Common ED Presentations: Minors

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Introduction

Patients with minor injuries, as well as those with minor medical and surgical conditions, will be streamed to ‘minors’ in the emergency department.

It takes time to gain confidence in dealing with minor injuries. The fast-paced environment, rapid diagnosis, and procedural skills involved make it an exciting and rewarding place to work.

In this guide, we will cover some of the common presentations to minors with a focus on minor injuries such as sprains, strains, broken bones, wounds, burns, nosebleeds and eye injuries.

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Sprains and strains

A sprain relates to a ligament injury, whereas a strain refers to an injury to a muscle or a tendon.

Ankle sprain

Most ankle sprains result from an inversion injury where the patient rolls their ankle inwards, causing damage to the lateral ligamentous complex (anterior talofibular ligaments, calcaneofibular ligament and posterior talofibular ligament). Isolated anterior talofibular ligament (ATFL) injuries account for 60-70% of all ankle sprains.¹

 The Ottawa ankle rules can be used to assist you in deciding whether or not a patient who presents with a simple ankle injury requires imaging.² The rule is based on clinical examination findings. A patient who was weight-bearing immediately after the injury and in the ED with no pain on the posterior edge or tip of the medial or lateral malleolus can be managed as an ankle sprain without the need for imaging.

The conventional wisdom for managing sprains and strains is rest, ice, compression and elevation (RICE). Resting allows the soft tissue to heal, and ice plus elevation reduces the accumulation of inflammatory fluid.

However, the evidence for compression bandages is variable, and most departments no longer routinely strap ankles following a sprain.

Patients should avoid an over-reliance on crutches for ankle sprains. Putting weight through the ankle as soon as possible will help it heal more quickly.

Simple analgesia and physiotherapy are also important in treating soft tissue injuries. Your department will have access to patient advice leaflets for specific joints, and NHS patient information leaflets can be found online.

Achilles tendon rupture

This is a common sports injury caused by sudden, forced plantarflexion of the foot. Patients may describe an audible snap and pain around the back of the leg. During the physical examination, you should feel for a step in the Achilles tendon and squeeze the calf to elicit passive plantarflexion (Simmonds-Thompson test). Absent plantarflexion suggests a tendon rupture.

Suspected Achilles tendon ruptures require an ultrasound scan and discussion with orthopaedics. Treatment involves either surgery or immobilisation in an equinus position with a boot or cast. These patients should be VTE assessed due to the risk of blood clots from prolonged immobility.

Knee injuries

Giving yourself a refresher on all large joint examinations is worthwhile before you start your first shift in minors.

Knee examination is complex and involves assessing the medial collateral ligament, lateral collateral ligament, anterior and posterior cruciate ligaments, the extensor mechanism of the knee and the menisci.

The Ottawa knee rules can help in deciding which patients require an X-ray following a knee injury.³ Patients who are unable to weight-bear both immediately and in the emergency department require an X-ray.

Most soft tissue injuries of the knee heal with conservative management advice (rest, ice, compression, elevation and physiotherapy).

A compression bandage or knee brace may help reduce the swelling and provide symptomatic relief in the initial stages.

You should discuss all fractures and significant ligamentous injuries with the on-call orthopaedic team.  A subset of those with significant ligamentous damage will go on to require surgical intervention. 

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Wounds

Assessment of wounds

The first step when evaluating any wound is to consider the mechanism of injury. Was it a puncture wound? Dog bite? Or a slice with a kitchen knife? Knowing the mechanism will assist in the proper assessment of the wound. Penetrating wounds pose a particular difficulty as the extent of the injury cannot be visualised.

The next thing to consider is the location of the wound. Wounds on the face and those crossing the vermillion border (between the mucous membrane of the lip and the skin) are cosmetically significant. They may warrant a discussion with the plastic surgery or maxillofacial team.

