above his bushy eyebrows? Are the surgeon's indelible ink marks still evident at the base of each tuft? Does anyone in the room dare ask?
Subconjunctival hemorrhage: Bleeding under the red inside part of the eyelid. Usually heals without treatment but looks terrible for a while.
Scleral hemorrhage: Bleeding beneath the white part of the eye that abates slowly. May suggest other more serious eye injuries.
Orbital cellulitis: Infection of the soft tissue about the eye with swelling, redness and pain in the eye; often must be treated in the hospital with IV antibiotics. This is a good problem to get character out of the way for a few days. A managed care plan may not allow hospitalization. Ruptured orbit: Fluid drains from eyeball, which collapses. Usually from impalement of eye with sharp object; results in blindness if not repaired, and may cause blindness regardless of treatment.
Cut Facial Nerves and Facial Paralysis
Upper facial laceration: A cut lateral to eye on cheek may produce a permanently open eye with drainage—a one-sided vacant stare. Lower facial laceration: If anywhere near jaw margin, this can produce a depression ("droopy") deformity at the corner of the mouth.
Stephen King hits the high-water mark for the medically grotesque in the prologue of The Dark Half when he describes a neurosurgeon opening the skull of a patient whose twin was all but absorbed during embryological development. Left on the surface of the brain, the fascinated surgeon discovers, is an eyeball that "looked as if it were trying to wink at them," three fingernails and two teeth. This, from the master of aberration.
Do what you will with the noble head. Create new injuries, bizarre scars. Make your readers remember your friends any way you can.
Witness expert trauma care at an accident scene and you will notice how obsessive paramedics are about protecting the neck in cases of potential cervical spine injury. Not only is head trauma often associated with neck injury, but the neck injury is potentially unstable.
Potentially. That means conflict.
Angular with soft muscular cords framed by brunette locks or massive from the fullback's hairline to his shoulders, the neck conceals a vital tangle of tubes, nerves and blood vessels. These essential structures travel from the head to the chest or arise from the heart and shoot upward in a sprig of branches to the head, neck and arms. Size does little to afford the neck protection from injury.
The neck is also a common target for assault. Weapons such as a knife, screwdriver, ice pick, piece of glass, length of wire or gun may be used to slash, stab, garotte or shoot the neck. A maddened, mindless attacker may not use a penetrating weapon. Grabbing anything in sight to bludgeon his victim, or employing his fists, the villain may smash repeatedly at the neck. Blunt trauma in the form of strikes or compressive force by hands, arm, wire or rope produce different injuries from those seen with penetrating trauma. A stranglehold may be used to frighten human prey as well as to kill.
While the spinal cord isn't always at risk, major blood vessels in the neck frequently come under attack. A lot of anatomical structures stand in the path of a neck assault, and most of them don't take kindly to being cut open. Before we get to specific injuries, e.g., those produced by blunt vs. penetrating impact, consider what's at risk regardless of the traumatic agent:
• Larynx (voice box)
• Trachea (windpipe)
• Jugular vein
• Carotid artery
• Esophagus (gullet)
• Spinal cord
• Vertebrae
The neck encompasses an impressive number of vital organs, and the injury of any of these structures, could result in death. Both blunt and penetrating neck trauma cause major injuries, and some are associated with prolonged disability.
As always, it's a matter of degree.
The treatment of any neck injury begins with two questions: (1) Is there an actual or potential spinal cord injury? (2) Does the victim have an adequate airway?
Assume for the moment we're dealing with penetrating neck trauma from a knife assault. Most neck injuries result from a stabbing attack. Sharp, penetrating attacks to the neck often come from in front and are aimed at the anterior neck or chest, and frequntly, structures in both anatomic areas become injured with a single assault. Attacks from behind are still directed for the most part at the throat. With a "reach-around" knife assault, the intent is to slash open the major neck blood vessels.
Thus, as a general statement, muscles, ligaments and vertebrae (including the spinal cord) are seriously injured by indirect neck trauma, while superficial anterior structures are at risk from sharp weapon
Master Injury List For Neck Trauma
Minor Neck Injuries
■ Neck sprain
■ Minor fracture of vertebral process
■ Stable ligament tear
■ Contusion of neck
■ Minor lacerations
■ Temporary spinal cord injury Major Neck Injuries
■ Laceration of the jugular vein
■ Laceration of the carotid artery
■ Perforation of the larynx
■ Perforation of the trachea
■ Perforation of the esophagus
■ Unstable neck fractures
■ Permanent spinal cord injury
assaults. On the other hand, gunshot wounds may rip through any part of the neck.
A discussion of penetrating injuries centers on whom the trauma surgeon should take to surgery in order to explore the neck structures for serious injury. But with neck fractures, the issue is what method of stabilization is most advantageous.
In a study on penetrating neck wounds, those victims explored immediately had a 6 percent mortality rate. Victims of a neck stab injury either not operated on at all or for whom surgery was delayed during initial observation had a 35 percent death rate—almost a sixfold increase.
Quite a difference. And while we don't know how many of the operated patients developed complications after surgery, the number of patients who had a neck operation with no findings of a major injury ranged from 40 to 63 percent. Still, this large negative exploration rate wasn't enough to discourage most trauma surgeons from an aggressive approach to these injuries. And these injuries are not a new problem. The first lacerated carotid artery was tied off by a French surgeon in the 1500s!
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Neck and Spinal Cord Injuries: Snapped, Stabbed and Strangled / 79 |
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To resolve the issue of whom to operate on and whom to observe, a system is used that divides the neck into three zones, as shown in Figure 10. Treatment decisions are now determined by the zone involved. Zone I: Root of the neck, from the collarbone to the lower edge of the larynx (Adam's Apple). This is the most dangerous neck zone as serious injuries to the great vessels arising from the heart occur with downward-directed knife assaults. An innocent-looking stab wound above the collarbone may lacerate the aorta in the chest. Beneath the skin in the middle of the neck lies the trachea (windpipe) and just behind it the esophagus (gullet). A knife attack may cut open the esophagus, spilling terrible bacteria into the chest. Immediate or delayed infections can occur if these injuries aren't recognized.
The surgeon may ask for an arteriogram, a special dye study (an x-ray) of the arteries in the region of the wound. This will indicate if there's a blood vessel leak. Other studies include an upper GI series, to examine the gullet for a perforation, and bronchoscopy, a look inside the windpipe with a fiberoptic instrument.
If a major injury is diagnosed, the surgeon will have to "crack" (surgically open) the chest. Midline sternum-splitting incisions as well as horizontal incisions beneath the collarbone are used.
Zone II: From the lower edge of larynx to angle of the jaw. Many of the stab wounds in this area are evaluated in the trauma room where a decision about further surgery depends on a few reliable physical findings. Because most of the vital structures are not deep in this zone, special x-rays are used less often.
Acute physical findings that require emergency surgery include:
• A hematoma (blood clot) that's expanding or growing as it is observed, the implication being that a major blood vessel continues to bleed and the airway may become squeezed
• Major bleeding from the wound not adequately controlled in the trauma room
• Air in the neck tissue (subcutaneous emphysema), which means the larynx or trachea has been perforated
• A major wound that must be debrided (cleaned up) surgically and inspected carefully (Bleeding and poor lighting in the ER mean that not all wounds are properly assessed there).
Zone III: The area above the jaw up to the base of the skull. It's not easy for a surgeon to dig around in the tight spaces of the upper neck and face without inadvertently causing more damage than already exists. If major hemorrhage is the problem, the radiologist will perform an arteriogram and inject material into the small arteries of the facial area to plug the holes and stop the bleeding without surgery. More superficial wounds may be explored directly.
In any of these zones, the wound may not appear to be deep, and careful observation—if local exploration in the trauma room reveals no major injuries—is a reasonable option. At times, a decision is made to observe a patient, only to be reversed hours later. With neck wounds, a healthy dose of suspicion is warranted. Proponents of the two schools of thought—to observe some neck wound victims or operate on everyone— cross swords over whose approach represents the best medicine.
Observation includes performing any number of the following tests at any time during the first few hospital days:
• Barium swallow to evaluate the gullet (esophagus)
• Endoscopy to look directly into the esophagus
• Laryngoscopy to assess the throat and upper airway
• Bronchoscopy to look at the lower airways
• Arteriogram to evaluate the arteries of the neck and upper chest (x-rays are never done on the veins), used most in Zones I and III
During your victim's trauma room evaluation, and through the uncertain early hospital course, the clock just keeps on ticking. If you need a subplot for your injury-strewn story, consider two doctors who disagree on which stabbed neck to explore. Make it the neck of a prominent citizen or a supermodel.
Turn up the heat. Penetrating neck trauma lets you play around with treatment options.
These are usually less severe although it's possible to clot off a carotid artery with blunt neck trauma, sometimes resulting in a stroke. Near hanging, garotting as a threat or an interrupted choking attempt all leave soft tissue swelling and the possibility of airway blockage.
It may not happen immediately; your heroine may turn purple at midnight.
Tick tock.
Neck Fractures and Dislocations
A broken neck can kill your character quicker than a jab in the throat. But the trauma patient who suffers from quadraplegia—loss of function of the arms and legs—may be the most unfortunate victim of chance. For the writer, a neck injury or a head injury with the potential for neck damage opens unlimited possibilities.
For example: paralysis—if that's the end point you are seeking— may occur:
• At the time of the accident
• When emergency personnel or a well-meaning friend first attempts to move the victim
• During transportation to the hospital
• When the ER doctors move the patient into the trauma room
• When the victim is being moved to x-ray for views of his cervical
spine
• During a surgical mishap
The neck bones may splinter in numerous ways, but we're interested in two patterns only: (1) stable neck fractures and (2) unstable neck fractures.
