Last month, I covered clots in the leg and, its serious sequel, a clot in the lung that is the pulmonary embolus.
I am going to cover injuries to the legs in this issue. These provide much of the work for the Minor Injury Units in Bantry and Cork. Just as the role of Emergency Units has changed from dealing with ‘emergencies’ to plugging gaps in the health service, as the only true 24/7 service, so the work of our Minor Injury Units sometimes has nothing to do with a minor injury! We all try to care and point the patient on the right path to get help.
I will give you some examples: When I worked at Bantry as a Minor Injury Doctor, I saw patients with broken necks and hips and so on. They were seen, stabilised, and transferred safely but by no means were the injuries minor!
That is the nature of the job, the HSE set up strict criteria of who we should see and who is inappropriate but a patient in trouble sees hospital and goes! We always try our best.
So back to your leg injury. The mechanism of injury is so important. This will determine the forces involved and the chance of serious injury. Height of fall, speed of collision, soft bones, on blood thinners and so on. So too is the age of the patient. Young children and toddlers are particularly difficult to assess and often need senior review in the major Eds, not the minor injury units.
The minor injuries units have different opening and closing times, which can vary, as well as the minimum age, so do check first.
So, you have twisted your ankle – what determines the need for an X-ray? If you can walk on it that is ok. Pain on pressing the bone at the side of the ankle, the fibula, particularly the rear of that bone signals an X-ray is needed and ditto for pain over on the side of the foot where the ankle ligament, when torn, can damage the long bone going to the little toe.
Pain over the inner aspect of the ankle and inability to take weight on it is more serious, as this is the deltoid ligament and very important for ankle stability. If this is damaged, it can be associated with damage to the fibula bone at the side of the knee, and this will need an X-ray.
If you are unsure, a good plan would be to elevate the ankle, and apply a cold compress to reduce the swelling. Don’t overdo the cold though.
If you are a sporty type and in training, it is a good idea to see a physio who may even advise a cast and crutches.
On the subject of sport, pain over the ball of the foot in long distance runners is often due to a stress fracture, which does not show up on X-ray initially and can take six weeks before training can resume. Pain over the front of the shin in runners is due to ‘Shin Splints’, as the muscles expand and stretch the tight skin of the shin.
Pain in the heel is common. If you fall off a high wall and land heavily, it is a serious problem, as the heel bone can break and not only need an x ray but a CT to confirm. It is often associated with injuries, due to a shock wave causing hip and spine fractures, and needs expert attention in CUH.
Pain in the toes is common after somebody in stiletto heels stamps on you and just needs rest and painkillers!
High speed twisting injuries to the foot – as in car crashes and falling off a horse with the foot trapped in the stirrup – is serious and needs an X-ray to make sure the bones of the forefoot are not dislocated. Once again mechanism is so important.
Pain in the heel without a fall or injury is often due to inflammation in the soft tissues, is difficult to treat and again, no X-ray is needed. We sometimes consider a steroid injection, weight loss and rest! This is called plantar fasciitis. It rarely needs surgery.
Moving to the knee, this is another area that keeps us busy. The knee is the largest joint in the body. Unlike the hip, which is a stable ball and socket job, the knee is a hinge joint, needing strong crossover ligaments, the cruciates; and ligaments either side called the collateral ligaments, which are often damaged in sport. It is not a good design.
So you twist your knee on the football field. Can you walk a few steps? Good, no need for panic. If you cannot walk and the knee swells immediately, this means there is potentially serious damage. You will have heard of the notorious ACL injury and torn cartilages. These can cause immediate swelling causing bleeding into the joint, which is not so good. You will need an X-ray; a doctor will test the joint looking for excessive movement or glide due to loss of ligamentous stability.
I usually drain the joint under local, which helps relieve the pain and confirms blood in the joint. We then arrange a visit to orthopaedics to consider treatment options. The knee will need to be rested and crutches with a support brace given.
If the knee swells a day after injury, this is common, as the joint repairs itself; it will need review but not necessarily an X-ray.
Pain and creaking in the knee is common as we get older and is due to wear and tear; it does not usually need a X-ray or MRI unless all simple measures have been tried and you are heading for a knee replacement.
Cuts and scrapes to the leg are common. The skin over the shin is very fragile; stitches make things worse. If a flap of skin is raised and bleeding briskly if the leg is raised above the heart and pressure applied, it will stop. The skin can be put back in place and kept in place with steristrips. Your GP/South Doc and Nurse will be the people to see. Occasionally a varicose vein can bleed and again don’t panic – get the leg up and put pressure over the area. Running around in a panic, as I have seen, can cause bleeding to get a lot worse.
I have covered much of the workload of Minor Injury Units here. I think they have been a great success and I hope my quick review of leg injuries helps you to decide whether to go or not. You can always ring first for advice – it is a great service. Waiting times are short and things much more relaxed than in the major ED units. Bantry Hospital 027 50133.
Next month, I will cover wrist, elbow and shoulder injuries. Till then take care and enjoy the summer.