You should then evaluate the extent of the wound:

• Are there any deep structures, such as tendons or ligaments involved?
• Is it a dirty or contaminated wound?
• Are there any foreign bodies?
• Is there neurovascular compromise?

Discussion with plastics is needed if there is a tendinous or ligamentous injury. Extensive, deep or heavily contaminated wounds may need to be referred to the surgical team for closure in theatre.

Management of wounds

Irrigation

Thoroughly irrigating a wound before closure is the most effective way of preventing infection. Sterile saline is commonly used for this. A useful tip for larger wounds is to connect a 500ml bag to a giving set and use this to irrigate the wound.

Foreign bodies

The removal of foreign bodies is needed before wound closure, as they act as a source of infection. This includes ensuring hair is not trapped inside the wound when suturing a scalp. If you are unsure if there is a foreign body present (e.g. glass), you should consider requesting an X-ray of the soft tissue.

Controlling bleeding

Scalp and finger wounds can bleed heavily as these are highly vascular areas. It is important to stop the bleeding before closing a wound to prevent the build-up of a haematoma, which can also act as a source of infection. The most effective way of stopping a wound from bleeding is by applying direct pressure and elevating the area. Other useful tips include using tranexamic acid or adrenaline-soaked gauze.

Pulsatile bleeding indicates an arterial bleeding, which may need tying off. Seek senior advice promptly when managing any wound with significant bleeding or which does not stop bleeding despite pressure and elevation.

Wound closure

Wound closure can be by primary intention (closure with Steri-Strips™ , sutures, glue or staples) or secondary intention (leaving the wound open and allowing granulation tissue to form). The method will depend on several factors, such as the wound’s location, size, and age.

Surgical glue is quick and easy to use and results in comparable cosmetic results for small wounds. However, sutures are needed for larger wounds or those at points of high tension, such as a joint line. Spend time with emergency nurse practitioners or experienced clinicians working in minors to get a feel for different wound closure methods.

When using lidocaine for primary closure, remember that the maximum dose is 4mg/kg plain or 7mg/kg with adrenaline. Lidocaine mixed with adrenaline is useful for wounds where there is ongoing bleeding, as it acts as a vasoconstrictor. However, remember that this should not be used in end arteries such as a digit.

Tetanus

Tetanus prone wounds are those which have been exposed to tetanus spores (present in soil and manure). This includes puncture wounds, extensive burns, open fractures, animal bites and scratches. You should ask all patients with a tetanus-prone wound about their tetanus immunisation status.

The UK Health Security Agency Green Book is an excellent resource that outlines which patients require a tetanus booster or tetanus immunoglobulin depending on the wound type and the patient’s immunisation status.⁴

Antibiotic prophylaxis

Routine prophylactic use of antibiotics for simple wounds is not recommended. However, antibiotics should be considered in human bites, animal bites and heavily contaminated wounds.

Whenever discharging a patient, you should provide verbal and written wound care advice, including safety netting for signs of infection and informing them when to have their sutures removed.

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Fractures

Most hospitals have guidelines on how to manage different types of fractures. You will soon become familiar with the common approaches to management (e.g. buddy strap, black boot, collar and cuff or broad arm sling). However, you should refer to the hospital guidelines or ask for advice if unsure.

Assessment of fractures

What was the mechanism of injury? High-risk mechanisms such as a high-speed road traffic collision should alert for the possibility of other injuries or damage to internal organs.

Is it open or closed? Open (compound) fractures require antibiotic cover, tetanus prophylaxis and discussion with orthopaedics.

Is there any neurovascular compromise? Assess the pulses and the sensory and motor function distal to the fracture site. Fractures resulting in neurovascular compromise require urgent discussion with the orthopaedic team and may need to be reduced in the emergency department.

What are the patient factors? Is the patient right or left-handed? What is their profession? How are they likely to manage at home?