Stable neck fractures are present when the majority of the vertebral bone is intact, the ligaments are still holding and there is no x-ray suggestion of dislocation. On the other hand, an unstable fracture is characterized by smaller bone fragments, torn ligaments and the overriding of one vertebra on the next. This sliding of one bone on the one above or below creates a shearing effect and pinches the spinal cord. The result is a damaged cord and interruption of information traveling to the brain and back down to muscles and other organs. It can lead to paralysis.
In any area of the vertebral column from the neck to the sacrum, any two vertebral bodies can slide on each other or dislocate without actually being broken. Held in place by massive ligaments running up and down the spine in front and behind the vertebral bodies, the bones are also anchored by shorter ligaments between bony projections on the vertebrae and by accessory joints. The smaller stabilizer joints are the ones that pop and crack like firewood when a chiropractor manipulates a patient's neck.
Severe flexion-extension motion of the neck causes most of the unstable as well as stable cervical spine injuries. "Whiplash" is a legal term. It's descriptive. A vivid image of forward bending of the neck with sudden force applied from behind followed by backward motion, or hyperextension, of the neck becomes indelible in your mind. Only the deep ligaments of the neck and the strap muscles can arrest this action. The automobile headrest is designed to modify this sort of movement of the head and neck should impact occur. Pain is often in proportion to the other person's insurance policy.
A blow to the top of the head may cause fracture of the first cervical vertebra, the atlas. If there's no nerve damage, the treatment is conservative with immobilization and rehabilitation. The situation becomes a little more complicated at this point with fractures and dislocations as well as combined fracture-dislocations. Any of these neck injuries may be unstable and therefore critical.
You may have heard of a youngster who became paralyzed after diving into a quarry, empty pool or shallow pond. Cervical spine injuries carry the potential to kill, or to maim for life. These injuries may cause one of two basic types of spinal cord injury: (1) contusion (bruise) of the spinal cord or (2) compression of the spinal cord.
Most severe cord injuries don't resolve. They may occur anywhere down the vertebral column, and as the distance from the neck increases, the degree of paralysis decreases. So the victim of a broken low back (lumbar fractures) would suffer from paraplegia if the cord damage was permanent. This involves loss of leg, bowel, bladder and sexual function.
Of course, many people have suffered from neck spasm at one time or another. Although quite painful, there is no neurological deficiency. A diagnosis of neck sprain can only be made after a careful physical examination and negative neck x-rays. Damage to soft tissues, muscles, ligaments and joints causes decreased range of motion and pain. Treatment involves immobilization with a cervical collar, rest and physical therapy.
Uncertainty always surrounds the exact nature of a cervical spine injury, and x-rays are needed to make the diagnosis of a fracture, dislocation or both. The victim may experience any number of symptoms, including numbness, incontinence, paralysis and pain. Neck pain is the most consistent complaint.
The Treatment of Neck Fractures
A broken neck may require a collar to restrict motion and relieve pain. A larger "halo" collar with rigid fixation, which permits limited neck motion, is used for less stable fractures. For very unstable fractures, inline traction in bed with skull tongs and weights is needed. It depends on what bones are broken and which ligaments are disrupted. The more severe the injury, the more rigorous the traction or immobilization.
Other treatments range from IV steroid medication to a more aggressive open surgical approach. The latter involves surgical fixation (wires, pins and rods) of unstable spine fractures to avoid spinal cord compression and paralysis.
Three time frames for death after an accident also apply to neck injuries, and therefore these traumatic insults carry a ton of anguish and conflict for your story. Death may occur:
• Immediately because of sudden loss of respiratory function
• After an hour or so from spinal cord compression (which may or may not be recognized)
• Following months of rehabilitation because of complications such as urinary tract infections or pneumonia
Death by hanging occurs as an act of homicide, suicide or autoerotic asphyxiation. We are interested in the botched hanging that doesn't cause death. A clean jerk at the end of the rope represents the preferred hanging method to fracture or dislocate the cervical vertebrae, compress the spinal cord and/or cause sudden death by asphyxiation.
In his novel Acceptable Risk, Robin Cook describes the hanging of the witches of Salem, one of whom was Elizabeth Stewart, the wife of Ronald, a friend of Reverend Cotton Mather. Unable to prevent Elizabeth's hanging because of the horrible evidence against her, the good reverend, we are led to believe, does the next best thing. Elizabeth is on the ladder leaning against an oak tree:
For a brief second Ronald saw Elizabeth's eyes rise to meet his. Her mouth began to move as if she was about to speak, but before she could, the hangman gave her a decisive shove. In contrast to his technique with the others, the hangman had left slack in the rope around Elizabeth's neck. As she left the ladder, her body fell for several feet before being jerked to a sudden, deathly stop. Unlike the others, she did not struggle nor did her face turn black.
Robin Cook dramatically and accurately depicts the different effects of a slow, painful hanging and a sudden, compassionate death. Because our discussion centers on near death from hanging, it's crucial to understand that suicide often fails because the rope, belt, electrical wire or whatever only partially strangulates the victim. If not sufficiently far above ground or the floor, the would-be suicide gags, passes out and then recovers. Near-death hanging creates swelling and tiny hemorrhages in the eyes, a circular bruise on the neck and an open-ended question: what to do next. Did the person really want to die or merely send a message?
Neck injuries reflect many of the unsavory aspects of violence. Victims of clinical depression who feel the compulsion to attempt self-destruction often attempt hanging. Neck trauma may also be a by-product of uncontrolled rage, attempted homicide, domestic violence or accidental strangulation during autoerotic asphyxiation. Regardless of the cause, nothing challenges a character's character like the loss of all ability to move, breathe and control one's destiny.
The possibility of paralysis, suffocation and major neck hemorrhage raises the stakes in your plot. It is indeed gruesome when someone takes it in the neck.
Whether you end up writing about a potentially lethal injury or about the cause of death—followed by crime scene investigation, how to deal with the body, disposal, etc.—depends on how you handle the window of opportunity for treatment. This moment is brief, variable. But your characters glimpse at it with the desperate intent of being saved.
For the fiction writer, this dread-drenched interval between life and death defines the ultimate ticking clock. Chest injuries, more than any others, possess their own self-limited course. The threat is death or a life-altering mishap. Only correct emergency medical decisions are acceptable to Madame Fate.
Because we're interested in injuries in this book, we'll now examine the kinds of things that can go wrong inside your character's heaving rib cage. With unexpected death, you fire off a cascade of emotional events that create or aggravate conflict and change the direction of your plot. But by not killing your character, you step back in the story's time line to the traumatic event itself and create even more conflict because of the uncertainty of the outcome of the injury.
His instinct and every fighting fiber of his body favored the mad, clawing rush to the surface. His intellect and the craft thereof, favored the slow and cautious meeting with the thing that menaced and which he could not see. And while he debated, a loud crashing noise burst on his ear. At the same instant he received a stunning blow on the left side of the back, and from the point of impact felt a rush of flame through his flesh.
Moments later in All Gold Canyon, Jack London's tense short story about a miner shot in the depths of a seven-foot-deep hole, the wounded man escapes after killing the intruder. The author's brief description of the miner's relief when he realizes the wound was not fatal rings of authenticity for the era as well as for its medical verisimilitude. Relieved to be alive, the miner opens his shirt and examines himself. "Went clean through, and no harm done!" he cried jubilantly. "I'll bet he aimed alright, alright; but he drew the gun over when he pulled the trigger."
Sometimes not knowing the outcome of an injury is more unnerving, more difficult to deal with than the certainty of a loved one's demise. What will happen next? The big story question is always open-ended with a serious injury and (almost) always shut tight in death—except for whodunit, and we're interested in howdunit.
Chest trauma is unique because so many insults may occur to the cavity that conceals your character's vital structures. Outcome becomes a literal crapshoot. How marvelous for you, the writer.
One quarter of the victims of chest injuries die, often after reaching the hospital. Fewer than 15 percent of these unfortunate souls need an operation, and their lives may be saved by your hero's actions before the ambulance arrives.
The basic organization of this chapter centers on the "dirty dozen" bad chest injuries and a few other common problems about which you are almost certainly already aware. Before we get to the bad stuff, remember that a bump on the chest may only cause rib bruises, which can be extremely painful, or broken ribs with no underlying injuries. These impacts get your character out of action for days as opposed to weeks or months.
Then there are the twelve terrors. This material is a little heavy, but hang in there. Once you get the basics, you can imply the rest.
Described below are twelve chest injuries that may threaten your character's life immediately or cause delayed death. The ultimate medical ticking clock is a serious but reversible injury that, when survived, may alter the course of your plot or a character's view of life. The only real difference between the first six chest insults and the rest is time.
All of these injuries can be survived. It's the threat of death that makes them so terrible and so remarkable when the patient walks out of the hospital alive.
No matter the specific injury, your hero should follow certain steps as he evaluates the chest trauma victim. Familiar by now, they are repeated with each new trauma problem. Remember, if you want to create more conflict, let someone forget to do something.
Steps in evaluating and treating the chest trauma victim:
1. Conduct primary survey—a quick search for major injuries.
2. Have a high index of suspicion for certain injuries based on history and visible marks.
3. Do simple lifesaving things.
4. Do a secondary survey—go back and look again for other injuries.
5. Get the victim to a medical facility.
Injuries That May Kill Within Minutes
Imagine you are a molecule of oxygen attempting to travel from room air through the mouth, down the windpipe into the terminal air sac in someone's lung. (If you can envision this peripatetic oxygen outing, you can write anything.) Airway obstruction is anything that impedes the molecule's progress down the road to the bloodstream; it usually involves what doctors call upper airway blockage. Anything from a smashed face, swollen lips-mouth-throat from an allergic reaction, the tongue "falling back" to block the inlet to the larynx (voice box) or a chunk of foreign material, such as a piece of meat, will clog the airway.
