a fair degree of success even on haematomas that have been present for several days. Method 1. After cleansing the pinna with a suitable solution (e.g. cetrimide), insert a 25-gauge needle into the haematoma and aspirate the extravasated blood. 2. Position the needle at the lowest point while pressing the upper border of the haematoma gently between finger and thumb (Fig. 9.2a). 3. Apply a padded test tube clamp to the haematoma site and leave on for 30–40 minutes. The test tube clamp has large jaws that allow it to be placed over the haematoma site (Fig. 9.2b). Generally, daily aspirations and clamping are sufficient to eradicate the haematoma completely.

(b)

Haematoma of the nasal septum Septal haematoma following injury to the nose can cause total nasal obstruction. It is easily diagnosed as a marked swelling on both sides of the septum when inspected through the nose (Fig. 9.3). It results from haemorrhage between the two sheets of mucoperiosteum covering the septum. It may be associated with a fracture of the nasal septum.

Fig. 9.2 Treatment of cauliflower ear

Note: This is a most serious problem as it can develop into a septal abscess. The infection can pass readily to the orbit or the cavernous sinus through thrombosing veins and may prove fatal, especially in children. Otherwise it

115

116

Practice Tips

• Prescribe systemic (oral) antibiotics, e.g. penicillin or erythromycin. • Treat as a compound fracture if an X-ray reveals a fracture.

Pretibial haematoma A haematoma over the tibia (shin bone) can be persistently painful and slow to resolve. An efficient method is, under very strict asepsis, to inject 1 mL of 1% of lignocaine and 1 mL of hyaluronidase and follow with immediate ultrasound. This may disperse or require drainage.

Roller injuries to limbs

Fig. 9.3 Inferior view of nasal cavity showing bilateral swelling of septal haematoma

may lead to necrosis of the nasal septal cartilage followed by collapse and nasal deformity. Treatment • Remove the blood clot on both sides through an incision, under local anaesthetic. This must be done within 2 hours of injury.

A patient who has been injured by a wheel or by rollers passing over a limb can present a difficult problem. An arm caught in the wringers of an old-fashioned washing machine used to be a common example, but a more likely problem now is the wheel of a vehicle passing over a limb, especially a leg. A freely spinning wheel is not so dangerous, but serious injuries occur when a non-spinning (braked) wheel passes over a limb, and then perhaps reverses over it. This leads to a ‘degloving’ injury due to shearing stress. The limb may look satisfactory initially, but skin necrosis will follow. To manage a ‘wheel over the limb’ injury, treat it as a serious problem and admit the patient to hospital for observation. Surgical intervention with removal of necrotic fat may be essential. Fasciotomy with open drainage may also be an option.

Fractures Testing for fractures This method describes the simple principle of applying axial compression for the clinical diagnosis of fractures of bones. It applies especially to suspected fractures of bones of the forearm and hand, but also applies to all bones of the limbs. Many fractures are obvious when applying the classic methods of diagnosis: pain, tenderness, loss offunction, deformity, swelling and sometimes crepitus. It issometimes more difficult if there is associated soft-tissue injury from a blow or if there is only a minorfracturesuch as a greenstick fracture of the distal radius. If the bone is compressed gently from end to end, a fracture will reveal itself and the patient will feel pain. A soft-tissue injury of the forearm will show pain, tenderness, swelling and possibly loss of function. It will, however, not be painful if the bone is compressed axially—that is, in its long axis.

Walking is another method of applying axial compression, and this is very difficult (because of pain) in the presence of a fracture in the weightbearingaxis or pelvis. Hence, every patient with a suspected fracture of the lower limb should be tested by walking. Method 1. Grasp the affected area both distally and proximally with your hands. 2. Compress along the long axis of the bones by pushing in both directions, so that the forces focus on the affected area (fracture site; Fig. 9.4a). Alternatively, compression can be applied from the distal end with stabilising counterpressure applied proximally (Fig.9.4b). 3. The patient will accurately localise the pain at the fracture site.

Chapter 9 | Common trauma

(a)

patient bites on spatula

(b) doctor holds spatula firmly, then rotates it

Fig. 9.5 Spatula test for fracture of the mandible

Fig. 9.4 Testing for fractures: (a) axial compression to detect a fracture of the radius or ulnar bones; (b) axial compression to detect a fracture of the metacarpal

Spatula test for fracture of mandible A simple office test for a suspected fractured mandible is to get the patient to bite on a wooden tongue depressor (or similar firm object). Ask them to maintain this bite as you twist the spatula (Fig. 9.5). If they have a fracture, they cannot hang on to the spatula because of pain.

First aid management of fractured mandible • Check the patient’s bite and airway. • Remove any free-floating tooth fragments and retain them. • Replace any avulsed or subluxed teeth in their sockets. Note: Never discard teeth. • First aid immobilisation with a four-tailed bandage (Fig. 9.6).

Fig. 9.6 Immobilisation of a fractured mandible in a four-tailed bandage

Treatment Refer for possible internal fixation. A fracture of the body of the mandible will usually heal in 6–12 weeks (depending on the nature of the fracture and the fitness of the patient).

Fractured clavicle There is a history of a fall onto the outstretched hand or elbow. The patient has pain aggravated by shoulder movement and usually supports the arm at the elbow and clasped to the chest. The most common fracture site

117

118

Practice Tips

is at the junction of the outer and middle thirds, or in the middle third. Treatment • St John elevated sling to support the arm—for 3 weeks. • Figure-of-eight bandage (used mainly for severe discomfort). • Early active exercises to elbow, wrist and fingers. • Active shoulder movements as early as possible. Special problem Fracture at the lateral end of the bone. Consider referral for open reduction. Healing time 4–8 weeks. The healing times for uncomplicated fractures are presented in Table 9.1, page 121.

Bandage for fractured clavicle A figure-of-eight bandage can be made simply by inserting pads of cotton wool into pantyhose or stockings.

Fractured rib A simple rib fracture can be extremely painful. The first treatment strategy is to prescribe analgesics such as paracetamol, and encourage breathing within the limits of pain. If pain persists in cases of single or double rib fracture with no complication, application of a rib support is most helpful.

The universal rib belt A special elastic rib belt can provide thoracic support and mild compression for fractured ribs (Fig. 9.7). Despite its flexibility it gives excellent support and symptom relief while permitting adequate lung expansion. The elastic belt is 15 cm wide and has Velcro grip fastening, so it can be applied to a variety of chest sizes.

Fig. 9.7 Method of application of rib belt

Angulation is usually obvious, but it is most important to check for rotational malalignment, especially with torsional fracture. A simple method is to get the patient to make a fist of the hand and check the direction in which the nails are facing. Furthermore, each finger can be flexed in turn and checked to see if the fingertips point towards the tubercule of the scaphoid (palpable halfway along the base of the thenar eminence and 1.5 cm distal to the distal wrist crease). The phalanges

Healing time 3–6 weeks.

• Distal phalanges:

usually crush fractures; generally heal simply unless intra-articular.

Towel method

• Middle phalanges:

tend to be displaced and unstable—beware of rotation.

The patient can wrap a standard-sized towel (folded lengthwise to a third of its width) around the chest and secure it with a large safety pin. When the patient is about to cough, the towel can be pulled tight by the patient.

• Proximal phalanges: are the greatest concern, especially of the little finger; intra-articular fractures usually need internal fixation.

Phalangeal fractures These fractures require as near perfect reduction as possible, careful splintage and, above all, early mobilisation once the fracture is stable—usually in 2 or 3 weeks. Early operative intervention should be considered if the fracture is unstable.

Treatment of uncomplicated fractures For non-displaced phalanges with no rotational malalignment, strap the injured finger to the adjacent normal finger with an elastic garter or adhesive tape for 2–3 weeks, i.e. ‘buddy strapping’ (Fig. 9.8). Start the patient on active exercises.

Chapter 9 | Common trauma

Collar and cuff sling This is useful for the patient with a fractured humerus, because it allows gravity to realign the distal and proximal parts of the fractured bones.

Fig. 9.8 Treatment of non-displaced phalanges by ‘buddy strapping’: the fractured finger is strapped to an adjacent healthy ftinger

If pain and swelling is a problem, splint the finger with a narrow dorsal or anterior slab (a felt-lined strip of malleable aluminium can be used) (Fig. 9.9). An alternative is to bandage the hand while the patient holds a tennis ball or appropriate roll of bandage in order to maintain appropriate flexion of all interphalangeal joints.

Fig. 9.9 Method of splinting a phalangeal fracture of the index finger by a posterior plaster slab

Slings for fractures There are three slings in common use in first aid: Sling

Main indications

Collar and cuff

Fractured humerus

Broad arm

Fractured forearm

St John

Fractured clavicle Dislocated acromioclavicular joint Subluxed acromioclavicular joint Infected or fractured hand

Method 1. Using a narrow bandage, make a clove hitch (Fig. 9.10a). The clove hitch is made by fashioning two loops—one towards your body and the other away, leaving one end of the bandage longer than the other. Now place your fingers under the loops and bring them together. 2. Slide the loops over the wrist of the injured arm with the knot of the clove hitch on the thumb side of the wrist. 3. Gently flex the elbow and elevate the injured arm so that the fingers point towards the opposite shoulder (Fig. 9.10b). 4. Place the long end of the bandage around the neck and tie the bandage, using a reef knot (Fig. 9.10c).

The broad arm sling This has multiple uses but is used mainly for injuries to the forearm and wrist. Method 1. Place an open triangular bandage over the patient’s chest, with the point of the triangle stretching beyond the elbow of the injured side. Place the flexed forearm over the bandage as shown (see Fig. 9.11a). 2. Carry the upper end of the bandage over the shoulder on the uninjured side, around the back of the neck. Ensure that the injured arm lies slightly above the horizontal position. 3. Tie the long ends of the bandage in the hollow abovethe collar bone of the injured side (see Fig. 9.11b). 4. Fold the corner adjacent to the injured elbow and secure it with a safety pin.

The St John sling This sling, used for a fractured clavicle, dislocated acromioclavicular joint, or fractured or infected hand, supports the elbow and keeps the hand in elevation resting comfortably on the shoulder of the uninjured side. Method 1. Place an open triangular bandage over the patient’s forearm and hand with the point of the triangle to the elbow and the upper end over the far shoulder. 2. Tuck the long edge of the bandage under the whole forearm to make a supporting trough (Fig. 9.12a). 3. Convey the lower dependent end around the patient’s back to the front of the far shoulder.

119

120

Practice Tips

(a)

(a)

(b)

(b)

(c)

Fig. 9.10  (a) Preparing a clove hitch; (b) flex the elbow and elevate the injured arm; (c) applying a collar and cuff sling

Fig. 9.11  (a) The broad arm sling: first step; (b) the broad arm sling

Chapter 9 | Common trauma

4. Tie the ends as close to the fingers as possible (Fig. 9.12b). 5. Tuck the triangular point firmly in between the forearm and the bandage. 6. Secure the fold with a safety pin when the sling is firm, comfortable and at the correct elevation.

Table 9.1  Healing of uncomplicated fractures (adults) Fracture

(Approximate) average immobilisation time (weeks)

Rib

3–6 (healing time)

The makeshift sling

Clavicle

4–8 (2 weeks in sling)

An effective sling can be made with a large jumper or windcheater.

Scapula

weeks to months

Humerus • neck • shaft • condyles

3–6 8 3–4

Radius • head of radius • shaft • Colles’ fracture

3 6 4–6

Radius and ulna (shafts)

6–12

Ulna—shaft

8

Scaphoid

8–12

Metacarpals • Bennett’s # • other

6–8 3–4

Phalanges (hand) • proximal • middle • distal

3 2–3 2–3

Pelvis

Rest in bed 2–6

Femur • femoral neck • shaft • distal

according to surgery 12–16 8–12

Patella

3–4

Method 1. Place the sleeves of the jumper around the neck and knot the ends. 2. Guide the affected arm into the sleeve until a suitable recess is found.

Important principles for fractures • Children under 8 years usually take half the time to heal. • Have a check X-ray in 1 week (for most fractures). • Radiological union lags behind clinical union. (a)

(b)

Fig. 9.12  (a) The St John sling: first step; (b) the St John sling

Tibia

12–16

Fibula

6

Both tibia and fibula

12–16

Potts fracture

6–8

Lateral malleolus avulsion

3

Calcaneus • minor • compression

4–6 14–16

Talus

12

Tarsal bones (stress #)

8

Metatarsals

4

Phalanges (toes)

0–3

Spine • spinous process • transverse process • stable vertebra • unstable vertebra • sacrum/coccyx

3 3 3 9–14 3

121

122

Practice Tips

Other trauma Primary repair of severed tendon Immediate repair of cut tendons by primary suture is important, preferably by an experienced surgeon. Partial ruptures usually require no active surgery, although primary repair is recommended if greater than 40% of the tendon is severed. Method for totally cut tendon 1. Debride the wound. 2. Pass a loop suture of 3/0 monofilament nylon on a straight needle into the tendon through the cut surface close to the edge to emerge 5 mm beyond and then construct a figure-of-eight suture as shown in Fig. 9.13a–c. 3. Pull the two ends of the suture to take up the slack without bunching the tendon (Fig. 9.13d). (a)

4. Repeat this with the other end of the tendon (Fig. 9.13e). 5. Tie the corresponding suture ends together in order to closely approximate the cut ends of the tendon (Fig. 9.13f ). 6. Bury the knots deep between the tendon and cut the sutures short (Fig. 9.13g). Post-operation Hold the repaired tendons in a relaxed position with suitable splintage for 3–4 weeks.

Burns and scalds Burns can be caused by flame/fire, hot liquids, hot objects such as irons and heaters, ultraviolet radiation, electricity and certain chemicals. Scalds are burns from hot liquids, hot food or steam. (c)

(b)

(d)

(e)

(f)

(g)

Fig. 9.13  Primary suture of a cut tendon: (a–c) inserting figure-of-eight suture; (d) pulling the two ends of the suture; (e) inserting a similar suture in the other end of the tendon; (f) tying the sutures and burying the knots; (g) suture is completed

Chapter 9 | Common trauma

First aid, including safety rules The immediate treatment of burns, especially for smaller areas, is immersion in cold running water such as tap water, for a minimum of 20 minutes. Do not disturb charred adherent clothing but remove wet clothing. • Ensure you and the burnt person are safe from further injury or danger. • Cool a burnt or scalded area immediately for at least 20 minutes with cool to cold (around 15˚C; preferably running) water. Safety first rules • Stop the burning process and remove any source of heat, if possible. • Flames: Smother with a blanket (preferably a ‘fire blanket’ if available). –– Direct flames away from the head or douse with water. –– Roll person on ground if clothing still burning. –– Remove clothes over the burnt area IF not stuck to skin. • Scalds: Remove clothing that has been soaked in boiling water or hot fat. –– Remove clothing carefully only if the skin is not blistered or stuck to it. –– Cool with cool or tepid water for at least 20 minutes. • Chemical burns: Remove affected clothing. –– Wash or irrigate the burn for at least 30 minutes. –– Do not try to neutralise the chemical. • Electrical: Disconnect the person from the electrical source. –– Use a wooden stick or chair to remove person if you cannot switch off the electricity. (Don’t approach if connected to high-voltage circuit.) Some useful rules • It is best to cut clothing with sharp scissors especially from limbs. • Remove possible constricting items, e.g. bracelets, watches, rings. • Cover the burn with plastic cling wrap (not the first 6 cm). Apply this in strips and not wrapped circumferentially. • A burnt hand can be placed in a plastic bag. • Give basic analgesics for small burns e.g. paracetamol. • Cool running water is useful for 3 hours after a burn. • Cool the burn; warm the patient. Some don’ts • Prick blisters (leave this to medical attendants). • Apply creams, ointments, grease, lotions. • Apply adhesive, sticky or fluffy cotton dressings. • Put butter, oils, ice or ice water on burns to children. Types of burns There are three levels of burns.

• Superficial—affects only the top layer of skin. The skin will look red and is painful. • Partial thickness—causes deeper damage. The burn site will look red, blistered, peeling and swollen with yellow fluid oozing and is very painful. • Full thickness—damages all layers of the skin. The burn site will look white or charred black. There may be little or no pain. Remember Consider your own safety as you stop the burning process: • if on fire—stop–drop–roll • if chemical— remove the stuff and flush with copious water • if electrical—turn off power. Refer the following burns to hospital: • > 9% surface area, especially in a child • > 5% in an infant • all deep burns • burns of difficult or vital areas (e.g. face, hands, perineum/genitalia, feet) • burns with potential problems (e.g. electrical, chemical, circumferential) • suspicion of inhalational injury • suspicion of non-accidental injury in children or vulnerable people • burns in the elderly, children < 12 months and pregnant women. Always give adequate pain relief. During transport, continue cooling by using a fine mist water spray.

Major burns A major burn is an injury to more than 20% of the total body surface for an adult and more than 10% for children. As a guiding rule, one arm is about 9%, one leg 18%, face 7% in adults and 16% in toddlers. The surface area of burns for a child is shown in Figure 9.14, which includes the useful Lund–Browder chart for estimating the extent of the burn. Major burns are a medical emergency and require urgent treatment: call triple zero (000) or your local emergency number. Guidelines for going straight to hospital (burnsunit) • Full thickness burns—adults over 10% and children over 5% of body surface • Burns including partial thickness burns to difficult and vital areas—hands, feet, face, joints, perineum and genitalia • Circumferential burns—those that go right around a limb or the body • Respiratory/inhalation burns (effects may be delayed for a few hours) • Electrical burns • Chemical burns

123

124

Practice Tips

3. Deep burns. If considerable ooze, apply the following in order. –– Solosite gel, Solugel or similar –– non-adherent neutral dressing (e.g. Melolin) –– layer of absorbent gauze or cotton wool (larger burns). Change every 2–4 days with analgesic cover. Surgical treatment, including skin grafting, may be necessary.

A

A

1 1 2

2

13

112

2

112

112

112 112

112

1

13

112 212

212

B

B

B

B

C

C

C

C

134 134

Area A = ½ of head B = ½ of one thigh C = ½ of one leg

2

112

• Keep open without dressings (good for face, perineum or single surface burns). • Renew coating of antiseptic cream every 24 hours.

Dressings (closed method)

134 134

Age 0 9½ 2¾ 2½

1 8½ 3¼ 2½

5 6½ 4 2¾

10 5½ 4¼ 3¼

15 4½ 4½ 3¼

Exposure (open method)

Adult 3½ 4¾ 3½

Fig. 9.14  Lund and Browder chart: estimation of extent of burns in children

Treatment 1. Very superficial—intact skin: Can be left with an application of a mild antiseptic only. Review if blistering. 2. Superficial—blistered skin: Apply a dressing to promote epithelialisation (e.g. hydrocolloid sheets, hydrogel sheets) covered by an absorbent dressing (e.g. paraffin gauze or MelolinTM) or a retention stretch adhesive material (e.g. Fixomull, Mefix, Opsite) with daily or twice daily cleaning of the serous ooze and reapplication of outer bandage. Leave 7 days. Guidelines to patient for retention dressings • First 24 hours: keep dry. If there is any ooze coming through the dressing, pat dry with a clean tissue. • From day 2: wash over dressing twice daily. Use gentle soap and water, rinse then pat dry. Do not soak. Rinse only. Do not remove the dressing as it may cause pain and damage to the wound. If the wound becomes red, hot or swollen or if pain increases, return to the clinic. • From day 7: return to the clinic for removal of the dressing.Two hours prior to coming into the clinic, soak the dressing with olive oil then cover with Glad Wrap. Note: Dressing must be soaked off with oil (e.g. olive, baby, citrus or peanut). Debride ‘popped blisters’. Only pop blisters that interfere with dermal circulation.

• Suitable for circumferential wounds. • Cover creamed area with non-adherent tulle (e.g. paraffin gauze). • Dress with an absorbent bulky layer of gauze and wool. • Use a plaster splint if necessary.

Burns to the hand For superficial blistered burns to the hand or similar ‘complex’ shaped parts of the body apply strips of the retention stretch adhesive dressings as described above. They conform well to digits. Apply an outer bandage. At 7 days soak the dressings in oil for 2 hours prior to coming into the clinic.

Rapid testing of the hand for nerve injury Following an injury to the arm or hand that has the potential for a nerve injury, it is important when one examines a hand to have a knowledge of simple tests that detect injuries to the three main nerves—the median, the ulnar and the radial.

The ‘quick’ hand test for nerve injury Get the patient to make the following configurations: • ‘4-fingered cone’ (Fig. 9.15a)—if the patient can do this, the ulnar nerve is intact • ‘5-fingered cone’ and ability to approximate the thumb (Fig. 9.15b)—success means the median nerve is intact • ‘trigger test’ for the thumb—that is, extension—if normal, the radial nerve is intact (Fig. 9.15c).

Summary of arm nerve injuries • Ulnar nerve—inability to abduct little finger • Median nerve—inability to abduct thumb • Radial nerve—inability to extend thumb

Chapter 9 | Common trauma

ulnar nerve

median nerve

radial nerve

Fig. 9.15 Rapid testing of the hand for nerve injury

Froment’s sign Ask the patient to grip a sheet of paper forcefully between the thumbs and index fingers while the examiner tries to pull the paper away. A positive Froment’s sign is a weak

pinch with marked flexion of the interphalangeal joint of the thumb. This occurs because of loss of action of adductor pollicis caused by injury to the deep branch of the ulnar nerve. Flexor pollicis longus overcompensates.

125

Chapter 10

Removal of foreign bodies General Cautionary note

maggots in the superior conjunctival fornix

Failure to diagnose the presence of a foreign body has emerged as a common cause of malpractice actions against general practitioners. It is particularly important to locate and remove foreign bodies, especially splinters in children, glass slivers after motor vehicle accidents and pub brawls and metal objects such as needles in the feet of children.

oedema of the upper lid

conjunctivitis

Removal of maggots The larvae of the common blowfly can find their way into the most unexpected corners of the body, and can be extremely difficult to remove. This unusual problem is more likely to occur in unkempt people, such as alcoholics and itinerants, and in those with exposed wounds. Examples of sites that can become infested are the eye, the ear, traumatic wounds in comatose victims, and rodent ulcers.

The eye The presence of maggots should be suspected when an unkempt person presents with a red eye and with marked swelling (Fig. 10.1). When disturbed, the maggots crawl for cover and are difficult to see and remove. Method 1. Instil LA (e.g. amethocaine). 2. Instil two drops of eserine or pilocarpine to ‘paralyse’ the maggots.

Fig. 10.1  Maggots in the eye

3. Remove the maggots with fine forceps.

Wounds A writhing mass of maggots can be a difficult problem, and has to be rendered inactive. The old ‘trick’ was to use chloroform, but ether is just as effective. Method 1. Irrigate the infested wound with the anaesthetic until the activity ceases. 2. Carefully remove all the intruders. Using dextrose Apply 10% dextrose to the maggots. If unsuccessful apply 50% dextrose.

Chapter 10 | Removal of foreign bodies

Removal of leeches There are several varieties of leeches in this country, but the most troublesome are the small, black leeches that inhabit the damp forests of New South Wales,Victoria and Tasmania. The major problem is the difficulty of removing a parasite adhering firmly to such awkward anatomical sites as the eye, or the urethral meatus in men. No attempt should be made to extract the leech manually. There are several methods of inducing leeches to ‘jump off’ rapidly: • application of hot objects • application of salt • application of a detergent • application of toothpaste • slicing the leech in half with a knife. Method 1. Carefully apply a hot object near the end of the leech. The object could be the hot tip of a snuffed out match (Fig. 10.2) or the heated end of a paper clip. 2. The leech soon lets go!

dislodging the tick, and more toxin is thereby injected into the host. As an office procedure, many practitioners grasp the tick’s head as close to the skin as possible with fine forceps or tweezers, and pull the tick out sideways with a sharp rotatory action. This is acceptable, but not as effective as the methods described here. First aid bush removal method 1. Saturate the tick with petrol, kerosene or insect repellant such as Rid, and leave for 3 minutes. 2. Loop a strong thread around the tick’s head as close to the skin as possible, and pull sharply. Alternative methods • Apply tea-tree oil 12 hourly—leave 24 hours and remove. • Apply 5% acetic acid firmly onto the tick with a cotton bud. Wait 30 seconds, then slowly turn the end of the bud anticlockwise until the tick is dislodged. Shock freezing Freeze the tick with liquid nitrogen Kryospray and remove it in toto. Lignocaine anaesthetic method Infiltrate 1% lignocaine under and around the head of the tick. It should then be easily extracted because of immobilisation and eversion of the mouth parts. If not, move on to the office procedure.

leech match

Fig. 10.2  Removal of leech from the eye

Embedded ticks Some species of ticks can be very dangerous to human beings, especially to children. If they attach themselves to the head and neck, a serious problem is posed. As it is impossible to distinguish between dangerous and non-dangerous ticks, early removal is mandatory. The tick should be totally removed, and the mouthparts ofthe tickmust not be left behind. Do not attempt to grab the tick by the body and tug. This is rarely successful in

Loop of suture material method 1. Select a long length of 3/0 nylon or silk or dental floss. 2. Loop it over the tick and tie a single knot. 3. Holding the nylon flush with the skin, slowly tighten the knot over the neck of the tick. 4. Pull off the tick with a sharp rotatory action. Office procedure 1. Infiltrate a small amount of LA in the skin around the site of embedment. 2. With a no. 11 or 15 scalpel blade make the necessary very small excision, including the mouth parts of the tick to ensure total removal (Fig. 10.3). 3. The small defect can usually be closed with a Bandaid (or Steri-strips). Punch biopsy method A very practical method is to inject local anaesthetic and then use a punch biopsy to remove the entire tick. If the punch will not fit over the tick cut it behind its head and then punch out the head parts. Use a cross pulley stitch (Fig. 4.13, p. 60) to close the wound.

127

128

Practice Tips

mouthparts of the tick

engorged tick skin line of excision

Fig. 10.3  Removing the embedded tick

Removal of ring from finger From time to time one is faced with the need to remove a ring from a swollen finger. Destruction of a possibly valuable piece of jewellery can often be avoided by the following. (a)

Method 1. Using a needle, bent paper clip or bobby pin, pass a length of dental tape (the best), cord or string (or Mersilk) under the ring (Fig. 10.4a). The ring should be over the narrowest part of the phalanx for this. 2. Liberally apply petroleum jelly or moistened soap paste to the finger, distal to the ring. Wind about six turns of the string around the finger close to and immediately distal to the ring (Fig. 10.4b). 3. While holding the end (B) of the cord firmly, pull the proximal end (A) over the ring, roughly parallel to the long axis of the finger, unwinding it steadily in the same direction in which the distal coils were wound originally (Fig. 10.4c). The pressure of the cord is thus applied successively around the periphery of the ring, forcing it distally. The distal cords, by applying pressure, also help to reduce the oedema of the finger. In many cases the ring slides off with little or no discomfort and without damage to ring or finger. Sometimes a digital block may be necessary.

Splinters under the skin The splinter under the skin is a common and difficult procedural problem. Instead of using forceps or making a wider excision, one method is to use a disposable hypodermic needle to ‘spear’ the splinter (Fig. 10.5) and then use it as a lever to ease the splinter out through the skin. Reactive objects such as thorns, spines and wood should be removed as soon as possible.

(b) splinter needle

(c)

skin

B

A

Fig. 10.4  Removal of ring from finger: (a) thread string through bobby pin or needle passed under ring; (b) wind string firmly round finger after liberally applying Vaseline; (c)hold firm at B and pull and unwind at A

Fig. 10.5  Removal of splinters

Superficial horizontal splinters These are usually readily palpated under the skin. Apply antiseptic and infiltrate with local anaesthetic. Incise the

Chapter 10 | Removal of foreign bodies

skin over the length of the splinter using a no. 15 scalpel blade, to completely expose the splinter. Lift it out with the scalpel blade or with forceps. Alternatively, the overlying skin can be deroofed with a sterile 19-gauge needle in a feathering motion and then speared out with the aid of fine forceps.

Detecting skin splinters High-resolution ultrasound imaging by experienced operators can assist in both the diagnosis and removal of these foreign bodies. Table 10.1 shows the comparative efficacy of X-rays and ultrasound. CT scans are also very effective.

The vertical splinter This is more difficult but can be removed by making a superficial circular excision over the splinter followed by a deeper encircling incision to undermine the sides of the wound. The free central block of tissue containing the object can be picked out with fine forceps (Fig. 10.6).

Table 10.1 Efficacy of X-ray and ultrasound Material

Plain X-ray

Ultrasound

Wood

Poor

Good

Glass

Good

Good

Metal

Good

Good

Plastic

Moderate

Good

Plant (e.g. thorns)

Poor

Good

Removing the Implanon rod

Fig. 10.6  Method of removal of the vertical splinter

Removing spines of prickly pear, cactus and similar plants from the skin Gently apply an adhesive dressing such as Fixomull or Mefix.Then remove the prickles by pulling in the direction that they are pointing out of the skin with the grain, otherwise they will break at skin level.

Detecting fine skin splinters— the soft soap method Problem Finding fine foreign bodies in the skin that are difficult to see, such as cactus spurs and glass slivers. Method 1. Spread soft soap very lightly over the skin. The soap permits easier identification of the foreign bodies. 2. Remove the foreign bodies with splinter (or other types) forceps. Alternatively they can be removed with hair removal wax applied to the skin.

Identify the 4 cm long rod in the subcutaneous tissue by palpation and the insertion scar. (If not palpable, arrange ultrasound examination.) Infiltrate around the rod with LA. Palpate to identify one end of the rod with your finger. Then manipulate and depress it so that the opposite end ‘tents’ the skin. Make an incision over this pointing end and then blunt dissect around the rod until it is sufficiently exposed to remove with forceps.

Detecting metal fragments A simple tip for detecting subcutaneous metal pieces is to use a magnet and run it over the skin (the larger the magnet the better). If the metal ‘tents’ the skin, this is the site to make the incision.

Embedded fish hooks Six methods of removing fish hooks are presented here, some relying on removal in a direction continuous with their direction of entry to conform with the nature of the barb, others requiring removal in the reverse direction, against the barb. Method 4 or 5 is recommended as firstline management.

Method 1 1. Inject 1–2 mL of LA in front of and then below the hook. 2. Cut the shank with wire cutters or pliers below the eye (Fig. 10.7a). Alternatively, repeated bending at this point will cause the shank to snap.

129

130

Practice Tips

3. With a needle holder grasp the shank, press the point of the barb through the skin and remove.

Method 2 1. A sharp pull in the direction shown (Fig. 10.7b) will in most cases make the barb continue on its natural path and come out through the skin. 2. It can then be cut off easily and the rest of the hook extracted. No surgical instruments are required, simply a pair of pliers or wire cutters, but all personnel present should close their eyes when the barb is cut off.

Method 3 1. Inject 1–2 mL of LA around the fish hook. 2. Grasp the shank of the hook with strong artery forceps. 3. Slide a D11 scalpel blade in along the hook, sharp edge away from the hook, to cut the tissue and free the barb (Fig. 10.7c). 4. Withdraw the hook with the forceps.

1. Take a piece of string about 10–12 cm long and make a loop. One end slips around the hook as a double loop, the other hooking around one finger of the operator. 2. Depress the shank with the other hand in the direction that tends to disengage the barb. 3. At this point give a very swift, sharp tug along the cord. (Some find that using a ruler in the loop to flick out the hook is ideal.) 4. The hook flies out painlessly in the direction of the tug (Fig. 10.7d). Note: You must be bold, decisive, confident and quick, as half-hearted attempts do not work. For difficult cases, some local anaesthetic infiltration may be appropriate. Instead of a short loop of cord, a (c)

Method 4 This method, used by some fishermen, relies on a loop of cord or fishing line to forcibly disengage and extract the hook intact. It requires no anaesthesia and no instruments—only nerves of steel, especially for the first attempt. (a)

cut

exit

(b)

(d)

local anaesthetic

(e) sharp pull

hold loop of fishing tackle taut

loop of string or tackle

Fig. 10.7 Five methods of removing fish hooks: (a) cutting the shank; (b) cutting the barb; (c) cutting a skin path; (d) intact removal; (e) using double-string method

Chapter 10 | Removal of foreign bodies

long piece of fishing line double-looped around the hook and tugged by the hand will work.

Method 5 This method, regarded by some as the best, involves ‘flicking’ the hook out by traversing its path of entry into the skin. 1. Loop a length of fishing tackle around the eye of the hook. 2. Loop a length of string around the front curve of the hook. 3. Keep the fishing tackle taut by holding it firmly in a straight line with the non-dominant hand. 4. Now pull sharply outwards with the dominant hand so that it flicks the hook out (Fig. 10.7e). Caution: Take care not to let the hook fly off uncontrollably.

Method 6: The Irish (Castletownbere) method Principle Cover the barb of the hook with the bevel of the needle, which must be large enough (e.g. 17G, 19G) to accommodate the tip of the barb. There is then no resistance to its removal. Method 1. Inject 0.5 to 1 mL of local anaesthetic using an insulintype syringe into the actual puncture wound, wait 10 minutes. 2. Insert a 19G needle into the entrance wound and feed it along the hook until it is stopped by the barb (ensure that the bevel of the needle is directed towards the hook). The sharp tip of the hook is now inside the lumen of the needle (Fig. 10.8a). 3. Reverse out the hook and needle. Withdrawal is easy as the barb is covered by the stylus of the needle and there is no resistance to bringing it out (Fig. 10.8b). Helpful tips • Some barbs are deflected slightly to one side (left or right) on the way back. It is helpful if the patient can bring a sample of the fish hook • It can help to practise on a cooked sausage first to convince you how easy it is. (a)

Penetrating gun injuries Injuries to the body from various types of guns present decision dilemmas for the treating doctor. The tips below represent guidelines including special sources of danger to tissues from various foreign materials discharged by guns.

Gunshot wounds Airgun The rule is to remove subcutaneous slugs but to leave deeper slugs unless they lie within and around vital structures (e.g. the wrist). A special, common problem is that of slugs in the orbit. These often do little damage and can be left alone, but referral to an ophthalmologist would be appropriate. 0.22 rifle (pea rifle) The same principles of management apply but the bullet must be localised precisely by X-ray. Of particular interest are abdominal wounds, which should be observed carefully, as visceral perforations can occur with minimal initial symptoms and signs. 0.410 shotgun The pellets from this shotgun are usually dangerous only when penetrating from a close range. Again, the rule is not to remove deep-lying pellets—perhaps only those superficial pellets that can be palpated. 12 gauge shotgun This powerful gun can produce extensive damage at a range of several metres and are difficult to deal with. Stray pellets are a common finding in rural patients and can be left.

Pressure gun injuries Injection of grease, oil, paint and similar substances from pressure guns (Fig. 10.9) cause very serious injuries, requiring decompression and removal of the substances.

(b)

Fig. 10.8  (a) Needle bevel engages barb; (b) fish hook removed with needle

131

132

Practice Tips

oil injections into digital pulp

high-pressure grease or paint gun injections

Fig. 10.9 Dangerous accidental injections into the hand

Grease gun and paint gun High-pressure injection of paint or grease into the hand requires urgent surgery if amputation is to be avoided. There is a deceptively minor wound to show for this injury, and after a while the hand feels comfortable. However, ischaemia, chemical irritation and infection can follow, with gangrene of the digits, resulting in, at best, a claw hand due to sclerosis. Treatment is by immediate decompression and meticulous removal of all foreign material and necrotic tissue. Oil injection Accidental injection of an inoculum in an oily vehicle into the hand also creates a serious problem with local tissue necrosis. If injected into the digital pulp, this may necessitate amputation. Such injections are common on poultry farms, where many fowl-pest injections are administered.

Ear, nose and throat Removal of various foreign bodies Removal of foreign bodies (FBs) from the nose in children is a relatively urgent procedure because of the risks of aspiration. The same mechanical principles of removal apply to the ear. The nose should be examined using a nasal speculum under good illumination. The tip of the nose should be raised and pressed with the tip of a thumb. Do not attempt to remove foreign bodies from the nose by grasping with ‘ordinary’ forceps.

Summary of methods of removal 1. It is best to pass an instrument behind the FB and pull it forward. Examples of instruments are: • a eustachian catheter (Fig. 10.10a) • a probe to roll out FB, e.g. bent wax curette • a bent hair pin • a bent paper clip. 2. Snaring the FB is the method most suitable for soft foreign bodies (e.g. paper, foam rubber, cotton wool). It is more applicable to the nose. Examples of instruments are: • a foreign-body remover (Fig. 10.10b) • crocodile forceps (Fig. 10.10c). 3. Application of suction that uses instruments such as: • a rubber catheter • a fine sucker. 4. Irritation of FBs in nose (e.g. white pepper sprinkled in nose to induce sneezing). 5. Blowing techniques.

Soft foreign bodies The snaring technique is most suitable for soft objects such as paper, foam rubber and cotton wool. Method Under good light and being careful not to push the object further back into the nose, snare the material with either crocodile forceps or a foreign-body remover and gently remove.

Probe technique The method shown in Figure 10.11 simply requires good vision, using a head mirror or head light and a thin probe. Method 1. Insert the probe under and just beyond the FB (Fig. 10.11a). 2. Lever it in such a way that the tip of the probe ‘rolls’ the FB out of the obstructed passage (Fig. 10.11b, c). This technique seems to be successful with both hard and soft foreign bodies.

Bent hairpin technique This method requires an old-fashioned hairpin (the type with crinkly edges) bent to an angle of about 30°. Method 1. Push the pin back beyond the FB. 2. Depress the pin to ensnare the object. 3. Gently withdraw the FB (Fig. 10.12).

Chapter 10 | Removal of foreign bodies

(a)

(a) external ear canal

foreign body ear drum

(b) probe

(b)

(c)

(c)

Fig. 10.11  Removal of foreign body from ear: (a) probe inserted under foreign body; (b) tip of probe is lifted by depressing outer end of probe; (c) continuing levering ‘rolls’ the foreign body out Fig. 10.10 Instruments for removal of foreign bodies: (a) eustachian catheter; (b) foreign-body remover; (c) crocodile forceps

133

134

Practice Tips

nose

foreign body

old-fashioned hair pin

bent pin

Extracting the foreign body

Fig. 10.12 Extracting the foreign body using a hairpin

This method is relatively painless and highly effective; other methods of removing FBs may push them deeper into the nares.

Bent paper clip technique A simple, effective and disposable instrument can be made with a paper clip. Method 1. As demonstrated in Figure 10.13, open the paper clip with the hairpin bends at both ends intact. 2. Angulate the smaller end of the clip. The sharp ends of the hairpin bends should be bent towards the straight stems of the clip so that they do not cause trauma. The degree of angulation can be increased by the use of small-artery forceps if desired. The larger loop acts as a handle to get an effective grip. 3. The angulated end, passed gently over the foreign body in the nose or ear canal, acts as a scoop to remove the foreign body. Note: It is important to remember that only foreign bodies that can easily be seen in the ear or nose could be removed by this method. The paper clip instrument is not suitable for the removal of deeper foreign bodies. Patient cooperation is also very important.

Rubber catheter suction technique The following is a relatively simple and painless way of removing foreign bodies from the ears and noses of children. The only equipment required is a straight rubber catheter (large type) and perhaps a suction pump. The procedure causes minimal distress to a frightened child, avoids the need for a general anaesthetic, and is less traumatic than mechanical extraction for objects such as a round bead. Method 1. Cut the end of the catheter at right angles (Fig. 10.14a). 2. Smear the rim of the cut end with petroleum jelly. 3. Apply this end to the FB and then apply suction. Oral suction may be used for a recently placed or ‘clean’ object, but gentle pump suction, if available, is preferred (Fig. 10.14b). It is advisable to pinch close the suction catheter until close to the foreign body, as the hissing noise may frighten the child.