Common fractures

Following are some eponymously named fractures which you may encounter during your time in the emergency department:

• Bennett’s fracture: Intra-articular fracture of the base of the thumb.
• Boxer’s fracture: Fracture of the neck of the 5th metacarpal (frequently sustained by punching a hard surface).
• Colles’ fracture: Distal radial fracture with dorsal angulation typically associated with falling onto an outstretched hand. These are some of the most commonly reduced fractures in the emergency department.
• Hill-Sachs fracture: Posterior humeral head impaction fracture from an anterior shoulder dislocation.
• Jones fracture: Fracture of the base of the 5th metatarsal.
• Lisfranc injury: Injury to the bones of the midfoot associated with complex ligamentous damage.
• Smith’s fracture: This is a reverse Colles’ fracture with ventral displacement and angulation of the fractured distal radius resulting from falling onto a flexed wrist.

Manipulating fractures

Manipulation of common fractures and dislocations is a core ED skill. The basic principle is to maintain steady inline traction to bring the fracture to length and return to normal anatomical alignment.

However, there are many different techniques used depending on the fracture or dislocation (e.g. Kocher’s technique for shoulder dislocations). You should take the opportunity to get involved with these whenever you get the chance.

Providing adequate analgesia is key during the manipulation of fractures and dislocations. Sometimes full procedural sedation will be needed (e.g. reducing hip dislocations or failed shoulder reductions).

Procedural sedation should performed by airway-trained ED doctors or anaesthetists in the resuscitation room and with full monitoring, including capnography. If the necessary staff or resources are unavailable to perform this safely in the ED, the patient should be booked for the procedure in theatre.

Interpreting X-rays

Interpreting X-rays of fractures is a skill which you will develop with time. You are not expected to be an expert in looking at the small bones of the foot on your first day!

While building your confidence, you should run all X-rays you are unsure about past a registrar or consultant. The on-call orthopaedic team and reporting radiologist are also there to provide advice if needed.

Discharge or referral

Simple closed fractures with no neurovascular compromise and with a clear pathway for outpatient management do not need to be referred to orthopaedics. These patients can be discharged with the appropriate cast, splint or sling and referred to the fracture clinic.

Contact the on-call orthopaedic team if you are unsure about managing a fracture or if the patient is likely to need inpatient treatment. Examples of fractures which always require inpatient management include open fractures, neck of femur fractures and fractures with neurovascular compromise.

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Burns

Burn injuries are the fourth most common type of civilian trauma worldwide.⁵ Here, we will go through some of the basic first aid and ED management, including when to refer to your local burns unit.

First aid

Adequate first aid involves removing the heat source and irrigating the wound with cool running water for 20 minutes.⁶

This is a crucial step to dissipate the thermal energy stored in the burn and to prevent further tissue damage. You can irrigate a wound up to three hours after the injury. If initial first aid was inadequate, you should repeat this in the ED by placing the burn under a running tap or shower.

Assessment of burns

The depth of a burn can be classified into one of four categories:⁶

• Epidermal: superficial burn affecting epidermis only. These are red and painful with no blisters.
• Superficial partial thickness: partial thickness burn affecting the epidermis and upper part of the dermis. The skin is pale pink and tender with blisters and a brisk capillary refill time.
• Deep partial thickness: partial thickness burn extending to the deep dermis. The skin appears blotchy and cherry red. They can be painful or painless with a sluggish capillary refill time.
• Full thickness: burn extends through all layers of the skin to the subcutaneous fat. There are no blisters. It is painless and non-blanching. The skin is dry and has a white or charred appearance.

The distinction between superficial partial-thickness and deep partial is not clinically relevant in the emergency department. However, you should be able to distinguish between epidermal, partial thickness and full-thickness burns.

Total body surface area (TBSA)

The Wallace rule of nines and the palmar surface rule can be used to estimate the total body surface area (TBSA) of a burn. Apps such as the ‘Mersey Burns app’ also facilitate the calculation. Epidermal burns do not count towards the TBSA.