Master Injury List For The Chest: The Dirty Dozen
Chest injuries that may kill within minutes
■ Airway obstruction—blockage of the windpipe
■ Tension pneumothorax—lung collapse with increased pressure inside the chest from broken rib (blunt trauma), knife, bullet
■ Open pneumothorax—the so-called "sucking chest wound," which means a chunk of the wall is missing
■ Massive hemothorax—a large amount of bleeding (a quart or more) inside the chest cavity
■ Flail chest—a floppy section of chest wall caused by ribs becoming broken in two places and leaving a "floating section" in between
■ Cardiac tamponade—the heart sac floods with blood and squeezes the heart, leading to shock
Chest injuries that may kill within hours
■ Lung bruise—from a direct hit (blunt trauma)
■ Heart bruise—from direct blunt trauma
■ Torn aorta—large artery coming off heart gets lacerated
■ Torn diaphragm—the thin muscle layer separating the chest and abdomen is lacerated
■ Torn windpipe (or its branches)—air leak; lung may collapse
■ Torn gullet—esophagus is lacerated, leaks and causes infection from swallowed bacteria; if the tear isn't treated, death may take days or weeks
Be creative. Imagine the special world of your story. What's in the environment that could be accidentally "inhaled"? At a banquet, someone plummets to the ground. Heart attack? No, she's suffered from what is called a cafe coronary. It's sudden upper airway obstruction from a chunk of food and mimics a true heart attack.
As you know, the treatment is the Heimlich maneuver. Swift pressure is exerted on the upper abdomen (by someone behind the victim who encircles her with his arms, pressing the "pit" of her abdomen) to increase the pressure inside the chest to force air in reverse up the windpipe and blast out the food gob.
The most common form of sudden upper airway obstruction occurs when the tongue falls back and blocks the free flow of air into the windpipe. Treatment involves lifting the chin or elevating the angle of the jaw.
Always, your rescuing hero should check inside the mouth for foreign material.
It's pronounced new-mo-thor-ax. A pneumothorax is simply a collapsed lung. Young people get them from ruptured blebs, or weak "ballooned" regions on the surface of their lungs that burst after exertion. It presents as shortness of breath with gasping, and is often accompanied by severe chest pain on the side of the collapse. The victim is treated with a chest tube. That's a simple pneumothorax. As the interns say, you "buy" a chest tube for a few days, then go home.
With a tension pneumo (that's doctor talk), a one-way valve effect develops, usually from a stab wound, bullet or the jagged end of a broken rib tearing the lung. Now we have a problem. One-way means out. Air flows down the windpipe, out through the hole in the torn lung tissue and out into the closed chest cavity, the pleural space (Figure 11).
What happens rather quickly is that the lung collapses and the heart and great blood vessels in the chest are pushed to the opposite side. Everything gets kinked. The heart now doesn't pump enough blood, oxygen delivery to vital tissues stops and your character's got a big problem.
Treatment involves putting a plastic hose, a chest tube, between the ribs of the victim's chest wall. To make the diagnosis, the smart paramedic or doctor inserts a big needle between the ribs just below the collarbone as soon as she considers the possibility of a tension pneumothorax. If air under pressure doesn't hiss out immediately, the small puncture doesn't cause any harm.
This is referred to as the sucking chest wound, and is also shown in Figure 11. Instead of a buildup of pressure inside the chest, as in the tension pneumothorax, the open chest wound is characterized by a hole in the chest wall through which air flows with every inspiratory effort. It's truly a case of lack of inspiration. The victim exchanges air through the chest wall hole instead of being able to create enough negative pressure to draw air into his airways for a deep breath.
Treatment in the field is a bandage to cover the hole. More on this
later. In the hospital, the trauma doctor will place a chest tube and repair the defect in the chest wall.
Heme, as in hemoglobin, refers to blood—in this case, blood loss into the chest cavity. Does it require blood replacement? Well, a hemothorax is a condition in which blood from torn blood vessels fills the chest cavity. The chest can hold a lot of blood, and transfusions are often part of resuscitation for these injuries.
The blood can come from several sources in the lung or chest wall and occurs with both blunt and penetrating trauma. The source is not important. But the chest is a pretty good bucket, and it can overflow with a lot of your victim's precious heme. The victim has difficulty breathing and shock from blood loss.
Have you figured out the treatment?
Two things, right? Place a chest tube (or two) and resuscitate, eventually administrating blood to reverse the shock state. And if the bleeding doesn't stop and the red stuff continues to pour out of the plastic hose, you might hear the intern cry, "Damn it, Luke, we gonna crack this chest or what?" (Ten years of higher education.) Cracking a chest means a chest operation: an emergency thoracotomy—cut between the ribs, pry open the bony struts and peek inside. The trauma surgeon sees what's bleeding and stops it.
A flail chest means the same rib is broken in two places with a floating piece of chest wall in between. Usually more than one rib gets the double whammy during blunt chest trauma.
Figure 11 (page 91) shows the chest wall with a floating segment with several broken ribs all next to each other. The pressure changes inside the chest make this segment move paradoxically, i.e., balloon out with inspiration and collapse with expiration. It moves in the opposite direction of the normal chest. The injured segment "flails." Oxygenation is hampered because the victim's breathing efforts aren't economical. But the real problem is the huge bruise to the underlying lung tissue from the blunt impact, which interferes with oxygen delivery.
Picture the throbbing heart inside its fibrous sac, a tomato inside a small balloon. Imagine the balloon filling with water as the tomato resists the increased pressure, water that compresses the tomato and then expands the balloon. Here's the rub.
While the heart sac fills with serum or blood, the heart constantly works at its task; it contracts and expands, filling up with blood and propelling it forward. The heart squeezes and swells from before birth to death. Ceaselessly, the fabled heart expands with blood, contracts with ejection. Diastole, then systole. Ebb, flow. Driven by emotions, pummeled by disease. Expands, demands. Ejection, rejection. Cycles.
Suddenly your character's car rattles off the road and crashes into a double-wide. Her chest smashes into the steering wheel. Directly behind her sternum lies her heart, which, in this steering wheel injury, is bruised. For the moment, we're interested in only one of the consequences of blunt chest trauma: flooding of the pericardial sac with blood.
It's referred to as cardiac tamponade.
A stab or gunshot wound to the anterior chest will often result in a cardiac tamponade, as will a major injury to the heart. In both penetrating and blunt chest trauma, the doctor should consider the possibility of a pericardial sac full of blood. It doesn't take a lot of blood to squeeze the pump into failing.
Do you have a doctor character who's pretty smart? (They're not all clever, you know.) OK, this is how he picks up (that's doctor talk for "diagnoses") a cardiac tamponade everyone else in the ER missed. He examines the victim's chest and notices what is called Beck's Triad:
1. Muffled or distant heart sounds. There's now a wall of blood between the heart valves (which are making the noises he wants to hear) and the chest wall.
2. Narrowing of the two blood pressure numbers. Because the heart can't fill and empty as well, the maximum and minimum pressures are closer together; instead of 120/80, blood pressure might be 90/70.
3. Enlargement or distention of the neck veins. Blood is "backed up" in the big veins because the heart is less efficient while trapped inside the pericardial sac.
The doctor inserts a huge needle between the ribs near the breastbone directly into the pericardial sac and removes (aspirates) the blood squeezing the heart.
Injuries That May Kill Within Hours
Most commonly associated with blunt chest trauma, a lung bruise is an area where blood and fluid collect within air sacs and interfere with oxygenation. If the bruise is small, it will heal spontaneously. If it's massive, your victim may require intensive care on a ventilator. It may take weeks to heal. The injury may even progress to the point where the lung tissue becomes solid—like liver.
Any degree of disability your story requires may be created by a whack in the ribs. A bunch of ribs may be busted. These fractures may be the usual one-crack-per-rib variety or they may become broken in two places producing a flail chest. Still, the ribs aren't the problem. They heal with rest. It's the ugly underlying lung bruise that can sneak up on your heroine and strangle her oxygen supply. Treat it with a ventilator, diuretics (IV water-pill-type drugs to dry out the lungs) and antibiotics if needed.
All you need to remember about this injury is that it's exactly like a heart attack. That's correct. A heart attack means a patch of cardiac muscle died beyond a blockage in one of the coronary arteries. In the case of a bruise, the muscle is injured by impact, but it dies nonetheless. As with a lung bruise, the heart is not very creative and, regardless of the cause of the injury, the tissue response is always the same.
If the patch is huge, cardiogenic shock occurs: The pump fails to propel enough blood to the body's vital tissues. Your character's now in big trouble, and special cardiac drugs are needed to support heart function. For lesser injuries, the patient is treated like a heart attack victim— with rest, medications and a graduated exercise program.
Not much imagination is needed to create this potential disaster. This huge blood vessel comes off the heart and is attached by a ligament to the chest wall as it arches over and down toward the back of the chest cavity. Now imagine, after a decelerating impact your character's aorta continuing in a straight line according to Newton's first law of motion— until it's acted upon by that little ligament, which tears the pulsating blood vessel.
You'll recall that this is one of the causes of immediate death at the scene of the accident. But that's only if the full thickness of aorta tissue rips open, pouring the victim's entire blood volume into his chest cavity. Often these trauma victims arrive in the ER in shock from bleeding from this injury or from hemorrhage from other impacts. Because the smaller tear is only partial thickness, the remaining tube holds and the victim lives until your hero either makes or misses the diagnosis.