Pneumatic otoscopic attachment vacuum technique The following method is ideal for the removal of a foreign body from the nose or ear of a child where it can be very difficult to extract without the use of a general anaesthetic. The method is similar to using a rubber catheter with the end cut off, and applying it to the foreign body using oral suction. Method • Use the pneumatic otoscope attachment by removing the end fitting. • Squeeze the bulb to create a vacuum effect.

(a)

(b) paper clip

Sharp ends are bent near the stem of the clip to avoid trauma. Angulation is increased at the small hairpin bend. Paper clip opened with hairpin bends at both ends intact

Fig. 10.13 Extracting the foreign body using a bent paperclip

Fig. 10.14 Extracting the foreign body using a rubber catheter: (a) catheter cut straight across near its extremity; (b) application of suction (orally or by pump)

Chapter 10 | Removal of foreign bodies

• Place the end of the rubber tubing against the foreign body (Fig. 10.15). • Release the hand-squeeze on the bulb in order to create suction. • Extract the object. This method works very well for smooth, round foreign bodies such as beads. pneumatic otoscope attachment

foreign body

Fig. 10.15 The rubber tubing is placed against the foreignbody

Tissue glue and plastic swab technique Method This technique employs the simple method of applying a rapidly setting adhesive to bond the FB to the extracting probe. It works best in dry conditions and for a smooth non-impacted foreign body. 1. Apply a thin coat of cyanoacrylate or tissue glue totheend of a hollow plastic swab stick or orange stick. 2. Insert the stick into the ear canal (or nostril) to allow the glue to bond with the FB (if clearly accessible and suitable) for about 1 minute. 3. Remove the FB using gentle traction, perhaps assisted by external pressure from the fingers. Caution: Avoid touching the skin or mucous membrane. If glue is accidentally applied to the skin, dissolve the glue with acetone.

First line blow technique Press the ‘normal’ nostril and encourage a seated­ co-operative child to blow out (snort) from the nose.

The ‘kiss and blow’ technique This method, also known as the ‘mother’s kiss’ technique, is used for a cooperative child with a firm, round foreign body such as a bead or hard pea impacted in the anterior nares. Method 1. Gently occlude the normal (not affected) nostril with a finger. Place the mouth over the child’s mouth, blowing

into the mouth until a slight resistance is felt. (This indicates that the glottis is closed.) 2. Then give a sharp high velocity blow to cause the foreign body to ‘pop out’. To encourage cooperation with the technique the child can be asked to give the doctor a ‘kiss’ (or any ruse to allow placement of the lips over the child’s open mouth). Better still, explain the technique to the child’s parent and encourage the parent to perform it. (Mother is best!) On all occasions that this technique has been used (adapted from an article in The New England Medical Journal), the foreign bodies ‘popped out’ after two attempts, thus avoiding general anaesthetic with intubation. If stubborn: • instill nasal decongestants in the nose, leave 20 minutes and try again.

General principles about a foreign body in the ear The main danger of a foreign body in the ear lies in its careless removal. Syringing is very effective and safe for small foreign bodies. Vegetable foreign bodies, e.g. peas, swell with water and are better not syringed. Insects commonly become wedged in the meatus, especially in the tropics. They can be syringed or removed with forceps under vision. Maggots cause a painful ear and their removal is difficult— insufflation of pulv. calomel is usually effective treatment.

Insects in ears Live insects should be enticed out or killed by first instilling warm water (first option), saline or olive oil, then syringing the ear with warm water if necessary. The neatest method is to gently drip 4–5 mL of warm water or saline into the ear canal with a syringe, and then snare the insect with forceps as it crawls to the opening. Dead flies that have originally been attracted to pus are best removed by suction. Maggots are best killed by eserine drops, although other fluids should work. Syringing the ear is then appropriate. Note: 2mL of 1% lignocaine introduced by the blunt end of a syringe or via a cut-off ‘butterfly’ needle (or other piece of plastic tubing) is also effective. Note: The ingredients in Waxsol drops can be a problem. Olive oil can be difficult to syringe so water or saline is preferable.

A moth in the ear This is a very distressing sensation for the patient, who invariably telephones urgently at night with the problem.

135

136

Practice Tips

warm water or olive oil

upward direction of water

(b)

(a)

tympanic membrane moth

ear syringe

Fig. 10.16 Insect in ear: (a) first aid; (b) office procedure

First aid method at home Instruct the patient to insert drops of lukewarm water, olive oil or a similar preparation into the ear to immobilise the moth (Fig. 10.16a). Note: Ideally, olive oil should be gently warmed, e.g. by placing the bottle under running hot water from a tap for a short while. Office procedure Simply syringe the moth out of the ear with tepid water (Fig. 10.16b).

Cotton wool in the ear A common problem is the finding of the cotton wool tip of a ‘cotton bud’ which has become dislodged from injudicious self ear toilet. It can be seen deep in the ear canal. Method Obtain a dental broach and fashion a very small hook on the end. When inserted in the ear canal under vision, this hook can easily engage some threads of cotton and then extraction of the foreign body is simple (Fig. 10.17).

Fish bones in the throat Take a history to include the type of fish (cod bones are dangerous!), whether the meal was finished, if the pain is localised and can the patient swallow (water and/or

hook picks up cotton threads dental broach

cotton wool ‘bud’

Fig. 10.17  Removal of cotton wool bud from ear

dry bread) without severe pain. After spraying the throat with local anaesthetic, use a frontal mirror and dental mirror to find the bone. A fish bone usually lodges in the tonsil or at the base of the tongue, in which case it can be seen on oral examination. If it cannot be seen, more thorough examination by nasopharyngoscopy is required. To overcome the difficulty of not having a spare hand to remove the bone, use a laryngoscope, having localised the bone, and remove with packing forceps or intubation forceps. If there is severe pain and muscle spasm, or a positive X-ray, give an intramuscular antibiotic and refer to an ENT service.

Gential and anal Extricating the penis from a zipper The patient has accidentally entrapped the foreskin ofhis penis in his ‘fly’ zipper. He will already have triedto extricate himself, and further manoeuvring

will not only be painful but will continue to impact theskin. It is worthwhile initially to lubricate the zipperwithmineral oil and make one attempt to unzip it.

Chapter 10 | Removal of foreign bodies

The following are simple and effective techniques, which free the skin but ruin the zipper. Simple ‘first pass’ method Grasp the upper free zip lines with each hand, then rapidly and forcefully separate them outwards and downwards. The zipper usually falls down and releases the entrapped foreskin. It is usually quite painless. Instrumental methods Method A 1. Cut the zipper from the trousers for access. 2. Infiltrate LA beneath the entrapped foreskin, or infiltrate the skin at the base of the penis (ring block).

3. Grasp the zip fastener with pliers or any similar ‘crushing clamp’. Apply pressure until the zip breaks and the skin is freed (Fig. 10.18a). Method B Alternatively, cut across the closed section of the zipper, keeping as close as possible to the fastener (Fig. 10.18b), with a suitable instrument such as a sharp scalpel, and the zipper will fall apart. Method C After infiltrating the area with LA, obtain a diagonal type wire cutter and cut the median bar on the top of the zipper slider (Fig. 10.19). The slider then falls apart into two pieces and the zipper teeth can be readily separated.

(a)

Fig. 10.19  Removing a zipper from penile skin by cutting the median bar

Removal of impacted vaginal tampon

(b)

The problem associated with this procedure is the unpleasant odour that envelops the surgery, causing considerable embarrassment to both patient and doctor. Management Under good vision, the tampon is seized with a pair of sponge-holding forceps and quickly immersed under water. A bowl of water (an old ice cream container is suitable) is kept as close to the introitus as possible. This results in minimal malodour.

Fig. 10.18 Extracting penis from zipper

Method 1. Inspection: usually in the Sims position with a Sims speculum (other positions can be used). 2. Removal: the tampon is grasped with a sponge-holding forceps (dorsal position; Fig. 10.20a). 3. Disposal: the tampon is quickly plunged under water without releasing the forceps (Fig. 10.20b). The tampon and water can be immediately flushed down the toilet (except in septic tank systems or where drainage problems exist). It may be preferable to use another disposal method, such as taking the forceps and tampon outside and inserting the tampon into a self-sealing plastic bag.

137

138

Practice Tips

(a)

(b)

Fig. 10.20  Removal of tampon

Note: The Master Plumbers Association warns against flushing tampons down toilets because of their tendency to block systems.

Gloved and extraction method The tampon can be grasped with the gloved hand and then invaginated into the glove, which acts as a receptacle for disposal.

Faecal impaction Faecal impaction, manifested as an aggregation of hard faeces in the rectum on rectal examination and associated with constipation or spurious diarrhoea, can be a difficult problem. It often presents in children and the elderly. A good method of doing a rectal examination on a home visit (in the absence of gloves in the doctor’s bag) is to apply moist soap around the finger and caked under the nail (in case of breakage), then plastic wrap and finally petroleum jelly (e.g. Vaseline). Before resorting to a good, old-fashioned ‘3H’ enema (hot water, high, and a hell of a lot) use a Microlax 5 mL enema. This can be carried in the doctor’s bag, is very easy to insert and most effective.

Manual disimpaction Rarely, one has to resort to manual disimpaction, which is a most offensive procedure for all concerned. However, the procedure can be rendered virtually odourless if the products are milked or scooped directly into a pan or preferably a container of water with a fragrant disinfectant such as Pine O Clean. A large plastic cover helps to restrict permeation of the smell. Discomfort and embarrassment are reduced by this and adequate premedication (e.g. intravenous diazepam, or even IV morphine if hard faecoliths are present).

Removal of vibrator from vagina or rectum Manual removal of a vibrator or similar object from the vagina usually presents no problem, but removal from the rectum (if high) can be difficult without general anaesthesia.

Chapter 11

Musculoskeletal medicine Temporomandibular Joint Temporomandibular dysfunction A tender and perhaps clicking temporomandibular joint (TMJ) is a relatively common problem presenting to the general practitioner. In the absence of obvious malocclusion and organic disease, such as rheumatoid arthritis, simple exercises can alleviate the annoying problem in about 2 weeks. Three methods are described as alternatives to splint therapy. Method 1 1. Obtain a cylindrical (or similar-shaped) rod of soft wooden or plastic material, approximately 15 cm long and 1.5 cm wide. An ideal object is a large carpenter’s pencil or piece of soft wood. 2. Instruct the patient to position this at the back of the mouth so that the molars grasp the object with the mandible thrust forward. 3. The patient then rhythmically bites on the object with a grinding movement (Fig. 11.1) for 2 to 3 minutes at least 3 times a day. Method 2 1. Instruct the patient to rhythmically thrust the lower jaw forward and backward in an anterior–posterior direction with the mouth slightly open, rather like a cheeky schoolchild exposing the bottom lip (Fig. 11.2). 2. This exercise hurts initially but should soon lead to relief of the uncomplicated TMJ syndrome.

Fig. 11.1  Chewing the ‘pencil’ exercise

Method 3: The ‘six-by-six’ program This is a specific program (separate from the exercises above) recommended by some dental surgeons. The six exercises should be done 6 times each time, 6 times a day. It takes 1 minute to do them. Instruct the patient as follows: 1. Hold the front one-third of your tongue to the roof of your mouth and take six deep breaths. 2. Hold the tongue to the roof of your mouth and open your mouth 6 times. Your jaw should not click.

140

Practice Tips

• Avoid chewing gum. • Always try to open your jaw in a hinge or arc motion. Do not protrude your jaw. • Avoid protruding your jaw, e.g. talking, applying lipstick. • Avoid clenching your teeth together—keep your lips together and your teeth apart. • Try to breathe through your nose at all times. • Do not sleep on your jaw: try to sleep on your back. • Practise a relaxed lifestyle so that your jaws and face muscles feel relaxed.

Dislocated jaw The patient may present with a unilateral or bilateral dislocation. The jaw will be ‘locked’ and the patient unable to articulate. Fig. 11.2 The lower jaw-thrust exercise

3. Hold your chin with both hands, keeping the chin still. Without letting your chin move, push up, down and to each side. Remember not to let your chin move. 4. Hold both hands behind your neck and pull the chin in. 5. Push on the upper lip so as to push the head straight back. 6. Pull your shoulders back as if to touch the shoulder blades together. Repeat each exercise 6 times, 6 times a day. Note: Patients should use a visual cue to remind them to do the exercises. These exercises should be pain-free. If they hurt, do not push patients to the limit until the pain eases.

Method 1. Get the patient to sit upright with the head against the wall. 2. Wrap a handkerchief around both thumbs and place the thumbs over the last lower molar teeth, with the fingers firmly grasping the mandible on the outside. 3. Firmly thrusting with the thumbs, push downward towards the floor and at the same time press upwards on the chin with the fingers (Fig. 11.3). This action invariably reduces the dislocation, withthereduction being reinforced by the fingers rotating the mandible upward as the thumbs thrust downward.

Method 4: Resisted ‘jaw’ opening For this isometric contraction method the patient grasps the jaw mainly on the jaw angle and strongly resists opening of the jaw. This simple exercise is repeated many times a day.

The TMJ ‘rest’ program This program is reserved for an acutely painful TMJ condition. • When eating, avoid opening your mouth wider than the thickness of your thumb and cut all food into small pieces. • Do not bite any food with your front teeth—use small bite-size pieces. • Avoid eating food requiring prolonged chewing, e.g. hard crusts of bread, tough meat, raw vegetables.

Fig. 11.3  Method of reduction of dislocated jaw

Chapter 11 | Musculoskeletal medicine

The spine Recording spinal movements

(a)

Method 1 Simple diagrams obviate the need for copious notes when recording the range of movement of the cervical spine. They are of particular value to the ‘whiplash’ accident patient, who requires repeated assessment and accurate recording. Done serially, the diagrams are an excellent guide to progress, and assist in the compilation of medicolegal reports. The neck movement grid (Fig. 11.4a) provides a two-dimensional field on which to record movements of the neck as viewed when standing behind and above the patient (looking down on the patient’s head). Not only is the range of movement written on the grid, but pain can be recorded also. Table 11.1 shows the movements recorded for the patient in Fig. 11.4b.

rotation

front

rotation

flexion

lateral flexion

lateral flexion

left

extension

right

(b)

Table 11.1  ‘Whiplash’ accident patient: Neck movement record Flexion

full and pain free

Extension

50% (of normal), painful through range

Left rotation

40%, painful at end of range

Right rotation

60%

Left lateral flexion

40%

Right lateral flexion

70%

Method 2 One can use a special direction of movement (DOM) diagram to record movements for all spinal levels. Figure 11.4c illustrates restricted and painful movements (blocked, indicated by II) in flexion, left lateral flexion and left rotation but pain-free extension, right lateral flexion and right rotation (free movements).

Spinal mobilisation and manipulation Spinal mobilisation and manipulation are examples of physical therapy that can be very beneficial in many spinal conditions where hypomobility that causes pain and stiffness is present. These therapies improve the range of joint movement, decrease stiffness and reduce pain. Mobilisation

(c)

F

LF

R

LF

left

right

R

E

Fig. 11.4 The neck movement grid (viewed from above thepatient) Part 11.4(c) Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

of the spine is a safe procedure but manipulation can have serious sequelae, especially if given inappropriately to the cervical spine. For the cervical spine, mobilisation is a relatively simple and most effective technique, with a similar outcome to manipulation (evidence-based). Manipulation should be left to the experts and is best avoided if possible.

141

142

Practice Tips

Key concepts • Mobilisation is a gentle, coaxing, repetitive, rhythmic movement within the range of movement of the joint (Fig. 11.5). • Manipulation is a high-velocity thrust at the end range (Fig. 11.5). • If in doubt, use mobilisation in preference to manipulation. • Always mobilise or manipulate in the direction of no pain. • Manipulation is generally more effective and produces a faster response, but requires accurate diagnosis and greater skill, and can aggravate some spinal problems.

A

B = normal active limit C = elastic limit D = anatomical limit

MO

B

active passive

C MA D

fixed

to the spinous process centrally (Fig. 11.6) or over tender points unilaterally. It is a very simple technique, directed either with the thumbs (placed side by side) or the pisiform process of the leading hand (for central mobilisation only). This method is suitable for anywhere along the spine, but particularly for the cervical spine and more so at lateral tender points. Method (using thumbs) 1. The patient lies prone, with head turned to one side and arms by the side. 2. For the thoracic and lumbar spines, stand at the patient’s side and place your thumbs over the tender area. For the cervical spine, stand behind the patient’shead. 3. Lean over the patient with your arms perfectly straight and head and shoulders over the treatment area. 4. Obtain an oscillatory movement by gently rocking the upper trunk up and down, with pressure being transmitted to your thumbs by the shoulders and arms. 5. Go as deeply as possible without causing pain. 6. Provide a small-amplitude, controlled oscillation at the rate of two per minute. Maintain this for about 30 to 60 seconds, with two or three repeats in one treatment session.

Fig. 11.5 Schematic representation of movement (by rotation) of a joint: mobilisation (MO), A–C; manipulation (MA), C–D

Important contraindications to spinal manipulation • Disease of the spine (e.g. osteoporosis, neoplasm, rheumatoid arthritis). • Neurological changes. • Evidence of nerve root compression (e.g. pain in theleg). • Instability of spine following trauma. • Cerebrovascular disease (for neck). • Anticoagulation therapy. • The elderly patient (my rule: avoid > 65 years). A golden rule: Opposite movement, no pain.This generally means that manipulation achieves a gapping or opening up of the painful side.

Anterior directed gliding—an example of spinal mobilisation The technique of anterior directed gliding, also termed posterior-anterior mobilisation, can be applied directly

anterior directed movement

fixed position

Stage 1 Stage 2 Stage 3

Fig. 11.6 Anterior directed central gliding mobilisation, illustrating the three stages of mobilisation Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Chapter 11 | Musculoskeletal medicine

Cervical spine Clinical problems of cervicalorigin Pain originating in the cervical spine is commonly, although not always, experienced in the neck. The patient may complain of headache, or pain around the ear, face, shoulder, arm, scapulae or upper anterior chest. If the cervical spine is overlooked as a source of pain, the cause of symptoms will remain masked and mismanagement will follow. Possible symptoms • Neck pain • Neck stiffness • Headache • Migraine-like headache • Arm pain (referred or radicular) • Facial pain • Ear pain (periauricular) • Scapular pain • Anterior chest pain

• Torticollis • Dizziness/vertigo • Visual dysfunction Figure 11.7 indicates the typical directions of referred pain. Surprisingly, headache, which is commonly caused by cervical problems, is often not considered by clinicians. Pain in the arm (brachialgia) is common, and tends to cover the shoulder and upper arm area indicated in Figure 11.7. This is the zone of referred pain that is not caused by nerve root compression. It can be a difficult diagnostic dilemma, because pain reference from the fifth cervical nerve segment (C5) involves musculoskeletal, neurological and visceral structures. Virtually all shoulder structures are innervated by C5. See dermatome chart (Fig. 11.25, p. 155). The practitioner must first determine whether the pain originates in the cervical spine or the shoulder joints, or in both simultaneously, or some other structure. The often missed diagnosis of polymyalgia rheumatica should be considered in the elderly patient presenting with pain in the zone indicated, especially if bilateral.

Locating tenderness in the neck upper cervical lower cervical

Fig. 11.7  Possible common directions of referred pain from the cervical spine Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Palpation of the neck to determine the precise level of pain or tenderness can be difficult; however, if the surface anatomy of the neck is clearly defined, the affected level can easily be determined. Method 1. The patient lies prone on the examination couch with hands (palms up) resting on the forehead. The shoulders should be relaxed. 2. Systematically palpate the spinous processes of the cervical vertebrae: • C2 (axis) is the first spinous process palpable beneath the occiput • C7 is the largest ‘fixed’ and most prominent process at the base of the neck • C6 is also prominent and easily palpable, but usually ‘disappears’ under the palpating finger with extension of the neck • the spinous process of C1 (atlas) is not palpable, but the tip of the transverse process is: it lies between the angle of the jaw and the mastoid process • the spinous processes of C3, C4 and C5 are difficult to palpate because of cervical lordosis, but their level can be estimated (see Fig. 11.8).

143

144

Practice Tips

C2

C6 C7

towards the patient’s painful side. During this phase the patient is asked to exhale slowly and to look downward to that side (Fig. 11.9b). 6. The patient will now be able to turn the head a little further towards the painful side. 7. This sequence is repeated at the new and improved motion barrier. Repeat 3 to 5 times until the full range of movement returns. 8. Ask the patient to return the following day for another treatment, although the neck may now be almost normal. The patient can be taught self-treatment at home using this method. (a)

motion barrier

Fig. 11.8 Relative sizes of spinous processes of cervical spine

Acute torticollis An amazingly effective treatment for an acute wry neck is muscle energy therapy, which relies on the basic physiological principle that the contracting and stretching of muscles leads to the automatic relaxation of agonist and antagonist muscles. Note: Lateral flexion or rotation or a combination of movements can be used, but treatment in rotation is preferred. The direction of contraction can be away from the painful side (preferred) or towards the painful side, whichever is most comfortable for the patient. Method 1. Explain the method to the patient, with reassurance that it is not painful. 2. Rotate the patient’s head passively and gently towards the painful side to the limit of pain (the motion barrier). 3. Place your hand against the head on the side opposite the painful one. The other (free) hand can be used to steady the painful level—usually C3–C4. 4. Ask the patient to push the head (in rotation) as firmly as possible against the resistance of your hand. The patient should therefore be producing a strong isometric contraction of the neck in rotation away from the painful side. Your counterforce (towards the painful side) should be firm and moderate (never forceful), and should not ‘break’ through the patient’s resistance. To reinforce the effect of this contraction (although not essential), you can ask the patient to inhale and hold the breath and also to look upward in the direction of the contracting muscles (Fig. 11.9a). 5. After 5 to 10 seconds (average 7 seconds) ask the patient to relax; then passively stretch the neck gently

resisted contraction

inhalation

(b)

limit of movement

reduced motion barrier

expiration

Fig. 11.9 Acute torticollis: (a) isometric contraction phase for problem on left side; (b) relaxation phase towards the affected (left) side Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Traction to the neck Traction to the neck can be given by machine but can also be applied manually, with or without the use of a belt. It is ideal for treating nerve root irritation with arm pain, and acute neck pain with headache.

Chapter 11 | Musculoskeletal medicine

Method 1. The patient lies supine, relaxed, with arms by the side and head at the end of the couch. 2. Stand at the head of the couch, with one hand clasping the occipital area and the other holding the chin (Fig. 11.10). 3. Traction is achieved by using body weight, not the arms alone. Hence, you should lean back during traction.

of breathing is considered to be a most effective facilitator of this method. It is very safe and gentle, and particularly helpful in the elderly with painful dysfunctional necks. Method 1. The patient sits on the chair (sitting is preferable to lying supine), with the head in a ‘neutral’ position. 2. Stand behind the patient and place the palms of your hands on the sides of the patient’s face (to spread the pressure evenly around the face and not in one or two sites). 3. Ask the patient to simultaneously breathe in and look upwards (without extending the neck). 4. Hold the patient’s neck in a fixed position with veryslight traction during this inspiration phase (Fig. 11.11a). The neck muscles will contract during this phase. 5. Ask the patient to then exhale while looking down. Apply a gentle but firm upward stretch (Fig. 11.11b). Maintain this traction for about 7 seconds. 6. Repeat this procedure about 4 times, applying traction during each expiration phase.

Neck rolls and stretches Fig. 11.10 Longitudinal traction to the neck for a mid-cervical problem Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Special notes • Avoid traction on an extended neck: use a neutral position for upper cervical problems and flexion (20–40°) for middle to lower problems. • Always take up traction slowly and release gently.

The belt method It is best to use a belt (a modified car seat belt or camping gear belt) for neck traction. The belt is applied around the waist and is then looped over the wrist and hands, which fit comfortably under the occiput. Traction is applied by leaning back and allowing the body weight to exert the force.

A simple traction technique for the cervical spine This technique demonstrates the use of longitudinal traction of the neck, especially for the upper cervical spine, as a muscular energy therapy. Coordination

Indications Dysfunction of neck, including tenderness and stiffness, usually following injury. Method The objective is to produce a smooth, circular motion to the end range in all directions so that stretching occurs at the end range. 1. Patients are instructed to ‘draw circles in the air’ (Fig. 11.12a) or ‘roll their head around their halo’. Awidearc of movement is not necessary, provided that stretch is obtained. 2. The roll is performed at a slow to medium pace, sothat tender or painful areas can be avoided by moving justshort of this level. As stretch is obtained, these areas become less painful, allowing further stretching. 3. Patients can be taught to stretch the neck themselves (Fig. 11.12b), including the use of a muscle energytechnique. No matter how stiff the neck initially, it is surprising how much immediate improvement can be obtained from simple, gentle, lateral stretching. Patients should be instructed to train themselves into a permanent daily habit of rolling the neck to assess flexibility.

145

146

Practice Tips

(a)

(a)

(b)

(b)

Fig. 11.12 Exercises for the dysfunctional neck: (a) the slow neck roll; (b) stretching neck into lateral flexion Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Fig. 11.11 Simple traction technique: (a) the therapist applies slight traction during inspiration and upward gaze; (b) the therapist applies firm traction during expiration and downward gaze

Chapter 11 | Musculoskeletal medicine

Thoracic spine Anterior directed costovertebral gliding This unilateral mobilisation method is directed at the tender costotransverse joint of the thoracic spine. The joint, which is about 4–5 cm from the midline, is arguably the most common source of musculoskeletal pain in the thoracic spine. The tender area determined by palpation is the target for mobilisation. Method 1. With the pad of the thumbs applied over the rib (Fig. 11.13), apply a rhythmic oscillating movement (abouttwo per second) at right angles. 2. Maintain this for 30 to 60 seconds with as much pressure as possible without causing discomfort.

over the therapist’s thigh. A low couch is necessary, or the therapist can stand on a stool or chair at the head of a high couch. Method 1. Stand at the head of the couch and flex your thigh and knee on the couch. 2. The patient lies supine on the couch and positions the spine on your thigh so that the tender area lies just above your knee. 3. The patient clasps hands firmly behind the neck. 4. Insert your arms through the patient’s arms (as far as possible) to grasp the patient around the sides of the thorax. 5. Take up the slack by gently stretching the patient over your thigh. 6. Extend the patient’s thoracic spine firmly and suddenly over your thigh by simultaneously lifting and rotating the patient’s trunk towards you, dropping your body back and down towards the floor and thrusting with your forearms down across the patient’s outer clavicular region (Fig. 11.14). It is a carefully controlled, decisive, but relatively gentle movement.

Fig. 11.13  Costovertebral gliding mobilisation Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Thoracic spinal manipulation A note of caution: Take care in patients with ‘red flags’ such as previous malignancy and cerebrovascular disease. Avoid manipulation in these patients using the following two techniques and ensure that the neck is not extended. Direct thrust techniques can be dangerous in women over 55, especially in the presence of risk factors for osteoporosis.

Thigh extension thrust technique This is very effective in the treatment of painful spinal dysfunction of the upper thoracic spine (T1–T7). The technique involves extension of the upper thoracic spine

Fig. 11.14 Upper thoracic spinal manipulation: the thigh extension technique, illustrating the direction of the appliedforces Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

147

148

Practice Tips

The sternal thrust (‘Nelson hold’) method This is a time-honoured method for patients with upper to mid-thoracic dysfunction. It is similar to the thigh extension method (and is used as an alternative), but involves a sternal (chest) thrust from the therapist. Method 1. Although the patient can be standing for this method, it is best to have them sitting across the couch with their back to you (buttocks to the edge of the couch), ideally with the head at the same level as yours. 2. Stand behind the patient and place a soft object such as a rolled-up towel on the back, with the upper edge just below the painful level. 3. Slide the hands in front of the patient’s axillae and grasp the wrists. 4. Gently but firmly extend the patient’s back against your chest in a lifting movement as you also extend your back. 5. Ask the patient to breathe in and breathe out, and to relax. 6. When the patient is relaxed, take up the slack, increase the stretching lift and backward extension, and apply a sharp forward thrust with your chest (Fig. 11.15).

 3. Roll the relaxed patient towards you.  4. Place your cupped hand (Fig. 11.16a) on the spine at the painful level, with this level in the palm.  5. Roll the patient back onto the hand, which should feel comfortable (if not, readjust).  6. Lean well over the patient, placing your forearm directly on theirs, and grasp the patient’s far elbow with your hand.  7. Rest your chest on your uppermost arm.  8. Ask the patient to inhale and exhale fully.  9. As the patient commences to exhale, lean down to take up the slack on your bottom hand. 10. Towards the end of exhalation, apply a sharp downward thrust with your chest and upper arm directly through the patient’s chest onto your hand (Fig. 11.16b). (a)

(b)

Fig. 11.15 The sternal thrust method Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Manipulation for the mid-thoracic spine Of the dozens of manipulative thrusts for dysfunction of the thoracic spine (T3–T8), the most effective is the postero-anterior indirect thrust, using the underlying hand as a block over the affected area. Method  1. The patient lies supine on a low couch, with a pillow supporting the head.  2. The patient folds the arms across the body with hands resting on opposite shoulders, the uppermost forearm being the one furthest from you.

Fig. 11.16  Mid-thoracic manipulation: (a) cupped hand position, showing position of the vertebrae on the hand— note how the spinous processes run along the long axis and occupy the hollow of the hand; (b) manipulation to midthoracic spine—note the direction of the applied force (X indicates blockage with the hand) Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Chapter 11 | Musculoskeletal medicine

Thoracolumbar stretching andmanipulation Rotation in the sitting position In this very effective technique, the patient fixes the pelvis by straddling a low couch or a chair; the couch provides the better position, because it allows greater flexibility of the trunk. The main indications are unilateral pain at the thoracolumbar junction. The method can be used also for pain (unilateral and bilateral) of the lumbar spine and the lower thoracic spine. The usual rules and contraindications apply. The technique must be coordinated with deep breathing. Method 1. The patient straddles the end of the couch and sits firm and erect. Alternatively the patient can straddle a chair, facing the back of the chair with a pillow used against the chair to protect the thighs. It must be a standard, open chair, with a carpeted floor. 2. The patient crosses the arms over the chest so that the hands rest on the opposite shoulders. The patient should be comfortable throughout the procedure, and proper padding should rest against the inner thighs. 3. Stand directly behind the patient. Adopt a firm, wide-based stance. 4. Grasp the patient’s shoulders with your hands. 5. Ask the patient to take a deep breath in, exhale fully and relax. 6. When you feel the patient relax, grasp the shoulders and rotate the patient’s trunk steadily and firmly, away from the painful side, to the limit of rotation. Before rotation is attempted the patient must be at the absolute limit of stretch. Gently oscillate the trunk at this position of full stretch. 7. If any sharp pain is reproduced at this end range abandon the treatment. Mobilisation: Consists of performing a gentle, repetitive, oscillatory rotation of the trunk at this end range for up to 30 seconds. Manipulation: Consists of a sharp, well-controlled rotation. Variations of this technique An alternative and better strategy is to ‘hug’ the patient’s trunk, using the arm that embraces the trunk to grasp the arm near the elbow on the side to be rotated. The thrusting hand can be applied to a specific area of the back corresponding to the level of pain. Thus, a type of ‘push–pull’ manoeuvre can be achieved, with the embracing arm pulling into rotation and the other hand pushing to achieve a complementary smooth rotation of the trunk. Coordinate this with breathing so the rotation only occurs during the relaxed exhaled stage.

Figure 11.17a demonstrates the technique for a rightsided problem at the thoracolumbar junction, while Figure 11.17b demonstrates the technique for low lumbar pain. Both rotations are to the left, since rotation to the right reproduces pain.

(a)

(b)

Fig. 11.17 Thoracolumbar manipulation: (a) rotation in sitting technique for thoracolumbar region (right-sided problem); (b) rotation in sitting technique for lumbar spine (right-sided problem) Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

149

150

Practice Tips

Lumbar spine Drawing and scale marking forback pain A very useful procedure to assess the nature of patients’ back pain is to ask them to draw the location of their pain on a sheet with blank outlines of the body. They can indicate also their perception of the intensity of the pain on a scale on the same page. The basic sheet is illustrated in Figure 11.18a, while examples of this application are provided in Figures 11.18b and c.

Reference points in the lumbarspine A working knowledge of the bony landmarks of the lumbar spine is vitally important for determining the level of the spinal pain and for procedures such as epidural injections and lumbar punctures. This anatomical knowledge is readily determined by using the iliac crests as the main reference point. (a)

Method 1. For the examination the adequately exposed patient should be relaxed, lying prone, with the arms by the sides. 2. Standing behind and below the patient, place your fingers on the top of the iliac crests and your thumbs at the same level on the midline of the back. This level will correspond with the fourth and fifth lumbar interspace (Fig. 11.19), or slightly higher at the fourth lumbar spinous process. 3. Consequently, the thumbs will either feel the L4–L5 gap or the L4 spinous process. (When inspecting X-rays of the lumbar spine, it becomes apparent that the upper limits of the iliac crest usually lie opposite the L4–L5 interspace.) The reference points should be marked and the level of each lumbar spinous process can then be identified.

mark the areas on your body where you feel the various sensations pins and needles

numbness

pain intolerable pain 10

Back

Front

9 8 7 6 moderate pain

5 4 3

left

2 1 0 no pain mark your level of pain on this scale

Fig. 11.18 Drawing and scale marking for back pain: (a) basic sheet

right

right

left

Chapter 11 | Musculoskeletal medicine

(b)

pain

numbness

pins and needles

10 9 8 7 6 5 4 3 2 1 0

(c)

pain

numbness

pins and needles

10 9 8 7 6 5 4 3 2 1 0

Fig. 11.18 Drawing and scale marking for back pain: (b) drawing by a patient with L5–S1 disc prolapse causing S1 nerve root compression (left side); (c) drawing by a patient with psychologically based problem (conversion reaction)

151

152

Practice Tips

(a)

(b)

Fig. 11.19  Illustration showing the placement of hands to determine the bony landmarks of the lumbosacral spine Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Tests for non-organic back pain Several tests are useful in differentiating between organic and non-organic back pain (e.g. that caused by depression or complained of by a known malingerer).

Magnuson method (the ‘migratory pointing’ test) 1. Request the patient to point to the painful sites. 2. Palpate these areas of tenderness on two occasions separated by an interval of several minutes, and compare the sites. Between the two tests divert the patient’s attention from his or her back by another examination.

Burn ‘kneeling on a stool’ test 1. Ask the patient to kneel on a low stool, lean over and try to touch the floor. 2. The person with non-organic back pain will usually refuse on the grounds that it would cause great painorthat he or she might overbalance in the attempt. Patients with even a severely herniated disc usually manage the task to some degree (Fig. 11.20a, b).

Fig. 11.20  Back pain tests: (a) abnormal attempt to kneel on a stool; (b) normal attempt to kneel on a stool

The ‘axial loading’ test 1. Place your hands over the patient’s head and press firmly downward (Fig. 11.21). 2. This will cause no discomfort to (most) patients with organic back pain.

The ‘hip and shoulder rotation’ test 1. Examine for pain by rotating the patient’s hips and shoulders while the feet are kept in place on the floor (Fig. 11.22). 2. The manoeuvre is usually painless in those with an organically based back disorder.

Chapter 11 | Musculoskeletal medicine

(a) extension spinous process C7

o

o

80

20 –30

o

flexion

sacrum

Fig. 11.21 The ‘axial loading’ test (b) shoulder girdle

30

o

30

o

Fig. 11.23  (a) illustration of degrees of movement of the lumbar spine in flexion and extension; (b) illustration of the degree of lateral flexion of the lumbar spine Fig. 11.22 The ‘hip and shoulder rotation’ test

Movements of the lumbar spine There are three main movements of the lumbar spine. As there is minimal rotation, which mainly occurs at the thoracic spine, rotation is not so important.The movements that should be tested, and their normal ranges, are as follows:

Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

• extension (20–30°) (Fig. 11.23a) • lateral flexion, left and right (30°) (Fig. 11.23b) • flexion (75–90°: average 80°) (Fig. 11.23a). Measurement of the angle of movement can be made by using a line drawn between the sacrum and the large prominence of the C7 spinous process.

153

154

Practice Tips

Nerve roots of leg and level ofprolapsed disc Pain in the leg from discogenic lesions in the lumbosacral spine is commonly due to pressure on the L5 or S1 nerve roots. Unlike discogenic lesions in the cervical spine, more than one nerve root can be involved with prolapses of the L4–L5 or L5–S1 discs, but this is uncommon. Working guidelines are given in Table 11.2 and Figure 11.24. It is worthwhile to know and refer to the dermatome chart, especially for the lower limb (Figure 11.25). Table 11.2 Typical lumbosacral disc causes of various clinicalproblems Problem

Usual causative disc prolapse

L3 nerve root lesion

L2–L3

L4 nerve root lesion

L3–L4

L5 nerve root lesion

L4–L5

S1 nerve root lesion

L5–S1

Severe low back pain, no leg pain

L4–L5

Severe sciatica, minimal low back pain

L5–S1

Low back pain with lateral deviation of spine

L4–L5

The slump test The slump test is an excellent provocation test for lumbosacral pain and more sensitive than the straight leg raising test. It is a screening test for a disc lesion and dural tethering. It should be performed on patients who have low back pain with pain extending into the leg, and especially for posterior thigh pain. A positive result is reproduction of the patient’s pain; this may appear at an early stage of the test (at which point the test is ceased). Method 1. The patient sits on the couch in a relaxed manner. 2. The patient then slumps forward (without excessive trunk flexion), then places the chin on the chest. 3. The unaffected leg is straightened. 4. The affected leg only is then straightened (Fig. 11.26). 5. Both legs are straightened together. 6. The foot of the affected straightened leg is dorsiflexed. Note: Take care to distinguish from hamstring pain. Deflexing the neck relieves the pain of spinal origin, not hamstring pain. Significance of the slump test • It is positive if the back or leg pain is reproduced. • If positive, it suggests disc disruption.

spinal cord dural sac L1 spinal cord ends L1–L2 disc level

L2

L3 L3–L4 disc prolapse may compress L4

L4

L5 nerve root may be compressed by two prolapsed discs: L4–L5 and L5–S1

L5

S1 S1 nerve root emerges from sacral foramen

sacrum

dural sac ends opposite lower border S2

Fig. 11.24  Posterior ‘window’ view of lumbosacral spine, illustrating the relationships of the nerve root to the intervertebral discs Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

• If negative, it may indicate lack of serious disc pathology. • If positive, one should approach manual therapy with caution

Schober test (modified) The Schober test is a useful objective means of measuring the mobility of the lumbar spine. The test described here is a modified version. A measurement of less than 5 cm of movement is indicative of hypomobility, and was used initially to detect the seronegative spondyloarthropathy—ankylosing spondylitis. Related spondyloarthropathies include Reiters disease, psoriasis and inflammatory bowel disorders. Other hypomobile spines are found with lumbar spondylosis (degenerative disease) and intervertebral disc disorders. Method 1. Stand the patient erect and mark the spine in line with the ‘dimples of Venus’ (the posterior superior iliac spines). This corresponds to the spinous process of S2.

Chapter 11 | Musculoskeletal medicine

C2 C3

C5 C6 Th1

C7

C8

C4 5 Th1 2 3 4 5 6 7 8 9 10 11 Th12 S2 S3

L1 L2 L3

C2 3 4 5 6 7 8 Th1 2 3 4 5 6 7 8 9 10 11 12 L1 2 L3 4 L5 S1 S2 3 S4

C6 C7 C8

L1 L2

Interpretation • Normal is greater than 5 cm increase in length. • Less than 5 cm represents hypomobility.

Manual traction for sciatica Although traction is usually administered by machines, it can also be performed manually, often with great benefit.

