Body Trauma

by David Page

  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.

  Leg

  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.

  Ankle

  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.

  Foot

  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.

  Most of the one million bites suffered by Americans each year are inflicted by mad dogs or miffed humans. Other than the terror a dog attack creates or the rage inherent in a human assault, are bites really dangerous? In this chapter you'll discover the answer is affirmative. To begin with, a lot of human bites aren't bites at all but rather lacerated knuckles slammed into someone's teeth. Human "bites" can lead to major tissue damage and are contaminated by mouth bacteria, which can lead to serious infections.

  Other creepy creatures besides canines may inflict bites with painful, disfiguring results. The damage is created by the ripping or crushing capacity of specific types of teeth and often includes the inoculation (contamination) of the injured tissues with many different types of dangerous bacteria. And there's always the worry about tetanus and rabies.

  Biting serves the survival needs of many species. It's not the exclusive attack mode of dogs and dummies. Any creature with a mouth, a moveable jaw or a stinger can inflict a nasty wound. The mechanism of injury varies with the type of teeth—grinding flat molars or slashing canines—as well as the style of biting. With some predators, the damage is created by the inoculation of poison. It's called envenomation.

  Venom is usually associated with snake bites, but unobtrusive little critters that populate hidden niches of your story's environment may be disturbed and retaliate by inflicting a painful poison packet. Every writer knows about the dreadful bites and stings of spiders, wasps and ants in North America. You may have heard about the bite of the Gila monster, a poisonous lizard of the southwestern U.S. It tears, disrupts tissue and occasionally breaks bones. But if you've got someone digging around in the Guatemalan jungle, you might consider the havoc wrought by the burrowing little botfly.

  What's so bad about a fly? You'll discover the answer later. Large or small, the biting predator may inflict a terrible wound either by crushing tissue or by injecting poison. And don't think for a momen
t Homo sapiens is excused from this act of aggression. Human bites imply anger and rage and say a lot about the person doing the gnawing. This excerpt from Stephen King's Rose Madder says a lot about Norman.

  But in the end, Slowik helped quite a bit. By then they were down cellar, because Norman had begun to bite, and not even the TV turned all the way to top volume would have completely stifled the man's screams. . . .

  . . . While he waited for the water to run hot, he looked in Thumper's medicine cabinet, found a bottle of Advil, and took four. His teeth hurt and his jaws ached. The entire lower half of his face was covered with blood and hair and little tags of skin.

  In animals at least, biting is a primitive response, a matter of self-defense. The animal kingdom evolved a system of feeding and renewal we know as the food chain. It's a nonjudgmental predatory system. As an adjunct to safe survival, animals maintain order within their ranks by minimizing dangerous fighting among themselves. They ritualize their aggressive behavior. One animal becomes the leader, the alpha male. During the fall rutting season, domination is a matter of short-term conflict, strutting and limited combat.

  Occasionally, one of the combatants dies.

  As part of Mother Nature's integrated design and despite the efficiency of her ways of orchestrating the animal kingdom, some creatures are bitten in response to a stimulus. In the scheme of things, big animals eat little creatures. Yet, in the human world, biting serves no real purpose.

  Now let's examine the more common types of nips and chomps. Later in this chapter we'll talk about the mammal that lost its way.

  Dog Bites

  Buck was beset by three Huskies, and in a trice his head and shoulders were ripped and slashed. The din was frightful. . . . Dave and Sol-leks, dripping blood from a score of wounds, were fighting bravely side by side. . . . Buck got a frothing adversary by the throat, and was sprayed with blood when his teeth sank through the jugular.

  No one would have difficulty recognizing this Jack London scene from The Call of the Wild. Dramatic use of primeval canine conflict at its best—except the jugular comment, as blood under pressure from the carotid artery next to the jugular was probably responsible for the "sprayed" blood and rapid exsanguination of Buck's adversary. (Forgive me this challenge of one of my literary heroes.)

  The terror is no less when a human is attacked by a dog. Typically, a provoked dog attacks the hand, arm, leg or face. Most breeds have the potential to be provoked, and no attempt will be made to foster the notion that some breeds are worse than others. Some big breeds, like German shepherds, Dobermans, giant schnauzers and pit bulls, are expected to be aggressive. Any animal may be provoked to attack or defend itself or those around it.

  Like hair color, the choice of a companion dog will characterize your heroine. Animals add tension to a scene.

  Stephen King drops an innocent observation in the beginning of Gerald's Game as Jessie lies spread-eagle handcuffed to the bedposts at the lake while her husband crawls onto the bed, his eyes gleaming with erotic interest. Off in the distance, she hears a loon laugh and the whine of a chainsaw, and a dog barks. Pretty much what you'd expect to hear on an evening night in the north country, it sets a benign if not serene scene for her upcoming terror-driven encounter. Not very much later, Gerald drops off the bed, dead of an apparent heart attack. Later still, the aforementioned dog discovers the cottage and the plump deceased lawyer. The starving canine sinks his teeth into Gerald's face and tears away a gourmet gob.

  ER doctors treat and, where appropriate, suture thousands of dog bites each year. Some bites barely break the skin while others require hours of tedious plastic surgery. Often the victim is an innocent child who unknowingly provoked the dog.

  Human Bites

  Along came a mammal with the biggest brain of all, complex cerebral circuitry that permitted jealousy, envy, resentment, hatred and—the species' favorite—revenge. But underneath these sophisticated cognitive functions lies the simple, incalculable rage, the same as what an animal feels when threatened, which reminds us: we are animals.