The middle compartment of the chest is the mediastinum and contains the heart and great blood vessels. So the red flag with blunt chest trauma—particularly a steering wheel injury—is a widened mediastinum on chest x-ray. To prove the aorta is torn, your character orders an arteriogram, an x-ray of the heart and aorta performed with special dye. If dye leaks out of the blood vessel, there's a tear in there somewhere.
You'll remember the diaphragm is the muscular sheet that separates the chest from the abdominal contents. It looks like a parachute with the strings anchored to the walls inside the belly. It helps you breathe and is traversed by the aorta heading south with fresh blood and the vena cava, the huge abdominal vein, returning old blood from the lower body to the heart. Also, your esophagus (gullet) passes through the diaphragm.
Injury to the diaphragm can be subtle. As with an aortic tear, a ruptured diaphragm is suggested by a chest x-ray that shows fluid or intestine in the left chest. Blunt trauma causes the diaphragm to "burst" with a large radial tear, whereas penetrating wounds, e.g., from a knife stab, cause small holes.
Often the diagnosis isn't made until weeks or months later when the chest x-ray doesn't improve or a trapped loop of intestine causes bowel obstruction (blockage). You can use this injury to get someone out of the picture again after his convalescence from the original accident is over.
Do you have a karate expert in your story? Suppose she defends herself by striking her attacker in the throat. He becomes hoarse and develops crackles in the tissues of his neck. A grating sound is produced when someone pokes his neck, which is now swelling.
He's got a broken voice box, a fractured larynx.
Chest trauma may burst the windpipe lower down or even rupture one of the branches (bronchi) of the windpipe. This may cause labored breathing, depressed level of consciousness or a tension pneumothorax. The doctor makes the diagnosis by looking into the windpipe and its branches (bronchoscopy).
Immediate surgical repair is mandatory.
This one's both dull and fascinating.
By now you need little imagination to picture a long kitchen knife slicing between the victim's ribs, penetrating the back of the chest cavity, narrowly missing the aorta but nicking the esophagus. Saliva, bacteria, booze and food drip into the sterile chest cavity, and if the injury is missed, the patient can insidiously slip into sepsis, an infected state with fever, pus formation and an urgent need for surgery.
It's subtle. It's a useful "missed diagnosis" ticking clock.
Now here's the really fascinating possibility. (Hopefully, you've blunted any tendency toward squeamishness by this point.) Suppose you've got a character who has just been admitted to the hospital with pneumonia. Two days later, he slips into shock from infection and his chest x-ray looks horrid. Finally, the doctor asks him how this all started (doctors are supposed to take the history first, but being as smart as they are, they often make the diagnosis first, and when it's wrong, they go back and do it right the second time around—don't tell anyone). Your character mentions that the left chest pain started when he began to forcefully vomit. The upper GI x-ray the doctor now orders shows a huge hole in the esophagus. Yep. Violent retching tore a hole in his esophagus, and he vomited into his left chest cavity!
This injury is treated by surgical repair of the hole and placement of a chest tube. It begins with left chest pain, is often confused with left-sided pneumonia and may require weeks of recovery. And if you have to know, it's called Boerhaave syndrome.
There they are: the dirty dozen. And a bonus.
All potentially lethal, these severe injuries may be successfully treated and serve your story by creating intrigue, tension and conflict. Of course, you can have your character injured less severely.
It should be clear by now that a gunshot wound of the chest may cause any of these injuries (or ones very similar), as depicted in Figure 12, including a wound in the heart. A quarter of the victims of a blast into the heart actually survive surgery and go on to battle once more. This is another reason why the chest is opened in the ER as an acute surgical emergency.
Don't forget that the other chest injuries that require only a chest wrap or splinting are rib bruises and simple rib fractures. Keep the fractures low in the chest. Upper rib fractures are associated with the dirty dozen.
Also, remember to use this material sparsely. Imply what you don't describe.
Next, we'll discover that some so-called chest injuries are actually a problem in the belly.
Unlike the chest wall propped up like a mountaineering tent by rib struts, the abdominal wall is soft, pliable, vulnerable. Gentle curves and powerful muscles mask injuries, conceal bleeding and confuse the doctor who attempts to diagnose a belly injury. In fact, it is so difficult to identify abdominal cavity problems (called intra-abdominal injuries) that most medical texts beg the physician who initially sees the patient to cultivate a high index of suspicion.
A trauma surgeon is ready for any kind of belly injury. For example, if a victim of a street fight comes to the ER in shock, one of the first places on the belly wall the surgeon examines is the right upper quadrant. Why? Because when a knife is employed in a premeditated attack, a right-handed assailant typically grasps the weapon with the blade pointing up. Then, he rips up and in, smack into the right upper quadrant— and the liver. (By contrast, someone attacking out of sudden, blind rage is more likely to jab downward, holding the knife point down.)
Here's good news for the writer. Unlike the specific and rather complicated injuries you learned about in the previous chapter, belly trauma is easier to understand because most abdominal organs become injured in the same way. Instead of listing a dozen quite distinct injuries, we'll be looking first at a method of understanding all intra-abdominal trauma no matter which organ is involved.
Patterns of Intra-Abdominal Injury
Two types of intra-abdominal organs make up the belly contents—hollow and solid—and so only two basic patterns of injury can occur. Most of these organs have something to do with digestion, although the kidneys, spleen and reproductive organs are also implicated in trauma. Before examining specific organ trauma, which you know as an internal injury—a nebulous collection of terrible things only the doctor is allowed to see—we'll first look at how hollow and solid organs become smashed up.
A long time ago, "living tubes" became necessary to permit the concept of a multiorgan human, a complex living creature distinguished from single-cell globs by complex internal support systems. Living tubes carry a variety of fluids (and some notable solids) about the body. If injured, these tubes leak, bleed or become gangrenous.
As Figure 13 (page 100) explains, the basic living tube unit consists of an artery carrying blood to the tube, veins transporting old blood away, and the tube. With both blunt and penetrating trauma, the artery and vein (being close to each other) are often injured as one. Thus, the three basic patterns of injury are:
1. Cut or torn blood vessels that hemorrhage
2. Cut or torn blood vessels that leave the tube without a blood supply, resulting in dead tissue, or gangrene
3. A cut or tear to the tube (a traumatic hole called a perforation) resulting in body fluid leak
The human body specialized by developing solid organs that assist in the various survival functions of excretion, digestion and procreation—all tied together by the heart, lungs and a massive tree of branching blood vessels. Many solid organs have more than one role. When injured, these solid organs and their special functions become compromised. Thus, loss of organ function is a possibility.
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Figure 14 (page 101) depicts a working model for a solid organ and its injuries. Again, the artery carries blood to the organ while veins permit old blood to exit. Most solid organs have the consistency of liver, and the basic injuries to these organs are: |
1. Cut or torn blood vessels that hemorrhage
2. Cut or torn blood vessels that leave the organ without a blood supply, resulting in partial or complete organ necrosis (means dead tissue, as in necrotic liver, and is pretty much the same as gangrene)
3. Cut or shattered organ tissue, resulting in hemorrhage
4. Leakage of specific body fluids
At first you might think blunt trauma is less destructive than a penetrating
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Abdominal Trauma: Beware of Hidden Damage / 101 |
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injury. Not necessarily so. Gunshot and other missile wounds to the belly do cause all sorts of unpredictable havoc, but blunt impacts destroy tissue as well.
Liver: The biggest organ in the body other than the skin, the liver serves as the body's waste scrubber as well as the producer of essential body chemicals and other vital substances. Blunt trauma to the right side of the lower ribs or abdomen results in various types of liver lacerations. Some are innocent and require no treatment; others cause a "burst" liver where the tissue literally explodes and hemorrhages so badly that survival is barely possible. In-between degrees of liver damage are often seen and require suturing to control bleeding.
Spleen: Unlike the liver, the spleen may be salvaged even if it is split
Master Injury List For the Abdomen
Blunt Abdominal Trauma Solid Organs
—Major: remove shattered parts, tie off blood vessels —Minor: observe with repeated CT scans and blood counts
—Major: remove spleen —Minor: repair spleen
—Bruised: observe or drain —Lacerated: remove injured segment and drain Hollow Organs
■ Bladder: repair; drain with suprapubic catheter
—Major: remove segment and sew back together —Minor: observe
—Major: remove segment, perform a colostomy (temporary) —Minor: observe
—Major: remove all or part —Minor: observe
Penetrating Abdominal Trauma Solid Organs
■ Liver, spleen, pancreas, kidney
—Knife trauma: clean (debride), drain and conserve tissue —Gunshot: clean extensively and remove dead tissue (bullet damages tissue beyond immediate track), drain extensively Hollow Organs
■ Small intestine: remove any damaged part and sew together (called an anastomosis of the bowel)
■ Colon/rectum: extensive removal of any torn tissue, may close small holes but remove segment; always a protective colostomy
in two after major trauma. Surgeons always make an attempt to preserve this portion of the body's immune system. At times, a chunk is removed surgically and the remaining portion saved with its blood supply.
A ruptured spleen occurs with trauma to the left side of the body, either to the lower ribs or flank. Hiding under the protective shield of the tenth, eleventh and twelfth ribs, the spleen may be split open by a hockey check, from a fall on slippery sidewalk ice, or after what seemed to be an innocent tumble at home, particularly if the spleen is abnormally enlarged. The victim will suffer from light-headedness, will become pale and may slip into shock from blood loss.
What happens next?