5

L4 L5

2. Place another mark 10 cm above the first and a third mark 5 cm below the first mark. 3. Ask the patient to bend forward (flexion), as if to touch the toes, to the point of maximal flexion. 4. Now measure the distance between the upper and lower marks.

L5 S1 S2

L3

L4 S1 L5

Fig. 11.25 Dermatome chart Reproduced from J. Murtagh, GP Companion Handbook (5th Edn), McGraw-Hill, Sydney, 2010.

Fig. 11.26 The slump test: illustrating one of the stages

Indication • Low back pain (central or unilateral), with or without sciatica, where the pain is acute and spinal manipulation is contraindicated. Particularly useful for sciatica radiating to the foot. Rules • Traction can be used on both legs simultaneously or just one leg (usually opposite the side of pain). • Commence traction to both legs simultaneously; if this double method proves ineffective, traction can be applied to a single leg (Fig. 11.27), preferably the leg opposite to the painful side at first and then to the painful leg. Method 1. The patient lies prone or supine (the author prefers the prone position), and can grasp the end of the table for support. This provides suitable counterpressure. 2. Stand at the feet of the patient and grasp the foot or feet firmly around the ankle. (It is advisable to use a belt around your waist, as this allows the body weight to supply the force, making possible a smooth, gentle and well-controlled traction. Although your hands can be used, the arms tire quickly and cannot sustain the traction.) 3. Apply the belt (such as a car seat belt or packing belt from a camping store) to the legs by looping it over your hands and apply body weight by leaning backwards on the belt. This action provides the traction force. 4. Apply the traction gently until the symptoms begin to ease, and then maintain at this level for about 2minutes. A gentle oscillatory force can be applied if this proves to be effective. 5. A key point is to keep talking to the patient, to determine what is happening as the traction is applied. • If the pain increases, stop (ease off gently). • If the pain decreases, maintain or increase traction. • If the pain is unchanged, apply stronger traction.

155

156

Practice Tips

Fig. 11.27 Longitudinal traction applied to one leg with patient lying supine

Rotation mobilisation for lumbar spine This technique is very useful for acute low back pain of the spine, especially where manipulation is contraindicated or of doubtful value. Patients tend to prefer gentler mobilisation to spinal manipulation. There are several grades of this technique. Method 1. The patient lies on the pain-free side, with the head supported by a pillow. 2. The lower shoulder is pulled forwards by grasping the arm at the elbow and gently rotating the spine. The uppermost arm rests on the lateral wall of the chest. 3. The uppermost leg is flexed at the hip (30–90°) and the knee flexed to a right angle. The patient places the palm of the lowermost hand under the head. 4. You stand behind the patient, opposite the pelvis. 5. Place both hands over the pelvis and apply a gentle, small-amplitude oscillatory movement (Fig. 11.28). 6. This is a gentle ‘push and pull’ method, with emphasis on the push. 7. The rocking movement occupies 30 to 60 seconds. It can be repeated 2 or 3 times on any one treatment visit.

Fig. 11.28 Lumbar mobilisation in rotation (for left-sided pain) Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Chapter 11 | Musculoskeletal medicine

Lumbar stretching and manipulation technique 1 This is a traditional method used for a thrusting manipulative movement but steady stretching is simpler and safer. Method 1. The patient lies on the pain-free side, reasonably squarely on the lower shoulder. The body should be in a straight line with the lower leg extended. The upper leg (on the painful side) can be either falling freely over the side of the couch or flexed with the foot tucked into the popliteal fossa of the lower leg. The lower arm should lie comfortably in front of the trunk. Alternatively, the hand of the lower arm can be placed under the head. 2. Stand behind the patient at the level of the patient’s waist. 3. Ask the patient to take a deep breath and breathe out. 4. When the patient has exhaled and relaxed, use one hand to push the trochanteric area of the hip forwards, and the other to gently force the front of the shoulder downwards (Fig. 11.29). It is best to keep hands in contact with the skin (avoid grasping clothing). 5. Apply steady rotational movement until a full stretch is applied to both shoulder and hip. Do not force the shoulder down too hard—take care to keep it firm and steady during the stretch.

6. Maintain sustained pressure for about 7 seconds at the end range. 7. Repeat this stretch twice. Manipulation: If desired, this position can be used to apply a sharp rotational thrust to the hip with the force along the axis of the femur.

Lumbar stretching and manipulation technique 2 This is the ideal stretching or manipulative technique for the lumbar spine and is the procedure of first choice for lumbar problems. It is designed to mobilise the lower lumbosacral segments, which are responsible for mostof the problems in the lower back.

The stretch Method 1. The patient lies on the pain-free side in a relaxed position with the head on a pillow facing the therapist. The uppermost leg is flexed at the hip and the knee, both to about 45°, with the foot tucked into the popliteal fossa of the lower leg. 2. Position yourself at the level of the patient’s waist. 3. Ask the patient to turn his or her head and look up at the ceiling. 4. Carefully rotate the trunk by grasping the patient’s lowermost arm just above or around the elbow and gently pulling the arm outwards. 5. Maintain smooth slow rotation of the trunk until you sense it is taut down to the upper lumbar spine. 6. Fix the trunk by asking the patient to place the hand of this arm under the head. 7. Rest the fleshy part of your upper forearm against the patient’s shoulder and upper chest via the axilla, and your other forearm over the ischium, just below the iliac crest. 8. Ensure that you are properly balanced. 9. Apply a distracting force for several seconds, gently rocking back and forth with the forearms as you move towards maximal rotating stretch. This stretching is usually sufficient to achieve the desired therapeutic effect (Fig. 11.30a, b).

The manipulation If desired, especially for a ‘locked’ lumbosacral level, this position can be used to perform a sharp manipulative thrust—but only from the position of full stretch.

Fig. 11.29 Lumbar stretching technique 1: illustrating the direction of the applied stretching forces Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Method 1. When all the slack is taken up by your forearms, ask the patient to take a deep breath and exhale. 2. At the end of the exhalation execute a sharp increase of rotatory pressure through both forearms, especially through the short lever to the pelvis.

157

158

Practice Tips

Note: It is important not to dig the elbow of the proximal arm into the patient’s body, since this can be painful. Likewise it is important to find a position for the distal forearm that is comfortable for the patient, and to avoid using the point of the elbow for thrusting, as the buttock area is very sensitive to sharp pressure.

Guidelines It is preferable to perform the exercise on a couch or very firm bed, but it can be done on the floor. It can be performed repeatedly throughout the day but should be repeated at least twice a day for about 3 to 5 minutes at a time.

Exercise for the lower back

Method 1. Lie on your back. 2. Bend the leg on the painful side and stretch it across the body while turning the head to the opposite side. 3. If possible, hang onto the side of the bed or couch with your free hand (the hand that is on the same side as the leg which is crossed over). 4. Use the other hand to grasp the bent leg at the level of the knee and increase the stretch as far as possible (Fig. 11.31). 5. Relax and return to the resting position. 6. Repeat on the opposite side, especially if that side also hurts. 7. Repeat several times, concentrating on stretching the painful joints. Note: If someone pins your shoulders to the floor or bed while you are performing this exercise, the stretch is better.

The following yoga-like exercise is highly recommended for patients with pain in the lumbosacral spine, usually after any muscle spasm has resolved.

Fig. 11.30a Lumbar stretching technique 2: the method

Fig. 11.30b Lumbar stretching technique 2: illustrating the direction of the applied stretching forces for left-sided problem Reproduced from C. Kenna & J. Murtagh, Back Pain and Spinal Manipulation, Butterworths, Sydney, 1989, with permission.

Chapter 11 | Musculoskeletal medicine

Fig. 11.31 An ideal exercise for the lower back (left-side problem illustrated)

Shoulder Dislocated shoulder Types of dislocation • Anterior (forward and downward)—95% of dislocations • Posterior (backward)—difficult to diagnose • Recurrent anterior dislocation

Anterior dislocation of the shoulder Management An X-ray should be undertaken to check the position and exclude an associated fracture. Reduction can be achieved under general anaesthesia (easier and more comfortable) or with intravenous pethidine ± diazepam. The following methods can be used for anterior dislocation.

traction with external rotation

Fig. 11.32 Kocher method for a dislocated shoulder

Kocher method (Figure 11.32) 1. The patient’s elbow should be flexed to 90° and held close to the body. 2. Slowly rotate the arm laterally (externally) as you apply traction. 3. Adduct the humerus across the body by carrying the point of the elbow. 4. Rotate the arm medially (internally). Hippocratic method Apply traction to the outstretched arm by a hold on the hand with countertraction from a stockinged foot in the medial wall of the axilla. This levers the head of the humerus back. It is a good method if there is an associated avulsion fracture of the greater tuberosity.

adduction

internal rotation

159

160

Practice Tips

Milch method (does not require anaesthesia orsedation) 1. The patient reclines at 30° and with guidance slowly bends the elbow to 90° (Fig. 11.33a). 2. The patient is asked to lift the arm up slowly with the elbow bent so that they can pat the back of their head (requires considerable reassurance and encouragement). 3. At this position, traction along the line of the humerus (with countertraction) achieves reduction (Fig. 11.33b).

Scapula pressure method 1. The patient lies prone with the dislocated arm hanging freely over the table. 2. Steady traction is applied to the arm by an assistant. 3. Firm pressure is then applied by the ‘butt’ of the hand to the inferolateral border of the scapula. The pressure is directed towards the glenohumeral joint.

Variation of Milch method This relies more on intervention by the therapist, who supports the shoulder with the thumb held firmly against the dislocated humeral head while the other hand facilitates adduction of the arm to the overhead position. At this position, the humeral head is pushed by the thumb into its normal socket.

The free-hanging method is relatively painless, yet simple. It is gentler than traditional methods, without rotational forces or direct pressure to the glenohumeral joint. It can be used with or without an intravenous analgesic or relaxant, which is not usually required for recurrent dislocation or in the elderly patient.

(a)

(b)

Free-hanging method

Preparation 1. Insert a ‘butterfly’ needle into a vein on the dorsum of the non-involved hand. 2. Prepare two solutions: (a) 10 mg of diazepam diluted to 5 mL with isotonic saline; (b) 50 mg of pethidine diluted to 5 mL with isotonic saline. 3. The patient sits at right angles to the chair with only half the buttock on the seat.The affected arm hangs freely over a pillow placed on the back of the chair and tucked into the axilla.The hand with the intravenous needle rests on the opposite knee (for easy access to the practitioner). 4. You sit on a very low stool, facing the back of the chair. Method 1. With both hands working simultaneously on the dislocated limb, grasp the patient’s wrist with one hand and exert a steady, downward pressure. 2. Place the other hand in the axilla, with the palm exerting a direct outward pressure against the upper part of the shaft of the humerus (Fig. 11.34). 3. When appropriate muscle relaxation is achieved, the head of the humerus slips up and over the glenoid rim. Analgesia and relaxation (if necessary) Steady traction should be maintained during administration of analgesic; 2.5 mL pethidine (25 mg) is given intravenously over 60 seconds (and may be repeated), then 1 mL diazepam (2 mg) a minute, until reduction is achieved. Note: Carefully monitor the patient’s vital signs.

The Mt Beauty analgesia-free method Fig. 11.33  Milch method for reduction of dislocated shoulder: (a) starting position with elbow bent to 90°; (b) patient bringing hand up to touch back of head

This technique, described by Zagorski, aims to reduce anterior shoulder dislocation without the need for any sedating or narcotic analgesics. It is very helpful in more remote situations and is ideal for recurrent dislocation. Fractures must be excluded.

Chapter 11 | Musculoskeletal medicine

Fig. 11.34 Reduction of the dislocated shoulder: free-hanging method

Method (e.g. left-sided dislocation) 1. Explain the procedure to the patient, emphasising its gentleness. 2. The patient sits upright in a straight-backed chair (no arm rests). 3. An assistant stands behind the patient with a hand on each shoulder to prevent tilting of the shoulder girdle. Alternatively, the assistant can prevent the patient tipping sideways to the affected side by supporting them with a towel passing under the injured axilla across to the opposite (normal) shoulder. 4. The doctor kneels facing the patient with the left knee beside the patient’s knees. 5. The patient rests his or her left hand on the doctor’s left shoulder. 6. The doctor places his or her left hand on the patient’s forearm just distal to the elbow (Fig. 11.35). 7. Very gentle downward traction is applied and gradually increased as the patient, distracted somewhat by conversation, is encouraged to relax (there should be minimal pain). 8. The doctor’s right hand feels for relaxation of the shoulder and the position of the humeral head as

Fig. 11.35 Reduction of dislocated shoulder by gentle steady traction (as shown) in seated position

161

162

Practice Tips

downward traction is maintained (it usually reduces after 1 to 2 minutes). 9. If not reduced by now, very gentle external rotation is applied by leaning around the outside of the patient away from the affected side. Reduction is heralded by a gentle click. Sometimes it feels that nothing has happened so traction should be relaxed, the shoulder reassessed and, if still dislocated, traction applied. Often the release of traction leads to relocation of the joint. Rules • Patient must be relaxed and distracted. • Patient must not tilt to one side. • Gentle steady traction to avoid spasm and pain.

patient has to concentrate on relaxing the muscles of the shoulder girdle. Recurrent dislocation requires definitive surgery.

Impingement test for supraspinatus lesions This is probably the most effective test for the rotator cuff, as it forces impingement of the greater tuberosity under the acromion. Supraspinatus tendinous lesions are the most common cause of pain in the shoulder.

For this condition, there is a way of effecting reduction without the use of force.

Method 1 1. The patient places the arms in the position of semiflexion (90° of forward flexion) and internal rotation with the forearms in full pronation. 2. You then test resisted flexion by pushing down as thepatient pushes up against this movement (Fig.11.37). 3. If pain is reproduced, this is called a positive ‘impingement sign’, and is a very sensitive test for the upper components of the rotator cuff, especially supraspinatus.

Method 1. The patient sits comfortably on a chair with legs crossed. 2. The patient then interlocks hands and elevates the upper knee so that the hands grip the knee (Fig. 11.36). 3. The knee is allowed to lower gradually so that its full weight is taken by the hands. At the same time the

Method 2 The ‘emptying the can’ method is an even better test for supraspinatus tendonopathy. It is almost identical to Method 1 except that the affected arm is moved 30° laterally (i.e. horizontal flexion) in the horizontal plane as though to empty a can of drink. Resisted elevation is tested in this position.

Recurrent dislocation of shoulder

anterior dislocation of shoulder hands grip elevated leg

leg gradually lowered

Fig. 11.36 Simple method for recurrent dislocation of shoulder

Chapter 11 | Musculoskeletal medicine

Fig. 11.37 The impingement test: resisted flexion in semiflexion, internal rotation and pronation

Elbow Pulled elbow This typically occurs in children under 8 years of age, usually at 2 to 3 years, when an adult applies sudden traction to the child’s extended and pronated arm: the head of the radius can be pulled distally through the annular radioulnar ligament (Fig. 11.38a). Symptoms and signs • The crying child refuses to use the arm. • The arm is limp by the side or supported in the child’s lap. • The elbow is flexed slightly. • The forearm is pronated or held in mid-position (Fig.11.38b). Treatment method 1. Gain the child’s confidence. Ask the parent to hold the unaffected arm as the child stands facing you. 2. Hold the child’s wrist or hand (on the affected side) as if to shake it. 3. Place one hand around the child’s elbow to give support, pressing the thumb over the head of the radius. 4. Using gentle traction, firmly and smoothly twist the forearm into full supination (Fig. 11.38c) as you fully flex the forearm. A popping sound indicates relocation of the radial head. An alternative and preferred method to the traditional method is to very gently alternate pronation and supination through a small arc as you flex the elbow.

If you cannot get the child’s cooperation apply a ‘high’ sling and send them home. It may reduce spontaneously within a few days.

Dislocated elbow A dislocated elbow is caused by a fall on the outstretched hand, forcing the forearm backwards to result in posterior and lateral displacement (Fig. 11.39).The peripheral pulses and sensation in the hand must be assessed carefully. Check the function of the ulnar nerve before and after reduction.

Usual treatment Attempt reduction with the patient fully relaxed under anaesthesia. It is important to apply traction to the flexed elbow but allow it to extend approximately 20–30° to enable correction of the lateral displacement with the hand pushing from the side, and then the posterior displacement by pushing the olecranon forward with the thumbs.

A simple method of reduction This method reduces an uncomplicated posterior dislocation of the elbow without the need for anaesthesia or an assistant. The manipulation must be gentle and without sudden movement. Method 1. The patient lies prone on a stretcher or couch, with the forearm dangling towards the floor. 2. Grasp the wrist and slowly apply traction in the direction of the long axis of the forearm (Fig. 11.40).

163

164

Practice Tips

(a)

(b)

(c)

Fig. 11.38  Pulled elbow: (a) mechanism of injury; (b) annular ligament displaced over head of radius; (c) reduction technique

3. When the muscles feel relaxed (this might take several minutes), use the thumb and index finger of the other hand to grasp the olecranon and guide it to a reduced position, correcting for any lateral shift. 4. After reduction the arm is held in a collar-and-cuff sling, with the elbow flexed above 90°, for 1 to 3 weeks.

olecranon

Tennis elbow A simple cure—the wringing exercise humerus

ulna

Fig. 11.39 Dislocated elbow: uncomplicated posterior dislocation

Chronic tennis elbow (lateral epicondylitis) can be alleviated by a simple wringing exercise using a small hand towel. Method 1. Roll up the hand towel. 2. With the arms extended, grasp the towel with the wrist of the affected side placed in slight flexion. 3. Then exert maximum wring pressure (Fig. 11.41): • first fully flexing the wrist for 10 seconds

Chapter 11 | Musculoskeletal medicine

• then fully extending the wrist for 10 seconds • alternate flexion and extension between hands. This is an isometric ‘hold’ contraction. Frequency This exercise should be performed only twice a day, initially for 10 seconds in each direction. After each week, increase the time by 5 seconds in each twisting direction until 60 seconds is reached (week 11). This level is maintained indefinitely. Apply ice for 10 minutes after completion, especially last thing at night. Note: Despite severe initial pain, the patient must persist, using as much force as possible. Review at 6 weeks (there is usually some relief by 4 to 6 weeks), to ensure that the patient is doing the exercise exactly as instructed.

Exercises Stretching and strengthening exercises for the forearm muscles represent the best management for tennis elbow. The muscles are strengthened by the use of hand-held weights or dumbbells. A suitable starting weight is 0.5kg, building up gradually (increasing by 0.5 kg) to 5 kg, depending on the patient.

Fig. 11.40 Dislocated elbow: method of reduction by traction on the dependent arm

Fig. 11.41  Grip for ‘wringing exercise’ at the end point of the isometric hold (right wrist in full flexion and the left in extension)

Method 1. To perform this exercise the patient sits in a chair beside a table. 2. The arm is rested on the table so that the wrist extends over the edge. 3. The weight is grasped with the palm facing downwards (Fig. 11.42a). 4. The weight is slowly raised and lowered by flexing and extending the wrist. 5. The flexion/extension wrist movement is repeated 10 times, with a rest for 1 minute and the program repeated twice. This exercise should be performed every day until the patient can play tennis, work or use the arm without pain. For medial epicondylitis (forearm tennis elbow, golfer’s elbow), perform the same exercises but with the palm of the hand facing upward (Fig. 11.42b). Tip: In colder conditions, keep the elbow warm with a woollen sleeve around it such as two or three modified old socks.

165

166

Practice Tips

Fig. 11.42 Tennis elbow: (a) dumbbell exercise for classical case (palm facing down); (b) dumbbell exercise for medial epicondylitis—forearm tennis elbow, golfer’s elbow (palm facing up)

Wrist and hand De Quervain tenosynovitis and Finkelstein test De Quervain disease is a stenosing tenosynovitis of the abductor pollicus longus or extensor pollicus brevis tendons over the radial styloid of the wrist, or both. It results from repetitive activity, such as that engaged in by staple gun operators on assembly lines, or from direct trauma.

3. A positive test is indicated by reproduction of or increased pain. tenosynovitis abduction of wrist in ulnar direction

Symptoms The major symptoms are: • pain during pinch grasping • pain on thumb and wrist movement. Tetrad of diagnostic signs Four key diagnostic signs are: • tenderness to palpation over and just proximal to the radial styloid • localised swelling in the area of the radial styloid • positive Finkelstein’s sign • pain on active extension of thumb against resistance.

thumb folded into palm

Fig. 11.43  Finkelstein test

Finkelstein test

Simple tests for carpal tunnel syndrome

Method 1. The patient folds the thumb into the palm with the fingers of the involved hand folded over the thumb. 2. Deviate the wrist in an ulnar direction (medially) to stretch the involved tendons (Fig. 11.43).

The carpal tunnel syndrome, caused by compression of the median nerve, is a common disorder that is usually easily diagnosed from the history. The most common and easily recognised symptoms are early-morning numbness and tingling or burning in the distribution of the median

Chapter 11 | Musculoskeletal medicine

nerve in the hand. In the physical examination for the suspected carpal tunnel syndrome, a couple of simple tests can assist with confirming the diagnosis. These are Tinel test and Phalen test. The Tinel test 1. Hold the wrist in a neutral or flexed position, and tap over the median nerve at the flexor surface of the wrist. This should be over the retinaculum just lateral to the palmaris longus tendon (if present) and the tendons of flexor digitorum superficialis (Fig. 11.44a). 2. A positive Tinel sign produces a tingling sensation (usually without pain) in the distribution of the median nerve.

(a)

flexor retinaculum median nerve

The Phalen test 1. The patient approximates the dorsum of both hands, one to the other, with wrists maximally flexed and fingers pointed downward (Fig. 11.44b). 2. This position is held for 60 seconds. 3. A positive test reproduces tingling and numbness along the distribution of the median nerve.

Simple reduction of dislocatedfinger This method employs the principle of using the patient’s body weight as the distracting force to achieve reduction of the dislocation. It is relatively painless and very effective. Getting a good grip is very important, so wrap a small strip of zinc oxide adhesive plaster around the finger.

(b)

median nerve

Method 1. Face the patient, both in standing positions. 2. Firmly grasp the distal part of the dislocated finger. 3. Request the patient to lean backwards, while maintaining the finger in a fixed position (Fig. 11.45). 4. As the patient leans back, sudden, painless reduction should spontaneously occur.

Strapping a finger Method 1. Instead of strapping an injured finger circumferentially, it is more comfortable and more effective to place a single strip of adhesive tape 2.5 cm or less in width on the dorsum of the finger from the tip of the nail to the carpometacarpal line (Fig. 11.46a). 2. The direction of the tape should follow the line of the extensor tendon (Fig. 11.46b). The effect is the use of the skin traction as a suspensory sling for the finger. The flexor and extensor tendons are allowed to relax with a decrease in position maintenance strain and

Fig. 11.44  Carpal tunnel syndrome: (a) Tinel test for diagnosis; (b) Phalen test to reproduce symptoms

167

168

Practice Tips

pain. At the same time the finger is free to flex with recovery, and frozen finger is unlikely. 3. The degree of mobility of the finger is adjusted by altering the tension along the line of the tape.

Mallet finger patient leans back

A forced hyperflexion injury to the distal phalanx can rupture or avulse the extensor insertion into its dorsal base. The characteristic swan neck deformity is due to retraction of the lateral bands and hyperextension of the proximal interphalangeal joint.

The 45° guideline Without treatment, the eventual disability will be minimal if the extensor lag at the distal joint is less than 45°; a greater lag will result in functional difficulty and cosmetic deformity.

patient

Fig. 11.45 Reduction of dislocated finger

(a)

(b)

level of carpometacarpal line

direction of extensor tendon

Fig. 11.46 Strapping a finger

doctor

Treatment Maintain hyperextension of the distal interphalangeal joint for 6 weeks, leaving the proximal interphalangeal joint free to flex. Even with treatment the failure rate is high—only about 50–60% recover. Equipment • Friar’s Balsam (will permit greater adhesion of tape). • Non-stretch adhesive tape, 1 cm wide: two strips approximately 10 cm in length. Method 1. Paint the finger with Friar’s Balsam (compound benzoin tincture). 2. Apply the first strip of tape in a figure-of-eight conformation. The centre of the tape must engage and support the pulp of the finger. The tapes must cross dorsally at the level of the distal interphalangeal joint and extend to the volar aspect of the proximal interphalangeal joint without inhibiting its movement (Fig. 11.47a). 3. Apply the second piece of tape as a ‘stay’ around the midshaft of the middle phalanx (Fig. 11.47b). Reapply the tape whenever extension of the distal interphalangeal joint drops below the neutral position (usually daily, depending on the patient’s occupation). Maintain extension for 6 weeks. Other splints There are a variety of splints. A popular one is a simple plastic mallet finger splint. One can improvise by cutting the handle of a large plastic milk carton or other similar household container.

Chapter 11 | Musculoskeletal medicine

(a)

hyperflexed PIP joint split extensor tendon

Fig. 11.48 Illustration of the mechanism of a boutonnière deformity padded metal splint

proximal interphalangeal joint

(b)

Fig. 11.49  Method of splinting for a boutonnière deformity Fig. 11.47  ‘Mallet finger’: (a) application of first tape; (b) application of ‘stay’ tape

Surgery Open reduction and internal fixation are reserved for those cases where the avulsed bony fragment is large enough to cause instability leading to volar subluxation of the distal interphalangeal joint.

Boutonnière deformity The ‘button hole’ deformity is a closed rupture of the extensor tendon apparatus over the PIP joint, which is permanently flexed towards the palm (Fig. 11.48). Treatment of uncomplicated deformity 1. Splint the PIP joint in full extension for 8 to 10weeks. 2. Leave the DIP joint free for movement (Fig. 11.49).

Tenpin bowler’s thumb Tenpin bowler’s thumb is a common stress syndrome in players. It usually presents as a soft-tissue swelling at the base of the thumb web (Fig. 11.50), with associated pain and stiffness of the digits used for bowling.

Fig. 11.50 Site of tender ‘mass’ at base of thumb web

Management The patient will need: • rest • massage • to bevel the bowling ball holes to reduce friction • an intralesional injection of 0.25 mL of longacting corticosteroid mixed with local anaesthetic (resistant cases).

169

170

Practice Tips

Skier’s thumb (gamekeeper’s thumb) A special injury is skier’s thumb (also known as gamekeeper’s thumb) in which there is ligamentous disruption of the metacarpophalangeal joint with or without an avulsion fracture of the base of the proximal phalanx at the point of ligamentous attachment (Fig.11.51).This injury is caused by the thumb being forced into abduction and hyperextension by the ski pole as the skier pitches into the snow. Diagnosis is made by X-ray with stress views of the thumb. Incomplete tears are immobilised in a scaphoid type of plaster for 3 weeks, while complete tears and avulsion fractures should be referred for surgical repair.

forced abduction

torn ligament ? avulsion fracture

metacarpophalangeal joint

Colles fracture Features • A supination fracture of distal 3 cm of radius. • Commonly caused by a fall onto an outstretched hand. • The fracture features (Fig. 11.52): –– impaction –– posterior displacement and angulation

Fig. 11.51 Skier’s thumb

(a)

(b)

(c)

(d)

Fig. 11.52  Colles fracture: (a) dinner-fork deformity; (b) lateral X-ray view; (c) anteroposterior X-ray view; (d) radial (lateral) tilt of distal segment

Chapter 11 | Musculoskeletal medicine

–– lateral (radial) displacement and angulation –– supination. Method of reduction Under appropriate anaesthesia: • traction on hand (to disimpact) • an assistant maintains countertraction • pronate • ulnar deviation for 10° (to correct radial displacement) • flexion (10–15°). Immobilise the wrist and forearm in a well-padded, below-elbow plaster for 4 to 6 weeks—forearm in full pronation, wrist in corrected position (ulnar deviation, slight flexion) described above (Fig. 11.53).

fracture

Fig. 11.54 Typical appearance of a fractured scaphoid

Fig. 11.53 Ideal position of the forearm in a Colles plaster. Note: ulnar deviation, slight flexion and pronation

Scaphoid fracture A scaphoid fracture (Fig. 11.54) is caused typically by a fall on the outstretched hand with the wrist bent backwards (dorsiflexed). The pain may settle after the injury, so presentation may be later. One has to be careful not to treat it as a simple sprain. The signs are: • tenderness in anatomical snuffbox (the key sign) • loss of grip strength with pain • swelling in and around the ‘snuffbox’ • pain on axial compression of thumb towards radius. If a fracture is suspected clinically but the plain X-ray is normal, a fracture cannot be ruled out. An MRI scan or isotope bone scan can be helpful after 24 hours post injury. If scans are not available, immobilise the wrist in a scaphoid plaster for 10 days, remove it and then re-X ray. For an undisplaced stable fracture, immobilise for 6weeks in a below-elbow plaster cast (Fig. 11.55). Displaced fractures require reduction (either open or closed) and, if unstable, internal fixation. All fractures require a later X-ray to check for non-union.

Fig. 11.55 Appearance of the scaphoid plaster

Metacarpal fractures Metacarpal fractures can be stable or unstable, intraarticular or extra-articular, and closed or open. They include the ‘knuckle’ injuries resulting from a punch, which is prone to cause a fracture of the neck of the fifth metacarpal. As a general rule, most metacarpal (shaft and neck) fractures are treated by correcting marked displacements with manipulation (under anaesthesia) and splinting with a below-elbow, padded posterior plaster slab that extends up to the dorsum of the proximal phalanx, and holds the metacarpophalangeal joints in a position of function (Fig. 11.56).

171

172

Practice Tips

Fig. 11.56  Fracture of the metacarpal: showing position of function with posterior plaster slab and the hand gripping a roll of felt padding

There is often a tendency for metacarpal fractures to rotate and this must be prevented. This is best achieved by splinting the MCP joints at 90°, which corrects any tendency to malrotation. If there is gross displacement, shortening or rotation then surgical intervention is indicated. A felt pad acts as a suitable grip. The patient should exercise 3 fingers vigorously. Remove the splint after 3 weeks and start active mobilisation.

Hip Age relationship of hip disorders

Ortolani test (IN test)

Hip disorders have a significant age relationship (Fig. 11.57). • Children can suffer from a variety of serious disorders of the hip, e.g. developmental dysplasia (DDH), Perthes disorder, tuberculosis, septic arthritis and slipped upper capital epiphysis (SCFE), all of which demand early recognition and management. • SCFE typically presents in the obese adolescent (10 to 15 years) with knee pain and a slight limp. • Every newborn infant should be tested for DDH, which is diagnosed early by the Ortolani and Barlow tests (abnormal third or clunk on abduction or adduction). However, ultrasound examination is the investigation of choice and is more sensitive than the clinical examination, especially after 8 weeks.

Flex hip to about 90°, gently abduct to 45°, and then note any click or jerk as the hip reduces, allowing the hip to abduct fully (Fig. 11.58b).

The Ortolani and Barlow screening tests Hold the leg in the hand with the knee flexed—thumb over groin (lesser trochanter) and middle finger over greater trochanter (Fig. 11.58). Steady the pelvis with the other hand.

Barlow (OUT test) Flex the hip to 90°, abduct to 10–20°, and then adduct and note any click or jerk as the hip ‘goes out’ of the acetabulum (Fig. 11.58c).

Pain referred to the knee Referred pain from the hip to the knee is one of the time-honoured traps in medicine. The hip joint is mainly innervated by L3, hence pain is referred from the groin down the front and medial aspects of the thigh to the knee (Fig. 11.59). Sometimes the pain can be experienced on the anteromedial aspect of the knee only. It is not uncommon that children with a SCFE present with a limp and knee pain.

septic arthritis

sciatica

neurogenic claudication vascular claudication

Perthes disorder DDH

SCFE

Transient synovitis

osteoarthritis

fractured neck of femur 0

4

8 10

15

Fig. 11.57 Typical ages of presentation of hip disorders

40 Age in years

Chapter 11 | Musculoskeletal medicine

5. Compress the joint through pressure down the axis of the femur. Dysfunction of the joint may be evident when internal rotation is attempted. Any internal rotation may be virtually impossible because of stiffness or pain. (a)

(b)

Fig. 11.58 Screening for developmental dysplasia of the hip (left side): (a) Ortolani sign; (b) Barlow sign

disorder of hip joint

typical site of referred pain

Fig. 11.59  Possible area of referred pain from disorders of the hip joint

Diagnosis of early osteoarthritis of hip joint The four-step stress test Degeneration of the hip joint is a common problem in general practice, and may present with pain around the hip or at the knee. Early diagnosis is very useful, and certain tests may detect the problem. It is worth remembering that, of the six main movements of the hip joint, the earliest to be affected are internal rotation, abduction and extension. A special stress test is described here that is sensitive to diagnosing disease in the hip. Method 1. Lay the patient in the supine position. 2. Flex the hip to about 120°. 3. Adduct to about 20–30° (Fig. 11.60). 4. Internally rotate.

Fig. 11.60 Stress test for osteoarthritis of the hip

The ‘hip pocket nerve’ syndrome If a man presents with ‘sciatica’, especially confined to the buttock and upper posterior thigh (without local back pain), consider the possibility of pressure on the sciatic nerve from a wallet in the hip pocket. This problem is occasionally encountered in people sitting for long periods in cars (e.g. taxi drivers). It appears to be related to the increased presence of plastic credit cards in wallets.

173

174

Practice Tips

Surface anatomy The sciatic nerve leaves the pelvis through the greater sciatic foramen and emerges from beneath the piriformis muscle at a position just medial to the midpoint of a line between the medial surface of the ischial tuberosity and the tip of the greater trochanter (Fig. 11.61). The lateral border of the nerve usually lies at this midpoint. It lies deep to the gluteus medius in the buttock.

sciatic nerve greater trochanter of femur wallet ischial tuberosity

2. The hip joint is now flexed, externally rotated and adducted. (This position stresses the hip joint, so that inguinal pain on that side is a pointer to a defect in the hip joint or surrounding soft tissue.) 3. The range of motion for the hip joint in this position can be taken to the endpoint (thus fixing the femur in relation to the pelvis), by pressing the knee downward and simultaneously pressing on the region of the anterior superior iliac spine of the opposite side (Fig. 11.62). This stresses the hip joint as well as the sacroiliac joint on that side. Thus, if low back pain is reproduced, the cause is likely to be a disorder of the sacroiliac joint. Such a lesion is uncommon, but is seen in nursing mothers and in those with inflammatory disorders of the joint (e.g. ankylosing spondylitis and reactive arthritis) and with infection (e.g. tuberculosis).

Snapping or clicking hip Some patients complain of a clunking, clicking or snapping hip. This represents a painless, annoying problem. sciatic nerve

Fig. 11.61  ‘Hip pocket nerve’ syndrome: location and relations of sciatic nerve in the buttock

Causes One or more of the following: • a taut iliotibial band (tendon of tensor fascia femoris) slipping backwards and forwards over the prominence of the greater trochanter

Ischial bursitis ‘Tailor’s bottom’ or ‘weaver’s bottom’, which is occasionally seen, is a bursa overlying the ischial tuberosity. Irritation of the sciatic nerve may coexist and the patient may appear to have sciatica. Features • Severe pain when sitting, especially on a hard chair. • Tenderness at or just above the ischial tuberosity. Treatment • Infiltration into the tender spot of a mixture of 4 mL of 1% lignocaine and 1 mL of LA corticosteroid (avoid the sciatic nerve). • Foam rubber cushion with two holes cut out for ischial prominences.

Patrick or Fabere test To test hip and sacroiliac joint disorders. Fabere is an acronym for Flexion, Abduction, External Rotation and Extension of the hip. Method 1. The patient lies supine on the table and the foot of the involved side and extremity are placed on the opposite knee.

Fig. 11.62 The Patrick (Fabere) test for right-sided hip or sacroiliac joint regions, illustrating directions of pressure from the examiner

Chapter 11 | Musculoskeletal medicine

• the iliopsoas tendon snapping across the iliopectineal eminence • the gluteus maximus sliding across the greater trochanter • joint laxity. Treatment method There are two major components of the treatment: a. explanation and reassurance b. exercises to stretch the iliotibial band. 1. The patient lies on the ‘normal’ side, and flexes the affected hip (with the leg straight and a weight around the ankle; Fig. 11.63) to a degree that produces a stretching sensation along the lateral aspect of the thigh. 2. This iliotibial stretch should be performed for 1 to 2 minutes, twice daily.

Dislocated hip Posterior dislocation of the hip is usually caused by a direct blow to the knee of the flexed leg (knee and hip flexed). The painful shortened leg is held in: • internal rotation • adduction • slight flexion (11.64a). With anterior dislocation, the shortened leg is held in abduction, external rotation and flexion.

Principles of management • Adequate analgesia, e.g. IM morphine for pain. • X-rays to confirm diagnosis and exclude associated fracture. • Reduction of the dislocated hip under relaxant anaesthesia. • Follow-up X-ray to confirm reduction and exclude any fractures not visible on the first X-ray.

Method of reduction A Standard method for posterior dislocation With the patient under relaxant anaesthesia and lying on the floor and with an assistant steadying or fixing the pelvis by downward pressure: • Apply traction as the hip is flexed to 90°. • Then apply gentle external rotation and abduction (maintaining traction) with hand pressure over the femoral head (Figure 11.64 a, b). For anterior dislocation, the leg is internally rotated and adducted under traction.

Method of reduction B Dependent reduction method This is especially useful if there is an associated fracture of the femur on the same side (Fig. 11.65).

weight around ankle

Fig. 11.63  Clicking hip treatment

175

176

Practice Tips

(a)

(b)

Fig. 11.64  (a) Posterior dislocation of hip with internal rotation; (b) method of reduction of the dislocated hip

The anaesthetised patient lies prone on the table: • drop the leg and flex the dislocated hip over the edge of the table • apply steady downward traction on the flexed hip • gently rotate externally with hand pressure on femoral head (from gluteal region).

traction anterior dislocation internally rotate and adduct

posterior dislocation externally rotate and abduct

Fractured femur Emergency pain relief can be provided by a femoral nerve block with local anaesthesia (see pp. 33–34).

stabilise

hip

patient on floor under relaxation anesthesia

Fig. 11.65 Dislocated hip: dependent reduction method

Knee Inspection of the knees Remembering the terminology Sometimes it is difficult to recall whether ‘knock knees’ is known as genu valgum or genu varus. A useful method is to remember that the ‘l’ in valgum stands for ‘l’ in lateral. Valgum refers to deviation of the bone distal to the joint, namely the tibia in relation to the knee. In the normal knee, the tibia has a slight valgus angulation in reference to the femur, the angulation being more pronounced in women.

The common types of knee deformity are: • genu valgum, ‘knock knees’ (Fig. 11.66a) • genu recurvatum, ‘back knee’ (Fig. 11.66b) • genu varum, ‘bowed legs’ (Fig. 11.66c).

Common causes of knee pain A UK study has highlighted the fact that the most common cause of knee pain is simple ligamentous strains and bruises due to overstress of the knee or other minor trauma. Traumatic synovitis may accompany some of

Chapter 11 | Musculoskeletal medicine

(a)

(c)

(b)

Fig. 11.66 Knee deformities: (a) genu valgum (‘knock knees’): tibia deviates laterally from knee; (b) genu recurvatum (‘back knee’); (c) genu varum (‘bowed legs’)

these injuries. Some of these so-called strains may include a variety of recently described syndromes such as the synovial plica syndrome, patellar tendonopathy and infrapatellar fat-pad inflammation (Fig. 11.67). Low-grade trauma of repeated overuse such as frequent kneeling may cause prepatellar bursitis, known variously as ‘housemaid’s knee’ or ‘carpet layer’s knee’. Infrapatellar bursitis is referred to as ‘clergyman’s knee’. Osteoarthritis of the knee, especially in the elderly, is a very common problem. It may arise spontaneously or be secondary to previous trauma with associated internal derangement and instability. The most common overuse problem of the knee is the patellofemoral joint pain syndrome (often previously referred to as chondromalacia patellae).