  When that primal rage takes over, humans can and do bite. It's probably the most regressive, and repulsive, form of human attack. Two things happen when someone takes a chunk out of someone else. As with all well-written fiction, there is an action, then a reaction. Despicable in its intent and style, a human bite provokes physical distress and often a missing part, but, more important for the writer, the attack is perceived as indignant, uncivilized, vulgar.

  It must be redressed.

  So, while the doctor cleans the wound in the ER and sutures together the edges of the bite, or attempts to replace a piece of an ear or a fingertip, the victim seethes with revenge. The trauma prescription is written with the end in sight. You want your character's nose sewn back in place with fifty-eight stitches, each a humiliating marker. Will he leave the ER and chase the black-haired youth who fought him in the bar? Will the youth ever be found? Does the rail-thin kid who bit him have AIDS?

  Any injury mentioned in this book where blood or other body fluids are exchanged by direct contact with an open wound may be associated with the transmission of disease. That's what makes a bite so horrible.

  The knuckle variety of human bite—a striking injury in reality— may involve finger tendons and hand joints, producing complicated hand infections. Each tendon has a sheath, and every joint possesses a cavity. When horrid mouth bacteria enter these sterile spaces through a laceration from a tooth, the resulting infection may require antibiotics, sophisticated hand surgery and hospitalization.

  A true human bite may be a crush injury (molar attack) or a laceration (incisors and canines). Tissue loss is possible (use your imagination). Fingers have been chomped off in barroom brawls and these digits are usually not candidates for replantation (even if the deserted digit wasn't lost in someone's mug of pale ale). Soft tissue bites to other anatomic areas are less severe in general, and local care and antibiotics often suffice without a trip to the local HMO.

  If you really want to be cruel, remember any appendage can be bitten off. Any human bite you can imagine has probably been treated by a doctor somewhere.

  Snake Bites

  Of the forty thousand people in the United States bitten by snakes every year, only fifteen die, and these are usually children or the elderly. Approximately 70 percent of venomous snake bites are from rattlesnakes; the remainder involve copperheads, cottonmouths and coral snakes (less than 1 percent). Maine, Hawaii and Alaska are the only states that do not have a native venomous snake. Worldwide, over three hundred thousand snake bites occur each year with only about thirty deaths.

  Curiously, almost 50 percent of the people bitten by snakes are intoxicated, and up to 60 percent of victims were deliberately handling the reptile! Not every snake bite results in the deposit of venom, and simple puncture wounds are often treated with first aid and observation,

  Important questions to be answered after a snake attack:

  • Is the snake poisonous?

  • Did the snake cause envenomation?

  • How far apart are the fang puncture wounds?

  Poisonous snakes have fangs, and the distance between the puncture wounds gives a rough estimate of the snake's size. Harmless snakes have teeth rather than fangs and a double row of anal plates.

  Pit vipers are poisonous snakes that have the following distinguishing characteristics: The thermoreceptor "pit" lies between the nostril and the snake's eye, the pupil of the eye is a vertical slit and the anal plates on the undersurface of the beast form a single row. Coral snakes vary in color but the guiding mnemonic is "Red on yellow, kill a fellow; red on black, venom lack." Nonpoisonous king snakes have incomplete red and black stripes, while the deadly coral snake of the southern United States possesses completely encircling red-next-to-yellow bands.

  Before we finish discussing snakes, two additional questions must be answered: What is it the venom actually does, and how do you treat a snake bite?

  When
you consider that snake venom is designed to immobilize prey to facilitate swallowing and digestion, it won't come as a surprise

  Clinical Presentation of a Snake Bite Victim

  Grade 0 No venom deposit; with pain; fang or tooth marks;

  an inch or less of redness

  Grade 1 Minimal venom deposit; severe pain; fang or tooth

  marks; one to five inches of redness and swelling

  Grade 2 Moderate venom deposit; fang or tooth marks; six

  to twelve inches of redness and swelling; general symtoms of nausea, light-headedness and shock

  Grade 3 Severe envenomation; fang or tooth marks; more

  than a foot of swelling and redness; decreased blood pressure; bleeding; bruising; shock

  Grade 4 Multiple tooth or fang marks; diffuse swelling and

  redness beyond local area to other anatomic regions; kidney failure; shock; coma

  that this obnoxious fluid contains enzymes. Enzymes are the active body substances that digest the snake's food, or digest parts of the victim who is bitten. You don't want to know the names of these molecules. Instead, we will list the common medical problems resulting from envenomation:

  • Local tissue damage

  • Coagulation problems resulting in excessive bleeding

  • Blood vessel damage and leakage of body fluid

  • Pulmonary edema (body fluids leak out and water floods the lungs), congestive heart failure

  • Numbness, paralysis and loss of consciousness

  • Kidney failure

  • Anemia

  • Shock (cardiovascular collapse)

  The steps for treating a snake bite are outlined on page 135.

  Shark Bites

  Are most shark bites fatal? Before 1968 almost 20 percent of all recorded shark attacks were deadly, but between the mid-1980s and 1994, only five deaths have been recorded by the International Shark Attack File.

  How to Treat a Snake Bite

  ■ Slow the absorption of venom. Tourniquet above bite site with just enough pressure to block venous flow, not compress the artery. Leave on up to two hours; don't periodically release. Immobilize limb with a splint.