Anything you want. Her coagulation system can kick in and eventually stop the bleeding, or you may choose to let her ooze and ooze until hospitalization and multiple transfusions are needed. Even if she does stops hemorrhaging initially, she may start bleeding uncontrollably later.
A ruptured spleen serves as a flexible plot tool in your devious hands.
Pancreas: A soup bowl full of enzymes is produced each day by the pancreas, the firm organ tucked behind the stomach. Attached to the duodenum (of ulcer fame) by a duct (tube), the gland's secretions are designed to digest protein, carbohydrates and fats. Also, the pancreas possesses scattered little islands of cells that produce insulin.
Even trivial injuries are poorly tolerated by the pancreas. If you need someone hurt by an innocent assault, for example, a playful punch in the gut, give the poor dolt a bruised pancreas and three months of lingering near death in the ICU from progressive multiple organ failure.
Leaking pancreatic enzymes can autodigest your favorite character—eat her alive from the inside out. It's the perfect setting for a lingering disability and a slow, painful recovery.
Large and small intestines: Both are hollow organs, or transport tubes, for your Chateaubriand for two. The differences between the colon (large intestine) and the small intestine are their size, location and contents. Foul feces is stored in the colon, the last station along a tortuous digestive system. If accidentally ripped open, the colon will leak feces into the sterile abdominal cavity and produce peritonitis.
In the trauma room, the doctor makes the diagnosis with peritoneal lavage: He places a plastic catheter in the belly, runs in saline and out comes saline and usually something ominous. If the fluid retrieved suggests feces, the victim goes immediately to the operating room for bowel repair and a colostomy.
The small intestine contains partially digested food products as well as bile and digestive juices from the pancreas upstream. A small intestine tear, much more subtle, can easily be missed. If not treated, a leaking gut causes peritonitis and big-league infection. Also, both colon and small bowel have supporting tissue called the mesentery that carries the blood supply. Major or minor hemorrhage may result when the mesentery and its blood vessels are severely torn.
Inappropriately worn seat belts can cause intestinal rupture by trapping a loop of intestine internally, causing the pressure in the loop to rise abruptly and burst the wall. Blunt abdominal trauma is anything but benign.
Seemingly innocent bumps on the belly can damage major intraabdominal structures, and the appearance of pain, bloating or other symptoms may be delayed. You can use this subtle type of traumatic injury to create a ticking clock, leaving a trail of small clues.
Kidney: The kidney is partly solid (the urine-forming, water- and salt-saving part) and partly hollow (the collecting system to transport urine to the bladder). Injuries include bleeding from a solid part laceration or urine leakage from a tear in the collecting tubes.
Penetrating Trauma to the Abdomen
The result of penetrating abdominal injury is similar to that produced by a blunt impact. For the uninitiated, a thrust with a butcher knife into the gut seems more ghastly than the by-product of slipping and falling on the ice. Sometimes it's the penetrating wound that's trivial.
Instead of listing each organ system again, we'll outline wounds, which will permit you to create an injury time line to suit your plot. Much of it has already been described above. Penetrating trauma may lacerate solid organs, causing bleeding and loss of function, or put a hole in a hollow tube which then leaks its contents. Remember, with a penetrating wound you need only trace the normal anatomy in your mind, decide what will be injured, then write about the ghastly visible results of that injury.
A stiletto stab wound in the right upper abdomen may hit the liver, causing trivial bleeding, which your villain survives in his room on the fifth floor of an abandoned building in the barrio. Or it might slice
Symptoms and Signs of Peritonitis
Subtle physical findings on exam with minimum complaints
■Elevated pulse rate
■ Low-grade fever (99° or more)
■ Mild swelling of the belly Obvious symptoms
■ Complaints of severe abdominal pain made worse by moving, coughing, jumping up and down, hitting a bump in car (on the way to the hospital)
■ Nausea, vomiting, bloating Obvious signs
■ Severe pain during doctor's examination when abdomen is pushed, then quickly released; location suggests the organ injured
■ Mass or lump in the belly
■ Bowel sounds (via stethoscope) absent
■ Major abdominal swelling
■ External markings suggesting injury, such as tire marks, cuts, bruises, abrasions; evidence of a knife wound or gunshot entry or exit wound
through the hepatic artery and throw the fellow into hemorrhagic shock. Sure, he can survive. Aren't you at the controls of that novel?
This is where cross-sectional anatomy comes in handy. A knife's path is direct, short and predictable. Some stab wound victims don't require surgery, just careful observation. A bullet wound, on the other hand, may ricochet anywhere in the belly, bounce off ribs, vertebrae or pelvic bones and shatter everything in its path. Refer to Figure 15 on page 106 and imagine a bullet nicking the liver, ripping through the stomach, smashing a rib and becoming redirected into the spleen or intestines.
Suppose your character, carelessly playing with a gun, accidentally drills his kid brother in the buttocks. Buttocks? Probably a trivial wound, right? The ER doctor cleans out the wound and sends the patient home on antibiotics and a rubber donut.
Or did the .38 hollow point tear into the kid's gluteus maximus,
smash his hip joint, nick his rectum and then lodge in his flank muscles? The time line of this more involved injury includes transport to a hospital, emergency surgery complicated by the need for a colostomy and extensive tissue loss from an infected hip wound. Eventually, he'll need either extensive home care with visiting nurses or management in a chronic care facility. At the writer's discretion, this tale may be followed by months of further care, including a total hip replacement, which may become infected requiring removal of the hardware and . . .
Anything can happen with a gunshot wound.
You decide.
The trauma surgeon handles small and large intestine injuries differently. Injured small intestine may be removed, a segment cut out, and the ends sewn or stapled together. However, in cases other than minor nicks or tears, the victim with a major perforation of the colon or rectum needs a temporary colostomy. This procedure (Figure 16) involves bringing the working end of the colon out through an opening in the belly wall to which it is sewn. A colostomy bag or appliance is worn for months until the intestine can be safely and electively prepared (cleaned of stool) and put back together.
Abdominal Trauma: Beware of Hidden Damage / 107
A colostomy may create dread, depression and disillusionment. Many patients think the stool collection bag is forever, and sometimes, the colostomy cannot be reversed. For transient distress and a test of deep character, a colostomy appliance full of feces in your heroine's lap could be distressing indeed.
A summary of what happens with penetrating abdominal trauma is listed below:
• Solid organs bleed.
• Hollow organs perforate and leak irritating body fluids.
• Virtually all gunshot wounds to the abdomen must be explored: The victim must go to surgery and have the trauma surgeon search for any and all possible injuries in the bullet's path.
• Some stab wound victims may be observed in the ICU if the wound is superficial and there are no signs of peritonitis.
• Deep stab wounds of the belly are usually explored (exploratory surgery).
• A stab or gunshot wound of the lower chest may cause damage in the belly.
Diagnosing a Major Abdominal Injury
The injured belly (one of the causes of what is called an acute abdomen) can be a diagnostic snake pit for the trauma surgeon. Notice how many of the problems listed above have similar symptoms and pain location? Twenty percent of major abdominal injuries are not associated with significant symptoms or physical findings. A lot of blood may hide in the belly without detection. The trauma surgeon's job is to always suspect a missed injury, particularly if surgery isn't performed immediately.
The victim's history may be helpful in blunt trauma. Information about the injuring object, weapon, speed of the car on impact or details from the scene of the accident all help to determine the likelihood of certain injuries. Skin abrasions, bruises or cuts may suggest deeper injury. In penetrating trauma, the availability of the weapon is useful in gauging depth of penetration. Any obvious external findings, such as a knife wound or gunpowder burns, will help direct further special tests.
When the surgeon examines the victim, she looks for tenderness, particularly increased soreness when she presses in on the belly wall, then releases suddenly. The sudden movement of the underlying peritoneal lining will hurt terribly if there is peritonitis. Severe pain produced by this maneuver ("rebound" tenderness) leads to emergency surgery. A belly that is swelling before the surgeon's eyes means massive bleeding and immediate surgery.
Clinical Picture of Abdominal Injuries
■ Bruised kidney: blood in urine, flank pain
■ Small liver laceration: skin abrasion over upper right abdominal skin with deeply located pain
■ Small spleen laceration: left lower rib pain or upper left abdominal pain
■ Mildly bruised pancreas: central abdominal pain that may radiate into the back
■ Minor tear of bowel: abdominal pain Major abdominal injuries
Usually associated with shock; any of these injuries may be heralded by diffuse or generalized abdominal pain.
■ Massively bleeding liver lacerations: upper right or diffuse abdominal pain
■ Shattered spleen with extensive bleeding: left rib or abdominal pain or diffuse abdominal pain associated with shock
■ Leaking small intestine (perforation): diffuse abdominal pain
■ Leaking colon or rectum (perforation): diffuse lower abdominal pain
■ Shattered kidney with bleeding or urine leakage
■ Ruptured urinary bladder (perforation): lower abdominal pain
■ Torn, bleeding aorta or vena cava: massive abdominal swelling, hemorrhage in belly, shock
Two special tests may lead the trauma surgeon to recommend an emergency operation:
1. Peritoneal lavage, a "washing out" of the abdominal cavity with saline solution, looking for blood, stool, bile or urine
2. CT scan of the abdomen to look for leaking fluid, gas outside the gut, a mass or a lacerated solid organ
Armed with information derived from the clinical examination, multiple tests and x-rays, the surgeon decides whether to explore the patient's
abdomen or observe the patient for further clarification of the clinical picture. Also, the surgeon searches for the appearance of new findings.
The Outcome of Abdominal Injury
Abdominal injuries, with or without exploratory surgery, usually heal without major complications, permitting a complete recovery and return to one's usual diet and activities. If a colostomy was needed, it will be closed at a later date. Drains may be left in for a prolonged period of time and removed in the surgeon's office or in the clinic. Wound infections occur sometimes.