Diagnosis of meniscal injuries of the knee Injuries to the medial and lateral menisci of the knee are common in contact sports, and are often associated with ligamentous injuries. Table 11.3 is a useful aid in the diagnosis of these injuries. There is a similarity in the clinical signs between

patellofemoral joint pain syndrome synovial plica popliteal cyst

prepatellar bursitis

patellar tendonitis infrapatellar fat-pad

infrapatellar bursitis bicepts femoris tendonitis/bursitis Osgood–Schlatter disorder

Fig. 11.67 Lateral view of knee showing typical sites of various causes of knee pain

177

178

Practice Tips

Table 11.3 Typical symptoms and signs of meniscal injuries

Mechanism

Symptoms 1. Knee pain during and after activity 2. Locking 3. Effusion Signs 1. Localised tenderness over joint line (with bucket handle tear) 2. Pain on hyperextension of knee 3. Pain on hyperflexion of knee joint 4. Pain on rotation of lower leg (knee at 90°) 5. Weakened or atrophied quadriceps

Medial meniscus tear

Lateral meniscus tear

• Abduction (valgus) force • External rotation of lower leg on femur

• Adduction (varus) force • Internal rotation of leg on femur

Medial side of knee Yes + or –

Lateral side of knee Yes + or −

Medial joint line Medial joint line Medial joint line On external rotation May be present

Lateral joint line (may be cyst) Lateral joint line Lateral joint line On internal rotation May be present

the opposite menisci, but the localisation of pain in the medial or lateral joint lines helps to differentiate between the medial and lateral menisci (Fig. 11.68). Note: The diagnosis of a meniscal injury is made if three or more of the five examination findings (‘signs’ in Table 11.3) are present.

Lachman test The Lachman test is a sensitive and reliable test for the integrity of the anterior cruciate ligament. It is an anterior draw test with the knee at 20° of flexion. At 90° of flexion, the draw may be negative but the anterior cruciate torn. Test method 1. Position yourself on the same side of the examination couch as the knee to be tested. 2. The knee is held at 20° of flexion by placing a hand under the distal thigh and lifting the knee into 20° of flexion. The patient’s heel rests on the couch. 3. The patient is asked to relax, allowing the knee to ‘fall back’ into the steadying hand and roll slightly into external rotation. 4. The anterior draw is performed with the second hand grasping the proximal tibia from the medial side (Fig.11.69) while the thigh is held steady by the other hand. 5. The feel of the endpoint of the draw is carefully noted. Normally there is an obvious jar felt as the anterior cruciate tightens. In an anterior cruciate deficient knee there is

Fig. 11.68 Localised tenderness over the outer joint line with injury to the lateral meniscus

excess movement and no firm endpoint. The amount of draw is compared with the opposite knee. Movement greater than 5 mm is usually considered abnormal. Note: Functional instability due to anterior cruciate deficiency is best elicited with the pivot shift test. This is more difficult to perform than the Lachman test.

Chapter 11 | Musculoskeletal medicine

sharp draw

supporting knee to thigh (optional)

Patellar tendonopathy (‘jumper’s knee’)

Fig. 11.69 Lachman test

Overuse syndromes The knee is very prone to overuse disorders. The pain develops gradually without swelling, is aggravated by activity and relieved with rest. It can usually be traced back to a change in the sportsperson’s training schedule, footwear, technique or related factors. It may be related also to biomechanical abnormalities ranging from hip disorders to feet disorders. (a)

Osgood–Schlatter disorder

biceps femoris tendonopathy

‘Jumper’s knee’ or patellar tendonopathy (Fig. 11.71a) is a common disorder of athletes involved in repetitive jumping sports, such as high jumping, basketball, netball, volleyball and soccer. The diagnosis is often missed because of the difficulty of localising signs. The condition is best diagnosed by eliciting localised tenderness at the inferior pole of the patella with the patella tilted. (b)

quadriceps tendonopathy or rupture

anserinus bursitis/ tendonopathy

Overuse injuries include: • patellofemoral joint pain syndrome (‘jogger’s knee’, ‘runner’s knee’) • patellar tendonopathy (‘jumper’s knee’) • synovial plica syndrome • infrapatellar fat-pad inflammation • anserinus bursitis/tendonopathy • biceps femoris tendonopathy • semimembranous bursitis/tendonopathy • quadriceps tendonopathy/rupture • popliteus tendonopathy • iliotibial band friction syndrome (‘runner’s knee’) • the hamstrung knee. It is amazing how often palpation identifies localised areas of inflammation (tendonopathy or bursitis) around the knee, especially from overuse in athletes and in the obese elderly (Fig. 11.70a, b).

iliotibial band friction syndrome patellar tendonopathy

quadriceps tendonopathy or rupture patella patellofemoral joint pain syndrome

medial collateral ligament

patellar tendonopathy

semimembranous tendonopathy/ bursitis anserinus tendonopathy/ bursitis

Fig. 11.70 Typical painful areas around the knee for overuse syndromes: (a) anterior aspect; (b) medial aspect

179

180

Practice Tips

Method 1. Lay the patient supine in a relaxed manner with head on a pillow, arms by the side and quadriceps relaxed (a must). 2. The knee should be fully extended. 3. Tilt the patella by exerting pressure over its superior pole. This lifts the inferior pole. 4. Now palpate the surface under the inferior pole. This allows palpation of the deeper fibres of the patellar tendon (Fig. 11.71b). 5. Compare with the normal side. Very sharp pain is usually produced in the patient with patellar tendonopathy. Treatment Explanation and conservative management including activity modification, stretching exercises and a strengthening program are the first-line treatment. However, the problem can be stubborn, and surgery has an important place in the management.

Diagnosis and treatment ofpatellofemoral joint painsyndrome This syndrome, also known as chondromalacia patellae, is characterised by pain and crepitus around the patella during activities that require flexion of the knee under loading (e.g. climbing stairs). Signs Patellofemoral crepitation during knee flexion and extension is often palpable, and pain may be reproduced by compression of the patella onto the femur as it is pushed from side to side with the knee straight or flexed (Perkins test).

Pain felt in the anterior part of the knee is very common and is most commonly caused by the patellofemoral joint pain syndrome. It needs to be distinguished from arthritis of the knee joint. It is common in sports medicine and is referred to sometimes as ‘jogger’s knee’, ‘runner’s knee’ or ‘cyclist’s knee’.

One method for the patella apprehension test (Fig. 11.72) 1. Have the patient supine with the knee extended. 2. Grasp the superior pole of the patella and displace it inferiorly. 3. Maintain this position and apply patellofemoral compression. 4. Ask the patient to contract the quadriceps (a good idea is to get the patient to practise quadriceps contraction before applying the test). 5. A positive sign is reproduction of pain under the patella and hesitancy in contracting the muscle.

(a)

(b)

Anterior knee pain

vastus medialis quadriceps tendon lla

commonest site of tendonopathy

femur

e at

p

tibial tubercle

tibia

Fig. 11.71  Patellar tendonopathy: (a) diagram of knee; (b) method of palpation

patella

Chapter 11 | Musculoskeletal medicine

Treatment Figure 11.73 illustrates a simple quadriceps exercise. Aseries of isometric contractions are each held for about 4 seconds and alternated with relaxation of the leg. This exercise can be repeated many times in one period and throughout the day.

contact quadriceps

compress patella displace patella into femur inferiorly

Fig. 11.72  Patellar apprehension test for patellofemoral joint pain syndrome

Dislocated patella Typical features • An injury of children and young adults (especially females). Also common in sport. • Caused by contraction of quadriceps with a flexed knee. • There is always lateral displacement. • Knee may be stuck in flexion.

Method of immediate reduction

(a)

(b)

The following can be attempted without anaesthesia (preferably immediately after the injury) or by using pethidine and IV diazepam as a relaxant. 1. Place your thumb under the lateral edge of the patella. 2. Push it medially as you extend the knee.

Important points

Fig. 11.73  Quadriceps exercise: tighten muscle by straightening the knee to position (a) from the relaxed position (b)

• Exclude an osteochondral fracture with X-rays. • Post-reduction rest with knee splinted in extension and crutches for 4 to 6 weeks. • Arthroscopic inspection and repair may be advisable. • Recurrent dislocation in young females (14 to 18 years) requires surgery.

Leg Overuse syndromes in athletes Athletes, especially runners and joggers, are prone to painful problems in the lower legs (Fig. 11.74). Diagnosis of the various syndromes can be difficult, but Table 11.4 will be a useful guide. The precise anatomical site of the painful problem is the best pointer to a diagnosis.

Torn ‘monkey muscle’ The so-called torn ‘monkey muscle’, or ‘tennis leg’, is actually a rupture of the medial head of gastrocnemius at the musculoskeletal junction where the Achilles tendon merges with the muscle (Fig. 11.75). This painful injury is common in middle-aged tennis and squash players who play infrequently and are unfit.

iliotibial band tendonopathy

shin splints

anterior compartment syndrome

tibial stress fracture

Achilles tendonopathy

plantar fasciitis

Fig. 11.74  Common sites of lower leg problems

181

182

Practice Tips

Table 11.4  Clinical comparisons of overuse syndromes Syndrome

Symptoms

Common cause

Treatment

Anterior compartment syndrome

Pain in the anterolateral muscular compartment of the leg, increasing with activity. Difficult dorsiflexion of foot, which may feel floppy.

Persistent fast running (e.g. squash, football, middledistance running).

Modify activities. Surgical fasciotomy is the only effective treatment.

Iliotibial band tendonopathy

Deep aching along lateral aspect of knee or lateral thigh. Worse running downhill, eased by rest. Pain appears after 3–4 km running.

Running up hills by longdistance runners and increasing distance too quickly.

Rest from running for 6weeks. Special stretching exercises. Correct training faults and footwear. Consider injection of LA and corticosteroids deep into tender areas.

Tibial stress syndrome or shin splints

Pain and localised tenderness Running or jumping on hard over the distal posteromedial surfaces. border of the tibia. Bone scan for diagnosis.

Tibial stress fracture

Pain, in a similar site to shin splints, noted after running. Usually relieved by rest. Bone scan for diagnosis.

Overtraining on hard (often bitumen) surfaces. Faulty footwear.

Rest for 6–10 weeks. Casting not recommended. Graduated training after healing.

Tibialis anterior tenosynovitis

Pain, over anterior distal third of leg and ankle. Pain at beginning and after exercise ± swelling, crepitus. Pain on active or resisted ankle dorsiflexion.

Overuse—excessive downhill running.

Rest, even from walking. Injection of LA and corticosteroid within tendon sheath.

Achilles tendonopathy

Pain in the Achilles tendon aggravated by walking on the toes. Stiff and sore in the morning after rising but improving after activity.

Repeated toe running in sprinters or running uphill in distance runners.

Relative rest. Ice at first and then heat. 10 mm heel wedge. Correct training faults and footwear. NSAIDs. Consider steroid injection.

Plantar fasciitis

Pain in medial or control aspect of base of the heel, worse with weight bearing. Sharp pain upon getting up to walk after sitting.

Running on uneven surfaces with feet pronated.

Relative rest. Orthotics in shoes. Injection of LA and corticosteroid.

Clinical features • A sudden sharp pain in the calf (the person thinks he or she has been struck from behind, e.g. by a thrown stone). • Unable to put heel to ground. • Walks on tip toes. • Localised tenderness and hardness.

Relative rest for 6 weeks. Ice massage. Calf (soleus stretching). NSAIDs. Correct training faults and footwear.

• Dorsiflexion of ankle painful. • Bruising over site of rupture. Management • RICE treatment for 48 hours. • Ice packs immediately for 20 minutes and then every 2 hours when awake (can be placed over the bandage).

Chapter 11 | Musculoskeletal medicine

Treatment of sprained ankle

site of rupture

Most of the ankle ‘sprains’ or tears involve the lateral ligaments (up to 90%), while the stronger tauter (deltoid) ligament is less prone to injury. The treatment of ankle ligament sprains depends on the severity of the sprain. Most grade I (mild) and II (moderate) sprains respond well to standard conservative measures and regain full, pain-free movement in 1 to 6 weeks, but controversy surrounds the most appropriate management of grade III (complete tear) sprains. (a)

Fig. 11.75  ‘Tennis leg’ or ‘monkey muscle’—illustrating typical site of rupture of the medial head of gastocnemius at the junction of muscle and tendon (left leg) (b)

• A firm elastic bandage from toes to below the knee. • Crutches can be used if severe. • A raised heel on the shoe (preferably both sides) aids mobility. • Commence mobilisation after 48 hours rest, with active exercises. • Physiotherapist supervision for gentle stretching massage and then restricted exercise.

Complete rupture of Achilles tendon A complete rupture of the Achilles tendon can be misdiagnosed because the patient remains able to plantar flex the foot by virtue of the deep long flexors. Two tests should be performed to confirm the diagnosis.

Fig. 11.76  Calf squeeze test for ruptured Achilles tendon: (a) intact tendon, normal plantar flexion; (b) ruptured tendon, foot remains stationary

Palpation of tendon Palpate for a defect in the Achilles tendon. This defect could be masked by haematoma if the examination is performed more than a couple of hours after the injury.

Grades I & II sprains R rest the injured part for 48 hours, depending on disability I ice pack for 20 minutes every 3 to 4 hours when awake for the first 48 hours C compression bandage, e.g. crepe bandage E elevate to hip level to minimise swelling A analgesics, e.g. paracetamol R review in 48 hours, then 7 days S special strapping Use partial weight bearing with crutches for the first 48 hours or until standing is no longer painful, then

The ‘calf’ squeeze test With the patient prone and both feet over the edge of the couch, squeeze the gastrocnemius soleus complex of both legs. Plantar flexion of the foot indicates an intact Achilles tendon (Fig. 11.76a); failure of plantar flexion indicates total rupture (Fig. 11.76b).

183

184

Practice Tips

encourage early full weight bearing and a full range of movement with isometric exercises. Use warm soaks, dispense with ice packs after 48 hours. Walking in sand, e.g. along the beach, is excellent rehabilitation. Aim towards full activity by 2 weeks.

(a)

Strapping of the ankle Method 1. Maintain the foot in a neutral position (right angles to leg) by getting the patient to hold the foot in that position by a long strap or sling. 2. Apply small protective pads over pressure points. 3. Apply one or two stirrups of adhesive low-stretch 6–8 cm strapping from halfway up the medial side, around the heel and then halfway up the lateral side to hold the foot in slight eversion (Figs. 11.77a, b). 4. Apply an adhesive bandage, e.g. Acrylastic (6–8 cm), which can be rerolled and reused. 5. Reapply in 3 to 4 days. 6. After 7 days, remove and use a non-adhesive tubular elasticised support until full pain-free movement is achieved.

(b) stirrups of adhesive tape

Mobilisation of the subtalarjoint The medial-lateral gliding mobilisation of the subtalar joint is indicated by a loss of function of the subtalar ankle joint, commonly with chronic post-traumatic ankle stiffness, with or without pain. The most common cause is the classic ‘sprained’ ankle. The objective of therapy is to increase the range of inversion and eversion. Method 1. The patient lies on the side (preferably the problematic side), with the affected leg resting on the table. The foot hangs over the end of the table with the lower leg supported by a flexible support, such as a rolled-up towel, small pillow, sandbag or lumbar roll. The foot is maintained in dorsiflexion by support against the therapist’s thigh. 2. Stand at the foot of the table facing the patient’s leg. 3. Grasp the patient’s leg with the stabilising hand just above the level of the malleolus. 4. The mobilising hand firmly grasps the calcaneum. 5. Apply a firm force to the foot at right angles to the long axis of the foot, so that an even up and down (medial-lateral) rocking movement is achieved. The movement should be smooth (not too forceful or jerky) and of consistent amplitude (Fig. 11.78).

(c)

Fig. 11.77 Supportive strapping for a sprained ankle: (a)Step 1 apply protective pads and stay tape; (b) Step 2 apply stirrups to hold foot in slight eversion; (c) Step 3 apply an ankle lock tape

Chapter 11 | Musculoskeletal medicine

Fig. 11.78  Position of foot for mobilisation of the subtalarjoint

Wobble board (aeroplane) technique for ankle dysfunction Proprioception exercises Strengthening of the leg muscles and the ligaments of the ankle can be improved by the use of a wobble board. The patient stands on the board and shifts his or her weight from side to side in neutral, forward or extended body positions to improve proprioception and balance.

An improvised wobble board Patients can construct a simple wobble board by attaching a small piece of wood (10 cm × 10 cm × 5 cm (deep)) to the centre of a 30 cm square piece of plywood or similar wood about 2 cm thick. (Suitable for patients with good balance.) Alternative Patients can simply place their slab of wood on a domeshaped mound of earth.

The ‘aeroplane’ exercise 1. Instruct the patient to stand in a neutral position and shift his or her weight from side to side to improve balance and proprioception. 2. After 2 or 3 days, perform the balancing exercises by leaning forwards in addition to using the neutral position (Fig. 11.79). 3. After a further 2 or 3 days, practise the exercise by leaning backwards—thus adding to the difficulty of the exercise.

Fig. 11.79  Wobble board technique for ankle dysfunction

Tibialis posterior tendon rupture Rupture of the tibialis posterior tendon after inflammation, degeneration or trauma is a relatively common and misdiagnosed disorder. It causes collapse of the longitudinal arch of the foot, leading to a flat foot. It is uncommon for patients to feel obvious discomfort at the moment of rupture. Most cases in middle age can be treated conservatively. Severe problems respond well to surgical repair, which is usually indicated in athletes.

Features • Middle-aged females and athletes. • Usually presents with ‘abnormal’ flat foot. • Pain in the region of the navicular to the medial malleolus. • Gross eversion of the foot. • ‘Too many toes’ test (Fig. 11.80). • Single heel raise test (unable to raise heel). • On palpation, thickening or absence of tibialis posterior tendon.

185

186

Practice Tips

‘Too many toes’ test More toes are seen on the affected side when the feet are viewed from about 3 metres behind the patient (Fig. 11.80).

Useful investigations • Ultrasound (the most economical). • MRI and CT scan—gives the clearest image.

Fig. 11.80 Tibialis posterior rupture (right foot): the ‘too many toes’ posterior view

Plastering tips Plaster of Paris The bucket of water • Line the bucket with a plastic bag for easy cleaning. • The water should be deep enough to allow complete vertical immersion. • Use cold water for slow setting. • Use tepid water for faster setting. • Do not use hot water: it produces rapid setting and a brittle plaster.

The plaster rolls • Do not use plaster rolls if water has been splashed on them. • Hold the roll loosely but with the free end firm and secure (Fig. 11.81). • Immerse in water until bubbles have ceased coming from the plaster surface. Ensure that the centre of the plaster is fully wet. • Drain surface water after removal from the bucket. • Gently squeeze the roll in the middle: do not indent. • Use about 2 cm × 10 cm and 1 cm × 8 cm rolls for below elbow and upper limb plasters. • Use 4 cm × 15 cm rolls for below knee leg plaster.

Padding • Use Velband or stockinet under the plaster. • With Velband, moisten the end of the roll in water to allow it to adhere to the limb. • For legs, make extra padding around pressure areas such as the ankle and heel. • Use two layers of padding but avoid multiple layers.

Fig. 11.81  Holding the plaster roll

Method 1. Use an assistant to support the limb where possible (e.g. hold the arm up with fingers of stockinet). 2. Lay the bandage on firmly but do not pull tight. 3. Lay it on quickly. Avoid dents. 4. Overlap the bandage by about 25% of its width. 5. Use only the flat of the hand so as to achieve a smooth cast.

Chapter 11 | Musculoskeletal medicine

Preparation of a volar arm plaster splint

velband

plaster strips

A volar arm plaster splint can be prepared with minimal mess and maximal effectiveness by following this procedure. Procedure 1. Measure the length of the required plaster splint. 2. Select Velband of the same width as the plaster and measure a length slightly more than twice the length of the splint. 3. On a flat bench top, lay out the length of the Velband on a piece of newspaper or undercloth. 4. Fold the plaster (10 cm roll for adults) according to the number of strips required (usually eight) and after immersing it in cool or lukewarm water and draining off excess water, place it on the Velband as shown in Figure 11.82. 5. Fold the Velband over the plaster to produce a ‘sandwich’ effect. 6. Using the fingers through the upper layer of Velband, mould two to three ridges along the length of the plaster on the outer surface of the slab. This provides reinforced strength for the splint. 7. Take a crepe bandage and apply the splint to the arm with appropriate moulding to hold the wrist in about 30° of extension. 8. This method can be adapted for plaster slabs for other areas.

Leg support for plaster application The awkward task of applying a leg plaster including a plaster cylinder can be aided by the use of a simple supportive device (Fig. 11.83).

Fig. 11.83 Supportive device for application of leg plaster

central ridge

volar slab

crepe bandage

Fig. 11.82  Preparation of volar arm plaster splint

The support, which should be at least 30 cm high, can be made by pinning a broad leather strap across a U-shaped frame.

Waterproofing your plastercast A suitable plastic protective cover for a plaster cast, especially for one on the arm, is a veterinary plastic glove, which is ideally long and fits on the arm like a mega ‘glove’. These are the gloves used in rural practice!

187

188

Practice Tips

A long-lasting plaster walkingheel

Onreview (day 2), the plaster cast is filled into the sneaker and tied over with the laces.

To avoid the plaster underlying the walking heel (incorporated into a leg plaster) becoming soft and therefore uncomfortable for walking (thus requiring repair), the following method can be used (Fig. 11.84). It involves incorporating a small piece of masonite (or similar wooden material) into the plaster cast at the time of affixing the heel. This is performed 24 hours after application of the original base plaster cast.

Method B A better alternative to the walking heel is the ‘open-toe cast shoe’, with its open heel and toe areas that can accommodate a wide variety of foot and cast types. The rocker sole, which is manufactured from EVA (a synthetic rubber), has three layers and minimises microtrauma to joints. The upper is made from reinforced canvas with Presto-flex adhesive straps. The shoes come in at least three sizes and fit neatly onto the plaster. They can be washed and will last throughout the life of a normal walking plaster. The shoes are available from various surgical suppliers.

Method 1. Apply a thin layer of plaster of Paris to the underside of the base of the cast. 2. Place the piece of masonite (or wood) against the plaster. 3. Place the heel over the wood. 4. Wrap adhesive plaster (such as Elastoplast) around the wood and heel to ‘fix’ the unit. 5. Apply the final coating of plaster of Paris to fix the heel. 6. Weight bearing can commence 24 hours later.

Supporting shoe for a walkingplaster

Use of silicone filler An economical walking plaster can be improvised by obtaining silicone filler (preferably resin type) from your hardware store and layering it over the base of the plaster with extra thickness over pressure areas.

Prescribing crutches

Method A An economical method is to get the patient to bring an old pair of rubber sneakers and cut out the front half (including the tongue) but leave the laces intact.

Patients with leg injuries are often given crutches without ensuring they are the correct height for the patient. The following guidelines are useful: • Wear the shoes that are usually worn. • Stand erect and look straight ahead, shoulders relaxed.

base plaster

adhesive plaster

thin layer of plaster of paris piece of masonite walking heel

Fig. 11.84  Plaster walking heel

outer layers of plaster of paris

Fig. 11.85  Correct fitting for crutches

Chapter 11 | Musculoskeletal medicine

• For fitting, the end of each crutch should be placed about 5 cm from the side of the shoe and about 15cm in front of the toe. • The top of the crutch should be about 2–3 finger breadths (about 5 cm) below the apex of the axilla. • The hand grip should be adjusted with the elbow bent 20–30° (Fig. 11.85). • The patient should have a trial walking practice under supervision before discharge.

Walking stick advice When prescribing a walking stick (cane), advise the correct height so that the patient’s elbow will be bent at slightly less than 45° when maximum force is applied (Fig. 11.86).

Fig. 11.86  Correct cane height

189

Chapter 12

Orodental problems

Knocked-out tooth If a permanent (second) tooth is knocked out (i.e. in an accident or fight) but is intact, it can be saved by the following, immediate procedure. The tooth should not be out of the mouth for longer than 20 to 30 minutes from the time of injury. Method 1. Using a sterile glove hold the tooth by its crown and replace it in its original position, preferably immediately (Fig. 12.1); if dirty, put it in milk before replacement or, better still, place it under the tongue and ‘wash’ it in saliva. Alternatively, it can be placed in contact lens saline or the solution in the ‘Dentist in a Box’ kit (www.dentistinabox.com.au). Note: Do not use water, and do not rub (it removes dentine) or wipe it or touch the root. 2. Fix the tooth by moulding strong silver foil (e.g. a milk bottle top or cooking foil) over it and the adjacent teeth. Moulding foil can be difficult: an alternative is to suture with a figure-of-eight silk suture to encompass the tooth. It can also be secured to the two adjoining teeth with a strip of tape cut from a disc in the ‘Dentist in a Box’ kit. 3. Refer the patient to his or her dentist or dental hospital as soon as possible. Tell the patient to avoid exerting any direct biting force on the tooth.

Note: If a blood clot is present, remove it after a nerve block. Teeth replaced within 20 to 30 minutes have a 90% chance of successful reimplantation.

Loosening of a tooth Loosening is excessive movement of a permanent tooth with no displacement. Splint the mobile tooth to a neighbouring tooth with the splinting material from the kit (see above). Alternatively, use chewing gum or Blu-Tack. Refer the patient to a dentist.

Chipped tooth Cover the exposed area, which is usually painful, with dental tape. Recover and store the tooth fragment for use by the dentist. If possible, secure the broken fragment with splinting material from the kit. Refer the patient to a dentist.

Fig. 12.1  Replacement of a knocked-out tooth

Chapter 12 | Orodental problems

Bleeding tooth socket First aid treatment method

Examination shows a socket with few or no blood clots, and sensitive bone surfaces covered by a greyish-yellow layer of necrotic tissue.

Instruct the patient to bite very firmly on a rolled-up handkerchief over the bleeding socket. This simple measure is sufficient to achieve haemostasis in most instances. Biting on a recently used tea bag is another suggestion.

Surgical treatment for persistent bleeding 1. Remove excess blood clot, using a piece of sterile gauze. 2. Bite on a firm gauze pack. 3. If still bleeding, insert a suture. (Chromic or plain catgut is suitable.) 4. Using a reverse suture, approximate the anterior and posterior mucosal remnants (Fig. 12.2). The idea is not to close the socket but to tense the mucoperiosteum against the bone. Avoid aspirin, rinsing and alcohol.

Treatment method 1. Self-limiting healing 10 to 14 days. 2. Refer for special toilet and dressing (palliative). If you have to treat: • irrigate with warm saline in a syringe • pack socket with 1 cm ribbon gauze in iodiform paste or pack a mixture of a paste of zinc oxide and oil of cloves or (usual dental formulation) zinc oxide and eugenol dressing. Leave 10 days. • analgesics • mouth wash. Note: Antibiotics are of no proven value. The differential diagnosis for the dry tooth socket is descending infection.

A simple way of numbering teeth Dentists utilise codes in which the teeth are numbered from 1 to 8 from the midline.

Dry tooth socket

International notation

Clinical features • Tooth extraction 1 to 3 days earlier. • Very severe pain, unrelieved by analgesics. • Continuous pain on the side of the face. • Foetid odour. • Mainly in the lower molars, especially the third (wisdom teeth).

Each of the four quadrants are numbered: Permanent teeth (n = 32; Fig. 12.3) 187654321 123456782 R.      L. 487654321 123456783 Deciduous teeth (n = 20) There are five teeth in each quadrant, and the four quadrants are notated 5 to 8. 554321 123456 R.        L. 854321 123457 Examples: • 1.6 = upper right first molar • 3.2 = lower left lateral incisor • 6.3 = upper left deciduous canine.

needle holder

socket

Palmer notation In this notation a cross is drawn to represent quadrants, but the numerals are used as above for permanent teeth. Deciduous teeth are represented by the letters A–E. The quadrants are noted by four right angles: mucosa of gingival margin

mucosa approximated over the socket

Fig. 12.2 Treatment for persistent bleeding of tooth socket

R

  L

Examples: • 5 = upper left second premolar • C = lower right deciduous cuspid.

191

Practice Tips

lower (mandibular) right

third molar

second molar

first molar

second premolar

first premolar

canine

upper (maxillary) left second incisor

upper (maxillary) right first incisor

192

lower (mandibular) left

Fig. 12.3 Permanent teeth

Wisdom teeth These are the third molars. They are usually normal teeth, but are prone to troublesome eruption and difficult extraction when impacted.

Aphthous ulcers (canker sores) These acutely painful ulcers on the mobile oral mucosa are a common problem in general practice and puzzling in their cause and response to treatment. Their cause is unknown, but several factors indicate a localised abnormal immune reaction. Minor ulcers: < 5 mm in diameter—last 5 to 10 days. Major ulcers: > 8 mm in diameter—last weeks and heal with scarring. Associations to consider Blood dyscrasias, denture pressure, Crohn disease, pernicious anaemia, iron deficiency. Precipitating factors Stress and local trauma. Treatment methods These treatments should be used early when the ulcer is most painful. Several optional healing methods are presented.

Symptomatic relief Apply topical lignocaine gel or paint, e.g. SM-33 adult paint formula or SM-33 gel (children) every 3 hours. If applied before meals, eating is facilitated. Alternatively, use a mixture of: • diphenhydramine (Benadryl mixture) 5 mL plus • Mylanta 15–20 mL. Gargle well and swallow 4 times a day.

Healing One of the following methods can be chosen. The teabag method Consider applying a wet, squeezed out, black teabag directly to the ulcer regularly, such as 3 to 4 times daily.The tannic acid promotes healing and alleviates pain. Another method is to prepare a strong cup of tea (concentrated), cool and dip in a cotton bud or ball and hold it against the ulcer for 3 minutes. Topical corticosteroid paste Triamcinolone 0.1% (Kenalog in orobase) paste. Apply 8 hourly and at night. Topical corticosteroid spray Spray beclomethasone on to the ulcer 3 times daily.

Chapter 12 | Orodental problems

Topical chloramphenicol Use 10% chloramphenicol in propylene glycol. Apply with a cotton bud for 1 minute (after drying the ulcer) 6 hourly for 3 to 4 days. Tetracycline suspension rinse for multiple ulcers 1. Empty the contents of a 250 mg tetracycline capsule into 20–30 mL of warm water and shake it. 2. Swirl this solution in the mouth for 5 minutes every 3 hours. An alternative method is to apply the solution soaked in cotton wool wads to the ulcers for 5 to 10 minutes. Note: This has a terrible taste but reportedly shortens the life of the ulcers considerably. We recommend spitting out the rinse, although some authorities suggest swallowing the suspension.

Method 1. Localise the calculus in the duct by finger palpation. 2. Anaesthetise the area with a small bleb of LA or surface anaesthetic (preferable if available), e.g. 5% cocaine placed under the tongue. 3. Insert a stay suture around the duct immediately behind the calculus (Fig. 12.4), and use this to steady the stone by elevation. 4. Make an incision over the long axis of the duct (the calculus easily slips out). 5. Remove the stay suture and leave the wound unsutured.

A ‘natural’ method of snaring a calculus

Topical sucralfate Dissolve 1 g sucralfate in 20–30 mL of warm water. Use this as a mouth wash.

1. Fast for about 6 hours. 2. Squeeze an unripe lemon and drink the juice. 3. Place a slice of lemon on the tongue. The calculus usually appears at the opening—it may then be possible to extract it using the preceding or following methods.

Geographic tongue (erythema migrans)

Simple removal of calculus from Wharton duct

Treatment Explanation and reassurance. • No treatment if asymptomatic. • Cepacaine gargles, 10 mL tds, if tender. • If persistent and troublesome, low dose spray of glucocorticoid (e.g. beclomethasone 50 mcg tds). Do not rinse after use.

Black, green or hairy tongue Brush tongue with a toothbrush to remove stained papillae. Use pineapple as a keratolytic agent. Method 1. Cut a thin slice of pineapple into eight segments. 2. Suck a segment on the back of the tongue for 40 seconds and then slowly chew it. 3. Repeat until all segments are completed. 4. Do this twice a day for 7 to 10 days. Repeat if symptoms recur.

If the calculus is visible at the opening of the duct it can be removed using the round end of a Jacob–Horne probe. The round end of the probe is placed over the meatus and firmly pressed inwards. Digital pressure is then applied from the opposite side of the frenulum. The calculus may ‘pop out’ quite readily.

Release of tongue tie (frenulotomy) The ideal time to release a tongue tie (ankyloglossia) is in infancy, when it may cause breastfeeding problems and maternal nipple pain.

stay suture

Calculus in Wharton duct The most common site for a salivary calculus is in the duct of the submandibular gland (Wharton duct). Obstruction to the gland by the calculus causes the classic presentation of intermittent swelling of the gland whenever the patient attempts to eat. The following method applies if the clinician can easily palpate the calculus with the finger under the tongue.

Wharton duct

incision over calculus

duct opening at base of tongue near midline

Fig. 12.4 Excision of calculus in Wharton duct

193

194

Practice Tips

Early signs • Tongue may appear as heart-shaped. • Infants should be able to lift the tongue halfway to the roof when the mouth is open. • Infants should be able to protrude the tongue over the lower lip. However, the condition is often not noticed until later in life, when it causes such symptoms as speech defects (e.g. a lisp), dental problems with the lower teeth, inability to protrude the tongue, and accumulation of food in the floor of the mouth. Treatment in infants (usually under 4 months, best at 3 to 4 months) Note: The frenulum is thin and avascular and there is minimal or no bleeding. 1. Ideally, a frenulum spatula should be used. 2. When the spatula is in place the tongue is stretched upwards. 3. Use a scalpel blade or sterile iris scissors to slit the frenulum just above the floor of the mouth. Alternative to frenulum spatula The infant is held by an assistant on the examination table with arms positioned either side of the head. The operator holds the frenulum between the index finger and thumb of the non-dominant hand and stretches it firmly (Fig. 12.5). The frenulum is then snipped with sterile scissors, taking care not to damage structures in the floor of the mouth and under the tongue.

frenulum stretched scissors snip frenulum

Fig. 12.5 Tongue tie release

Treatment in adults or older children 1. Perform the procedure under local or general anaesthesia. 2. When the tongue is elevated, use a no. 15 scalpel blade to incise the frenulum horizontally, taking care to avoid the Wharton ducts. 3. Tongue traction will then convert the horizontal incision into a vertical one, which can be closed in a vertical plane with interrupted plain catgut sutures.

Chapter 13

Ear, nose and throat URTIs and sinus problems Diagnosing sinus tenderness Eliciting sinus tenderness is important in the diagnosis and follow-up of sinusitis. Firm pressure over any facial bone, particularly in the patient with an upper respiratory infection, may cause pain. It is important to differentiate sinus tenderness from non-sinus bone tenderness. Method 1. This is best done by palpating a non-sinus area first and last (Fig. 13.1), systematically exerting pressure over the temporal bones (T), then the frontal (F), ethmoid (E) and maxillary (M) sinuses, and finally zygomas (Z), or vice versa. 2. Differential tenderness both identifies and localises the main sites of infection.

Diagnosis of unilateral sinusitis A simple way to assess the presence or absence of fluid in the frontal sinus, and in the maxillary sinus (in particular), is the use of transillumination. It works best when one symptomatic side can be compared with an asymptomatic side. It is necessary to have the patient in a darkened room and to use a small, narrow-beam torch.

T

T F

E

Z M

F

E

Z M

Fig. 13.1  T (temporal) and Z (zygoma) represent no sinus bony tenderness, for purposes of comparison (F = frontal sinuses; E = ethmoid sinuses; M = maxillary sinuses)

Frontal sinuses Shine the torch above the eye in the roof of the orbit and also directly over the frontal sinuses, and compare the illuminations.

196

Practice Tips

Maxillary sinuses Remove dentures (if any). Shine the light inside the mouth, on either side of the hard palate, pointed at the base of the orbit. A dull glow seen below the orbit indicates that the antrum is air-filled. Diminished illumination on the symptomatic side indicates sinusitis.

(b)

cardboard carton

Inhalations for URTIs Simple inhalations for upper respiratory tract infections (including upper airways obstruction from the oedema and secretions of rhinitis and sinusitis) can promote symptomatic relief and early resolution of the problem. The positive effect of making the patient responsible for active participation in management often helps to counterbalance the occasional disappointment when no antibiotic is prescribed. The old method of towel over the head and inhalation bowl can be used, but it is better to direct the vapour at the nose. Equipment • Container. This can be an old disposable bowl, a wide-mouthed bottle or tin, or a plastic container. • The inhalant. Several household over-the-counter preparations are suitable: e.g. Friar’s Balsam (5 mL), Vicks VapoRub (one teaspoon), Euky Bear, eucalyptus oil or menthol (5 mL). • Cover. A paper bag (with its base cut out), a cone of paper (Fig. 13.2a) or a small cardboard carton (with the corner cut away; Fig. 13.2b). (a)

Fig. 13.2 Inhalations using: (a) cone of paper; (b) cardboard carton

Method 1. Add 5 mL or one teaspoon of the inhalant to 0.5 L (or 1 pint) of boiled water (allow to cool for 5 to 10 minutes) in the container. 2. Place the paper or carton over the container. 3. Get the patient to apply nose and mouth to the opening to breathe the vapour in deeply and slowly through the nose, and then out slowly through the mouth. 4. This should be performed for 5 to 10 minutes, 3 times a day, especially before retiring. After inhalation, upper airway congestion can be relieved by autoinsufflation.

Hot water bottle method A relatively safe and convenient way is to use a hot water bottle for inhalations. The top fits neatly over the mouth and nose.

Vacuum flask method

cone of paper

vapour

inhalant

An old vacuum flask (thermos) is an ideal container to fill with very hot/boiling water and the inhalant. It is also portable. Warning: Avoid using these hot water methods in children.

A practical inhalation method for busy workers Dr Tony Dicker claims great success using a coffee cup for inhalations. By placing the inhalant, e.g. Vicks, on a teaspoon then adding boiling water, an inhalation bowl is made by placing the hands over the cup to suit the nose and mouth. People find this easy to use during meal/coffee breaks.

Chapter 13 | Ear, nose and throat

Nasal polyps Nasal polyps are small ‘bags’ of fluid and mucus following engorgement of the mucosa of the sinuses usually due to allergic rhinitis. They pop out through the sinus openings into the nasal cavity (Fig. 13.3). They are best treated by medical polypectomy using topical nasal hydrocortisone solution or corticosteroid sprays for small polyps and oral corticosteroids for extensive polyps, e.g. prednisolone 50 mg per day for 5 to 7 days (avoid aspirin). Antibiotics may be needed for infection. Surgery is usually reserved for failed medical treatment. Polyps can be simply removed under local anaesthetic by snaring the base or stalk with a loop of cutting wire. More severe cases may require sophisticated surgery.

sinuses

nasal cavity polyp from maxillary sinus

nasal septum

Fig. 13.3 Cross-section of nose demonstrating origin of nasal polyps

The ear and hearing A rapid test for significant hearing loss The age of the digital watch has meant a decline in the use of the ‘ticking watch’ test as a rough screening procedure for hearing loss. In children and in adults with a reasonable amount of hair, an alternative method can be used. Method 1. Grasp several scalp hairs close to the external auditory canal lightly between the thumb and index finger. 2. Rub lightly together (Fig. 13.4) to produce a relatively high-pitched ‘crackling’ sound.

If this sound cannot be heard, a moderate hearing loss is likely (usually about 40 dB or greater). If a hearing loss is detected, tuning fork assessment and other investigations will then be required.

