This patient was running from an assailant at top speed and fell, tumbling for several feet. Medics found him in this position and pondered how to secure him for transport. eventually they just used straps and belts to hold him on a backboard.
The injury is an interesting one. He has a femur fracture, but there is a twist (literally). If he was a contortionist and had found a way to bend his knee toward his head, his toes would point to his face. If you look at the thigh, twisted muscle bellies can be seen.
The diagnosis is a mid-shaft femur fracture with a 180 degree rotation of the distal portion.
I’ve written several times on the importance of getting patients off the backboard promptly in the ED. Many hospitals use slide boards to facilitate patient movement on and off the ED cart when undergoing imaging studies. How should we manage the use of this device?
There is no difference between a backboard and a slide board to the patient. It’s hard and uncomfortable to lie on for any period of time, and can cause soft tissue injury. To trauma professionals in the ED it is thinner, less bulky, easier to manipulate, and does not interfere with xrays as much. We tend to pay less attention to it than a backboard. Although it does not immobilize the spine as well as a backboard does, the difference is not clinically significant (in a cooperative patient). Remember, if your patient actually has a spine fracture, they will be placed on logroll precautions on a soft mattress only somewhere in your hospital! No stiff boards of any kind!
Slide board management tips:
Slide boards are for blunt trauma only! Patients with penetrating injury may need an upright chest xray in the ED and the board won’t flex enough.
Insert the slide board in any patient who will be getting several diagnostic studies. For trauma activation patients, this can occur as you roll them off the backboard.
As soon as diagnostic studies are done, remove the slide board
If there are unforeseen delays, remove the slide board and reinsert when ready to move
Remember that the soft tissue timer is counting down as soon as the patient is placed on a backboard or slide board
Plan an efficient road trip through diagnostic studies for your patient. This allows you to minimize time on the board.
Repeated logrolls onto and off of the slide board are discouraged. Every roll is an opportunity for mishap.
I find that many trauma professionals are nervous about closing stab wounds. They seem to worry a lot about infections and lean toward leaving the wound open to heal by secondary intention. But is this warranted?
The answer is: probably not. Most knives used for assaults are clean, but not quite sterile. Yes, there are a few bacteria on the blade, but not very many. So if the usual wound management guidelines are followed, the patients generally do quite well.
The guidelines are:
No gross contamination. If the knife was used to cut raw chicken or to stir up manure, that’s a problem. Leave it open.
No devitalized tissue. Complex lacerations with dusky skin bridges may get infected. Debride or leave open.
Don’t let the wound get fully colonized with skin bacteria. There is no good literature on this, but more than 12 hours for most of the body and 24 hours for the face is a reasonable guideline.
If any of these guidelines have been violated, it’s probably best to leave the wound open. Otherwise the default should be to try to close it as soon and as cleanly as possible. This means irrigating with saline to decrease any bacterial counts. Either sutures or staples are acceptable.
The most important part of this process is patient education. They must be informed about what signs of a wound infection to look for so they can return earlier rather than later to have you deal with it.
Diaphragm injuries are notoriously hard to detect, and there is a significant rate of delayed or missed diagnosis. Today I’ll offer a few practical tips on finding and managing this rare injury.
Mechanism is important. Penetrating injury is more common, and it can be really tough to diagnose this injury in stabs to the lower chest. Anything below the nipples is suspect. Blunt injury requires substantial force. This is seen in deceleration injuries, usually with a crush component to the abdomen. Ejection and partial ejection is common.
Left sided injury is much more common than right. The liver probably diffuses the force more evenly, protecting the right diaphragm. Be very skeptical if a radiologist tries to tell you the patient has a right diaphragm injury.
Patients have significant symptoms with blunt injury. Respiratory distress is common on the left, and deep visceral pain on the right if the liver partially herniates into the chest. Serious associated injuries are common due to the high energy involved.
Diagnosis is difficult. CT is a very good, but imperfect, tool. Coronal and sagittal reconstructions can be very helpful.
If you are inclined to explore for a possible diaphragm injury in a stable patient, consider laparoscopy first. But warn the anesthesiologist! If your patient has the injury, they will rapidly develop a complete pneumothorax, so you need to be ready to quickly insert a chest tube.
Caress the diaphragm to find small holes. Place your hand in the palm up position so your fingers will drop into any defect. Be thorough, since small knife and bullet wounds are easy to miss, especially when located posteriorly.