Unlike the residual limps, lapses and language deficits seen after neurological damage, recovery from abdominal surgery is quite uncomplicated. Nonetheless, the major focus of the abdominal surgeon remains fixed on deciding whether to explore the trauma victim's abdomen at all. The surgeon cultivates a high degree of suspicion even if there is no obvious belly injury.
Some diagnoses are difficult to make, particularly when other injuries, such as coma, complicate the picture. The trauma surgeon will return to the bedside over and over to reevaluate the patient until he is certain no injury exists.
Some belly injuries are subtle. Some diagnoses are delayed.
After major torso trauma, there may be heard inside the victim's belly, without the assistance of a stethoscope, a loudly ticking clock.
Most writers have suffered a painful impact at some juncture in their lives. Perhaps an awkward stumble resulted in a twisted knee, or a slam in the thigh produced a painful muscle knot. The injuries discussed in this chapter—lumps, bumps, abrasions, twisted ankles, broken bones and dislocations—are undoubtedly familiar maladies.
In some ways, arm and leg injuries are more useful than catastrophic injuries of the trunk as subjects for characterization. All sorts of potential characters come to mind. Think of Uncle Wheezer with his gimpy leg. Or Cousin Billy's annoying trigger finger, the one he snaps incessantly. What about Grandma's hammer toe? Or Martha's unresolved sciatica?
In Madame Bovary, Charles is about to splint a man's broken leg; the scene occurs in a small farmhouse. Gustave Flaubert describes Charles observing Mademoiselle Emma's hands as she prepares strips of sheets for the splint:
Charles was surprised at the whiteness of her nails. They were
shiny, delicate at the tips, more polished than the ivory at Dieppe,
and almond-shaped. Yet her hand was not beautiful, perhaps not white enough, and a little hard at the knuckles, besides, it was too long, with no soft inflections in the outlines.
Perfect nails, imperfect fingers. A reflection of the young woman's work on the farm? Flaubert carved intrigue into her knuckles to be read by the perplexed Charles, subtle indications of deep character, polished by repetitive minor trauma.
We are known by our hands and feet.
Engineers often build a prototype when working on something new, a model of the real thing. The prototype is really a physical scheme with essential elements crafted and enjoined. Thus, a prototype arm or leg could be represented as a cylinder of concentric layers of tissue through which course a variety of tubes and cables, all supported by a central rod with joints. Figure 17 demonstrates all of the elements of a human limb. With this model in mind, you'll easily understand the effects of common injuries. For a particular scene, you may choose an isolated injury or a combination of afflictions. These elements represent the trauma prescription for an injured arm or leg. Or both.
For both extremities, we'll discuss acute impact injuries first. At the end of the chapter, you'll discover ways to employ chronic injuries from repetitive motion, often occupational, to create back story and establish character verisimilitude. For example, envision the cracked, grease-filled fingernails of a mechanic or the stained fingers of the ever-suffering woman working in a dingy print shop. Sometimes old injuries, for example, loss of a fingertip from frostbite, reflect a forgotten passion for adventure. Arm and leg injuries may be major or minor, and the time line of each injury determines how each plays out in the plot.
Several direct and indirect impacts create problems in the shoulder. Lesser shoulder injuries include contusion (bruise); tendonitis, e.g., inflammation or damage to the rotator cuff; or bursitis (inflammation of the tiny bags of fluid around any joint, which act as cushions for tendons). Repetitive motion as in swimming, in throwing a baseball or in various occupations produces diseases of wear and tear—the arthritis-bursitis-worn-out-old-tendon syndromes.
The most common acute shoulder injuries are fractures and disloca-
tions. Fractures occur in the neck of the upper arm bone (humerus) or in different parts of the shoulder blade (scapula), part of which forms the shoulder socket. A bone-shattering impact may result from a fall directly on the shoulder, from force transmitted to the shoulder from a fall on the outstretched arm or from direct trauma, e.g., a club strike.
It's possible to dislocate the shoulder with a fall on the arm or by yanking or striking the shoulder while it's relatively unprotected. The worst position (most susceptible to dislocation) is when the arm is held away from the body and rotated backward. Most shoulder dislocations are anterior, or in front of the joint, and may be reduced in the field or in the ER with sedation. Basically, the dislocated head of the humerus (contrary to the sound of that name, there's nothing funny about a shoulder dislocation) must be replaced into the socket before the shoulder
Mechanisms of Extremity Injuries
Acute injuries occur by:
■ Direct trauma to the injured area
■ Indirect force transmitted up or down the arm or leg to the injured area
Chronic injuries occur by:
■ Direct, repetitive low-level intensity impact
■ Indirect irritation associated with repetitive motion
■ Deterioration of the limb from an acute injury
muscles go into spasm.
A dislocated shoulder is diagnosed when:
• There is a flat angular shoulder profile (loss of gentle shoulder curve)
• Shoulder pain is severe (except in the case of a chronic dislocation, which may not be painful)
• The elbow is bent slightly away from the body with the forearm turned in (palm down)
There are two ways to reduce a dislocated shoulder:
1. Place the stocking foot into the armpit and apply steady traction on the arm until the head of the humerus "clunks" back into the socket.
2. Apply the Kocher maneuver's four moves: first, pull down on the bent elbow; second, rotate the arm out (externally); third, slide the elbow in toward the middle of the chest with the victim's hand still out; fourth, cross the hand over the body, or rotate the arm medially.
The owner of a chronically dislocating shoulder may be able to reduce the slack joint without assistance. Some acute dislocations cannot be reduced with the two conservative methods mentioned above. Part of the joint capsule or a chunk of the rotator cuff (muscle or tendon) may become stuck between the joint surfaces. Open surgery is then needed.
Fractures of the shoulder blade, which result from a major direct smack on the shoulder or back, are not common. It takes an impressive direct hit to break the flat part of the scapula, and other major injuries, such as damage to the arm nerves, may also occur.
Connecting the scapula (shoulder blade) to the sternum (breastbone) is the bony strut called the clavicle (collarbone). It's a good one to break if your hero attacks a villain using a karate chop to the root of the neck. Severe pain and deformity result from a fractured clavicle. It gets the bum out of the picture for a few weeks.
A shoulder separation (AC, or acromioclavicular, separation) may be slight or may result in disruption of all of the complex ligaments that tie the lateral end of the collarbone to the shoulder. These injuries are seen frequently in contact sports.
The sternoclavicular joint is where the collarbone attaches to the breastbone and rarely is the site of a dislocation. If the dislocation is anterior (in front of the sternum), it's not dangerous, but if the end of the collarbone dislocates posteriorly, it may damage blood vessels in the lower neck causing major hemorrhage.
Any of these orthopedic problems may be associated with a significant tissue tear and disruption of the joint anatomy. Thus, some injuries become chronic. If so, open surgery may be the only solution to persistent pain or disability. Surgery is the only solution to a major fracture or dislocation.
Not to be confused with the forearm (below the elbow), the arm extends from the shoulder to the elbow crease and is known best for its cultivated biceps and massive triceps. Common acute injuries to the arm include fracture of the shaft of the humerus, tears of the biceps or strains of the triceps. An interesting acute injury occurs when the long head of the biceps tears away from the shoulder area where it inserts, leaving the belly of this impressive muscle to curl up like a burrowing rodent beneath the arm skin.
Five nerves arise from a tangle of interconnections in the neck and go south to the arm, forearm and hand. Each has the task of supplying sensation to specific areas of skin as well as innervating specific arm and forearm muscles. For example, spiraling behind the middle of the arm (hugging the humerus bone) lies the radial nerve, which controls the extensor (bending backward) muscles of the wrist and fingers. These muscles form the mass below the elbow and can be knocked out of commission in two interesting circumstances:
1. The radial nerve may be damaged acutely by a broken shard of
bone following a fracture of the midhumerus.
Master Injury List For the Arm
■ Shoulder: bursitis, first-degree AC (acromioclavicular) shoulder separation, muscle strain, arthritis, shoulder bruise
■ Arm: biceps or triceps strain, muscle contusion (bruise)
■ Forearm: "tennis elbow," bursitis of the elbow
■ Wrist: sprain, cyst, tendonitis
■ Hand: minor abrasions, laceration, nail injuries, arthritis, trigger finger
■ Shoulder: fracture of neck of humerus, dislocation, third-degree AC shoulder separation, sternoclavicular separation, rotator cuff tear, injury to nerves to the arm and shoulder
■ Arm: fracture of shaft of humerus, fractures at elbow with artery damage, injury to radial nerve at midarm, tear of biceps tendon
■ Forearm: fracture of one or both bones, fracture of one with dislocation of the other at the elbow, severe "tennis elbow"
■ Wrist: Colles' fracture of wrist, dislocated navicular bone, fracture of scaphoid bone, dislocation of carpal (wrist) bone, fracture of carpal bone(s)
■ Hand: severe infections, lacerations, "degloving" (stripping off of skin) injuries, crush injuries, amputation of fingers, broken fingers
2. The radial nerve may be damaged by direct pressure or a smack on the back of the arm by a club. For example: A drunk falls asleep on a park bench (be warned, this is a time-told tale in the halls of academic medicine, so alter the telling) and compresses his radial nerve against the back of the bench as he flops his arm over the bench. It's called Saturday night palsy, and it may become chronic.
In both situations, the injury produces radial nerve damage and what is called "wrist drop." The victim can't extend the wrist or hand, and varying degrees of paralysis are possible. The acute injury may disappear quickly; the more chronic problem may become permanent.