The whispered voice test The whispered voice test has been proved as an accurate screening test for hearing impairment. It is less accurate in children than in adults. It is important to exhale quietly before whispering. Method 1. Stand 60 cm behind the patient. 2. Mask the non-test ear by gently occluding the auditory canal and rubbing the tragus in a circular motion. 3. Exhale quietly before whispering a combination of numbers and letters (e.g. ‘5, M, 2, A’). 4. If the patient responds correctly (i.e. repeats at least 3 out of 6 numbers and letters correctly), hearing is considered normal. 5. If the patient responds incorrectly, repeat the test using a different number-and-letter combination. 6. Test each ear individually, beginning with the better ear. Use a different number–letter combination each time.

Crumpled paper test

Fig. 13.4  Test for hearing loss in a child

Another simple rapid test is to use the sound of paper. Gently rub two pieces of paper together about 1–2 cm from the ear and request the patient to indicate if they hear the sound. For infants, crush a piece of paper behind the ear and note their response.

197

198

Practice Tips

Water- and soundproofing ears Waterproofing ears with Blu-Tack An excellent earplug can be made with Blu-Tack, which can be gently moulded to the external auditory canal. It is ideal for children if they need to keep an ear dry when swimming or showering, for example those with perforations, ventilating grommets and recurrent otitis externa (‘swimmer’s ear’). Ideally, a swimming cap should also cover the ear and diving should be advised against. The Blu-Tack provides excellent waterproofing, stays in place and is reusable. Do not use in hot saunas, where it softens easily. Children should be instructed not to keep poking the ‘tack’ into their ears with their fingers. Be prepared to remove retained bits of Blu-Tack sometimes.

New type of ear plug A new form of ear protection is the expanding ear plug. The plugs can be used during exposure to excessive noise and for middle ear protection while swimming, especially for children with ventilating tubes inserted in their ears. Made of compressible foam, when cut in half the plug can be rolled into a cylindrical shape that fits neatly in a child’s ear. Keeping a finger on the outer part of the ear canal allows the plug to expand and fill the canal. A small coating of petroleum jelly and a standard rubber bathing cap make them waterproof, but the child should not dive under water. Parents who have tried to use a full-sized ear plug for a child have sometimes found that the bathing cap rubbed on the end of it, pulling it out of the ear—hence the reason for cutting them in half. (E.A.R. Plugs are available from most acoustic services for approximately $1.00 a pair. They are washed easily in warm, soapy water, and a pair will last between 6 and 12 months.)

Use of tissue ‘spears’ for otitis externa and media The debris from otitis externa and the discharge from otitis externa or media can be mopped out with ‘spears’ fashioned from toilet paper or other tissue. They are widely used in Indigenous children. In otitis externa this toileting can be followed by acetic acid 0.25% washout— then topical steroid and antibiotic ointment if necessary.

Preventing swimmer’s otitis externa Get patients to rinse ears out with fresh water (possibly using a 5 mL syringe) and then dry with a hair dryer on moderate heat.

Treatment and prevention of swimmer’s ear Use a drying topical medication, e.g. Aquaear or Ear Clear (acetic acid and isopropyl alcohol). An alternative less expensive preparation is a ‘homebrew’ mixture of acetic acid (vinegar) and methyl alcohol (methylated spirits), 3 parts to 7. Instil 2 to 3 drops daily during the swimming season.

Chronic suppurative otitis media and externa Wash the canal with dilute povidone-iodine (Betadine) 5% solution using a 20 mL syringe with plastic tubing 1, 2 or 3 times daily. Dry mop with rolled toilet paper ‘spears’.Teach this method to family members. If available, suction kits are useful.

Ear piercing This simple method of ear piercing (for the insertion of ‘sleepers’) requires only an 18- or 19-gauge sterile needle. Local anaesthesia is optional. A freezing spray can be used. Method 1. Carefully place marks on the ear lobe (this is better done by the patient or patient’s parents). 2. Introduce the needle through the selected site (Fig. 13.5a). One can use a cork or piece of potato on the exit side. 3. Insert the pointed end of the sleeper into the bore of the needle, ensuring that it fits tightly, and withdraw the needle (Fig. 13.5b).

Ear wax and syringing Ear syringing is a simple and common procedure, but it should be performed with caution. Contraindications Syringing should not be performed in the acute stages of otitis media or when perforation of the tympanic membrane cannot be excluded. In these instances, wax should be cleared with a hook or curette under direct vision (Fig. 13.6a). In otitis externa, syringing may be performed to remove debris from the canal. Meticulous drying after the procedure is mandatory. Wax softeners Proprietary preparations may be used as an alternative to syringing or to assist removal, but dioctyl sodium sulphosuccinate should not be used if perforation is suspected. Sodium bicarbonate (available on

Chapter 13 | Ear, nose and throat

(a)

(b)

reduced by coating the inner plunger with petroleum jelly; it can also be primed with liquid soap. Water at body temperature (37°C) is a satisfactory solution (vertigo, nausea and vomiting may be precipitated by excessively hot or cold fluid coming in contact with the tympanic membrane). The nozzle of the syringe should rest just inside the auditory meatus and the syringe should be angled slightly upwards (Fig. 13.6b). Water directed along the roof of the external auditory canal cascades around and behind the plug of wax. Pulling the pinna upward and slightly backward straightens the canal, and may assist partial separation of the wax plug. While a kidney dish is the traditional collecting vessel for the syringed fluid, an empty plastic ice cream ‘bucket’ is a practical alternative: the pliable sides mould easily into the shape of the neck. Another improvised ear ‘cup’ can be cut out from a used hospital 1 L plastic bottle. A small recess can be made for the ear (Fig. 13.6c). Method 2 This is a very effective system that provides a constant flow of water, maximum safety, and a free hand when syringing the ear. (a)

Fig. 13.5  Ear piercing method

prescription)or olive oil drops may also be used. Culinary vegetable oil can be used by the patient prior to visiting the office. A study by Kamien led to the conclusion ‘that the most effective, cheapest and least messy cerumenolytic is a 15% solution of sodium bicarbonate’. It can be readily made by dissolving ¼ teaspoon of sodium bicarbonate in 10 mL of water. Apply it with a dropper. Another simple method is to fill the ear with liquid soap. Request the patient to ‘pump’ their tragus for a couple of minutes then attempt syringing.

Ear syringing Method 1 The syringe should have a properly fitting nozzle and an airtight plunger. Friction in a metal syringe can be

(b)

(c)

recess for ear

part of 1 L plastic bottle

199

200

Practice Tips

(d)

metal weight

extra tubing

Higginson syringe

eustachian catheter

Fig. 13.6 Removal of wax: (a) a hook is rotated behind the wax to remove it; (b) syringing technique, in which water is directed around (not at) wax; (c) ear ‘cup’ to collect water; (d) the Higginson syringe with special attachments

The apparatus consists of: a Higginson syringe a heavy metal washer (acts as a weight) a metal eustachian catheter additional tubing. The washer maintains the rubber syringe in the basin of water during the ear syringing. The metal eustachian catheter provides an ‘accurate’ jet of water, which is aimed superiorly above the wax in the usual, recommended manner (Fig. 13.6b).

Use This ‘ear syringe’ is flexible, safe and easy to use, especially for children. The curve at the end of the tubing permits good positioning in the ear canal. Note: Some doctors testify to the value of adding a small quantity of povidone-iodine solution to the water, especially if otitis externa is present. Others prefer hydrogen peroxide (100 mL bottles of 30 mg/mL are available in supermarkets) for ear toilet, especially with low-grade otitis externa.

Post-syringing If the patient complains of deafness due to water retention, instil acetic acid-alcohol drops (Aquaear or Ear Clear). This gives instant hearing. Some doctors routinely use these drops after syringing out the wax.

Hair spray and hard wax

• • • •

People who use hair sprays are prone to developing hard wax if it finds its way into the ear canal. Advise these people to cover their ears when they use the spray.

A ‘gentle’ ear syringe A simple ear syringe can be improvised from a 20 mL or 50 mL syringe and a plastic ‘butterfly’ intravenous cannula.The apparatus is also useful for instilling ointment to treat otitis externa. Method Firmly attach the ‘butterfly’ cannula to the syringe and cut off the tubing, leaving it about 3–4 cm long (Fig. 13.7).

20 mL syringe 20

15 10

Fig. 13.7 A ‘gentle’ ear syringe

‘butterfly’ cannula with needle cut off plastic tubing

Chapter 13 | Ear, nose and throat

Recognising the ‘unsafe’ ear Examination of an infected ear should include inspection of the attic region, the small area of drum between the lateral process of the malleus, and the roof of the external auditory canal immediately above it. A perforation here renders the ear ‘unsafe’ (Fig. 13.8a); other perforations, not involving the drum margin (Fig. 13.8b), are regarded as ‘safe’. The status of a perforation depends on the presence of accumulated squamous epithelium (termed cholesteatoma) in the middle ear, because this erodes bone. An attic perforation contains such material; safe perforations do not. Cholesteatoma is visible through the hole as white flakes, unless it is obscured by discharge or a persistent overlying scab. Either type of perforation can lead to a chronic infective discharge, the nature of which varies with its origin. Mucus admixture is recognised by its stretch and recoil when (a) attic perforation

superior margin of tympanic membrane

this discharge is being cleaned from the external auditory canal. The types of discharge are compared in Table 13.1. Table 13.1 Comparison of types of discharge Unsafe

Safe

Source

Cholesteatoma

Mucosa

Odour

Foul

Inoffensive

Amount

Usually scant, never profuse

Can be profuse

Nature

Purulent

Mucopurulent

Management If an attic perforation is recognised or suspected, specialist referral is essential. Cholesteatoma cannot be eradicated by medical means: surgical removal is necessary to prevent a serious intratemporal or intracranial complication.

Air pressure pain when flying Ear pain during descent can be helped by instilling a nasal decongestant such as Drixine 1 hour beforehand, and also by chewing gum during descent.

Excision of ear lobe cysts Small ear lobe cysts can be removed by simple excision with the aid of ring forceps (meibomian clamps). Such forceps are especially useful when they can be applied over accessible areas, such as eyelids, lips, webbing, scrotum and ear lobes. They enable a firm hold over a small cyst and help to control haemostasis. lateral process of malleus

(b)

Method 1. For a small ear lobe cyst, apply the forceps over the ear and clamp so that the surface chosen for excision occupies the open ring. 2. Make an incision over the cyst with a small scalpel blade and dissect the cyst gently away from adherent tissue (Fig. 13.9). 3. Once it is relatively free, it may be possible to squeeze out the entire cyst by digital pressure on either side.

Infected ear lobe The cause is most likely a contact allergy to nickel in the jewellery, complicated by a Staphylococcus infection.

Fig. 13.8 Infected ear: (a) unsafe perforation; (b) safe perforation

Management method 1. Discard the earrings. 2. Clean the site to eliminate residual traces of nickel. 3. Swab the site, then commence antibiotics (broadspectrum antistaphylococcus).

201

202

Practice Tips

stud cyst ear

forceps

incision over cyst

butterfly clip

Fig. 13.10 Removal of embedded earring stud

ear lobe ring forceps (meibomian clamp)

Fig. 13.9  Excision of ear lobe cysts

4. Get the patient to clean the site daily, then apply the appropriate ointment. 5. Use a ‘noble metal’ stud to keep the tract patent. 6. Advise the use of only gold, silver or platinum studs in future.

Embedded earring stud The embedded earring stud can be difficult to remove, but a simple technique using curved mosquito artery forceps can disimpact the stud easily. The typical stud consists of a post that slots into a butterfly clip. Method 1. Insert the tips of the mosquito artery forceps into the two openings of the butterfly clip. 2. Open the forceps, thus gently springing apart the butterfly clip (Fig. 13.10).This manoeuvre removes the pressure on the post, and the stud can then be separated.

Tropical ear For severe painful otitis externa, which is common in tropical areas: • prednisolone (orally) 15 mg statim, then 10 mg 8 hourly for six doses, followed by • Merocel ear wick or ichthammol and glycerine wick • topical Locacorten Vioform or Sofradex drops for 10 days.

Instilling otic ointment Otic ointment can be instilled into the ear canal, starting from deep near the tympanic membrane, by using the ‘gentle’ ear syringe described on page 200 for ear syringing. A more economical way is to use a small 1 or 2 mL syringe to squirt in 0.5–1 mL of cream, e.g. a mixture of hydrocortisone and clotrimazole.

Problems with cotton buds Avoid cotton buds to instil ointment and other material in the ear. Don’t use cotton buds to clean the ear. They tend to impact wax and other debris.

The nose Treatments for epistaxis

Other simple office methods

Remember to use protective eyewear if there is significant bleeding.

• Remove any clots—blow nose and then apply 5–6 sprays of a decongestant nasal spray (e.g. Drixine). • A cotton wool ball soaked in Xylocaine with adrenaline or a decongestant is also a useful method.

Simple tamponade In most instances, haemostasis can be obtained by pinching the ‘soft’ part of the nose between a finger and thumb for 5 minutes and applying ice packs to the bridge of the nose (Fig. 13.11).

Matchstick tamponade Several practitioners claim excellent results using a matchstick (¾ of its length) jammed up in a horizontal

Chapter 13 | Ear, nose and throat

ice pack

Method 1. A small loop can be made in the broach by bending the wire around the tip of fine forceps. 2. The loop is placed in the TCA so that a small amount fits neatly in the loop. 3. The loop is then applied to the appropriate site on Little’s area in the nasal septum (Fig. 13.12). The small amount of acid is delivered accurately and cauterises a specific area, without spillage to the healthy adjacent tissue. broach with a fine loop

Fig. 13.11 Simple tamponade method for epistaxis

position under the upper lip to the roof of the gum reflection on the teeth. Leave it in place for several minutes. It compresses the superior labial arteries that also supply the nasal septum. Note: Dental packing (hard cotton wool roll) would be ideal and preferable to a matchstick.

little’s area vessel

Simple cautery of Little’s area Local anaesthetic Cophenylcaine forte nasal spray—leave 5 minutes; or an equal mixture of 10% cocaine HCl and adrenaline 1:1000 (0.5 mL of each) soaked in a small piece of cotton wool about the size of a 5 cent piece. This pledget is gently compressed against the area and left for 2 minutes. Cautery methods The three methods of cautery are: • electrocautery • trichloroacetic acid (pure) • silver nitrate stick (preferred). Fashion cotton wool onto the end of the silver nitrate stick to dry the treated site. Put the silver nitrate directly onto the small vessels. Beware of silver nitrate stains. Apply Vaseline twice daily to the cauterised area.

Use of dental broach for treatment of epistaxis A dental broach can be modified to pick up a small but adequate amount of trichloroacetic acid (TCA) for nasal cautery.

Fig. 13.12 Shows loop of broach applied to the site of bleeding

Intermittent minor nose bleeds If not actively bleeding: • avoid nose blowing • avoid digital trauma • apply petroleum jelly (e.g. Vaseline) or an antibiotic ointment twice daily for 2–3 weeks.

Recurrent anterior epistaxis For patients with recurrent epistaxis from Little’s area, especially in the presence of localised rhinitis, several topical options are available: • Nasalate cream tds for 7 to 10 days, or • Aureomycin or Nemdyn otic ointment bd or tds for 10 days, or • Rectinol ointment. Rectal ointment containing local anaesthetic and a vasoconstrictor, e.g. Rectinol, is a very useful topical agent.

203

204

Practice Tips

Persistent anterior bleed Use Merocel (surgical sponge) nasal tampon or a Kaltostat pack or a vaginal tampon.

Severe posterior epistaxis Occasionally, severe posterior nasal bleeding cannot becontrolled by an anterior pack. Insertion of a nasopharyngeal pack via the oropharynx is technically difficult and distressing for the patient. A simple and effective method of applying postnasal pressure uses a Foley catheter. The traditional ribbon nasal pack with bismuth iodoform paraffin paste (BIPP) can still be used, or glycerine or Vaseline can be used instead of BIPP. Method 1. Anaesthetise the nasal passage. 2. Select a small Foley catheter (no. 10, 12, 14 or 16) with a 30 mL balloon and self-sealing rubber stopper. 3. Lubricate the deflated catheter and pass it directly into the nasal passage along the floor of the nose until resistance is felt in the nasopharynx (the tip might be visible behind the soft palate). 4. Using a 20 mL syringe, partially inflate the balloon with 5–8 mL of saline or, preferably, air. 5. Gradually withdraw the catheter until resistance is felt; inject another 5 mL of saline or air. 6. Draw the catheter taut so that the balloon fits snugly in the nasopharynx against the choana (Fig. 13.13). 7. Pack the anterior chamber with ribbon gauze in the usual manner. Note: The patient should be admitted to hospital. Administration of oxygen might be necessary for the elderly patient whose respiration is compromised.

The Epistat catheter: A special catheter called the Epistat has been developed specifically for this method. It is ideal but relatively costly. It has two inflatable balloons, one to act as a stay posteriorly and a wider ‘anterior’ balloon. There is a central airway in the device. This catheter can be autoclaved for further use.

Instilling nose drops To achieve the best results from nasal drops instil as follows: • to insert into the left side, incline the head to the left • for the right side, incline the head to the right.

Offensive smell from the nose Ensure no foreign body present. Treatment • mupirocin 2% nasal ointment instil 2 to 3 times a day or • Kenacomb ointment instil 2 to 3 times a day

Stuffy, running nose Treatment • Blow nose hard into disposable paper tissue or handkerchief until clear. • Nasal decongestant for 2 to 3 days only. • Steam inhalations with Friar’s Balsam or menthol. • Simply take promethazine (Phenergan) 25 mg nocte.

Senile rhinorrhoea This is a common, distressing problem in the elderly, caused by failure of the vasomotor control of the mucosa. It may be associated with a deviated septum and dryness of the mucosa. The treatment is to keep the nasal passages lubricated with an oil-based preparation e.g. insufflation with an oily mixture (a commercial preparation is Nozoil, which is sesame oil based) or petroleum jelly. Topical decongestants can cause serious side effects in the elderly.

Use of Nozoil (sesame oil preparation)

Fig. 13.13 Semi-inflated Foley catheter in nasopharynx and posterior nasal cavity

This can be used when temporary relief of dry and crusting nasal tissue is required. This can be caused by: • dry air • CPAP and oxygen • drugs such as isotretinoin • age-related dryness ± rhinorrhoea • post-surgery including cautery for epistaxis • nasal steroid use • nasal crusting from colds and influenza.

Chapter 13 | Ear, nose and throat

Nasal factures Fractures of the nose can occur in isolation or combined with fractures of the maxilla or zygomatic arch. They may result in nasal bridge bruising, swelling, non-alignment and epistaxis. Always check for a compound fracture or head injury and, if present, leave alone and refer. If the patient is seen immediately (such as on a sport’s field) with a straightforward lateral displacement, reduction may be attempted ‘on the spot’ with digital manipulation before distortion from soft tissue swelling. This involves simply using the fingers to push laterally on the outside of the nose towards the injured side to realign the nose. Tips • X-rays are generally unhelpful unless excluding other facial skeletal injuries. • If a deformity is present, refer the patient within 7 days, ideally from days 3–5.

• Skin lacerations (i.e. a compound fracture) usually require early repair. • The optimal time to reduce a fractured nose is about 10 days after injury. There is a window period of 2–3 weeks before the fracture unites. • Closed reduction under local or general anaesthetic is the preferred treatment. • Open reduction is more suitable for bilateral fractures with significant septal deviation, bilateral fractures with major dislocations or fractures of the cartilaginous pyramid. Refer • Uncontrolled epistaxis • Recurrent epistaxis • Concern about cosmetic alignment

Miscellaneous ENT pearls Hands-free headlight Ideal hands-free lights to examine the ears, nose and throat include the Vorath headlight kit or the Welch Allyn portable binocular microscope, the LumiView—a headband flat surface magnifier. A less expensive alternative is a caving headlamp, which can be obtained at a camping shop at a reasonable cost.

Self-propelled antral and nasal washout This method works well for patients with persistent catarrh and sinus problems. Equipment You will need: • a drinking straw • a tea cup • warm water with 1 teaspoon of salt and 1 teaspoon of sodium bicarbonate. Method 1. Place the straw in the water and the other end in the nostril. 2. Holding the other nostril closed with a finger, the patient inhales the fluid rapidly into the nostril and then expectorates.

Use of FLO sinus care This preparation is a sinus douche of physiological ‘extracellular fluid’. It can be delivered as a nasal metered

pump, which limits the distribution to the nose only, or as a 200 mL douche bottle to thoroughly wash nasal and sinus cavities.

Hiccoughs (hiccups) For simple brief episodes, try any of the following. • Rebreathe air in a paper bag (as for hyperventilation). • Hold the breath. • Suck ice/swallow iced water. • Swallow a teaspoon of table sugar (some practitioners add vinegar to the sugar; others, whisky or gin). • Swallow 20 mL of spirits (37% or more alcohol). • Insert a catheter quickly in and out of the nose. • Apply pressure on the eyeballs. When persistent (assuming exclusion of the organic diseases): • chlorpromazine orally or IV, or • valproic acid. Consider acupuncture, hypnosis or phrenic nerve block.

Nasal catheter for hiccoughs Persistent hiccoughs can be arrested quickly by irritation of the nose with a soft rubber or plastic nasal catheter. The method is particularly useful for the post-operative patient. A catheter is introduced into one of the nasal passages and withdrawn as soon as the patient shows irritation.

205

206

Practice Tips

Worth a try?

Glue ears

Ask the patient what they ate for breakfast 2 days ago. The thoughtful pause that ‘freezes’ the diaphragm may work!

Autoinflation of ears via the eustachian tube can be achieved by a device called Otovent, which consists of a balloon attached to a nose piece. The child with a glue ear holds the nose piece to the nostril and inflates the balloon to the size of a grapefruit while keeping the other nostril compressed with a finger and the mouth firmly closed.The balloon is then allowed to deflate while the child swallows. It is performed 2 to 3 times a day for 2 to 3 weeks.

Snoring Important strategies to prevent snoring include: • avoid sleeping on the back • weight reduction to ideal weight • no alcohol in the evening. Otherwise refer to a medical consultant in sleep disorders. Continuous positive airway pressure (CPAP) delivered through a special face mask may be prescribed.

Nasal device A device suitable to prevent ‘collapsing’ of the front of the nose is ‘Nozovent’, which is a simple medical-grade plastic device that fits into the nose. The device, invented by a Swedish ENT surgeon, increases the diameter of the nostrils and prevents them from collapsing on inhalation. An Australian version is the Breathing Wonder, which is inexpensive and freely available.

Tinnitus Precautions • Exclude drugs (including marijuana), vascular disease, depression, aneurysm and vascular tumours. • Be mindful of lonely elderly people living alone (suicide risk). Management • Educate and reassure the patient. • Encourage the patient to use relaxation techniques. • Encourage background ‘noise’, e.g. music playing during night. • Tinnitus maskers. • Hearing aids. Drug trials to consider (limited efficacy) • Betahistine (Serc) 8–16 mg daily (max 32 mg) • Carbamazepine (Tegretol) • Antidepressants • Sodium valproate (Epilim, Valpro, Valprease)

Acute severe tinnitus Slow IV injection of 1% lignocaine (as for migraine—see p. 11). Up to about 5 mL is very effective.

Swallowing with a sore throat Rather than painful sipping of fluids, advise the patient to fill the mouth with as much fluid as possible and then swallow.

Auriscope as an alternative to nasal specula An auriscope with the widest possible attachment will allow an excellent view of the nasal cavity. The patient should mouth breathe during the inspection.

Chronic anosmia following URTI For patients complaining of loss of the sense of smell following an upper respiratory infection, prescribe a nasal decongestant such as Spray-Tish Menthol for 5 to 7 days (maximum).

Ticklish throat For an irritated persistent ticklish throat instruct the patient to make a trilling musical sound like an opera singer for 2 to 3 minutes.

Doctor-assisted treatment for benign paroxysmal positional vertigo Theory This condition is considered to be caused by displacement of floating crystalline calcium carbonate deposits (otoconia) in the posterior semicircular canal. This creates the illusion of motion. The Brandt–Daroff exercises can be performed by the patient at home. The particle repositioning manoeuvres of Semont and Epley can be performed as office procedures by the therapist.

The Epley manoeuvre This exercise should be tried first. The basic manoeuvres are (Fig. 13.14): • move the patient’s head into four different positions • hold the head in each postural position for 1 minute • after doing this sit still for 10 minutes to allow the crystals to settle. Method 1. The patient sits on the bed with the head slightly extended and turned 45° in the direction that precipitated the vertigo (Fig. 13.14a).

Chapter 13 | Ear, nose and throat

(a)

(d)

45°

(e) (b) 45°

(c) 45°

Fig. 13.14  (a) to (e) The Epley manoeuvre for treatment of right-sided disease (reverse head position for left-sided disease) Reproduced from Therapeutic Guidelines: Neurology, 2011, with permission.

2. Lie the patient on their back with the head hanging over a pillow placed at the shoulder level. Wait 1minute (Fig. 13.14b). 3. From this position turn the head through 90° to the opposite side and wait 1 minute (Fig. 13.14c). 4. Turn the head through a further 90° and roll onto that side so that the ear is parallel to the floor. Wait another minute (Fig. 13.14d). 5. Slowly sit the patient upright and still for 10 minutes (Fig. 13.14e). Follow up: Get the patient to sleep in a semi-upright position. Repeat until the attacks abate.

The Semont manoeuvre (Fig. 13.15) 1. Sit the patient upright in the middle and on the edge of the bed or couch. Turn the head 45° to the side

opposite to that which precipitated the vertigo (the unaffected ear). 2. While maintaining the head position, tip the patient to the affected side so that they are lying on the affected side (with nose up) and wait 1 minute. 3. Move the patient quickly 180° through the upright position (maintaining the original head position) and lower to the other side (nose now pointing down). Wait 1 minute. 4. Slowly return the patient to the upright position and then rotate the head to the normal position. Sit still in this position for 10 minutes.

207

208

Practice Tips

A

B

C

A

B

C

Fig. 13.15  (A) to (C) The Semont manoeuvre. For right-sided problems, the labelled boxes show the orientation of the vestibular labyrinth in each head position with the corresponding positions of the free-floating deposits that eventually fall into the utricular cavity on completion of a successful particle repositioning manoeuvre Reproduced from Therapeutic Guidelines: Neurology, 2003, with permission.

Chapter 14

The eyes

Basic kit for eye examination Recommended by the Royal Victorian Eye and Ear Hospital, the kit comprises: • eye-testing charts at 18 inches (46 cm) and 10 feet (305 cm) • multiple pin holes • fluorescein sterile paper strips, e.g. Flourets • torch • magnification (necessary to examine cornea) • isotonic saline solution to irrigate eyes • local anaesthetic (e.g. MINIMS unidose) • sterile cotton buds • glass rod to double-evert eyelids in chemical burns • non-allergenic tape (e.g. Micropore). Eye tip: The eye holds only one drop of liquid, which usually remains in the eye for only a few seconds. The action can be prolonged by pinching on either side of the nose to occlude the lacrimal duct for 60 seconds.

which is easy to withdraw and has a handle that keeps fingers out of the field of inspection (Fig. 14.1). 2. Care must be taken not to slide the end of the clip over the lid but to place it gently and precisely along the appropriate line (about 15 mm from the edge of the lid and parallel to it). 3. You must also make sure not to slide the end of the clip across the lid and scratch it on removal. Care must also be taken with uncooperative children.

Eversion of the eyelid Paperclip method No eye examination is complete without eversion of the upper eyelid to exclude hidden pathology, particularly a foreign body. The method generally taught is to evert the lid over a matchstick, but this can be difficult. The use of a paperclip can simplify this examination. 1. By bending the long arm of the paperclip to make a right angle, you can create an instrument with a fine diameter,

Fig. 14.1  Paperclip method for eyelid eversion

210

Practice Tips

Cotton bud method The use of a cotton bud is recommended for eyelid eversion. Its effectiveness depends on correct placement. 1. Ask the patient to put the chin up and to look down. 2. Gently grasp the eyelashes of the upper lid between the index finger and thumb of the non-dominant hand and pull gently downwards. 3. Apply the cotton bud 15 mm above the upper eyelid margin. 4. With gentle pressure, push the bud back while lifting the lashes upward. 5. Eversion of the lid can be maintained even after removal of the cotton bud.

Blepharitis Blepharitis is inflammation of the lid margins and is commonly associated with secondary ocular effects such as styes, chalazia and conjunctival or corneal ulceration. There are three main causes or types: • seborrhoeic—associated with seborrhoeic dermatitis • rosacea—associated with facial seborrhoea • staphylococcal—due to S. aureus. Precautions Corneal ulceration, recurrent staphylococcal infections. Management • Eyelid hygiene is the mainstay of therapy. The crusts and other debris should be gently cleaned with a cotton wool bud dipped in clean, warm water or a 1:10 dilution of baby shampoo or a solution of sodium bicarbonate, once or twice daily. An alternative is to apply a warm water or saline soak with gauze for 20 minutes followed by a rest for 60 minutes. • Treat infection with an antibiotic ointment smeared on the lid margin (this may be necessary for several months), e.g. tetracycline 1% or bacitracin ointment to lid margins 3 to 6 hourly. • For chronic blepharitis, short-term use of a corticosteroid ointment, e.g. hydrocortisone 0.5%, can be very effective. • Ocular lubricants such as artificial tear preparations may greatly relieve symptoms of keratoconjunctivitis sicca (dry eyes), e.g. hypromellose 1%. • Control scalp seborrhoea with regular medicated shampoos, e.g. ketoconazole. • Systemic antibiotics may be required for lid abscess. • Discontinue wearing contact lenses until the problem has cleared.

Flash burns A common problem usually presenting at night is bilateral painful eyes from keratitis caused by ultraviolet ‘flash

burns’ to both corneas some 5 to 10 hours previously. Sources of UV light such as sunlamps and snow reflection can cause a reaction. Management • Local anaesthetic (long-acting) drops, e.g. amethocaine 1% eye drops: once only application (do not allow the patient to take home more drops). • Instil homatropine 2% drops statim. • Analgesics, e.g. paracetamol, for 24 hours. • Broad spectrum antibiotic eye ointment in lower fornix (to prevent infection). • Firm eye padding for 24 hours, when eyes reviewed (avoid light). • A cold compress applied to the lid can be soothing. The eye usually heals completely in 48 hours. If not, check for a foreign body. Use fluorescein if in doubt. Note: Contact lens ‘overwear syndrome’ gives the same symptoms.

Wood’s light and fluorescein After fluorescein is instilled into the eye, look for a dendritic ulcer with a Wood’s light.

Simple topical antiseptics for mild conjunctivitis • Saline: prepare a saline solution by dissolving a dessertspoon of salt in 500 mL of boiled water then bathe the eye regularly (1 to 2 hourly) with cotton wool or gauze. • Dilute povidone-iodine solution: dilute Betadine solution 1 in 10 parts water and use this to clean the eye.

Removing ‘glitter’ from the eye Make-up glitter can adhere to the conjunctiva and cornea. Its removal can be aided by ointment such as chloromycetin or hydrocortisone, which binds it and ‘flushes’ it to the inner canthus where it can be removed by wiping with a tissue or gauze.

Dry eyes Dry eyes can cause burning or stinging, itching, a gritty sensation, redness and a feeling of ‘something in the eye’. Simple test Hold the eyelids wide apart for about 20 seconds—it will reproduce symptoms such as burning, stinging or dryness.

Chapter 14 | The eyes

Treatment For uncomplicated dry eyes it is usual to use artificial tear preparations, which relieve the symptoms. In some people these may be needed for life. There are three main types of artificial tears: • Lubricating drops: these are instilled during the day, usually 1 to 2 drops about 4 times a day or as often as required. Examples: Liquifilm, Teardrops, Murine Tears, Isopto Tears, Tears Naturale, Methopt. • Lubricating gels or ointments: these are instilled at bed time. Examples: Poly Vise, Duratears, Lacri-Lube OSP. • Stimulant drops: these are given in the same ways as lubricating drops and are very effective. Examples: Thera Tears, Cellufresh. Remember that bathing the eyes with clean water will help relieve dry eyes. Room humidifiers also help in rooms where there is dry heating.

(a)

(b)

adhesive tape

3 cm

Eyelash disorders Irritation of the eye by lashes rubbing on it is usually caused by either entropion or ingrowing lashes.

1 cm

Entropion

Fig. 14.2 Treatment of entropion: (a) before; (b) after

With entropion, the eyelashes of the lower lid are pushed to the side by the regular inturning. The condition can be demonstrated by asking the patient to close the eyes tightly and then open the eyes. The danger is ulcerative scarring of the cornea by the eyelashes, so it should be examined by staining with fluorescein. Entropion in the frail elderly can be corrected by the use of a strip of hypoallergenic, non-woven surgical tape (1 cm × 3 cm). Attach one end to the lower lid just below the lashes, with tension sufficient to hold the lid everted, and the remainder to the face (Fig. 14.2). It should be changed as often as necessary and may be done by a relative, the doctor or a district nurse.

Removal of corneal foreign body

Ingrowing eyelashes (trichiasis) In this condition the lid is in a normal position but the eyelashes may grow inward. Magnification may be necessary. For only a few ingrowing lashes, epilation is the best method. Use fine-artery forceps, jeweller’s forceps or, better still, eyebrow tweezers (available from chemists) to pluck out the offending eyelashes. The lashes tend to regrow, and regular epilation may be necessary. If there are many ingrowing eyelashes, the best options are electrolysis of the hair roots or cryotherapy.

Use adequate magnification with a magnifying loupe, ideally those with an inbuilt light source. Use local anaesthetic (e.g. benoxinate HCl). Recent and superficial Attempt removal of the foreign body (FB) by using a sterile cotton bud, lightly moistened with a drop of local anaesthetic, to gently lift it off. Embedded Use a sterile, disposable needle (25- or 23-gauge) with a small syringe attached to steady the needle. It is best to bend the end of the needle so that it forms a scoop. Hold the unit with a pen grip and keep the bevel upwards. Introduce the needle horizontally so that the tip lifts the edge of the FB (Fig. 14.3a). The rust ring The needle can lift loosely bound rust. A sterile dental burr can be used. The burr, which is applied vertically, should be rotated gently once and then the cornea inspected after each rotation (Fig. 14.3b). This should not be attempted on deep rust or central FBs. An ‘automatic’ safety burr can be used.

211

212

Practice Tips

(a)

The abrasion may be associated with an ulcer, which is a defect in the epithelial cell layer of the cornea. Symptoms • Ocular pain • Watering of the eye • Foreign body sensation • Blurred vision Think corneal abrasion if the eye is ‘watering’ and painful.

(b)

Fig. 14.3 Removal of foreign body: (a) disposable needle steadied with syringe using a horizontal approach; (b) dental burr rotated once, using a direct vertical approach

Assessing the depth of injury—Seidal test This test can evaluate suspected global rupture but a slit lamp with a cobalt blue filter is ideal. Apply 2% fluorescein eye drops and observe to see if the dye is diluted by leaking aqueous fluid. The ruptured area stains weakly while bright green concentrated dye surrounds the leak site. Follow-up Instil antibiotic drops and pad the eye for 30 minutes only. Review at 24 hours. Inspect and stain the cornea with fluorescein. Continue to instil antibiotic drops 3 times a day for 3 days. (Drops are preferable to ointment.) Precautions • Do not give LA for pain relief. • Refer deep rust stains to experts. • Never forcibly rub the cornea. • Do not use corticosteroids on the eye initially. • Get patients to wait until LA wears off (about 20 minutes). They should drive home without an eye pad.

Corneal abrasion and ulceration The many causes of abrasions include trauma from a foreign body, fingernails including ‘French nails’, contact lenses, UV burns and insects.

Diagnosis This is best performed with a slit lamp using a cobalt blue filter and fluorescein staining. Place a drop of LA on the end of a fluorescein strip (or two drops into the conjunctival sac). If a slit lamp is unavailable, the direct ophthalmoscope can be used to provide illumination as well as blue light for corneal examination. Magnifying loupes can then be used for viewing the illuminated cornea. You usually see an epithelial flap of tissue on the cornea. Management • Stain with fluorescein and look for a foreign body. • Treat with chloramphenicol 1% ointment ± homatropine 2% (if pain due to ciliary spasm). • Consider double eye pad for 24 hours (max.). • Give analgesics. • Consider an ice pack on the eyelid (best avoided). • Review in 24 hours. • Consider specialist referral.

The recurrent erosive syndrome Be aware of this syndrome especially with fingernail injuries. Pain is triggered upon opening the eye first thing in the morning because the lid pulls off epithelium. Treatment is Lacri-Lube applied at night.

Excision of Meibomian cyst The meibomian cyst (tarsal cyst, chalazion) is simple to treat by incision of the cyst and curettage of its wall. Equipment You will need: • a small syringe and needle • a chalazion clamp (blepharostat) • a chalazion curette • a scalpel handle and no. 11 blade. Note: A disposable kit is now available. Method 1. Instil LA drops (e.g. MINIMS oxybuprocaine, benoxinate HCl). 2. Inject about 1 mL of 2% lignocaine around the cyst through the skin (see Fig. 14.4a). 3. Apply the chalazion clamp, with the solid plate on the skin side.

Chapter 14 | The eyes

(a)

meibomian cyst

8. Apply a small quantity of chloramphenicol eye ointment. 9. Remove the clamp and then double-pad the eye, folding one pad over to ensure firm pressure. Advise the patient to change the eye pad 24 hours later and to clean away the debris with warm water or saline. Apply the ointment daily until the conjunctiva has healed (3 to 5 days).

Local anaesthetic for the eyelid (b)

For minor surgical procedures of the eyelid, such as a meibomian cyst, it is advisable to infiltrate local anaesthetic just under the skin of the eyelid around the lump. Start from the outer aspect of the lid with the needle entry being about 10 mm below the eyelid margin for cysts of the lower lid. Keep the needle tangential to the globe (Fig. 14.4a) and use about 1.5–2 mL of 1 or 2% lignocaine with adrenaline.

Non-surgical treatment for Meibomian cysts Before proceeding to excision of a meibomian cyst (chalazion), another method is worth attempting.

(c)

Method • Twice daily ‘hot spoon’ the eye. (Pad a spoon with cotton wool and a bandage, dip in hot water and gradually bring it up to the eye—similar to steaming the painful eye) (Fig. 14.5). • After ‘hot spooning’ for 5 minutes, instil ‘golden eye ointment’ (or soframycin eye ointment if use of mercury compounds is undesirable). • Massage the ointment into the chalazion for 5 minutes. • Using this method twice a day, it usually takes 2 to 4 weeks for the meibomian cysts to resolve. meibomian cyst

Fig. 14.4 Removal of meibomian cyst: (a) the cyst; (b) incising with clamp in place; (c) curetting contents

4. Tighten the clamp just enough to stop the bleeding. 5. Evert the eyelid to expose the bulging cyst in the ring. 6. Make a vertical incision in the cyst (Fig. 14.4b) to avoid damage to other glands. 7. Vigorously scrape out cyst contents with the curette (Fig. 14.4c).

padded spoon

Fig. 14.5 Simple treatment for meibomian cyst

213

214

Practice Tips

Padding the eye The materials used are single packs of sterile gauze eye pads and 25 mm non-allergenic (Micropore) tape. A single, flat eye pad is satisfactory for protection, but for healing, especially for the cornea, more care is required. Method 1. Two pads are required for healing. 2. Fold the first eye pad so that the folded edge rests just below the eyebrow (Fig. 14.6). 3. The pad is then reinforced by a single, flat pad over the top. 4. Secure the pads firmly and apply 25 mm non-allergenic tape carefully to the skin. Precaution: Never pad a discharging infected eye.