The Royal College of Emergency Medicine recommends that adults with greater than 15% TBSA burns and children with greater than 10% TBSA burns require fluid resuscitation.⁶ These patients should not be in the minors department!

Patients with extensive burns should be triaged straight to majors or the resuscitation room and managed with an ABCDE approach.

Management of a minor burn

After adequate first aid, the burn should be cleaned with normal saline and devitalised tissue removed. A specialised burns dressing should then be applied. The purpose of dressing a burn is to promote healing, prevent infection and prevent fluid loss in large areas. Burn dressings also offer effective analgesia by cooling the area and covering exposed nerve endings.

The British Burns Association advises keeping small, non-tense blisters under 6mm intact. All larger blisters should be ‘de-roofed’ and removed.

Adequate analgesia is needed before cleaning a burn and de-roofing the blisters, as this can be very painful.

Paraffin-impregnated gauze and topical antimicrobial gels are frequently used as burn dressings. Cling film can also be applied in a first aid or pre-hospital setting. However, care should be taken not to wrap this circumferentially around a burn to prevent a tourniquet effect.

Check which dressings are available in your local department. Often, the nursing team and the emergency nurse practitioners are the experts in burn dressings.

Tetanus prophylaxis should be given when an inadequate primary course of tetanus vaccination has been received or where there is heavy contamination, devitalised tissue or signs of sepsis.⁴

Referring to a specialist burns service

The British Burns Association has established the following national minimum criteria for referring to a specialist burns service:⁷

• All burns ≥2% TBSA in children or ≥3% TBSA in adults
• All full-thickness burns
• All circumferential burns
• Any burn not healed in 2 weeks
• Any burn with suspicion of non-accidental injury should be referred to a burn unit/centre for expert assessment within 24 hours

Additionally, you should consider discussing any patient with a burn to the hands, feet, face, perineum or genitalia. Check your local department’s referral criteria, as these may vary regionally.

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Epistaxis

Assessment and first aid

Approximately 95% of nosebleeds arise from the anterior nasal septum in an area known as Kiesselbach’s plexus or Little’s area. This is a vascular bed formed by the anastomosis of several arteries.

As well as inspecting the nose and anterior nasal septum, you should use a tongue depressor to visualise the oropharynx looking for a posterior bleed.

It is possible to lose a large quantity of blood through the nose, and major nosebleeds should be managed with an ABCDE approach, activation of the major haemorrhage protocol and early involvement of the ENT team.

However, the Royal College of Emergency Medicine estimates that up to 85% of nosebleeds are minor and can be managed in the ED without specialist input or admission.⁸ Most minor nosebleeds will stop with basic first aid consisting of pinching the soft part of the nose firmly for at least 10 minutes (a surprising number of people will come in pinching their nasal bridge!).

Nosebleeds often occur following mucosal irritation from an upper respiratory tract infection or overzealous nose-picking.

Fit and healthy patients with minor nosebleeds do not require formal blood tests. However, those with recurrent nosebleeds, significant blood loss or suspected coagulopathy would benefit from further investigation, including a full blood count and coagulation profile.⁸

Management

If first aid does not stop the bleeding you should inspect the anterior nasal septum to see if there is a bleeding point which can be cauterised.

Silver nitrate sticks can be used to cauterise the bleeding point after applying a local anaesthetic and vasoconstricting spray. Ask the doctors you are working with to show you the technique for nasal cautery. Remember that both sides of the nasal septum should not be cauterised at the same time due to a risk of septal perforation.

If first aid and silver nitrate cautery have been unsuccessful, you should pack the nose to apply direct pressure to the bleeding area.

Different brands of nasal tampons exist, with the Rapid Rhino inflatable device being a common choice. These should be lubricated with sterile water and inserted horizontally into the nasal cavity, parallel to the septal floor, similar to a nasopharyngeal airway. The balloon can then be inflated with air to tamponade the bleeding. The rapid rhino device has a pilot balloon to guide inflation. You should stop inflation when the pilot cuff becomes rounded and feels firm.  