It seems there's nothing in-between about the elbow. Either you break it and risk catastrophic damage to the nerves and blood vessels to the forearm and hand or you just cause all sorts of pain and annoyance for yourself. Not much else happens at this dingy hinge joint.
Take the minor problem of "tennis elbow," not so minor if you've ever had it and certainly not restricted to racquet enthusiasts. Inflammation of the origin (from the bone) of the extensor muscles of the forearm, tennis elbow occurs because of repetitive pronation and supination of the hand and wrist. Place your palm facedown: That's pronation. Now rotate your hand until it's facing up, as if you're holding a bowl of soup in your palm: That's supination. Tennis elbow often becomes chronic and may require steroid injections or the application of an external compression band.
Bursitis of the elbow can occur in the pocket of fluid located posteriorly over the bone. It's diagnosed as an acute inflammation or infection when the bursa becomes red, hot and tender. It may need to be drained by an incision or by needle aspiration, and antibiotics are often required. At times, it must be removed if the inflammation becomes chronic.
Kids can easily dislocate the radial head (the end of the forearm bone at the elbow) because the flare part of the bone doesn't develop until later in life. An adult could cause this injury by yanking a child by the arm.
As with the knee, the most terrible injury to the elbow is a dislocation or fracture-dislocation. The artery and nerves are at risk because they hug the bones, and major hand complications can follow these injuries. At times, the neurovascular bundle (as the blood vessels and nerves are called when considered together) is severely injured despite the orthopedic surgeon's best efforts.
Two bones form the framework of the forearm where a galaxy of muscles weaves its way to the wrist and fingers. Complicated beyond reason, forearm anatomy may be summed up by thinking of it as two groups of muscles: flexors on the inside and extensors on the outside. Well, there are a few more muscles that rotate the forearm (that pronation and supination thing). And a couple of outcropping muscles that control the thumb.
Imagine the forces exerted against the muscles and bones of the forearm when a blow is deflected by the raised forearm. Anything from a muscle contusion, bone bruise or fracture of the ulna (the ulna bone is directly beneath the forearm skin; check it out on your own forearm), fracture of the radius or both. A stab wound to the forearm may cut nerves, muscles and large blood vessels.
Forearm injuries occur in folks who tumble and try to break the fall as well as in those attempting to defend themselves. Chronic forearm muscle strain may occur in people performing repetitive occupational tasks. More commonly, the forearm is spared and the wrist (carpal tunnel syndrome) and elbow (tennis elbow) take the brunt of the insult.
Fractures and sprains occur commonly at the wrist. The classic wrist fracture, perhaps the best-known bone break in the body, is the Colles' fracture. These injuries meld with those of the carpal bones, those eight stone-size bone lumps between your forearm struts (radius and ulna bones) and the delicate finger bones that elongate to form your hand. The proper diagnosis can only be made with an x-ray.
A couple of other traumatic injuries characterize the wrist area and provide you with methods of sidelining a character with a pesky problem for weeks or months.
The scaphoid bone in the wrist is subject to fracture from direct violence, such as a fall on the outstretched hand, or by direct impact. Because of the unique blood supply to this funny little ossicle, one of the broken fragments may die, and thus begins an oft-protracted tale of orthopedic surgical care. Whether pinned, screwed or casted, the broken bone stone may eventually need to be removed and replaced with a plastic implant.
The other more or less common wristbone injury involves the scaphoid's next-door neighbor, the navicular bone. For reasons of ligament design, this baby doesn't break easily; it dislocates. Squirted out of alignment, the bone creates acute and chronic pain and may ruin the plans of the professional athlete and concert pianist alike.
Carpal tunnel syndrome is a well-known chronic wrist problem. Many people, particularly folks such as writers who use their hands in repetitive tasks, develop numbness, tingling and aching of the hands. Trapped in a tight tunnel at the wrist, the median nerve becomes compressed and often surgery is needed to release the carpal ligament. This may be done with a special scope (closed surgery) or with open surgery.
Some orthopedic and plastic surgeons do nothing but hand surgery. And though palm reading is intriguing, what Flaubert accomplished in the passage quoted at the start of this chapter represents more clearly what we are seeking to emulate creatively. On the parchment of a character's fingers and palms, you may write a life history. What can the hand tell you about your character?
Lots.
Scars, knobby arthritis, missing digits, crooked fingers that won't straighten, flushed palms and splintered fingernails all imprint the individual with a unique back story. Arthritis and scar tissue contractures may distort the tissues until the hand becomes a gnarled knot, a contorted, impotent fist.
A number of hand infections may put your character out of action for days or weeks. Treatment may include antibiotics, elevation and rest and, in some conditions, surgery. Often in a story, the writer wishes to take someone out of the action for a short while, someone who needs their hands, such as a musician, artist or surgeon. These hand infections can do the trick.
If someone gets stuck in the hand or finger with a sharp object— look at the story's environment and pick something appropriate, e.g., garden tool, rose bush, hunting knife, exposed nail in a barn—an infection may result called cellulitis. It means a red, tender swollen body part with a diffuse infection with bacteria. A simple cellulitis may turn into a deep hand space abscess. The hand cellulitis may be accompanied by streaks of red traveling up the arm and is often mislabeled blood poisoning. Actually, the red marks represent lymphangitis, more infection running up the lymphatics of the arm, and mean things are definitely out of control. Treatment at this stage includes intravenous antibiotics, rest and elevation in the hospital. If a specific swelling occurs, say, in the palm, then surgical drainage of the abscess becomes an emergency.
From the humdrum cellulitis your pianist picked up trimming her Presidential roses a day before the big concert, there evolves a nasty swollen index finger full of pus. The tendon sheath abscess becomes a ticking clock.
Other hand injuries include:
• Ruptured tendons: require surgical repair; may be from wear and
tear or sharp trauma
• Ruptured ligaments: tearing of ligaments that hold the finger bones together; may need surgery
• Dislocated fingers: painful; short term (two to four weeks) disability; may require surgical reduction if closed reduction takes too much force
Degloving injury of the hand refers to the traumatic stripping off of full-thickness skin from the top (dorsum) of the hand where it is less well fixed than in the palm. Ripped from its attachments, the curled skin flap remains attached at one end. It must be replaced surgically, although if the blood supply is severely damaged, the flap may not survive. Then a skin graft is needed.
Finally, there are congenital deformities of the hand that are quite striking. A claw hand, for example, occurs when a huge cleft develops between the third and fourth fingers, leaving a truly clawlike (lobster) appearance. Two or more fingers may fuse together before birth. Or six fingers may develop.
These types of injuries will be echoed in the discussion of lower limb injuries.
In a young person, the hip is a sensual signal of firmness, physical health and allure. In the elderly, the hip strains to carry the load of accumulated poundage that overloads an already crooked back. The youthful woman's hips rock as she walks and suggest a generous pelvic cavity friendly to new life and birth. The old woman's hip shatters when she tumbles to the floor, her foot caught on a rug, her eyesight dim. There is an insidious degeneration that the hip joint endures as age creeps into our bones.
It does not respect gender. Hips do not age well. Falls and fractured hips in the elderly and hip "pointers," or contusions, with skin abrasion in younger people make up the lion's share of acute hip pain. Bursitis and degenerative arthritis play a role in chronic suffering in middle and old age. A lifetime of bearing the body's weight wears down the hip joint and thins out the cartilage designed to keep the joint running smoothly. Thin bones break at or near the angle between the vertical thigh bone (femur) and the short neck of the bone that supports the head (ball of the ball-and-socket joint). Limping may result
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Extremity Trauma: Crunched Arms and Legs / 121 |
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Master Injury List For the Lower Extremity
■ Hip: acute pain from bursitis; a "hip pointer" or skin abrasion from scraping injury; chronic degenerative osteoarthritis resulting from "wear and tear"
■ Thigh: acute and chronic groin pull or adductor muscle tear (minor or major), quadriceps (anterior thigh muscles) contusion, abrasions, hamstring pull (posterior muscles)
■ Knee: acute minor sprains or strains involving the four major ligaments with localized pain: medial collateral, lateral collateral, anterior cruciate, posterior cruciate; minor meniscus cartilage tear; fluid in knee (joint effusion); chronic osteoarthritis
■ Leg: minor acute "shin splints" and minor anterior compartment syndrome, bone contusion ("bone bruise"), simple fracture of the fibula, abrasions and lacerations, chronic tendon or muscle strains
■ Ankle: minor acute sprained ankle, acute partial tear or tendonitis of the Achilles tendon (may become chronic), chronic degenerative arthritis, tendonitis of long tendons to toes
■ Foot: fallen arches (flat feet), bunions, fracture of metatarsal bone (so-called "stress" or "march" fracture), Morton's neuroma (painful swelling of a nerve to the toes), gouty arthritis of great toe, hammer toe, plantar warts—all chronic
These injuries are acute but may have chronic, painful complications.
■ Hip: fractured hip, posterior dislocation of hip, pelvic fracture through hip joint
■ Thigh: fractured femur with major blood loss, major torn quad-raceps muscle, major hamstring tear, major soft tissue injury or crush injury (direct trauma), traumatic amputation of leg through thigh
■ Knee: fractured patella (kneecap), complete tear of one of the four ligaments, complete tear of two ligaments, dislocation of the knee with damage to artery supplying the lower leg, fracture of femur or tibia through knee joint
■ Leg: compound (open) or comminuted (many broken bone fragments) fracture of tibia with or without a fibular fracture, major soft tissue trauma with vascular or nerve damage, crush injury to leg
■ Ankle: trimalleolar fracture (all three bones making up the ankle are broken), complete rupture of the Achilles tendon, open (compound) fracture of the ankle, major laceration of tendons, nerves or arteries to foot, traumatic amputation of the foot
■ Foot: traumatic amputation of part of the foot, severe lacerations with tissue loss ("degloving" injury), major crush injury
from any of these lower extremity injuries.