2. Lie down or sit with head over the back of a lounge chair. 3. Look up, spread the lower eyelid and instil the drop into the lateral conjunctival sac. 4. Close the eyes and press a finger against the lacrimal sac to stop quick drainage.

Visual acuity A representation of a Snellen eye chart, comparing the metric and British ‘feet’ distances is shown in Figure14.8. Choose the appropriate distance and ask the patient to cover one eye and note the eye being tested. If the patient has a pair of distance glasses, ask them to read the lowest possible line left to right. Then test the other eye, reading the lines from right to left. If the acuity is reduced out of either eye, then a pinhole must be used to help compensate for an uncorrected refracture error. Finally assess acuity with both eyes open and glasses on.

The pinhole test for blurred vision The pinhole test (Fig. 14.7a) is a useful and under-utilised test in clinical practice. It is important to use the test for any patient presenting with indistinct or blurred vision, whether it is sudden or gradual, painful or painless.

Fig. 14.6  Method of eye padding

Managing styes A stye is an acute abscess of a lash follicle or associated glands, caused usually by Staphylococcus aureus. Treat as for any acute abscess, by drainage when the abscess has pointed. Method 1. Direct steam from a thermos onto the closed eye (see Fig. 14.9), or use a hot compress. This helps the stye to discharge. 2. Perform lash epilation to allow drainage of pus. (Incise with a D11 blade if epilation does not work.) 3. Use chloramphenicol ointment if the infection is spreading locally.

Application of drops The following instructions are advisable for patients: 1. Avoid contamination of the tip of the dropper bottle (fingers, eyelashes, etc.).

Theory The pinhole reduces the size of the blur circle on the retina in the uncorrected eye. A pinhole acts as a universal correcting lens and a 1 mm pinhole will improve acuity in refractive errors. If not, further investigation is mandatory as the defective vision is not due to a refractive error. Using a multiple pinhole occluder Multiple pinhole occluders are freely available (Fig. 14.7b). The patient is given the occluder and tests vision in one eye by covering the other eye and then examining an eye chart through any pinhole. The other eye is tested by reversing the procedure for the eyes. If the blurred vision is normalised and no other abnormality is discovered on ophthalmic examination, the patient should be referred for a sight test. If the vision is unchanged, an organic cause should be suspected and appropriate referral arranged.

Relief of ocular pain by heat Heat, in the form of steam, applied to the closed eye is practical and very effective for the symptomatic relief of any ocular pain. Indications for the use of steam include styes, meibomian cysts and iritis.

Chapter 14 | The eyes

(a)

(b) pinhole

Fig. 14.7  (a) Pinhole test for blurred vision; (b) multiple pinhole occluder

A

D F

Metric Feet 6/60 20/200

Method 1. Using a thermos of boiled water, allow steam to rise onto the painful eye. 2. The eye must be closed for this treatment (Fig. 14.9). 3. The steaming, which should be comfortable to the sore eye, is used for about 15 minutes.

Hot spoon bathing Another method is to place a padded wooden spoon in very hot water and hold it close to the eye.

6/36 20/120

H Z P

6/24 20/80

TXUD

6/18 20/60

Z A D N H 6/12 20/40 P N T U H X 6/9 6/6 U A Z N F D T 6/5 N P H T A F X U

20/30 20/20 20/16

Fig. 14.8 Snellen eye chart comparing the metric and ‘feet’ classification

Fig. 14.9 Steaming the painful eye

215

216

Practice Tips

Chemical burns to the eye Acid or alkali injury to the eye may occur from domestic and industrial products, especially household cleaning products and cosmetics. Alkali injury (e.g. oven and drain cleaners, lime, cement, plaster and fertilisers) is more common and more severe. Alkali causes liquefactive necrosis of the surface epithelium of the eye. Acid (e.g. from toilet cleaner, pool cleaners, bleaches and battery fluid) causes coagulative necrosis of the cornea. Equipment for treatment 1 L bag of Hartmann or normal saline solution, IV tubing, litmus paper, cotton buds, benoxinate eye drops. Treatment • Apply immediate copious irrigation of the eye for 30 minutes. Commence with tap water irrigation followed by Hartmann or N saline solution via IV tubing until the pH is normalised. • Ask the patient to look in all directions during irrigation. • Give a topical anaesthetic (benoxinate drops). • Sweep the upper and lower fornices with a moistened cotton-tipped applicator as you lift the eyelids away from the eye and remove any debris, including loose conjunctival tissue. • Stain with fluorsecein. Test and record vision and refer for specialised assessment.

Protective industrial spectacles All workers at risk of eye injury should wear protective spectacles. One recommended set of economical spectacles with polycarbonate lenses is Alsafe 20-20 (made by New Zealand Safety Ltd). Features • One-piece wrap-around safety spectacles manufactured from high-impact-resistant polycarbonate material with scratch-resistant, coated lens.

• Available in clear, amber, green and infrared for harmful infrared and ultraviolet radiation.

Effective topical treatment of eye infections The application of eye ointment or drops for such infections as conjunctivitis can be rendered ineffective by the presence of debris, such as mucopurulent exudate. Method One simple method is to use a warm solution of saline to bathe away any discharge from conjunctivae, eyelashes and lids. The solution of saline is obtained by dissolving a teaspoonful of kitchen salt in 500 mL of boiled water.

Hyphaema This is usually caused by injury from a fist/finger or ball, e.g. squash ball. Management • First, exclude a penetrating injury. • Avoid unnecessary movement: vibration will aggravate bleeding. (For this reason, do not use a helicopter if evacuation is necessary.) • Avoid smoking and alcohol. • Do not give aspirin (can induce bleeding). • Prescribe complete bed rest for 5 days and review the patient daily. • Apply padding over the injured eye for 4 days. • Administer sedatives as required. • Beware of ‘floaters’, ‘flashes’ and field defects. Arrange follow-up ophthalmic consultation to exclude glaucoma and retinal detachment (within 1 month).

Chapter 15

Tips on treating children Making friends • A good aphorism is: never examine the child until you have made the mother laugh. • Establish rapport in the waiting area with children— show interest, use considerable eye contact and make favourable comments. • Ask them what they like to be called. • Have special stickers to put on the backs of their hands, T-shirts, etc. • Take time to converse and/or play with them. • Have interesting toys for them to handle while listening to their parents. • Compliment the child on, for example, a clothing item or a toy or book they are carrying. • Ask them about their teacher or friends. • Try to examine them on their parent’s lap.

Distracting children Children are sometimes difficult to examine but can be readily distracted, a characteristic the general practitioner can use effectively in carrying out the all-important examinations. In the consulting room, a small duck with a rattle inside it can be used for palpating the abdomen of young children. This seems more acceptable to them, as it becomes a game and you obtain the same information as if you had palpated with your hand. Another method of examining the abdomen in an upset child is to use a soft toy to play a game on the abdomen and then slip your other hand under the toy for closer assessment.

Alternatively, use the diaphragm of your stethoscope (preferably one with a small soft toy attached) to apply pressure, starting lightly and then pressing harder while watching the child’s reaction. Rebound tenderness can also be tested. Perhaps the best abdominal palpation method is to use the child’s hand under yours to palpate. When performing painful procedures, a recommended technique for infants (especially under 3 months) is ‘the three Ss’ method: • swaddling for firm containment • swaying (where appropriate) • sucking using a pacifier (dummy) with 15–50% sucrose. Another way of diverting a child’s attention, especially if giving an injection, is to blow up a balloon in front of them and let the air out slowly through a narrow opening to make a high-pitched ‘squealing’ sound—or let it go and ‘shoot’ around the room. When examining the ears of young children sitting on their mother’s lap, difficulty is encountered when the child follows the auroscope light and moves his or her head. A small rabbit or other animal on the desk, which, at the press of a button under the desk, will play a drum, distracts the child sitting to the right and enables you to get a good look into the left ear. Similarly, over the examination couch, a clockwork revolving musical toy will distract the child for examination of the ear. It is also a distraction for the examination of children on the couch, and can become a most useful instrument.

218

Practice Tips

An excellent method to distract upset or uncooperative children is to blow bubbles for them. Have a bubble blowing kit on hand for this. Another technique when giving an injection is to get the child to take a deep breath followed by a series of rapid blowing, during which the injection is given. Then there is the ‘cough trick’ whereby the child is asked to perform a ‘warm up’ cough of moderate intensity, followed by a second cough to coincide with the vaccine needle puncture.

Management of painful procedures The treatment of painful procedures in children requires special consideration and planning because pain preventive measures reduce both short-term and long-term morbidity. Current evidence indicates that pain and distress in children is poorly managed and children continue to suffer unnecessarily. This can lead to anticipatory anxiety, needle phobia and the avoidance of health care. Obviously, it is impossible to make many basic procedures such as immunisation and other injections painless, but there are strategies to minimise the pain. Before inflicting pain on a child always consider if the procedure is justified.

‘BitE the bullet’ strategy A novel method of achieving the cooperation of some children for an uncomfortable procedure such as giving injections or injecting local anaesthetic for suturing is to distract them by asking them to ‘bite the bullet’ at the appropriate time. Boys of primary school age in particular seem very attracted to this novelty, as they equate it with being brave and tough. Rather than use a dead (gunpowder removed) .38 or .45 calibre bullet, which is too hard, a ‘toy’ bullet made out of a plastic or rubber compound would be ideal. Method 1. Explain the method to the child and parents. 2. Place the ‘bullet’ between the child’s teeth and askaparent or assistant to hold the end of the bullet firmly. 3. Ask the child to bite the bullet as you perform the painful part of the procedure. Biting on a chocolate with a hard coating and a soft centre is another novel tip.

Using pacifiers (dummies) to easepain A study reported in the British Medical Journal (1999, 319, pp. 1393–7) recommended that all newborn babies

undergoing minor procedures (e.g. veneuncture, IV injections, lumbar puncture) should be given a dummy to ease the pain. This is reinforced using 15–50% sucrose on the pacifier (dummy). Refer to the ‘cough trick’ under ‘Distracting Children’ on page 217.

Deep breath with blowing distraction A distraction technique for giving children injections, e.g. routine immunisations, is to get them to take a deep breath followed by a series of rapid blowing (similar to childbirth exercises).

Taking medicine There are many tricks used by parents to get their children to swallow medicine. One method is to apply the mixture to a chocolate ripple biscuit (or other suitable item). Another is to mix it into a small glass of a cola drink.

Swallowing a tablet Ask the child to put the tablet on the tip of the tongue and then take a big suck on a straw from soft drink or other fluid.

Administration of fluids Oral Sabin vaccine Some older children refuse to take the vaccine from a spoon. Method 1. Introduce the vaccine with a syringe. The vaccine will draw up readily into a 1 mL syringe (three drops equals 0.2 mL: the usual dose is two drops). 2. Squirt the solution well back into the oropharynx and to one side. This avoids choking and prevents the child spitting out the vaccine, a common problem with taking it from a spoon. Many children enjoy the ‘waterpistol’ connotation.

Improving fluid intake in a small child Place a child who is refusing oral fluids in a bath with a face washer in such a way that the child is encouraged to suck the wet washer. Some children will do this even when they refuse to take fluids in the conventional manner. This method will help to reduce fever, if present.

How to open the mouth Some children refuse to open their mouths to have an examination of their throat. Getting the spatula between

Chapter 15 | Tips on treating children

clenched teeth is not easy. Hold their nose closed by gently pinching the nostrils together and they will reflexively open their mouth. One tip is to ask the child to take a deep breath while you inspect the pharynx with your torch. Another tip is to ask them to look up at a 45° degree angle and yawn, or ask them to make a loud noise like a tiger. This may need to be repeated.

Spatula sketches for children Many young patients have quickly forgotten any inspection of their throats while observing the preparation of a ‘present’ in the form of a drawing on the wooden spatula used in one practitioner’s examination. After the examination they are informed of their special present, and you can then proceed to draw on the unusedend of the spatula. The drawings take about 15 seconds. Figure 15.1 illustrates three sketches from one repertoire: a penguin (with optional bow tie), a caterpillar and a racing car. Tip: Use an ink pad with special stamps, e.g. Disney characters, Bananas in Pyjamas, to stamp onto the spatulas. Another idea is to make a human face on the spatula then make a split of about 1–2 cm at the top of the spatula. Insert wisps of cotton wool or tissue to create the impression of hair.

Instilling eye drops in cooperative children Method 1. Gently hold the lower lid down. 2. Get the child to look up and instil the necessary drops. 3. Ensure that the tip of the bottle does not touch the eye (Fig. 15.2a). If the child is unable to keep the eyes open: 1. Lay the child on his or her back. 2. When the eyes are ‘screwed up’, instil the drops into the depression formed above the inner canthus (Fig. 15.2b). 3. When the child opens the eyes (preferably slowly), the drops soon gravitate into the eye. Note: This is suitable for antibiotic drops, but unsuitable for drops acting through the autonomic nervous system. (a)

(b) nie’s pha Ste cing ra r ca

Fig. 15.2 Instilling eye drops in cooperative children

caterpillar with GT stripes

Intravenous cannula insertion penguin

Fig. 15.1 Spatula sketches

Instilling nose drops A trick to get a toddler to inhale nose drops is to instill a drop or two at the nasal openings and cover the child’s mouth. The reverse of the previous tip.

The preferred site is the dorsum of the non-dominant hand. Other sites are the radial aspect of the forearm, the dorsum of the foot, great saphenous vein or cubital fossa. Give topical local anaesthetic and consider an injection of local anaesthetic (preferable). Keep the child as still as possible by wrapping in a sheet. Grasp the wrist and hand to facilitate insertion into the dorsum of the hand. Keep the cannula as still as possible at an angle of 10–15° and advance it gently into the vein (Fig. 2.2). Splint the arm and wrap the whole arm in a firm crepe bandage.

219

220

Practice Tips

Use of subcutaneous local anaesthetic

Button and disc battery ingestion

An intravenous cannulation can be very painful so insertion of subcutaneous local anaesthetic is recommended.

If not in the stomach, these (and especially lithium batteries) create an emergency if in the oesophagus, because the electric current they generate destroys mucous membranes and causes perforation within 6 hours. They must be removed. This also applies to the ear canal and nares.

Method Draw up 1% lignocaine into an insulin syringe. After skin preparation, the skin overlying the target vessel is pulled laterally and a small volume (about 0.2 mL) is injected into the subcutaneous tissue.When the skin returns to its former position, wait for 1 to 2 minutes and then insert the cannula.

Difficult vein access To raise a vein for cannulation in chubby children, consider the methods on page 20 but remember that a neat vein can be raised over the fourth metacarpal on the dorsum of the hand.

Easier access to a child’s arm To achieve relaxation in an arm, for example to insert an intravenous line, distract the child by getting them to squeeze a special toy (as used in children’s hospitals) with the hand of the opposite arm. This muscular activity of one arm leads to relaxation of the opposite arm.

Impacted foreign bodies Obstruction of the oropharynx and tracheal opening by a larger foreign body (especially a large food bolus) can be rapidly fatal. As a rule, the obstruction can usually be removed by asking patients to cough (first line) or by giving them a sharp blow to the back. On the other hand, sweeping a finger around the pharynx to hook out the bolus is a good method. In children, a sternal thrust over the lower end of the sternum can be used to depress the chest for about onethird of its diameter. Yet another method is to place the child over your knees with head down, and apply blows to the back with a firmness applicable to the child’s age.

Wound repair

Swallowed foreign objects

Wherever possible it is worth using a simple painless technique without compromising good healing.

Hard objects swallowed by children are common emergencies in general practice.

Scalp lacerations

A golden rule The natural passage of most objects entering the stomach can be expected. Once the pylorus has been traversed, the foreign body usually continues.Typical foreign bodies are: • coins • buttons • sharp objects • open safety pins • glass (e.g. ends of thermometers) • drawing pins. Special cases are: • very large coins (e.g. 50 cent pieces): watch carefully • hair clips (usually cannot pass duodenum if under 7 years). Management • Manage conservatively. • Investigate unusual gagging, coughing and retching with X-rays of the head, neck, thorax and abdomen (check nasopharynx and respiratory tract). • Watch for passage of the foreign body in stool (usually 3 days). Avoid giving aperients. • If not passed, order an X-ray in 1 week. • If a blunt foreign body has been stationary for 1 month without symptoms, remove at laparotomy.

If lacerations are small but gaping, use the child’s hair as the suture. This, of course, only pertains to children with long hair. Do not use this method for large wounds. Method 1. Make a twisted bunch of the child’s own hair of appropriate size on each side of the wound. (The longer the hair, the better the result.) 2. Tie a reef knot and then an extra holding knot to minimise slipping (Fig. 15.3). 3. As you tie, ask an assistant to drip compound benzoin tincture solution (Friar’s Balsam) or spray plastic skin or similar compound on the hair knot. 4. As this congeals, the knot is further consolidated against slipping. Leave the hair suture long. The parents can cut the knot about 5 days later when the wound is healed. The whole procedure is painless until tetanus toxoid is given (if indicated).

Forehead lacerations Despite the temptation, avoid using reinforced paper adhesive strips (Steri-strips) in children for open wounds. They will merely close the dermis and cause a thin,

Chapter 15 | Tips on treating children

the cornea or conjunctiva must be avoided, as this can cause adhesions.The glue must not be used on mucosal surfaces. Method • Ensure the wound is clean and dry and the wound edges are precisely opposed. No gaps are permissible with the glue method (Fig. 15.4). • Clean the wound with normal saline or aqueous chlorhexidine and let dry. • Apply a thin layer of glue directly to the tissue edges to be joined with the fine end of the tapered plastic ampoule (Fig. 15.5)—squeeze out gently.

laceration in scalp

twisted bunch of hair

glue

wound reef knot

incorrect

Fig. 15.3  Method of using hair to repair scalp lacerations glue

stretched scar. They can be used only for very superficial epidermal wounds and in conjunction with sutures.

Lacerated lip or gums A practical method to soothe and distract an upset child with a mouth wound is to ask the child to suck on a teaspoon of sugar. This strategy seems to alleviate oozing of blood.

Glue for children’s wounds

correct

Fig. 15.4 Application of glue to a wound

A tissue adhesive glue can be used successfully to close superficial, smooth and clean skin wounds, particularly in children. It is useful for wounds less than 3 cm.

Skin glues—an alternative to sutures Cyanoacrylate tissue adhesions are available for wound closure. These glues act by polymerising with the thin water layer on the skin’s surface to form a bond. Those available include Histoacryl, Derma-bond and Epi-Glu. Some practitioners find that a similar type, such as Superglue, also serves the purpose but sterility and toxicity have to be considered and so this is not recommended. Precautions The glue should be used only for superficial, dry, clean and fresh skin wounds. It must not be applied for deep wounds or wounds under excessive tension. Contact with

coloured glue

cut about here

Fig. 15.5 The ampoule of Histoacryl

221

222

Practice Tips

• Press the tissue surfaces together for 30 seconds. • Remove any excess glue immediately with a dry swab. • Apply Steri-strips to prevent access to the wound, e.g. ‘picking’ by the child. • Do not wash the wound for 3 to 4 days. Follow instructions in the product data sheet. Caution: The glue bonds skin and eye tissue in seconds. If spilt on skin, remove with acetone as soon as possible.

Topical local anaesthesia for children’s lacerations Topical anaesthetic drugs that can be used for instilling in minor wounds in children are listed in Table 15.1. The preparations include a variety of drugs, so toxicity and safety factors have to be considered. Cocaine is very effective, but it is relatively toxic and as a rule should be avoided in open wounds. Adrenaline-containing preparations should be avoided in wounds in end-artery areas, such as digits, pinnae, tip of the nose, penis, or on mucous membranes such as inside the mouth where rapid absorption may occur. The recommended topical combinations are Lacerine and LAT (see Table 15.1), but these may have to be prepared by a hospital or compounding pharmacy. A variation of LAT and Lacerine is the readily available preparation EMLA cream. It requires at least 60 minutes of skin contact to be effective and is not recommended for open wounds. Method • Thoroughly clean the wound (should be less than 5 cm). • Use LAT or Laceraine in a dose 0.1 mL/kg bodyweight.

Table 15.1 Topical preparations for local analgesia Topical preparation

Contents

Lacerine (previously ALA)

adrenaline 1:1000, lidocaine 4%*, tetracaine 4%

LAT

lignocaine 4%, adrenaline 1:2000, tetracaine† 2%

TAC

tetracaine† 0.5%, adrenaline 1:2000, cocaine 11.8%

AC gel

adrenaline, cocaine

AnGel

amethocaine 4%

EMLA

lignocaine, prilocaine

*lidocaine = lignocaine †  tetracaine = amethocaine

• Apply this solution on a piece of gauze or cotton wool placed inside the wound and hold in place with an adhesive clear plastic dressing. • Leave for 20 to 30 minutes (an area of blanching about 1 cm wide will appear around the wound). Anaesthesia is obtained about 20 to 30 minutes after instillation. Test the adequacy of anaesthesia by washing and squeezing the wound or prodding it with forceps—if this is pain free, suturing will usually be painless. Note: Use these solutions with caution. Death and convulsions with doses greater than 3 mL of TAC in infants have been reported.

Improvised topical ‘anaesthesia’ Some practitioners use an ice block or a wet ice-cold piece of gauze to chill the lacerated site in children.The child or parent is asked to hold the ice then lift it while a suture is rapidly inserted or while local anaesthetic is introduced.

Liquid nitrogen topical ‘anaesthesia’ A useful technique for a variety of topical anaesthesia, especially useful in older children, is to spray liquid nitrogen or other vapocoolant over the skin where a procedure such as incising an abscess is necessary.

Wound infiltration For a larger wound requiring suturing, infiltrate lignocaine 1% into the wound edges using a small 27-gauge (or smaller) needle with a 3 mL syringe (Fig 3.4). The pain of injection can be reduced by: • using topical anaesthesia first • injecting slowly • placing the needle into the wound through the lacerated surface, not through intact skin • passing the needle through an anaesthetised area into an unanaesthetised area • buffering the acidic solution with 8.4% sodium bicarbonate in a 9:1 ratio, that is 9 mL lignocaine 1% with 1 mL sodium bicarbonate.

Fractures Skeletal injuries in children differ from adults in many respects and fractures should be considered in children presenting with unusual loss of function such as walking or use of an arm. Significant differences • Children’s fractures differ in nature and management due to bone plasticity and other factors. • Epiphyseal or growth plate fractures provide challenging management problems.

Chapter 15 | Tips on treating children

Removing plaster casts from children

• As a rule, sprains do not occur in childhood. • Greenstick fractures which involve one cortical surface only. • Buckle fractures due to compressed metaphyseal bone. • Child abuse must be considered as a cause of fractures in infants under 6 months. • Meticulous X-rays are required for fractures around the elbow joint.

To facilitate removal of plaster, especially a plaster cylinder from a child, request that the patient soaks the plaster in warm water prior to seeing you. The patient should soak it in the water for about 15 minutes or longer on the evening or morning prior to his or her visit. Alternatively, the plaster can be soaked in water at the surgery, but it is preferable for it to be performed at home in a large bucket or container (the bath is suitable) (Fig. 15.6a). The POP bandage can then be easily teased out and unrolled (Fig. 15.6b), or cut with a knife or scalpel. This method saves time and the unpleasant experience of a plaster cutter or saws. Note: Making the initial plaster: a fun thing is to add a food dye to children’s plaster when smoothing it out, or the dye can be put in the bucket of water.

Specific fractures • The ‘toddler’s fracture’, spiral fracture of tibia—often no history of injury; requires immobilisation in an above knee plaster. • Clavicle—requires a simple sling for 2 weeks. • Shaft fracture of humerus—treat conservatively with collar and cuff sling ± supportive plaster slab holding arm against chest. • Supracondylar fracture of humerus—a potentially complex and serious injury usually requiring referral for specialised treatment. Circulation and major nerve injuries are a concern. • Condylar fractures of humerus—also ‘tiger country’ if epiphyseal plates and metaphyses involved. Requires orthopaedic referral. • Forearm fractures—often are areas for greenstick fractures but beware of the Monteggia fracture with associated dislocation of the radius. Include the elbow and wrist joints in X-rays.

Cutting plaster with an electric saw Children will be more reassured if a wooden tongue depressor or similar object is inserted under the plaster in the sawing line.

The crying infant Checklist of common causes • Hunger (underfeeding is the main feeding problem causing crying) • Wet or soiled nappy • Loneliness • Infant colic: typically 2–16 weeks • Teething (more likely after 12 months) • Reflux oesophagitis

Splints for minor greensticktype fractures Non-displaced fractures of the arm can be splinted using one or two plastic tongue depressors under the bandage as an alternative to a plaster backslab.

(a)

(b)

Fig. 15.6 Removal of plaster cast: (a) soak in warm water to soften; (b) unroll bandage

223

224

Practice Tips

The role of 5 Ss to comfort the infant 1. Swaddling—firm clothing, not too loose 2. Lie baby on side or stomach 3. Shush (i.e. ‘sshusshhing’ as loudly as the child 4. Swing—sway away from side to side 5. Suckling—nipple, teat or dummy

2. Pour some of the stool into a test tube and add two parts of water. 3. Place 15 drops into another test tube. 4. Add a Clinitest tablet and note the reaction. Alternatively, put 5 drops of the faecal fluid directly into a test tube and add 10 drops of water.

Infant colic

Interpretation A reading of 0.75 to 2 indicates lactose intolerance. A reading of 0 or 0.25 is probably negative (Fig. 15.7b).

If cow’s milk intolerance, lactose intolerance and oesophagitis from reflux are excluded, recommend the pacifying methods above. Avoid medications if possible. Some parents are desperate and buy OTC preparations from pharmacists (e.g. Hartley Gripe Water, Infants’ Friend, Brauer Colic Relief ). These may contain naturopathic oils, baking soda or ethanol and tend to cause loose bowels and napkin rash. The safest preparation to consider is Infacol Wind Drops (simethicone).

Reflux with oesophagitis This tends to affect the older child and cause great distress. If basic methods such as thickening of feeds and antacids are ineffective, a recommended effective preparation is omeprazole (Losec) 5 mg bd. (Some hospital pharmacies prepare this in mixture format.)

Cleaning a child’s ‘snotty’ nose A child’s blocked nose can be cleaned with sodium chloride (normal saline) including Narium mist spray or FLO Saline Plus. A simpler way to remove lumps of mucus is to use the firmer tissue ‘spears’ described on page 198. Insert the ‘spear’ adjacent to and then behind the snot to dislodge it. Another method is to use an all-rubber 30 mL ear syringe (usually stocked by pharmacies). Insert the lubricated tip in the infant’s nostril and use the suction effect to clear the nares.

Test for lactose intolerance Theory If lactose intolerance is suspected in a child with diarrhoea, especially if fluid diarrhoea follows milk feeds, a simple test can be performed with a Clinitest tablet. This test detects reducing sugars such as lactose and glucose but not sucrose. Specific glucose oxidase reagents such as Testape and Glucostix detect glucose only and will not detect lactose or sucrose. Method 1. Line a napkin with plastic and collect faecal fluid (Fig. 15.7a).

Breath-holding attacks Diagnosis • Precipitating event (minor emotional or physical). • Children emit a long loud cry, then hold their breath. • They become pale and then blue. • If severe, may result in unconsciousness or a fit. • Lasts between 10 to 60 seconds. • Age group usually 6 months to 6 years (peak 2 to 3 years). Management • Reassure the parents that attacks are self-limiting and are not associated with epilepsy or mental retardation. • Advise parents to maintain discipline and to resist spoiling the child. • Try to avoid incidents known to frustrate the child or to precipitate a tantrum.

(a) pipette

fluid stool

2 parts water 1 part stool (b) negative 0

clinitest lablet 15 drops

0.25 0.5 0.75 1.0 1.25 ??

positive

Fig. 15.7 Test for lactose intolerance: (a) test method; (b) interpreting reading

Chapter 15 | Tips on treating children

Itching and swollen skin rashes An ice pack is an excellent method of giving relief to an acute itchy or swollen skin lesion such as an insect bite in children (and adults). A simple method is to place a few ice cubes in a handkerchief or small cloth and complete the pack with a string tie or rubber band. It soothes and prevents excessive scratching.

Note: If unsuccessful, the bladder is probably empty so try at another time. Tip: Hold the tip of the penis in males to prevent voiding but have a sterile bottle on standby for a clean catch should voiding occur.

Traumatic forehead lump If a child develops a forehead lump, such as after a fall onto the edge of the table, apply a cold flannel, then a thick smear of honey. Repeat twice a day for 3 days.

Suprapubic aspiration of urine This is the most accurate way of collecting urine in children less than 2 years old. It is very suitable in the toxic and ill child. Contraindications • Age greater than 12 months (unless the bladder is palpable or percussable). • Coagulopathy. Preparation • Best performed when the child has not voided for at least 1 hour. Give the child a drink, e.g. bottle over the preceding hour or so. • Select a 23-gauge needle attached to a 5 mL syringe. • Local anaesthetic is not necessary but a topical anaesthetic is recommended. Position of patient • The patient’s legs should be straight (preferable) or bent in the frog-leg position. Method 1. Check the bladder position by gentle percussion. 2. Prepare the skin in the suprapubic area with povidoneiodine solution. 3. Ask an assistant to hold the child supine with the legs extended. 4. Insert the needle attached to the syringe directly through the abdomen wall in the midline 1–2 cm above the symphysis pubis (this usually corresponds to the skin crease above the pubis) (Fig. 15.8). 5. Insert it to a depth of about 2–3 cm in infants or deeper according to the child’s age. Have a bottle on stand-by for a midstream clean catch in case the child voids. 6. Apply steady suction until urine is obtained. 7. Aspirate the urine while slowly withdrawing the needle. 8. Take the needle from the syringe and express the sample into a sterile microurine container. 9. Forward the urine for microscopy and culture.

Fig. 15.8 Suprapubic aspiration of urine in a child

The ‘draw a dream’ technique A useful interview technique for children with behavioural disorders is to ask them to ‘draw a dream’, especially if bad dreams are a feature of their problem. It is an excellent avenue to help children effectively communicate their understanding of the stressful events in their lives. Professor Tonge believes that ‘it is the royal road to the child’s mental processes and the family doctor is ideally placed to use the technique’. Method 1. Make a simple drawing of someone in bed and add a large cartoon balloon (Fig. 15.9). 2. If the child’s name is John, for example, say as you draw the dream balloon, ‘Here is a boy named John having a bad dream; perhaps it is even you. I wonder if you could draw that dream for me’. 3. Then ask the child to help you interpret the significance of the drawing.

Fig. 15.9 The ‘draw a dream’ technique

225

226

Practice Tips

Assessing anxious children and school refusal Assessment of the degree and nature of the child’s anxiety and possible contributing factors to school refusal is an essential first step in management and provides a baseline against which to monitor progress. The following three useful measures of school refusal assist in the assessment of such children.

Fear thermometer The fear thermometer (Fig. 15.10) is an easily administered measure that provides a global rating of the child’s fear about school attendance. In relation to their worst day in the past few weeks of school, the child is asked: ‘How afraid were you of going to school on that day?’  They are

asked to nominate their level of fear, from 0 ‘not scared’ to 100 ‘very scared’, on the pictorial thermometer. This global rating may reflect fear related to (a) separation from significant others; or (b) a dreadful aspect of the school setting.

Self-statement questionnaire The self-statement questionnaire (Fig. 15.11) allows for a more detailed understanding of the sorts of things that may be contributing to school refusal. It taps the child’s thoughts about seven aspects of school attendance (including such things as the other children at school, and the process of actually going to school in the morning). In addition, it allows the child to nominate any other issues that may lead to a reluctance to attend.

FEAR THERMOMETER Name Very scared

Date 100 90 80 70 60

Scared

50 40 30 20

Fig. 15.11 Self-statements: child form

10 Not scared

Think about your worst day over the past 2 school weeks. How afraid were you of going to school on that day?

Fig. 15.10 The fear thermometer

The clinician can use the information elicited during administration of the questionnaire to help in the development of a treatment program that addresses the specific anxiety-provoking thoughts of the child.

Surgery Table 15.2 Optimal times for surgery/intervention in children’s disorders Disorder

Surgery/intervention

Squint (fixed or alternating)

12–24 months absolutely before 7 years

Deafness (children are born with hearing)

Screen at or before 8 months hearing aids required by 12 months

Ear deformity

After 6 years

Tongue tie

3–4 months or 2–6 years

Cleft lip

Less than 3 months

Chapter 15 | Tips on treating children

Cleft palate Inguinoscrotal lumps • Undescended testes • Umbilical hernia • Inguinal hernia

• • • •

Femoral hernia Torsion of testicle Hydrocele Varicocele

Leg and foot development problems • Developmental dysplasia of hip • Bowed legs (genu varum) • • • • •

Knock knees Flat feet Internal tibial torsion Medial tibial torsion Metatarsus varus

6–12 months best assessed before 6 months surgery best at 6–18 months leave to age 4 surgery at 4 if persistent (tend to strangulate after 4) never tape down! general rule is ASAP, especially infants and irreducible hernias reducible herniae: the ‘6–2’ rule birth–6 weeks: surgery within 2 days 6 weeks–6 months: surgery within 2 weeks over 6 months: surgery within 2 months ASAP surgery within 4 hours (absolutely within 6 hours) leave to 12 months then review (often resolve) leave and review most treated successfully by abductor bracing with a Pavlic harness normal up to 3 years usually improve with age: refer if ICS > 6 cm normal 3–8 years then refer if IMS > 8 cm no treatment unless stiff and painful refer 6 months after presentation if not resolved leave for 8 years then refer if not resolved refer 3 months after presentation if not resolved

227

Chapter 16

The Skin

Rules for prescribing creams and ointments How much cream? On average, 30 g of cream will cover the body surface area of an adult. Ointments, despite being of a thicker consistency, do not penetrate into the deeper skin layers so readily, and the requirements are slightly less. Pastes are applied thickly, and the requirements are at least 3 to 4 times as great as for creams. The ‘rule of nines’, used routinely to determine the percentage of body surface area affected by burns (Fig.16.1), may be used also to calculate the amount of a topical preparation that needs to be prescribed. For example: • If 9% of the body surface area is affected by eczema, approximately 3 g of cream is required to cover it. • Nine grams of cream is used per day if prescribed 3times daily. • A 50 g tube will last 5 or 6 days. One gram of cream will cover an area approximately 10cm × 10 cm, and this formula may be used for smaller lesions.

Some general rules 1. Use creams or lotions for acute rashes. 2. Use ointments for chronic scaling rashes. 3. A thin smear only is necessary. 4. On average, 30 g: • will cover an adult body once • will cover hands twice daily for 2 weeks • will cover a patchy rash twice daily for 1 week.

5. On average, 200 g will cover a quite severe rash twice daily for 2 weeks.

Topical corticosteroids for sunburn When a patient with severe sunburn presents early, the application of 1% hydrocortisone ointment or cream can reduce significantly the eventual severity of the burn. This has been proved experimentally by covering one-half of the burnt area with hydrocortisone and comparing the outcome with the untreated area. The application can be repeated 2 to 3 hours after the initial application and then the next morning. The earlier the treatment is applied the better, as it may not be useful after 24 hours. Hydrocortisone should be used for unblistered erythematous skin, and not used on broken skin.

Skin exposure to the sun There is evidence that our skin needs exposure to sunlight to provide a substantial dose of vitaminD. This is a preventive for osteoporosis. Hats and sunscreens prevent the natural synthesis of vitamin D in the body. There should be a balance between receiving enough sunlight exposure to prevent vitamin D deficiency on one hand and receiving too much, causing skin cancer, on the other (see Table 16.1).

Chapter 16 | The Skin

4.5% 4.5%

18% 18% 4.5% 4.5%

4.5%

4.5%

1% 9%

9%

9%

9%

anterior

posterior

Fig. 16.1  ‘Rule of nines’ for body surface areas Table 16.1  Recommended sunlight exposure to the head and hands per day (minutes) Australian city

Summer

Winter

Darwin

5

5

Brisbane

5

5

Perth

5

12

Sydney

5

15

Adelaide

6

20

Melbourne

8

25

10

65

Hobart

Ocular protection from UV light The best protection from the harmful effects of strong UV light is from wraparound UV-absorbing sunglasses (Australian Standard 100%).

Acne Some topical treatment regimens Mild to moderate acne 1. Apply isotretinoin 0.05% gel or tretinoin 0.05% cream each night (especially if comedones).

2. If inadequate control after 6 weeks, add benzoyl peroxide 2.5% or 5% gel or cream once daily (in the morning). That is, after 6 weeks, maintenance treatment is: • isotretinoin 0.05% gel at night • benzoyl peroxide 2.5% or 5% mane. In more severe cases, add clindamycin 1% topically. 3. Maintain for 3 months and review. Clindamycin use Use clindamycin HCl in alcohol. Apply to each comedone with fingertips twice daily. • A ready clindamycin preparation is Clindatech. • Clindamycin is particularly useful for pregnant womenand those who cannot tolerate antibiotics or exfoliants. Other topical alternatives are: • erythromycin 2% gel • azelaic acid lotion, apply bd • adapalene 0.1% cream or gel, apply nocte.

Oral antibiotics Use if acne is resistant to topical agents. Tetracycline 1 g per day or doxycycline 100 mg per day or minocycline 50–100 mg bd for 4 weeks (or up to 10 weeks if slow

229

230

Practice Tips

response), then reduce according to response (e.g. doxycycline 50 mg for 6 weeks). If tetracyclines not tolerated or contraindicated (e.g. in pregnancy) use erythromycin 250–500 mg (o) bd.

Facial scars Injections of collagen can be used for the depressed facial scars from cystic acne.

Nappy rash • Keep the area dry. • Change wet or soiled napkins often—disposable ones are good. • Wash area gently with warm water and pat dry (do not rub). • Avoid excessive bathing and soap. • Avoid powders and plastic pants. • Use emollients to keep skin lubricated, e.g. zinc oxide and castor oil cream. • Standard treatment for persistent or widespread rash is 1% hydrocortisone with nystatin or clotrimazole cream (qid after changes)—you can get separate steroid and antifungal creams and mix before application. Avoid stronger steroid preparations. Consider continuing the antifungal cream for another 7 days. If seborrhoeic dermatitis: 1% hydrocortisone and ketoconazole ointment. Tip: If rash is resistant and ulcerated, add Orabase ointment bd or tds. Another tip is to add petroleum jelly to the above medication in equal parts—this can be used for a ‘normal’ nappy rash since it promotes longer action. Another strategy is to give oral zinc.

Atopic dermatitis (eczema) Note importance of good education.

Medication Mild atopic dermatitis • Soap substitutes, such as aqueous cream or emulsifying ointment. • Emollients (choose from): –– aqueous cream –– emulsifying ointment with 1% glycerol –– sorbolene –– sorbolene with 10% glycerol, e.g. Hydraderm, –– paraffin creams (e.g. Dermeze) (good in infants) –– bath oils, e.g. Alpha-Keri, QV, Dermareen –– moisturising lotions (e.g. QV) in summer. • 1% hydrocortisone (if not responding to above).

Moderate atopic dermatitis • As for mild eczema. • Topical corticosteroids (twice daily): –– vital for active areas –– moderate strength, e.g. fluorinated, to trunk, scalp and limbs –– weaker strength, e.g. 1% hydrocortisone, to face and flexures –– use in cyclic fashion for chronic cases (e.g. 10 days on, 4 days off). • Non-steroidal alternative: pimecrolimus (Elidel) cream bd; best used when eczema flares, then cease. • Oral antihistamines at night for itch. Severe dermatitis • As for mild and moderate eczema. • Potent topical corticosteroids to worst areas (consider occlusive dressings). • Consider hospitalisation. • Systemic corticosteroids (may be necessary but rarely used). • Allergy assessment if unresponsive. Weeping dermatitis (an acute phase) This often has crusts due to exudate. Burrow’s solution diluted to 1:20 or 1:10 can be used to soak the affected areas. Tip for children If severe eczema is not responding to topical treatment, try evening primrose oil and/or oral zinc. General tips • Rehydration is the single most important treatment strategy. Avoid soaps. • Avoid creams (tend to sting and less potent). • Topical steroids: –– potent steroids safe for short periods –– intermittent rather than continuous use –– replace with emollients when clear. • Lotions rather than creams are best for moisturising. • For dry scaly lesions, use ointments with or without occlusion.

Psoriasis General adjunctive therapy • Tarbaths, e.g. Pinetarsol or Polytar. • Tar shampoo (e.g. Polytar, Ionil-T). • Sunlight (in moderation).

For chronic stable plaques on limbs or trunks Topical steroids—potent ones preferred, or

Chapter 16 | The Skin

Method A • Apply dithranol 0.1% cream to affected area at night. Leave 20–30 minutes and then wash off under shower. Increase strength every 5 d to 1% (up to max. 2 hrs). • Then apply topical fluorinated corticosteroid in the morning. Combined method • dithranol 0.1% salicylic acid 3% in white soft paraffin LPC tar 10% Leave overnight (warn about dithranol stains—use old pyjamas and sheets). Review in 3 weeks, then gradually increase strength of dithranol to 0.25%, then 0.5%, then 1%. Can cut down frequency to 2 to 3 times per week. Shower in morning, and then apply topical fluorinated corticosteroid. Note: Dithranol tends to ‘burn’ skin. • Don’t use dithranol on face, genitalia or flexures. • A higher strength (0.25% to start) can be used for short contact therapy (30 minutes before shower).

}

• 20% potassium hydroxide (preferably in dimethyl sulfoxide) • a microscope. Method 1. Scrape skin from the active edge. 2. Scoop the scrapings onto the glass microscope slide. 3. Cover the sample with a drop of potassium hydroxide. 4. Cover this with a cover slip and press down gently. 5. Warm the slide and wait at least 5 minutes for ‘clearing’. Microscopic examination 1. Examine at first under low power with reduced light. 2. When fungal hyphae are located, change to high power. 3. Use the fine focus to highlight the hyphae (Fig. 16.2). Note: Some practice is necessary to recognise hyphae.

epidermal cells

New method (adults only) • Calcipotriol ointment—apply bd. Tends to irritate face and flexures; wash hands after use. Limit to 100 grams per week.

For milder stabilised plaques • Egopsoryl TA—apply bd or tds, or • topical fluorinated corticosteroids.

For resistant plaques • Topical fluorinated corticosteroids (II–III class) with occlusion. • Intralesional injection of triamcinolone mixed (50:50) with LA or normal saline (see Fig. 5.20 on p. 85).

For failed topical therapy (options)— specialist case • • • •

Refer for PUVA or other effective therapy. Acitretin—often used with UVB. Methotrexate—can have dramatic results. Biologicals, e.g. infliximab, etanercept.

Skin scrapings for dermatophyte diagnosis Equipment You will need: • a scalpel blade • glass slide and cover slip

fungal hyphae

Fig. 16.2  Diagrammatic representation of microscopic appearance of fungal hyphae

Spider naevi The most effective treatment of spider naevi for cosmetic reasons is to insert the fine tip of the electrocautery or the hyfrecator (diathermy) needle into the central papule and cauterise the vascular lesion. No local anaesthetic is required.

Wood’s light examination Wood’s light examination is an important diagnostic aid for skin problems in general practice. It has other uses, such as examination of the eye after fluorescein staining. (New, low-cost, small ultraviolet light units called ‘the black light’ are available, e.g. the Radio Shack UV scanner or fluorescent lantern.) Method Simply hold the ultraviolet light unit above the area for investigation in a dark room.

231

232

Practice Tips

Limitations of Wood’s light in diagnosis Not all cases of tinea capitis fluoresce, because some species that cause the condition do not produce porphyrins as a byproduct. See Table 16.2 for a list of the skin conditions that do fluoresce. Porphyrins wash off with soap and water, and a negative result may occur in a patient who has shampooed the hair within 20 hours of presentation. Consequently, a negative Wood’s light reading may be misleading. The appropriate way of confirming the clinical diagnosis is to send specimens of hair and skin for microscopy andculture. Note: Wood’s light examination can also be used for eye diagnosis after instilling fluorescein. Table 16.2  Skin conditions that produce fluorescence in Wood’s light Tinea capitis

green

Erythrasma

coral pink

Tinea versicolor

pink

Pseudomonas pyocyanea

yellowish green

Porphyria

red (urine)

Squamous cell carcinoma

bright red

Applying topicals with a ‘dish mop’ The self-application of creams or ointments to relatively inaccessible areas such as the back, especially in the elderly, can be difficult. One method is to acquire an old-fashioned dish mop, give it a ‘crew cut’ and use this to apply the preparations.

Glove over hand to enhance topical efficacy Patients with florid hand dermatitis handicapped by a slow response to topical corticosteroids can be boosted by the application of a surgical glove to wear for 60 minutes after applying the cream or ointment or even overnight if tolerated. This leads to less frequent application.

Chilblains Precautions • • • •

Think Raynaud. Protect from trauma and secondary infection. Do not rub or massage injured tissues. Do not apply heat or ice.

Physical treatment • Elevate affected part. • Warm gradually to room temperature.

Drug Rx • Apply glyceryl trinitrate vasodilator spray or ointment or patch, e.g. Nitro-Bid ointment (use plastic gloves and wash hands for ointment).

Other Rx • Rum at night (worth a try). • Nifedipine 20 mg bd or CR 30 mg once daily.

Herpes simplex: treatment options Herpes labialis (classical cold sores) The objective is to limit the size and intensity of the lesions. Topical treatment At the first sensation of the development of a cold sore: • apply an ice cube to the site for up to 5 minutes every 60 minutes (for first 12 hours) • topical applications include: –– idoxuridine 0.5% preparations (Herplex D liquifilm, Stoxil topical, Virasolve) applied hourly, or –– povidone-iodine 10% cold sore paint: apply on swab sticks 4 times a day until disappearance, or –– 10% silver nitrate solution: apply the solution carefully with a cotton bud to the base of the lesions (deroof vesicles with a sterile needle if necessary). May be repeated, or –– acyclovir 5% cream (Zovirax), 5 times daily for 4 days. Oral treatment Acyclovir or famciclovir or valaciclovir for 7 to 10 days or until resolution (reserve for immunocompromised patients and severe cases). Zinc treatment This empirically based treatment is favoured by some therapists. Zinc sulfate 220 mg tds, half an hour before meals, and large amounts of coffee during the day. Topical zinc treatment Zinc sulfate solution 0.025–0.05%, apply 5 times a day for cutaneous lesions and 0.01–0.025% for mucosal lesions. Prevention If exposure to the sun precipitates the cold sore, use a 15+ sun protection lip balm, ointment or solarstick. Zinc sulfate solution can be applied once a week for recurrences. Oral acyclovir 200–400 mg bd or similar

Chapter 16 | The Skin

agent (6 months) can be used for severe and frequent recurrences (> six per year).

Genital herpes: Antimicrobial therapy Topical treatment The proven most effective topical therapy is topical acyclovir (not the ophthalmic preparation). Alternatives: • 10% silver nitrate solution applied with a cotton bud to the raw base of the lesions, rotating the bud over them to provide gentle debridement. Repeat once or twice. This promotes healing and helps prevent spreading, or • 3% chromic acid, or • 10% povidone-iodine (Betadine) cold sore paint on swab sticks for several days. Pain relief can be provided in some patients with topical lignocaine. Saline baths and analgesics are advisable. Oral treatment Acyclovir for the first episode of primary genital herpes (preferably within 24 hours of onset). Dosage: 200 mg 5 times a day for 7 to 10 days or until resolution of infection. Famciclovir or valaciclovir can be given bd for 5 to 10 days. This appears to reduce the duration of the lesions from 14 days to 5 to 7 days. These drugs are not usually used for recurrent episodes, which last only 5 to 7 days. Very frequent recurrences (six or more attacks in 6 months) benefit from low doses of these agents for 6 months (200 mg 2 to 3 times per day).

Drugs and dosage • Acyclovir 800 mg 5 times daily for 7 days or • famciclovir 250 mg 8 hourly for 7 days or • valaciclovir 1000 mg 8 hourly for 7 days.

Post-herpetic neuralgia Some treatment options are: 1. Topical capsaicin (Capsig) cream. Apply the cream to the affected area 3 to 4 times a day. 2. Oral: paracetamol is first line. Second line is a tricyclic antidepressant, gabapentin or pregabalin. 3. TENS as often as necessary, e.g. 16 hours/day for 2weeks, plus antidepressants. 4. Excision of painful skin scar. If the neuralgia of 4months or more is localised to a favourable area of skin, a most effective treatment is to excise the affected area, bearing in mind that the scar tends to follow a linear strip of skin. This method is clearly unsuitable for a large area. Method 1. Mark out the painful area of the skin. 2. Incise it with its subcutaneous fat, using an elongated elliptical excision (Fig. 16.3). 3. Close the wound with a subcuticular suture or interrupted sutures.

elliptical excision

painful scar from herpes zoster

Herpes zoster (shingles) Topical treatment For the rash, use a drying lotion such as menthol in flexible collodion. Acyclovir ointment can be used but it tends to sting. Oral medication 1. Analgesics, e.g. paracetamol, codeine or aspirin. 2. Guanine analogue antiviral therapy for: • all immunocompromised patients • any patient, provided rash present < 72 hours (especially those over 60 years) • ophthalmic zoster (evidence to reduce—reduces scarring and pain but not neuralgia) • severe acute pain.

Fig. 16.3 Example of type of excision for severe postherpetic neuralgia

Unusual causes of contact dermatitis Reactions to the following have been reported: • spirit preparation • paper-based ‘hypoallergenic’ tape.

233

Chapter 17

Varicose veins

Percutaneous ligation for the isolated vein

(a)

This method can be used for the cosmetically unacceptable, isolated varicose vein in the leg, as an alternative to sclerotherapy. A 3/0 polyglycolic acid (Dexon) suture is simply inserted through the skin to encircle and ligate the vein. Equipment You will need: • 3/0 polyglycolic acid suture • cutting-edge needle • needle holder and scissors • local anaesthetic agent. Method 1. Infiltrate LA around the site or sites of the vein to be ligated: • small veins (up to 5–10 cm), a single suture • larger veins, multiple sutures, 5–10 cm apart. 2. Using a cutting-edge needle, pass the suture under the vein (Fig. 17.1a). 3. Bring the suture through the skin and then simply tie it tightly to occlude the vein by constriction (Fig. 17.1b).The treated vein thromboses and atrophies after a short period. 4. Review the patient in 4 weeks and remove the suture. Precautions Avoid areas near the dorsalis pedis artery and the common peroneal nerve, or other significant arteries, veins or nerves.

(b)

Fig. 17.1  Percutaneous ligation for isolated varicose vein

Avulsion of the isolated varicose vein This method can be used to treat the cosmetically unacceptable isolated varicose vein in the leg. It is possible to avulse the vein using local anaesthesia along the length of the varicose vein.

Chapter 17 | Varicose veins

Equipment You will need: • local anaesthetic • no. 15 scalpel blade with scalpel handle • 6 small Halsted artery forceps (‘mosquitoes’) • self-adhesive closure strips 1.2 cm (Steri-strips), or nylon suture with cutting edge needle • non-stick gauze dressing with wool and crepe bandage. Method 1. Infiltrate LA along the length of varicose vein to be avulsed (up to 20 mL of 1% lignocaine can be used): • small vein (up to 5–10 cm): a single incision (5–10 mm) along or across the midpoint of the vein • larger veins: multiple incisions 5–10 cm apart, depending on the length of the varicose vein avulsed at first incision (Fig. 17.2a). 2. Locate and identify the vein using an artery forceps, ensuring that it is not a nerve. The vein is then divided between two forceps (Fig. 17.2b). 3. Avulse the vein on either side by applying further forceps while pulling on the vein (Fig. 17.2c). Provided the length of the varicose vein has been infiltrated with LA, there should be no pain. Apply pressure for 2 to 3 minutes to stop bleeding once the vein has been avulsed. 4. Achieve skin closure by using either self-adhesive closure strips or suture. The suture can be removed in approximately 10 to 14 days. (a)

(b)

incisions over veins

Fig. 17.2 Avulsion of the isolated varicose vein

5. Apply non-stick gauze dressing to the wound, followed by a wool and crepe bandage. The dressing can be left for 3 days and then removed. If multiple avulsions have been carried out, it may be necessary to reapply a crepe bandage for another 2 to 3 days. 6. The patient should be free to do limited walking after the operation, and usually unrestricted walking after 24 hours. Special precautions Beware of nerves and arteries, avoiding areas involving the foot and the region of the lateral popliteal nerve where it curves around the neck of the fibula.

Treatment of superficial thrombophlebitis When a large varicose vein becomes thrombosed, a tender, raised nodular cord is formed along the line of the vein. There is thrombosis in the superficial vein with no connection to deeper veins. Clinical features 1. The skin is reddened and the tender nodular cord is palpable (Fig. 17.3a). 2. There is pain. 3. Localised oedema is present. 4. There is no generalised swelling of the limb or the ankle. (c)

235

236

Practice Tips

crepe bandage foam pad

(a)

(b)

Fig. 17.3 Superficial thrombophlebitis

Management method Propagation of thrombus can usually be prevented by uniform pressure over the cord. 1. The whole of the tender cord should be covered by an adhesive pad or a thin strip of foam (Fig. 17.3b) and then a firm crepe bandage applied. 2. The bandage and the pad are left on for 7 to 10 days. 3. Bed rest with leg elevated, if severe, otherwise keep active. 4. Prescribe a non-steroidal anti-inflammatory drug for about 7 days. No anticoagulants are required. A specialist opinion should be sought for superficial thrombophlebitis above the knee, as this disorder may require ligation at the saphenofemoral junction. Finally, one must always bear in mind the association between thrombophlebitis and deep-seated carcinoma elsewhere in the body.

• Pneumatic compression • Electrical calf muscle stimulation during surgery • Surgery: unfractionated heparin 5000 U (SC) bd or tds (LMW heparin for orthopaedic surgery) • Long flights/sitting: LMWH prior to flying and on arrival Treatment • Admit to hospital (usually 5–7 days) if any corrections, but can treat as an outpatient, which is current practice • Collect blood for APTT, INR and platelet count (check kidney function) • One-way-stretch elastic bandages (both legs to above knees) or class II graded compression stocking to affected leg, especially if swelling • IV heparin—5000 U statim SC then continuous monitored infusion (at least 10 days); aim for APTT 1.5–2 times normal or daily SC injection of LMW heparin (enoxaparin) • Oral anticoagulant (warfarin) for 6 months (monitor with INR) • Mobilisation upon resolution of pain, tenderness and swelling Surgery is necessary in extensive and embolising cases.

Ruptured varicose vein Advice for this potentially dangerous (because of heavy blood loss) problem is often sought over the telephone. Advise local pressure (not proximal) and elevation. Both a proximal and a distal percutaneous suture (see Fig. 17.1a, b on p. 234 may be necessary.

Venous ulcers The area typically affected by varicose eczema and ulceration is shown in Figure 17.4. The secret of treating

Management of deep venous thrombosis Investigations • Duplex US: accurate for above-knee thrombosis; improving for distal calf (repeat in 1 week if initial test normal). • Contrast venography, esp. if ultrasound –ve. • MRI is very accurate. • D dimer test (consider in certain cases): where probability of DVT is low, a normal D dimer usually excludes diagnosis. Management • Early and frequent mobilisation • Elastic or graded compression stockings • Physiotherapy

Fig. 17.4 Area typically affected by varicose eczema and ulceration (the ‘gaiter’ area)

Chapter 17 | Varicose veins

ulcers due to chronic venous insufficiency is the proper treatment of the physical factors, especially compression. Removal of fluid from a swollen leg is also mandatory. Debridement of leg ulcers using topical anaesthesia (e.g. EMLA cream applied 30 minutes beforehand) is considered to hasten ulcer healing. Treatment method 1. Clean the ulcer with N saline. If slough, apply Intra Site Gel. 2. Apply paraffin gauze, then pack the defect with sponge rubber (Fig. 17.5). 3. Apply a compression bandage below the knee (e.g. graduated compression stockings, Eloflex bandage, Unna’s type boot). Alternatively, an occlusive medicated paste bandage (e.g. Viscopaste or Icthaband) can be applied for 7days from the base of the toe to just below the knee. 4. Consider using a Tubigrip stockinette cover. 5. Prescribe diuretics if oedema is present. 6. Insist on as much elevation of the leg as is possible. Note: Dressings should be changed when they become loose or fall off, or when discharge seeps through. Patients may get ulcers wet and have baths.

paraffin gauze

sponge rubber

compression bandage

Leg ulcers—unorthodox methods For uncomplicated ulcers, such as non-infected posttraumatic and venous ulcers, various simple preparations have been claimed by many practitioners to promote healing. These include: • honey • sugar • sugar and povidone-iodine (Betadine) paste • Intal powder.

Fig. 17.5  Dressing for venous ulcer

Applying a compression stocking To facilitate the sliding of a compression stocking over an ulcer on the leg place a plastic shopping bag firmly over the foot and then slide the stocking over this. Once on, the plastic bag is pulled down and out.

237

Chapter 18

Miscellaneous

Measurement of temperature Temperature can be measured by several methods, including the mercury thermometer, the liquid crystal thermometer and the electronic probe thermometer. The mercury thermometer, however, is probably still the most widely used and effective temperature-measuring instrument. Table 18.1 gives a basic guide to interpreting the temperature values obtained. Table 18.1  Interpretation of temperature measurement Normal values Mouth

36.8°C

Axilla

36.4°C

Rectum

37.3°C

Ear

37.3°C

Pyrexia Mouth

>37.2 early morning >37.8°C at other times of day

Basic rules of usage 1. Before use, shake down to 35–36°C. 2. After use: –– shake down and store in antiseptic –– do not run under hot water

–– wipe rectal thermometers with alcohol and store separately. 3. Recording time is 3 minutes orally, 1 to 2 minutes rectally.

Oral use 1. Place under the tongue at the junction of the base of the tongue and the floor of the mouth to one side of the frenulum—the ‘heat pocket’. 2. Ensure that the mouth is kept shut. 3. Remove dentures. Note: Unsuitable for children 4 years and under, especially if irritable.

Rectal use An excellent route for babies and young children under the age of 4. Method 1. Lubricate the stub with petroleum jelly. 2. Insert for 2–3 cm (1 inch). 3. Keep the thermometer between the flexed fingers with the hand resting on the buttocks (Fig. 18.1). Don’t • Dig thermometer in too hard. • Hold it too rigidly. • Allow the child to move around.

Chapter 18 | Miscellaneous

Obtaining reflexes Ankle-jerk technique The method, illustrated in Figure 18.2a, provides a good opportunity to see and feel for a doubtful reflex. It is readily performed on a patient lying prone to allow examination of the back.

Fig. 18.1  Rectal temperature measurement

Method 1. Lift the foot slightly off the examination couch and hold it so that the Achilles tendon is under slight tension. 2. With the plessor held in the other hand, tap the tendon. Alternatively, have the patient kneel on a chair with the feet freely suspended over the edge (Fig. 18.2b). Ask him or her to grasp the back of the chair firmly; this adds an element of reinforcement, which tends to increase the reflex. Tap the Achilles tendon in the usual way.

Axillary use Very unreliable, and generally should be avoided but it is practical for young chidren and gives a helpful guide. If used it should be placed high in the axilla for 3 minutes.

(a)

Groin use This route is not ideal but is more reliable than the axilla. It closely approximates oral temperature. In infants, the thigh should be flexed against the abdomen.

Vaginal use

(b)

Mainly used as an adjunct to the assessment of ovulation during the menstrual cycle. Should be placed deeply in the vagina for 5 minutes before leaving the bed in the morning.

Infrared aural (ear drum) use The temperature can be measured in 3 seconds with an infrared device placed in the ear canal (e-2 therm). There is much debate about its efficacy but it appears to be worthwhile as it is a simple method and in general practice the benefits of convenience outweigh possible lack of accuracy. The normal range is the same as for rectal temperature.

Accidental breakage in mouth If children bite off the end of a mercury thermometer there is no need for alarm, as the small amount of mercury is non-toxic and the piece of glass will usually pass in the stool.

Fig. 18.2  Testing a doubtful reflex: (a) while the patient lies prone; (b) while the patient kneels on a chair

239

240

Practice Tips

Uncooperative children Children under 10 years of age have a disturbing tendency to tense their arms and legs at the wrong moment. Give them a squash ball or similar rubber object and instruct them to squeeze the ball as hard as possible on the countof 3. Test the required reflex during this distraction.

(a)

Restless legs syndrome Also known as Ekbom syndrome, this consists of poorly localised aching in the legs (a crawling sensation) and spontaneous, continuous leg movements. Organic causes that need to be excluded include the neuropathies caused by diabetes, uraemia, hypothyroidism and anaemia. However, it is generally a functional disorder affecting the elderly, and results in marked insomnia. Management • Diet: Eliminate caffeine and follow a healthy diet. • Medications (last resort): Taken before bed time, these include paracetamol, hypnotics, tricyclic antidepressants, clonazepam, levodopa and propranolol. First choice is paracetamol 1000 mg (0) or clonazepam 1 mg, 1 hour before retiring. • Exercises: These involve stretching of the hamstrings and posterior leg muscles for at least 5 minutes before retiring (Fig. 18.3). Exercise (a) demonstrates hamstring stretching; (b) illustrates calf muscle stretching; (c) stretches all posterior muscles of the lower limb, especially the hamstrings. The patient lies on his or her back and uses a 1.2 m (4 foot) length of rope or flat tape to lift the leg. This exercise should be repeated to produce effective stretching.

(b)

Nightmares For severe persistent nightmares, give a trial of phenytoin (in recommended dosage) for 4 weeks and review.

(c)

Nocturnal cramps Consider underlying causes such as drugs and electrolyte disturbances. Physiological muscle-stretching and relaxation techniques may be effective in the prevention of nocturnal cramps. Other strategies include keeping well hydrated, avoiding caffeine before retiring and taking magnesium supplements, e.g. magnesium orotate, Crampeze.

Exercise 1 1. Get the patient to stand bare-footed approximately 1m (3 ft) from a wall, leaning forwards with the back straight and outstretched hands against the wall.

Fig. 18.3  Exercises for restless legs: (a) hamstring stretching; (b) calf muscle stretching; and (c) stretching of all posterior muscles of the lower limb

Chapter 18 | Miscellaneous

2. Then get them to lift the heels off the floor and then force the heels to the floor to produce tension in the calf muscles. 3. They should then hold for 30 seconds and repeat 5 to 6 times. An alternative is to keep the heels on the floor and climb the hands up the wall. Patients should do these exercises 2 to 3 times a day for 1 week, then each night before retiring (Fig. 18.4).

Special uses for vasodilators Venepuncture Venepuncture, whether for blood collection, the introduction of intravenous drugs or cannulation, can be very difficult in some patients whose veins are not dilated. Methods • Rub glyceryl trinitrate (GTN) ointment (e.g. Nitro-Bid Nitrolate) over the vein that you wish to puncture. or • Give the patient one-half of an Anginine tablet sublingually, provided there are no contraindications to glyceryl trinitrate use. The veins will soon appear.

Painful heels Some patients, particularly elderly diabetics with smallvessel disease, develop painful heels. Glyceryl trinitrate ointment or transdermal pads applied to the painful area can provide considerable relief. The transdermal pads (e.g. Nitro-dur, Minitran, Transderm-Nitro) are applied once daily and the ointment applied twice daily in a small amount under tape.

Chilblains Apply GTN ointment over the painful chilblains as necessary. Advise use of plastic gloves or immediate washing of hands (to avoid headache). Other tips for chilblains include taking rum at night or nifedipine for prevention.

Tendonopathy Fig. 18.4  Exercise for leg cramps

Exercise 2 This can follow Exercise 1 before retiring. The patient should rest in a chair with the feet out horizontally to the floor, with support from a cushion under the Achilles tendon, for 10 minutes. Drug treatment • Quinine sulfate 300 mg nocte • Biperiden 2–4 mg nocte • Magnesium compound, two capsules bd The effectiveness of quinine has to be considered against the risk of thrombocytopenia or other complications. Its use is not recommended. Quinine drinks Consider quinine-containing drinks, e.g. tonic water or bitter lemon, last thing at night. Baking soda (sodium bicarbonate) Consider a half-teaspoon of baking soda in half a glass of water at the onset of the cramp.

The use of transdermal GTN patches to treat tendonopathies such as Achilles and lateral epicondyle tendonopathies has been advocated by many therapists. The usual dose is 1.25 mg per day (a quarter of a 5 mg/24 hr patch) over the affected area. One Australian study by G. Hunte and R. Lloyd-Smith (‘Topical glyceryl trinitrate for Achilles tendinopathy’, Clin J Sport Med, 2005, 15(2), p. 116–7) concluded that the method was better than a placebo, but the overall evidence is unclear and the routine treatment cannot be recommended at this point.

Nocturnal bladder dysfunction The woman with the urethral syndrome or bladder dysfunction who constantly wakes during the night with an urge to micturate, yet only produces a small dribble of urine, can be helped by the following. Method Instruct the patient to perform the following pelvic lift exercise when she awakes. 1. The patient balances on her upper back. 2. The patient then lifts her pelvis, supported by her flexed knees, and holds this position for about 30 seconds.

241

242

Practice Tips

3. As she holds the position, the patient can also squeeze the pelvic floor inward. 4. Repeat the exercise 2 or 3 times.

Facilitating a view of the cervix Fists under the buttocks If having difficulty viewing a cervix for smear taking, ask the patient to rest her hands, preferably as fists, under her buttocks. If necessary she can lift her buttocks slightly higher with her fists. A small, firm cushion could be placed under the buttocks as an alternative. If you are still having trouble have the patient cough. Note: Remember to warm the metal speculum in warm water and test the comfort of the temperature on the patient’s thigh.

Condom on the speculum If you are troubled by the vaginal walls collapsing into the gap between the two blades of the bivalved speculum you can slip a condom over the blades and then cut the tip off the condom. The condom then supports the vaginal walls.

Optimal timing and precautions for Pap smears • • • • •

Avoid during menstruation. The best time is any time after cessation of the period. Avoid in presence of obvious vaginal infections. Avoid within 24 hours after intercourse. Avoid within 48 hours of use of vaginal creams, pessaries or douching. • Avoid lubrication or cleaning of cervix before pelvic examination.

Priapism Various methods can be attempted to alleviate the acute or subacute onset of priapism, especially that which is drug induced: • ice cubes, inserted rectally • pseudoephedrine, especially for alprostadil (Caverjet injection or Muse) induced priapism. If drug-induced priapism lasts longer than 2 hours, give the patient two pseudoephedrine tablets—repeat at 3 12 hours if necessary. If all fails and specialist help is remote, aspiration and irrigation should be attempted and is best performed in the first 6 to 8 hours (exclude polycythemia and leukaemia via an urgent blood film). Under local anaesthetic and using a 16-gauge needle, aspirate thick blood from the ipsilateral corpora cavernosa through the glans penis. 20 mL of blood is drawn out at a time and the penis is then flushed with saline. If resolution is incomplete, use a very slow injection of 10 mL of saline containing 1 mg aramine, followed by massage.

Premature ejaculation It is worth a trial of an SSRI antidepressant agent, e.g. fluoxetine (Prozac) 20 mg daily.

Indomethacin for renal/ureteric colic After a patient has received an intramuscular injection of pethidine or morphine for the severe pain of renal colic, further pain can be alleviated by indomethacin. Suppositories are satisfactory, but limit them to two a day. Some practitioners have submitted an anecdotal tip of getting the sufferer of ureteric colic to jump up and down vigorously on the leg of the affected side. An effective alternative treatment is an IM injection of 75 mg diclofenac (if available), then diclofenac 50 mg (o) tds for 1 week.

Record keeping for after-hours calls When called out to make a home visit, general practitioners will need to either go to the surgery for the records or write the new notes in a notebook or on scraps of paper. If the patient record is not required for immediate management, a practical suggestion is to carry sheets of self-adhesive, plain paper on which to take notes to include in the practice record later. This paper is available in gloss or matt finish. Write the patient’s name in the top left-hand corner of the space and record notes in your usual style within a confined space. If you have to see two or three patients, leave a clear space between the notes for each. On return to the surgery, cut the notes of each patient into individual blocks, strip off the backing and apply to the appropriate section of the patient’s practice file. Alternatively add the notes to the computer file. Self-adhesive paper may be bought in widths of approximately 170 mm and in various lengths from most stationery stores (Millfix or Quick-Stick, for example, are two suitable brands.)

Sticking labels in the patient notes After administering vaccine that has a sticky label on it, such as Infanrix, remove the label and place it in the patient’s notes, or make a note in the computer file.

Uses of a fine cataract knife The fine size 52 L eye knife known as a Beaver eye knife (Fig. 18.5) or Eent-Super Sharps can be used for several minor procedures involving minimal surgical invasiveness.

Chapter 18 | Miscellaneous

Examples • Neurofasciotomy for painful trigger spots in back pain • Lateral and medial epicondylitis (tennis elbow) • Lateral sphincterotomy (see Fig. 6.6 on p. 96)

Cool cabbages for hot breasts Cabbage leaves have been used in some cultures for hundreds of years in the treatment of sprains, infections and some breast problems. Recently, they have become popular in many maternity hospitals for managing breast engorgement. There appears to be an unknown substance that is absorbed from the cabbage leaf through the mother’s skin, resulting in decreased oedema and improved milk flow. Uses Local breast engorgement: • blocked ducts or mastitis. Generalised breast engorgement: • when milk supply is greater than demand –– early postpartum –– sudden weaning • when lactation suppression is required –– after a baby dies –– after mid-trimester abortion. Method 1. Wash the cabbage leaves well (beware risk of contamination with dirt or pesticides) and dry. Store the cabbage in a refrigerator. 2. Cut stalks from leaves (to prevent pressure on breast) and apply the crisp leaves to the breast, avoiding the nipple area. (Cut out openings for the nipples.) 3. Remove after 2 hours (or earlier if the leaves are limp) and assess the need for further leaves. 4. Cease using leaves when engorgement settles, as prolonged use can reduce the milk supply. 5. Do not use if the patient has a history of allergy to cabbage. Many women using this home remedy have found cool cabbage leaves soothing when their breasts are engorged. Cabbage leaves have a role as an adjunct to the management of breastfeeding problems. It is still essential to correctly position the baby on the breast and not restrict the baby’s access to the breast.

Makeshift spacing chambers for asthmatics An improvised temporary ‘aerochamber’ can be made by one of three methods: 1. Plunge the end of the puffer through the bottom of a paper or polystyrene (preferable) cup. 2. Cut the end (base) off a plastic soft drink bottle and insert the end of the puffer into the mouth of the bottle.

3. Make a cruciate incision in the base of a plastic bottle to accommodate the end of the puffer and then advise the patient to breathe through the normal bottle opening.

Coping with tablets Breaking tablets in half When a tablet is manufactured with a line down the middle it may be easily broken, especially if it is a big tablet with a deep scored line. Method 1. Place the tablet on a flat surface with the line uppermost. 2. Place one finger on each side of the tablet and press down firmly (Fig. 18.5). 3. The tablet will split easily.

thumbs (or fingers) press down simultaneously

Fig. 18.5  Coping with tablets

Swallowing tablets This method is recommended for those who may have trouble swallowing tablets. Method 1 Try swallowing the tablet with the head bent forward. Method 2 Simply place the tablet on the tongue and drink water through a straw with the head slightly flexed forwards. The stream of water ‘hoses’ the tablet down the throat.

Patient education techniques in the consulting room Organ removal torso model A colourful model of the human body (head to groin) can be obtained to install in the surgery. The organs can be systematically removed and explained to the patient (Fig. 18.6).

243

244

Practice Tips

This visual education can be enhanced by the use of graphics, which some practitioners who have developed skills in computing are now using with amazing effectiveness. Advise patients to check the accuracy of information on the internet.

Improvised suppository inserter Some people find it difficult or unaesthetic to insert a suppository digitally. An interesting method is to rearrange a disposable plastic syringe so that it is converted into a plunger for ease of insertion of the suppository.

Rearranging the syringe • Remove the plunger. • Cut the end off the barrel (at the narrow end). • Place the plunger through the opposite end at this new opening.

Inserting the suppository • Place the suppository in the syringe barrel (Fig. 18.7). • Firmly place the flange up against the anus. • Press the plunger rapidly.

plunger (reversed) cut off barrel

Fig. 18.6  Patient education model

Whiteboard A small whiteboard can be installed, either portable or fixed to the wall, in the consulting room. A Sandford Expo kit can be installed alongside the board. It consists of a set of coloured whiteboard markers which clip onto slots in the kit, and an eraser. This is ideal for explanatory sketches.

suppository

Computer education Your patient can be briefly taken through a patient education information program (e.g. J. Murtagh’s Patient Education, 6th Edn, McGraw-Hill Australia, Sydney, 2013) on the computer screen and then take home a printout. This can be individualised by including the patient’s name on the top of the general sheet.

placed at anus

Fig. 18.7  Position of suppository

Chapter 18 | Miscellaneous

The many uses of petroleum jelly (Vaseline) • To kill lice, e.g. pubic lice or those on the eyelashes, apply petroleum jelly twice daily for 8 days, then pluck off any remaining nits. • Apply to dry and cracked skin (also useful to prevent cracking), e.g. on heels. • Apply for the protection of normal skin surrounding lesions such as warts and seborrhoeic keratoses before the application of corrosive substances, e.g. chromic acid or liquid nitrogen. • Use as a lubricant for rectal examination. • Use as a lubricant and sealant for the plunger on the metal ear syringe. • For nappy rash use it in equal parts with a mixture of hydrocortisone and antifungal creams to promote length of action of the medication. • For senile rhinorrhoea (see p. 204). • Dr Clarrie Dietman (personal communication) claims great success using petroleum jelly as a firstline treatment for allergic rhinitis. He recommends insertion of a liberal amount high into each nostril twice daily for as long as necessary. It has to be considered as a trial. It is important to advise patients to blow each nostril separately, before and after, to avoid middle-ear and parasinus complications.

The many uses of paper clips • Heated clips for subungual haematoma (see p. 107) • Removal of foreign body from nose and ears (see pp. 132–136) • Removal of wax hearing aids • Removal of ‘stuck’ punch biopsy specimens • Eyelid eversion (with care) • Pin back scalp hair during minor repairs

The uses of fine crystalline sugar Fine crystalline sugar (common table sugar) can be used to help reduce oedematous swelling, for example: • paraphimosis • rectal prolapse • prolapsed haemorrhoids.

Sea sickness There are several ‘mariner’s tips’ to prevent sea sickness, especially involving the use of ginger. • Take a ginger preparation, e.g. drink ginger ale or ginger beer. • Place a plug in one ear. • Look to the horizon.

Honey as a wound healer The use of honey is controversial, with controlled studies showing mixed outcomes. At the 2002 Australian Wound Management Conference in Adelaide, researchers emphasised the healing powers of honey, especially Manuka honey, for conditions such as infected wounds, burns, ulcers and possibly acne. Honey has antibacterial activity but its healing power is adversely affected by arterial insufficiency. Professor Geoff Sussman, a leading Australian authority on wound healing, concludes that it is most useful on contaminated wounds. The usual method is to apply 20 mL of honey (25–30 g) on a 10 cm × 10 cm absorbent dressing pad daily, reducing to twice weekly.

Snapping the top off a glass ampoule Breaking off the top of those stubborn ampoules can cause injury. To reduce the risk of this, it is best to use a small file; however, even these may not be effective. If you are using your hands to complete the snap, try using a gauze swab, the alcohol swab package or an appropriate-sized plaster auriscope earpiece.

Medico-legal tips Tips from medical defence The big six presenting problems requiring extra care and follow up: • breast lumps • acute abdominal pain • acute chest pain • sick, febrile children < 2 years • headache • chronic dyspnoea/cough. 10 deadly sins—resulting in negligence claims • Poor record keeping. • No documentation of consent process. • The altering of records with a problem. • Failure to follow up referrals. • Failure to follow up test results. • Failure to check history with scripts. • Giving phone diagnosis and treatment. • Rushing consultations. • Insufficient time/care to establish sound doctor–patient rapport. • Not saying anything if something’s gone wrong. Handball tip (for undiagnosed multiple visits problem) • Three strikes and you’re out.

245

246

Practice Tips

Tips for aged care (Dr Jill Rosenblatt)

Scalp subeorrhoea An effective treatment is ketoconazole shampoo, e.g. sebizole or Nizoral. A second lather must be used and this kept on the scalp for 3–5 minutes (with care to protect the eyes). This presents a challenge with the elderly showering themselves or a carer assisting.

Wax in the ears The most effective drops are carbonide peroxide, e.g. ‘EarClear’. These may be used twice daily or even hourly during waking hours and with the resultant wax dissolution, syringing can be avoided. Patients with dementia often do not tolerate ear syringing, but sometimes they don’t tolerate ear drops every hour either.

Impaired hearing Up to 80% of hearing aids become expensive chest-ofdrawers ornaments! Some considerations: If you can converse easily one to one, a hearing aid should not be necessary. If a hearing aid is to be used, it should be worn in the ear with the better hearing. When in a crowded room, attempt to stand or sit next to a wall for greater sound concentration. If an audiogram demonstrates R and L hearing disparity, a CT scan should be performed.

Rhinorrhoea Clear rhinorrhoea in the elderly may be related to lactose intolerance since a dairy-free diet is known to relieve symptoms in four weeks. Lactose-free milk, now readily available, and yoghurt may be used as alternatives. Long-term, intermittent oxymetazoline nasal drops or spray, e.g. Drixine can be effective but the preferred treatment is lubrication of the nasal passages with Vaseline or an oil-based preparation such as natural sesame seed oil spray, e.g. Nozoil.

Insomnia Exclude underlying causes of sleep disturbance. Avoid hypnotics if possible and in particular avoid combining them with alcohol. Ideally, the use of benzodiazepines as hypnotics should be short-term only. Sleep hygiene issues need to be discussed, consider caffeine cessation from lunch time onwards and the avoidance of electronic stimulation right up to bed time.

Paraphrenia This is isolated paranoia in the elderly and a sign of early dementia. It can cause havoc with family, neighbours and

police, with accusations of theft or property trespass. Auditory hallucinations may also be present. Risperidone or olanzapine are very effective medications for this problem. Keep in mind that risperidone can aggravate Lewy body dementia.

Faecal impaction A useful approach is to use macrogol 3350 (Movicol), up to eight sachets in 6 hours on successive days with subsequent daily Movicol maintenance.

Trochanteric bursalgia This presents as pain in the affected thigh, laterally, and may radiate to the lateral knee and even into the foot. Localised tenderness over the trochanteric bursa site is confirmatory and an ultrasound may add further evidence. An injection of local anaesthetic with corticosteroid is very effective in the short term. During this procedure, a gritty end-point may be detected with the needle tip.

Benign senescent forgetfulness This popular term is also referred to as ‘aged related memory loss’ or ‘delayed recall of ageing’ or ‘mild cognitive impairment of ageing’. This is a common sign of ageing and may be an early symptom of dementia, which certainly develops in at least 10% of cases.