With a hip dislocation the thigh bone (femur), positioned horizontally in a seated driver, is driven posteriorly with direct impact of the knee against the dashboard (or by any major force against the flexed hip). The weak posterior hip joint capsule ruptures, and the head of the femur dislocates backward. Surgical correction is required.
Hip fractures occur almost exclusively in the elderly and require hospitalization and surgical fixation with special orthopedic prosthetics, plates, and screws or "superglue." Often the patient must wait a few days after the accident for operating room time to become available. The big postoperative risk is phlebitis (blood clots forming in the legs) because of the patient's immobility. After surgery, prolonged rehabilitation is needed to help the patient regain muscle strength, balance and maneuverability.
Fractures lead the list of severe thigh injuries, and although a hip fracture technically occurs in the neck of the femur bone, it is a shaft fracture that we refer to in the thigh. Two common patterns may be seen, each with a different impact on the patient. Besides the disability experienced because a major bone has been broken, a bone that ordinarily supports much of the body's weight, these two fractures carry additional ominous complications:
1. A midshaft fracture of the femur may be associated with major blood loss—up to one or two units of blood lost into each thigh. Bilateral (on both sides) thigh bone fractures can cause shock from blood loss.
2. A fracture of the femur above the knee (called a supracondylar fracture) may cause disruption of the artery to the leg, producing a cold foot. This is a vascular emergency, and the fracture often requires surgical fixation (with pins, plates or screws).
The basic principles of emergency treatment for fractures of the femur include:
• Clean and bandage any open wound and cover with a dry sterile dressing
• Place a traction splint, manipulating the fracture only enough to straighten severely angulated bones
• Transport to a hospital with an orthopedic surgeon
Crush injuries to the lower extremity are especially devastating when the meaty thigh muscles are smashed, creating increased IV fluid volume requirements as well as releasing toxins. Major lacerations require extensive debridement (surgical cleaning up) and suturing of torn tissue. Major tissue loss must sometimes be filled in by rotation flaps from elsewhere (done later when the threat of infection is less). Other plastic surgery techniques may also be required, but that would be much later in the hospital course.
Lesser thigh injuries include contusions (bruises), groin pulls (a tear of the adductor muscles) and strains or major injury to the quadriceps tendon at the kneecap (patella). Chronic "quad" contusions seen in football, lacrosse, soccer and hockey players occasionally will become calcified and mimic a chunk of bone within the muscle. And, of course, your character can get shot or knifed in the leg.
In John Sandford's novel Mind Prey, the cops find bad guy John Mail's house and attempt to corner him as he runs out of the cellar. Police officer Sherrill jumps out from around the corner of the house, and Mail shoots her in the thigh with a shotgun.
Del was kneeling over her, had ripped open her pants leg. Sherrill had taken a solid hit on the inside of her left leg between her knee and her hip; bright red arterial blood was pulsing into the wound.
"Bleeding bad," Del said, his voice was cool, distant.
Mail nailed Sherrill's superficial femoral artery, and the subsequent description of the cop applying pressure, then whisking her off on a helicopter rings true. And there's no mention of the artery, but Sandford knew it was there.
Acute knee injuries, ligament strains or tears, or torn cartilage often occur during strenuous sports activity. Each supporting structure may be mildly or severely injured. The damage may occur during vigorous activity in the highly trained person as well as in the untrained weekend athlete. Tissue tears are partial or complete. Any of these injuries may become chronic.
The following acute knee injuries may be the result of a direct or indirect impact on the knee:
• Medial collateral ligament strain/sprain/tear
• Lateral collateral ligament strain/sprain/tear
• Medial meniscus tear
• Lateral meniscus tear
• Anterior cruciate ligament tear
• Posterior cruciate ligament tear
• Patellar (kneecap) ligament strain
When a knee structure is repeatedly strained or torn, a chronic knee problem results. This is often seen in athletes who strain or tear the aforementioned ligaments or cartilage that then may wear out and snap or tear. Like old rope, the ligaments may become frayed and weak and often must be replaced by prosthetic material or other ligamentous tissue from the patient's body. With time, the cartilage lining the knee joint becomes worn because joint mechanics are thrown off by ligament imbalance. Traumatic arthritis results.
An additional potentially devastating knee injury is a dislocation of the knee (with or without fracture). While this injury is quite rare, it must be treated immediately because of the potential for damage to the nerves and artery to the lower leg. Remember the neurovascular bundle? These structures pass behind the knee in close proximity to the joint and are stretched or torn when the femur-tibia joint relationship is disrupted. As with any injured joint, it is impossible to determine if a fracture has occurred in association with a dislocation without an x-ray.
There's not much tissue between the tibia (bone) and the skin, and if you run your finger along your own shin, you'll notice your anterior leg is all skin and bones except lateral to the bone where there's a fleshy muscle mass.
Two serious leg injuries are related to these observations, and each may be uncomplicated or quite involved. As with all damage, it's a matter of how much traumatic force is applied to the region. There are two leg bones, the larger weight-bearing tibia and the recessive fibula, which is clothed in muscle. You can't feel the fibula unless you crack it.
The two injuries we'll consider are fractures of the tibia (with or without a fractured fibula—simple, complicated or compound) and anterior compartment syndrome.
Tibial fractures are common.
Boot-top ski breaks involve the tibia and/or fibula and often require casting, possibly complicated orthopedic surgery and a lot of healing time. A fractured leg from sliding and crashing a motorcycle usually breaks both bones, and it's often a compound fracture, i.e., the broken ends often stick out of a nasty jagged laceration. Chances are your "hog"-riding character will wear a complicated stainless steel jungle gym fixator on the broken leg for months. With any luck, he'll walk again, perhaps with the slightest limp.
Blunt trauma to the leg may also cause a compartment problem. In a lesser form, "shin splints" are a result of repetitive trauma to the fleshy (as opposed to the more resilient tendinous) origin of the toe and ankle extensor muscles. As these muscles swell within the closed space in the front of the leg, the pressure in the compartment rises. Blood vessels are squeezed. If the problem isn't diagnosed, pulses may be lost and muscle death (necrosis) can occur. This so-called "anterior compartment syndrome" may occur following severe exercise, such as marathon running, or after blunt leg trauma. It may even occur in the postoperative period following reconstruction of the arteries to the leg when blood flow increases to the leg.
Treatment for the compartment syndrome involves filleting open the leg, a fasciotomy. The procedure is directed at cutting open and releasing the natural fascial envelope (tough anchoring tissue for the muscle) of the leg. Muscle then bulges out of the surgical incision until the swelling dissipates, at which time it recedes and the incision heals. But the scenario leaves an ugly scar on the side of the leg.
There is a posterior compartment (and a small lateral one, too), but it is less well developed and compression is not often seen in the back of the leg.
Sprains, strains and tears of the ankle ligaments occur on the less severe side of the trauma equation. Fractures and fracture-dislocations with open wounds lead the major trauma list for this region. Treatment requires emergency reduction of the fracture/dislocation and plate or screw fixation of the break with suture repair of torn ligaments. Open traumatic wounds must be closed. Antibiotics are given for days. Late complications include nonunion (bones fail to knit together), bone infection and traumatic (chronic) arthritis.
From stepped-on toes to traumatic amputation of the foot, injuries below the ankle may be trivial or devastating. A variety of lesser injuries cause pain and limping. These may be self-treated or may require surgery.
As with the hand—but to a much lesser degree—arthritis, infection and wear and tear on tendons cause a laundry list of foot complaints. Pain in the foot leads the list of laments. Abscess (from stepping on sharp object), cellulitis, tendon rupture, etc., all occur in the foot and produce pain.
A few unique problems add to the whimpering wrought by foot discomfort. Foot pain may be caused in the heel by Achilles tendon bursitis, under the foot by plantar fasciitis (inflammation of the tough tissue supporting the arch), a broken foot bone (metatarsal), a benign tumor of a small nerve to the toes (Morton's neuroma), ingrown toenail, bunion or an occult foreign body (stepped-on glass or wood) in the foot. These may arise acutely or in the setting of chronic irritation.
Speaking of stepping on a rusty nail, ever wonder how that rust is suppose to cause gas gangrene in your foot but never bothers you when you're rubbing it off of your fender? Rusty nails often are found in old buildings where there's lots of dirt and Clostridium bacteria, the ones that are responsible for gas gangrene infections. They live in the soil, hate oxygen and love misbehaving after they've been pushed into the sole of the foot. If diagnosed early, surgical cleaning (debridement) and antibiotics are all that's needed. If missed, removal of major muscles or amputation may be the only way to save your character's life. It's not the rust; it's the bugs in the dirt.
Finally, treatment for acute upper and lower limb impact injuries seen in sports and daily activities include the modalities reflected in the mnemonic PRICE:
• Protection from additional insult
• Rest (stop sports activity)
• Ice (cryotherapy) to reduce pain and swelling
• Compression to reduce swelling
• Elevation to reduce swelling
Chronic injuries also respond to rehabilitation such as muscle training, electric stimulation, massage therapy, ultrasonic and deep heat therapy and icing down area before and after activity. Steroid injections into painful "trigger" points are sometimes required to get an athlete or active person back to full activity.
Some folks go through life dealing with their aches and pains; how they handle the frustration of chronic muscle and joint distress says a lot about them. Damage to an extremity becomes interesting when the character's existence depends on the use of his hands and feet.