Dementia prevention strategies This program is based on the research work of Dr Michael Valenzuela, as found in his book MaintainYour Brain (HarperCollins, Sydney, 2001) 1. Healthy blood pressure—‘a healthy heart means a healthy brain’—the strongest evidence for dementia prevention. 2. The three keys: a. physical: walking 30–60 minutes 3–4 times a week, plus strength exercises, balance and stretching exercises—reportedly known to enhance brain cell growth, brain cell interconnections and angiogenesis b. mentally stimulating activities c. social activities in company that are both fun and rewarding. 3. Alcohol control: avoid binge drinking and always promote a safe intake, i.e. 1–2 standard drinks with a meal for 3 days a week. 4. Diet—Mediterranean in style, oily fish 2–3 times a week (consider Chia seed), 2 fruits and 5 vegetables daily.

247

Bibliography Brown, J.S., Minor Surgery. A Text and Atlas, Chapman and Hall,London, 1986. Carbajel, Paupe A. et al., ‘Randomised trial of analgesic effects of sucrose, glucose and pacifiers in term neonates’, British Medical Journal, 1999, 319, pp. 1393–7. Chan, C. and Salam, G., ‘Splinter removal’, American Family Physician, 2003, 67, pp. 2557–62. Chapeski, A., ‘Simple care for the ingrown toenail’, Australian Family Physician, 1998, 27, 4, p. 299. Claesson, M. and Short, R., ‘Lancet with less pain’, Lancet, 1990, December 22–9, pp. 1566–7. Cook, J., Sankaran, B. and Wasunna, A., General Surgery at the District Hospital, World Health Organization, Geneva, 1986. Corrigan, B. and Maitland, G.D., Practical Orthopaedic Medicine, Butterworths, Sydney, 1986. Daniel, W. J., ‘Anorectal pain, bleeding and lumps’, Australian Family Physician, 2010, 39, pp. 376–81. Eriksson, E., Illustrated Handbook in Local Anaesthesia, Munksgaard, Copenhagen, 1969. Freidin, J. and Marshall, V., Illustrated Guide to Surgical Practice, Churchill Livingstone, Edinburgh, 1984. Garden, O.J., Bradbury, A.W., Forsythe, J.L. and Parks, R.W., Principles and Practice of Surgery (5th Edn), Churchill Livingstone, Edinburgh, 2007. Györy, A.E., ‘A duct tape-free wart remedy’, Complementary Medicine, September/October 2003, p. 4. Hampton, J.R., The ECG made easy (7th Edn), Churchill Livingstone, Oxford, 2008. Hayes, J.A. and Burdon, J.G.W., ‘The management of spontaneous pneumothorax by simple aspiration’, Australian Family Physician, 1988, 17, pp. 458–62. Hoppenfield, S., Physical Examination of the Spine and Extremities, Prentice-Hall, Englewood Cliffs, NJ, 1976, pp. 172–30. Huckstep, R.L., A Simple Guide to Trauma, E&S Livingstone, Edinburgh, 1970. Hunte, G. and Lloyd-Smith, R., ‘Topical glyceryl trinitrate for chronic Achilles tendonopathy’, Clinical Sports Medicine, 2005, 15(2), pp. 116–7. Kamien, M., ‘Which cerumanolytic?’, Australian Family Physician, 1999, 28, p. 817. Kenna, C. and Murtagh, J.E., Back Pain and Spinal Manipulation (2nd Edn), Butterworths Heinemann, Oxford, 1997.

La Villa, G., ‘Methylprednisolone acetate in local therapy of ganglion’, Clinical Therapeutics, 1968, 47, pp. 455–7. Marwood, J., ‘Sebaceous cyst excision’, General Practitioner, 1994, 2, pp. 4–5. McGregor, A.D., McGregor, I., Fundamental Techniques of Plastic Surgery (10th Edn), Churchill Livingstone, Edinburgh, 2000. McLaren, P., ‘Dilating peripheral veins’, Anaesthesia and Intensive Care, 1994, 22, p. 318. Molan, P.C., ‘Treatment of wounds and burns with honey’, Current Therapeutics, September 2001, pp. 33–9. Orlay, G., ‘Non-malignant rectal and anal conditions’, Australian Doctor, 16 April 2004, pp. I–IV. Penfield, W. and Boldrey, E., ‘Somatic motor and sensory representation in the cerebral cortex of man as studied by electrical stimulation’, Brain, 1937, 60, pp. 389–443. Perry. R. (Ed.) Fundamental Skills for Surgery, McGraw-Hill, Sydney, 2008. Peterson, L. and Renstrom, P., Sports Injuries and their Prevention and Treatment, Methuen, Sydney, 1986. Quail, G., ‘Regional nerve blocks’, Australian Family Physician, 1996, 25, pp. 391–6. Sheon, R.P., Moscowitz, R.W. and Goldberg, V.M., Soft Tissue Rheumatic Pain (2nd Edn), Lea & Febiger, Philadelphia, 1987. Skinner, I., Basic Surgical Skills Manual, McGraw-Hill, Sydney, 2000. Snell, G.F., Primary Care Clinics in Office Practice: Office Surgery, Saunders, Philadelphia, 1986, p. 25. Tonge, B., ‘I’m upset, you’re upset and so are my mum anddad’, Australian Family Physician, 1983, 12, pp.497–9. Valenzuela M.J., Maintain your brain, ABC Books, Sydney, 2001. van der Walt, J.H., ‘Dilating peripheral veins—another suggestion’, Anaesthesia and Intensive Care, 1994, 22, p. 624. Warren, G., ‘Controlling callus’, Medicine Today, 2003, 4, 4, p. 95–7. White, A.D.N., ‘Dislocated shoulder—a simple method of reduction’, Medical Journal of Australia, 1976, 2, pp. 726–7. Wishaw, K.L., ‘Dilating veins, a simple approach’, Letter to editor, Anaesthesia and Intensive Care, 1995, 23, p. 123. Zagorski, M., ‘Analgesia-free reduction of anterior dislocation of the shoulder joint’, Australian Journal of Rural Health, 1995, 3, pp. 53–5.

This page intentionally left blank

249

Index A abrasions, 115 abscess drainage of breast, 87 healing cavity of, 74 perianal, 97 Achilles tendon complete rupture, 183–4 injection for paratendonopathy, 20–1 tendonopathy, 182, 241 acne, 229–30 acne cysts, 79 acromioclavicular joint injection, 50–1 sling, 119 acute bacterial mastitis, 86 acute coronary syndromes, 2 acute paraphimosis, 6 acute torticollis, 144 adhesive gel dressings, 86 adrenaline autoinjector, 15–16 aeroplane exercise, 185 aged care, 246 airgun wounds, 131 alcohol swabs, 29 Algerbrush II, 107 ampoules, topping, 245 amputated finger, 114 anal dilatation, 96 anal fibro-epithelial polyps, 98 anal fissures, 95–7 anaesthetic infiltration for wounds, 30 anaphylaxis, 15–16 ankle sprained, 183–4 strapping, 184 wobble board technique, 185 ankle-jerk reflex technique, 239 ankyloglossia, 193–4, 224 anosmia, 206 ant bites, 15 anterior compartment syndrome, 182 anterior directed gliding, 142, 147 antral/nasal washout, 205 anxious children, 226–7

aphthous ulcers, 192–3 arm pain, 143 arm sling, 119–21 ascites, tapping, 25 aspiration of breast lump, 87–9 of pleural effusion, 26 asthma, makeshift spacing ­chamber, 243 atopic dermatitis, 230 attic perforation, 201 auriscope, to view nasal cavity, 206 autoinjector for anaphylaxis, 15–16 avulsion of toenail, 112 axial loading test, 152, 153 axillary sweat glands, wedge ­resection, 71 axillary temperature measurement, 239

B ‘back knee’, 176, 177 back pain disc prolapse, 154 drawing/scale-marking for, 150,151 lower back exercise, 159 sciatica, 155 slump test, 154, 155 tests for non-organic, 152–3 trigger point injections, 42–3 Baker cyst, 83–4 Bartholin cyst, 88 Barlow test, 172, 173 basal cell carcinoma (BCC), 82 Beaver eye knife, 242–3 bed bug bites, 14 bee stings, 15 benign paroxysmal positional ­vertigo, 206–7 benign senescent forgetfulness, 246 bicipital tendonitis injection, 44 Bier block, 38 biopsies, 79–80 bite wounds, 13–15 ‘bite the bullet’ strategy, 218

bladder dysfunction, nocturnal, 241–2 blanket stitch suture, 59 blepharitis, 210 blood loss, 16 blurred vision, 214 botulinum toxin, 96 boutonnèire deformity, 169 box jellyfish stings, 15 brachialgia, 143 breast abscess drainage, 86–7 cabbage leaves for engorgement, 243 lump aspiration, 87–8 breath-holding attacks, 224 Breathing Wonder, 206 broad arm sling, 119, 120 burns, 122–4 dressings, 124 first aid, 123 hand, 124 Lund-Browder chart, 124 major burns, 123 safety first rules, 123 Burn ‘kneeling on a stool’ test, 152 burr holes, 8–9 bursitis ischial, 174 olecranon, 80–1 pre-patellar, 80–1 subacromial, 44 trochanteric, 47–8, 246 button hole deformity, 169

C cabbage leaves, for breast engorgement, 243 calculus, in Wharton duct, 193 calf squeeze test, 183 calluses, 99, 100, 101 canker sores, 192–3 cannulation, 20–1 intravenous, in child, 219–20 carbon dioxide slush, 90–1 carotid sinus massage, 13 carpal tunnel injection, 48–9 carpal tunnel syndrome, 166–7

250

INDEX

cat bites, 14 cataract knife, uses of, 242–3 catheterisation, 22–4 caudal epidural, 39–41 cauliflower ear, 115 centipede bites, 15 cephalic vein, 4–5 cervical polyps, 88, 89 cervical spine mobilisation, 141–2 referred pain, 143 spinous processes, 143–4 traction, 145 cervix, viewing, 242 chalazion, 212, 213 chemical burns to eye, 216 chest drain, 25–6 chilblains, 232, 241 children ankyloglossia, 193–4, 224 anxious, 226–7 arm relaxation, 220 ‘biting the bullet’, 218 breath-holding attacks, 224 cannulation, 21 choking, 220 colic, 224 cricothyroidostomy, 12 crying infant, 223–4 distracting, 217–18 ‘draw a dream’ technique, 225 dummy (pacifier) use, 217, 218 eczema, 230 eye drops, instilling, 219 fear thermometer, 226–7 fluid administration, 218 forehead lacerations, 220 forehead lump, 225 foreign bodies, removal from nose/ear, 132–6 foreign bodies, swallowed, 220 fractures, 222–3 glue for wounds, 221–2 hip disorders, 172, 173 intravenous cannulation, 21, 219–20 lactose intolerance test, 224 making friends with, 217 mouth opening, 218–19 nappy rash, 230 nasogastric tube insertion, 22

nose cleaning, 224 nose drops, instilling, 219 oesophagitis, 224 oral Sabin vaccine, 218 painful procedures, 218 plaster cast removal, 223 pulled elbow, 163, 164 rectal temperature measurement, 238–9 reflex, obtaining, 240 reflux, 224 scalp lacerations, 220–1 school refusal, 226 self-statement questionnaire, 226–7 skin rashes, 225 spatula sketches, 219 splints, 223 surgery, optimal times, 226–7 suturing wounds, 222 swallowing tablets, 218 taking medicine, 218 tongue tie, 193–4, 224 topical local analgesia, 222 urine aspiration, suprapubic, 225 vein cannulation, 220 wound infiltration, 222 wound repair, 220–2 choking, 13, 220 cholesteatoma, 201 chondrodermatitis nodularis ­helicus, 83 clavicle, fracture, 117–18 bandage for, 118 clenched fist injuries, 14 clindamycin, 229 cold sores, 232 colic, 224, 242 collar and cuff sling, 119, 120 Colles fracture, 170–1 coma scale, Glasgow, 8 compression stocking, applying, 237 conjunctivitis, mild, 210 contact dermatitis, 233 convulsions, injection for, 31 coral cuts, 15 corneal abrasion and ulceration, 212 corneal foreign bodies, 211–12 corns, 99, 100, 101

coronary syndromes, 2 costovertebral gliding, 147 cotton wool, in ear, 136 cramps, nocturnal, 240–1 creams, prescribing rules, 228 cricothyroidostomy, 12 crocodile forceps, 133 cross-stitch, 60 crown excisions, 66–7 crutches, 188–9 cryotherapy, 88–91 cysts acne, 79 Baker, 83–4 Bartholin 88 breast, 87–8 dermoid, 78–9 deroofing, 78 ear lobe, 201 epididymal, 84 healing cavity of, 74 Meibomian, 212–13 mucous, 106 recurrent, 88 sebaceous, 77–8

D de Quervain tenosynovitis Finkelstein test, 166 injection for, 46 symptoms, 166 deafness, 197, 224 debridement for wound debris, 59 in hairy area, 73 deep venous thrombosis, 236 dementia prevention strategies, 246 dental problems see teeth dermabrasion, 59 dermatitis, 230, 232, 233 dermatome chart, 154, 155 dermatophyte diagnosis, 231 dermoid cysts, 78–9 diabetic hypoglycaemia injection, 31 digits avascular field, 70–1 cut, 113 see also finger dish mop, for applying topicals, 232

INDEX

dislocations elbow, 163–4, 165 finger, 167, 168 hip, 175–6 jaw, 140 patella, 181 shoulder, 159–62 dog bites, 14 ‘dog ears’, 61 drain, inserting in chest, 25–6 ‘draw a dream’ technique, 225 dry eyes, 210–11 dupuytren contracture, 86

E ear cotton bud problems, 136, 202 discharge, 168 external, nerve block for, 37 facial blocks for, 37 foreign body removal, 132–6 glue ear, 206 hearing tests, 197 insect in, 135–6 instilling otic ointment, 202 pain when flying, 201 piercing, 198–9 swimmer’s ear, 198 syringing, 198–200 tropical ear, 202 ‘unsafe’, 201 waterproofing, 198 wax, 200, 246 wax softeners, 198–9 wedge resection, 68–9, 70 see also otitis externa; otitis media ear drum temperature measurement, 239 ear lobe cysts, 201 embedded earring stud, 202 infected, 201–2 pricking, 31 ear plugs, 198 ECG see also electrocardiogram ECG recording, 2–3 eczema, 230 ejaculation, premature, 242 Ekbom syndrome, 240 Elastoplast Scar Reduction Patch, 86

elbow dislocated, 163–4, 165 injection, 51 pulled, 163, 164 see also golfer’s elbow; tennis elbow electric shock, 7–8 electrocardiogram, 2–3 electrocautery ingrowing toenail, 109 sebaceous cyst, 77–8 subungual haematoma, 107 electrodissection of warts, 92 emergency procedures, 1–19 entropion, 211 epicondylitis, injection for, 45 epidermoid cysts, 77–8 epididymal cysts, 84 Epistat catheter, 204 epistaxis, 202–4 Epley manoeuvre, 206–7 eustachian catheter, 133 everted wounds, 56 excisions common mistakes, 55 crown, 66–7 dead space, 56 ‘dog ears’, 61 elliptical, 60–1 facial, 60 for ingrowing toenail, 109 knot tying, 56–7 lipomas, 81 Meibomian cyst, 212–13 minimising bleeding, 55 nail bed, 111–12 non-melanoma skin cancer, 72 repair principles, 55–6 safety measures, 55 scalpel holding, 57–8 skin tumours, 63–4 suture material, 55 eye chemical burns, 216 conjunctivitis, 210 corneal abrasion and ulceration, 212 corneal foreign body, 211–12 drop application in eyes, 214 dry eyes, 210–11 examination kit, 209 flash burns, 210

fluorescein, 210, 212 ‘glitter’ removal, 210 hyphaema, 216 infections, 216 maggot removal, 126 Meibomian cysts, 212–13 ocular pain relief, 214–15 padding, 214 recurrent erosive syndrome, 212 Seidal test, 212 Snellen eye chart, 215 styes, 214 eyelashes entropion, 211 ingrowing, 211 eyelid blepharitis, 210 everting, 209–10 local anaesthetic for, 213 repair of laceration, 69, 70 styes, 214 xanthomas, 91

F Fabere test, 174 face acne scars, 230 nerve block, 36–7 skin lesion excision, 66–7 facial nerve blocks, 36–7 faecal impaction, 138, 246 fall, from height, 113 fear thermometer, 226–7 femoral nerve, anatomy, 33–4 femur fracture, 176 finger amputated, 114 boutonnière deformity, 169 dislocated, 167, 168 dressing for tip, 114 fractures, 118–19 injecting, 45–6, 51–2 lancing, 31 loss of tip, 114 mallet finger, 168–9 nerve block, 31–2 removal of ring, 128 skin loss, 114 strapping, 167–8 tourniquet, 113 trauma, 114

251

252

INDEX

finger joint, injection, 51–2 fingernails see nails Finkelstein test, 166 fish bone, in throat, 136 fish hook, embedded, 129–31 fish-tail cut, 61 flap repairs, 62–7 flap wounds double Y on V advancement, 63 H double advancement, 64 on lower leg, 62 rhomboid, 66 rotation, 65 sliding, 63 transposition, 65 triangular, 62 Y on V advancement, 63 flash burns, 210 FLO sinus care, 205 fluid infusions, subcutaneous, 26–7 fluorescein, 210, 211, 212 foot calluses, 99, 100, 101 corns, 99, 100, 101 cracked heels, 102 fractures, 113 heel pain, 241 injecting, 34–5 nerve blocks, 35 plantar warts, 99–101 rupture of tibialis posterior tendon, 185–6 tibialis posterior tendonopathy injection, 50 see also ankle; plantar fasciitis; toenail foreign bodies bent hairpin technique, 132, 134 bent paper clip technique, 134 buried as result of trauma, 113 corneal, 211–12 in ear, 132–6 fish hook, 129–31 fish bone in throat, 136 gunshot wounds, 131–2 insect in ear, 135–6 ‘kiss and blow’ technique, 135 leeches, 127

maggots, 126, 135 metal fragments, 129 in nose, 132 pneumatic otoscopic vacuum, 134–5 probe technique, 132, 133 ring on finger, 128 rubber catheter suction, 134 splinters, 128–9 swallowed by children, 220 ticks, 127–8 tissue glue and plastic swab technique, 135 ultrasound or X-ray for, 113, 129 foreign-body remover, 133 fractures associated injuries, 16–17 calcaneus, 121 in children, 222–3 clavicle, 117–18, 121 Colles’, 121, 170–1 femur, 121, 176 greenstick, 223 healing time, 121 humerus, 119, 121 mandible, 117 metacarpal, 172–3 nasal, 205 phalangeal, 118–19, 121 Potts, 121 radius, 121 rib, 118, 121 scaphoid, 121, 171 scapula, 121 slings for, 119–21, 121 testing for, 116–17 wrist, 170–2 free-hanging method, 160 frenulotomy, 193–4 Froment’s sign, 125 frontal sinuses, 195 fungal hyphae, 231 funnel-web spider bites, 14

G gamekeeper’s thumb, 170 ganglions, 80 genital herpes, 233 genu recurvatum, 176, 177 genu valgum, 176, 177 genu varum, 176, 177

geographic tongue, 193 Glasgow coma scale, 8 glenohumeral joint injection, 51 glue ear, 206 gluteus medius tendonopathy injection, 48 golfer’s elbow, 45 gout, in great toe, 53–4 granny knot, 57 gravel rash, 115 grease gun wounds, 132 greenstick fractures, 223 groin temperature measurement, 239 gunshot wounds, 131–2

H haemangioma, of lip, 83 haematoma block by local infiltration anaesthetic, 38–9 nasal septum, 115–16 perianal, 93–4 pinna, 115 pretibial, 116 septal, 115–16 subungual, 106–8 haemorrhage, 16 haemorrhoids injecting, 95 rubber band ligation, 94–5 hairpin for removal of foreign bodies, 132 hand burns, 124 carpal tunnel syndrome, 166–7 Colles fracture, 170–1 dermatitis, 232 fracture healing time, 121 fractures caused by falling on, 113 nerve blocks, 32–3 nerve injury test, 124–5 oil injection, 132 scaphoid fracture, 171 sling, 119–20 see also finger; thumb head injuries children, 220–1 and conscious state, 8–9 headlight, hands-free, 205

INDEX

hearing loss in the elderly, 246 tests, 197 heat, to relieve eye pain, 214–15 heels cracked, 102 painful, 241 Heimlich manoeuvre, 13 herpes labialis, 232 herpes simplex, 232 herpes zoster, 233 hiccoughs, 205–6 hip developmental dysplasia, 172, 173 dislocated, 175–6 injecting, 47–8, 52 ischial bursitis, 174 and knee pain, 172 osteoarthritis in, 173 Ortolani and Barlow screening tests, 172, 173 Patrick test, 174 snapping/clicking, 174–5 tendonitis, 48 trochanteric bursitis, 47–8, 246 hip disorders, age relationship of, 172 ‘hip pocket nerve’ syndrome, 173 hip and shoulder rotation test, 152–3 Hippocratic method, 159 honey, as wound healer, 245 hormone implants, 41–2 hot spoon bathing, 213, 215 human bites, 14 humerus fracture, 119, 121 hydroceles, 84 hypertrophic scars, 85 hyperventilation, 11 hyphaema, 216 hysterical ‘unconscious’ patient, 7

I iliotibial band tendonopathy, 182 Implanon rod removal, 129 implantation cysts, 78–9 incisions, 56 indomethacin, 242 infant colic, 224 infraorbital nerve block, 36

infrared aural temperature measurement, 239 ingrowing eyelashes, 211 ingrowing toenail central thinning, 108 elliptical block dissection, 110–11 excision of ellipse of skin, 109 phenolisation, 109–10 post-operative pain relief, 111 spiral tape, 108 inguinoscrotal lumps, 224 inhalations for URTIs, 196 injections Achilles paratendonopathy, 50 basic, 28–41 bicipital tendonitis, 44 carpal tunnel, 48–9 caudal (trans-sacral), 39–41 diabetic hypoglycaemia, 31 elbow, 45, 51 epicondylitis, 45 gluteus medius tendonopathy, 48 great toe gout, 53–4 into joints, 50–3 intramuscular, 29 musculoskeletal, 42–54 needle gauge, 29 painless, 28–9 plantar fasciitis, 47 rectal, 31 rotator cuff lesions, 43–4 slow, 30 supraspinatus tendonitis, 44 tarsal tunnel, 49 tibialis posterior tendonopathy, 50 trigger finger, 45–6 trigger points in back, 42–3 trochanteric bursitis, 47–8, 246 see also nerve blocks insect, in ear, 135–6 insomnia, 246 instrument knot, 57 intercostal catheter, 11 intercostal nerve block, 39 international notation of teeth, 191 intraosseous infusion, 6 intravenous cutdown, 4–6 intravenous regional anaesthesia, 38

inverted mattress suture, 62 ionising radiation illness, 18–19 ischial bursitis, 174

J jaw dislocated, 140 mandible fracture, 117 jellyfish stings, 15 jogger’s knee, 180 joint injections, 50–3 jumper’s knee, 179–80

K keloids methods of treatment, 86 prevention, 86 keratoacanthomas, 81–2 keratoses, 83 ‘kiss and blow’ technique, 135 knee anterior pain, 180 back knee, 176, 177 common causes of pain, 176–7 dislocated patella, 181 injecting, 52 jogger’s, 180 jumper’s, 179–80 knock knees, 176, 177 Lachman test, 178–9 meniscal injuries, 177–8 overuse syndromes, 179 pain referred from hip, 172 ‘kneeling on a stool’ test, 152 knock knees, 176, 177 knot tying, 56–7 Kocher method, 159

L lacerations eyelid, 69, 70 gums, 221 lip, 67, 221 ragged, 65, 72 scalp, 220–1 topical local anaesthesia, 222 Lachman test, 178–9

253

254

INDEX

lactose intolerance test, 224 lancing finger, 31 lateral epicondylitis, 45 lateral sphincterotomy, 96 leech removal, 127 leg bowed, 176, 177 crutches, prescription of, 188–9 lower leg problems, 181–3 nerve roots, pressure on, 154 nocturnal cramps, 240–1 overuse syndromes, 181, 182 pain from disc prolapse, 154 restless legs syndrome, 240 tennis leg, 181, 183 torn monkey muscle, 181, 183 triangular flap wounds, 62 ulcers, 236–7 walking stick, 189 see also ankle; knee; varicose veins ligatures, on vessels, 57, 65 Limberg flap, 66 lip haemangioma, 83 repair of cut, 67–9, 221 wedge excision, 67–8 lipomas, 81 liquid nitrogen plantar wart treatment, 100 skin lesion therapy, 88–90 to remove skin tags, 76 topical anaesthesia for children, 222 Little’s area, cautery of, 203 local anaesthetic infiltration for wounds, 30 lumbar epidural, 39–40 lumbar puncture, 24–5 lumbar spine dermatome chart, 154, 155 drawing/scale-marking back pain, 150, 151 movements of, 153 reference points, 150 rotation mobilisation, 156 Schober test, 154–5 stretching/manipulation, 157–8 lumbosacral spine bony landmarks, 152 disc prolapse, 154 leg nerve roots, 154 lower back exercise, 158

posterior view, 154 slump test, 154, 155 Lund-Browder chart for burns, 124

M maggots, removing, 126 Magnuson method, 151 mallet finger, 168–9 mandible fracture of, 117 spatula test, 117 marsupialisation, 88, 89 mastitis, acute bacterial, 86 matchstick tamponade, 202–3 maxillary sinuses, 196 medial epicondylitis, 45 median nerve block, 33 medical defence, 245 Meibomian cysts, 212–13 meniscal injuries, 177–8 mental nerve block, 37 metacarpal fractures, 171–2 metal fragments, 129 mid-thoracic spine manipulation, 148 migraine, 10–11 migratory pointing test, 152 Milch method, 160 milker’s nodules, 83 molluscum contagiosum, 92 ‘monkey muscle’, torn, 181, 183 morphine, subcutaneous infusion of, 27 moth, in ear, 135–6 mouth aphthous ulcers, 192–3 calculus in Wharton duct, 193 opening a child’s, 218–19 see also teeth; tongue Mt Beauty method, 160–2 mucous cysts, 106 musculoskeletal injections, 42–54 myocardial infarction, 2–4 myxoid pseudocyst, 106

N nail bed ablation, 106 excision, 111–12

nails avulsion by chemolysis, 112 onychogryphosis, 106 paronychia, 111 splinter under, 105–6 subungual haematoma, 106–8 see also toenail nappy rash, 230 nasal fractures, 205 nasal polyps, 197 nasal septum haematoma, 115–16 nasogastric intubation, 21–2 neck muscle energy therapy, 144 palpating, 143 rolls and stretches, 145–6 torticollis, 144 traction, 144–5, 146 neck movement grid, 141 needle disposal, 30–1 negligence claims, avoiding, 245 Nelson hold, 148 nerve blocks digital, 31–2 elbow, 33 external ear, 37 facial, 36–7 femoral, 33–4 foot, 47, 50 hand, 32–3 intercostal, 39 median, 33 penile, 37 radial, 33 sural, 35 tibial, 34–5 ulnar, 33 nerve injury, quick hand test, 124–5 nightmares, 240 nose auriscope, use of, 206 cleaning child’s, 224 epistaxis, 202–4 foreign bodies in, 132, 134 fractured, 205 instilling drops, 204 nasal washout, 205 offensive smell from, 204 polyps, 197 senile rhinorrhoea, 204, 246

INDEX

septal haematoma, 115–16 severe posterior epistaxis,204 ‘snotty’, 225 stuffy/running, 204 Nozoil, 204 Nozovent, 206

O ocular pain relief, 214–15 oesophagitis, 224 oil injections into hand, 132 ointment, prescribing rules, 228 olecranon bursitis, 80–1 onychocryptosis, 108–11 onychogryphosis, 106 oral temperature measurement, 238 orf, 83 Ortolani test, 172, 173 osteoarthritis in hip joint, 173 otic ointment, instilling, 202 otitis externa preventing swimmer’s ear, 198 suppurative, 198 tissue ‘spears’ for cleaning, 198 tropical ear, 202 otitis media suppurative, 198 tissue ‘spears’ for cleaning,198 Otovent, 206 oxygen therapy, 2

P paint gun wounds, 132 palmar nodule, 86 Palmer notation of teeth, 191 Pap smears, 242 paper clip bent, for removal of foreign bodies, 133 hot, for subungual haematoma, 107 uses, 245 papillomas, 91 paraphimosis, 6 paraphrenia, 246 paronychia, 111 patella, dislocated, 181 patellar tendonopathy, 179–80

patellofemoral joint pain, 180–1 patient education in consulting room, 243–4 Patrick test, 174 penile nerve block, 37 penis acute paraphimosis, 6 extricating from zipper, 136–7 perianal abscess, 97 haematoma, 93–4 skin tags, 94 warts, 97–8 perineal skin repair, 62 petroleum jelly, uses, 245 phalangeal fractures, 118–19 Phalen test, 167 phenolisation, for ingrowing toenail, 109–10 pinhole test, for blurred vision, 214 pinna, haematoma, 115 plantar fasciitis, 102, 182 exercises, 102–3 hydrotherapy, 102 injecting, 47, 104 strapping, 104 plantar warts, 99–101 plastering leg support while applying plaster, 187­ plaster of Paris, 186 plaster walking heel, 188 removal of cast from child, 223 silicone filler, 188 supporting shoe, 188 volar arm plaster splint, 187 waterproofing, 187–8 pleural effusion, 26 pneumothorax, 11 polymyalgia rheumatica, 143 polyps anal fibro-epithelial, 98 cervical, 88, 89 nasal, 197 post-herpetic neuralgia, 233 pre-patellar bursitis, 80–1 premature ejaculation, 242 pressure gun injuries, 131 pretibial haematoma,116 priapism, 242 prickles, removal of, 129 proctalgia fugax, 97

prolapse, rectal, 98 prolapsed disc, 154 proprioception exercises, 185 pruritis ani, 98 psoriasis, 230 steroid injections, 85, 231 pulley suture, 59 pulse oximetry, 1–2 punch biopsy, 79–80 pupillary reaction test, 7 pyogenic granuloma, 83

Q quadriceps exercise, 181

R radial nerve block, 33 radiation sickness, 18–19 rape victims, 10 rashes, 225 recapping needles, 31 record keeping, after hours, 242 rectal ‘injection’, 31 rectal prolapse, 98 recurrent erosive syndrome, 212 red-back spider bite, 14 reef knot, 56 reflexes, 239–40 reflux with oesophagitis, 224 renal colic, 242 restless legs syndrome, 240 rhomboid flap, 66 rib belt, universal, 118 rib fracture, 118 ring, removing from finger, 128 roadside emergency, 17–18 roller injuries to limbs, 116 rotation flaps, 65–6 rotator cuff lesions, injecting, 43–4 ‘rule of nines’, 229

S Sabin vaccine, 218 sacral hiatus, identifying, 40 salivary calculus, 193 sandfly bites, 14 saphenous vein, long, 4–5 scalp lacerations, 220–1

255

256

INDEX

scalp seborrhoea, 246 scalpel holding, 57–8 insertion and removal of blade, 58 scaphoid fracture, 171 scapula pressure method, 160 Schober test, 154–5 sciatica in buttock, 173 ‘hip pocket nerve’ syndrome, 173 manual traction, 155 scorpion bites, 15 scrotum, hydroceles, 84 sea sickness, 245 sea wasp stings, 15 sebaceous cysts, 77–8 sebaceous hyperplasia, 78 seborrhoea, scalp, 246 seborrhoeic keratoses, 83, 91 Seidal test, 212 Semont manoeuvre, 207–8 senile rhinorrhoea, 204, 246 septal haematoma, 115–16 serious injuries, clues from association, 16–17 sexual assault (female), 9–10 shave biopsy, 79, 80 shaved area, cleaning, 73 shin splints, 182 shingles, 233 shoulder dislocated, 159–62 injecting, 51 recurrent dislocation, 162 referred pain, 143 silicone filler in plaster cast, 188 sinus tenderness, 195 sinusitis, unilateral, 195–6 skier’s thumb, 170 skin cancer, 81–3 skin creams and ointments, 228 skin glues, 221–2 skin lesions biopsies, 79–80 carbon dioxide slush, 90–1 liquid nitrogen therapy, 88–90 steroid injections, 85 skin scrapings, 231 skin tags, 76–7 perianal, 94 primary suture, 64

skin tears, avoiding, 65 skin tumours, excising, 63–4 slings, 119–21 makeshift, 121 slump test, 154, 155 snake bite, 13 Snellen eye chart, 215 snoring, 206 ‘snotty’ nose, 225 sore throat, swallowing with, 206 spacing chamber, makeshift, 243 spatula sketches, 219 spectacles, protective, 216 spider bites, 13 spider naevi, 231 spine anterior directed gliding, 142,147 manipulation, 141–2 mid-thoracic, 148 mobilisation, 141–2 recording movements of, 141 see also cervical spine; lumbar spine; ­lumbosacral spine splinters detecting, 129 under nails, 105–6 under skin, 128–9 splints finger, 168, 169 minor fractures, 223 squamous cell carcinoma (SCC), 82–3 squint, 224 St John sling, 119, 121 stab wounds, 113 sternal thrust method, 148 steroid injections ganglions, 80 hypertrophic scars, 86 psoriasis plaques, 85 skin lesions, 85 stingrays, 15 stings, 15 stucco keratoses, 83 styes, 214 subacromial space injections for rotator cuff lesions, 43 for subacromial bursitis, 44 subcutaneous fluid infusions, 26–7 subtaler joint mobilisation, 184–5 subungual haematoma, 106–8 sugar, uses, 245

sunburn, 228 sunglasses, 229 sunlight exposure, 228–9 suppository inserter, 244 supra ventricular tachycardia, 13 supraorbital nerve block, 36 suprapubic aspiration of urine, 225–6 supraspinatus tendonitis impingement test, 162–3 injection for, 44 sural nerve block, 35 surgeon’s knot, 57 surgery, optimal times for children’s ­disorders, 226–7 sutures blanket stitch, 59 continuous, 59 cross-stitch, 60 inverted mattress, 62 materials, 55 non-absorbable, 75 number of, 56 over-and-over, 59 primary, 64 pulley, 59 removal of, 71, 75 subcuticular, 59 three-point, 61 vertical mattress, 56 suturing cut tendon, 122 ‘dog ears’, 61 holding the needle, 56 knot tying, 56–7 lip repair, 67–8 painless, 29 tongue wound, 69, 71 swallowing, with sore throat, 206 sweat glands, wedge resection of,71 swimmer’s ear, 198 syringing, ear, 198, 200

T tablets halving, 243 swallowing, 243 tailor’s bottom, 174 tampons, removal of impacted, 137–8 tarsal tunnel injection, 49

INDEX

teeth bleeding socket, 191 chipped, 190 dry socket, 191 knocked out, 190 loosened, 190 notation, 191–2 wisdom teeth, 192 temperature measurement, 238–9 temporomandibular joint dysfunction, 139–40 injection, 53 TMJ rest program, 140 tendon, severed, 122 tendon sheath injection, 50 tendonopathy Achilles, 50, 182 bicipital, 44 gluteus medius, 48 iliotibial band, 182 supraspinatus, 44 vasodilator use, 241 tennis elbow exercises, 165 injection for, 45 wringing exercise, 164–5 tennis leg, 181, 182 tenosynovitis of the wrist injection for, 46 see also de Quervain tenosynovitis tenpin bowler’s thumb, 169 testicle torsion of, 84 tumours, 84 thermometer, breakage in mouth, 239 thigh extension thrust technique, 147 thoracic spine anterior directed costovertebral gliding, 147 manipulation, 147–8 mobilisation, 147 thoracolumbar stretching/­ manipulation, 149 three-point suture, 61 throat fish bone in, 136 swallowing when sore, 206 ticklish, 206 thrombophlebitis, 235–6

thumb injecting, 32, 46, 51 joint, 51 lancing, 31 skier’s/gamekeeper’s, 170 tenpin bowler’s, 169 trigger, 46 tibial nerve block, 34 tibial stress fracture, 182 tibial stress syndrome, 182 tibialis anterior tenosynovitis, 182 tibialis posterior tendon rupture, 185–6 tibialis posterior tendonopathy, 50 tick removal, 127–8 Tinel test, 167 tinnitus, 206 tissue glue and plastic swab technique, 135 toenail dystrophic, 112 ingrowing, 108–11 onychogryphosis, 106 paronychia, 111 subungual haematoma, 106–8 traumatic avulsed, 112 tongue black, 193 geographic, 193 hairy, 193 repairing, 69, 71 tongue tie, 193–4 ‘too many toes’ test, 186 torticollis, 144 traction for cervical spine, 145 to neck, 144–5, 146 transposition flaps, 65 trauma, 113 ‘triangle of safety’, 25–6 trichiasis, 211 trichloroacetic acid, 91 trigger finger injection, 45–6 trochanteric bursalgia injection, 47–8, 246 tropical ear, 202

U ulcers aphthous, 192–3 corneal, 212 venous, 236–7

ulnar nerve block, 33 ultrasound efficacy in detecting splinters, 129 for detecting foreign bodies, 113, 129 ‘unconscious’ hysterical patient, 7 upper respiratory tract infections see URTIs Upton’s paste, 100 ureteric colic, 242 urethral catheterisation children, 24 female, 23 male, 22 urine aspiration, suprapubic, 225 URTIs anosmia following, 206 inhalations for, 196 UV light protection, 229

V vaccination, needle gauge, 29 vaginal temperature measurement, 239 varicose veins avulsion, 234 percutaneous ligation, 234 ruptured, 236 Vaseline, uses, 245 vasodilators, special uses, 241 veins, dilating, 20 venepuncture, 20, 241 venous ulcers, 236–7 vertical mattress suture, 56 vertigo, positional, 206–7 vessel ligation, 57, 65 vibrator, removal from vagina/ rectum, 138 vision, blurred, 214 vital signs, normal values, 1 vitamin D, 228 volar arm plaster splint, 187

W W-plasty, 72 walking stick, 189

257

258

INDEX

warts electrodissection, 92 perianal, 97–8 plantar, 99–101 treatment options, 91–2 washout, antral/nasal, 205 wasp stings, 15 wax removal, 198–200 weaver’s bottom, 174 wedge excision of lip, 67–8 wedge resection axilliary sweat glands, 71 ear, 68–9, 70 ingrown toenail, 109–10 wisdom teeth, 192 wobble board technique, 185

Wood’s light examination, 210, 231–2 wounds dressings, 73–4 everted, 56 healing cyst/abscess cavities, 74 honey as healer, 245 injecting analgesia, 222 keeping hair out of, 73 local anaesthetic infiltration, 30 maggot removal, 126 painless suturing, 29 post-operative care, 74 skin glue, use of, 221–2 traumatic, 73 Z-plasty, 67 see also sutures; suturing

wrist injection, 46, 51 nerve block, 32–3 tenosynovitis, 46

X X-ray, detecting splinters, 129 xanthelasmas, 91 xanthomas, 91

Z Z-plasty, 67 zipper, extricating penis from, 136–7

Murtaghs Practice Tips 6th Ed [PDF][Tahir99] VRG - PDFCOFFEE.COM (2024)

References

Top Articles
Latest Posts
Recommended Articles
Article information

Author: Horacio Brakus JD

Last Updated:

Views: 5927

Rating: 4 / 5 (71 voted)

Reviews: 94% of readers found this page helpful

Author information

Name: Horacio Brakus JD

Birthday: 1999-08-21

Address: Apt. 524 43384 Minnie Prairie, South Edda, MA 62804

Phone: +5931039998219

Job: Sales Strategist

Hobby: Sculling, Kitesurfing, Orienteering, Painting, Computer programming, Creative writing, Scuba diving

Introduction: My name is Horacio Brakus JD, I am a lively, splendid, jolly, vivacious, vast, cheerful, agreeable person who loves writing and wants to share my knowledge and understanding with you.