If bleeding persists despite nasal packing, the bleeding is likely coming from the posterior nasal cavity. Single cuff rapid rhinos (the most common variety found in the ED) will not be sufficient to tamponade a posterior bleed. These need to be referred to the ENT team.

In extremis, you can insert a Foley catheter into the nasal cavity and inflate the balloon to apply pressure to the bleeding site. This last resort technique should only be attempted if the patient is unstable and immediate specialist input is unavailable.

Referral and follow-up

You should refer all patients who require nasal packing to ENT. Some patients may be safe to discharge with the pack in situ but will require early ENT follow-up.

When discharging a patient, you should advise them to avoid nose-picking, heavy lifting, nose-blowing and hot drinks. If they have to sneeze they should try and do so with their mouth open (after an appropriate warning to those around them!).

A topical antiseptic cream such as naseptin applied to the meaty part of the nostril and rubbed into the nasal septum can be offered to the patient on discharge to prevent re-bleeding.

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Eye injuries

Eye problems account for approximately 6% of emergency department presentations, with almost half being injuries.⁹

This is not a topic covered extensively in medical school and it may take a while for you to gain confidence in managing these injuries. For more information, see the Geeky Medics guide to eye trauma.

The eye exam

You should start by performing a thorough eye examination. This does not mean reaching straight for the Ishihara charts but there are a few key aspects of the examination which need to be covered following an injury.

Inspection

Look for obvious trauma, foreign bodies, conjunctival erythema, irregular pupil, asymmetry etc.

It is important to consider the mechanism of injury here. Were they grinding, suggesting a metal foreign body? If this is the case, you will often see the offending article as a speck of black on the cornea. Were they welding without eye protection, suggesting a flash burn? Exposure to UV light from welding or a tanning bed can cause photokeratitis, which is more evident on fluorescein staining.

Evert the lid

Use a cotton bud or pointed object as an anchor point to evert the upper lid. Foreign bodies, such as a grain of sand, can get stuck here and will continue to scratch the cornea if not removed.

Reflexes

Test the pupillary reflexes, including the direct and indirect response, and look for a relative afferent pupillary defect.

Visual acuity

Assess the patient’s visual acuity with a Snellen chart.

The Snellen chart is normally placed 6 metres away from the patient (or three metres with a mirror in front of the patient and a reverse Snellen chart directly behind them). A visual acuity of 6/12 means that the patient can see at 6 metres what a ‘normal’ patient would be able to see at 12 metres.

Fluorescein staining

This is a key part of examining the eye following an injury, as it will allow you to visualise any damage to the cornea, including corneal abrasions and ulcers.

One or two drops of fluorescein should be applied to the affected eye. This will coat the surface of the eye and collect at sites where there has been corneal damage.

Shining a blue light onto the eye will then cause the areas of fluorescein accumulation to shine a bright green colour.

Slit lamp exam

The slit lamp allows you to carefully examine the eye under magnification. There are a dozen or so buttons, dials and switches which allow you to adjust the light intensity, colour and aperture as well as finely control the movement of the eyepiece up, down and side to side.

When you start in minors, you should ask someone to explain the ‘knobology’ of the slit lamp and have a go at examining one of your colleagues. It is a really useful piece of equipment and, once mastered, will greatly enhance your ability to perform an eye exam.

Removing foreign bodies

Removing pieces of metal from the cornea following a grinding accident is a common emergency department procedure.

Foreign bodies can often be seen with the naked eye and will become more apparent on slit lamp examination. Before attempting to remove a foreign body, you should apply topical anaesthetic eye drops.

A moist cotton bud tip may be sufficient to lift the piece of metal or speck of sand out of the eye. If unsuccessful, a high gauge needle with the bevel facing towards you (and a steady hand) can be used to flick the foreign body off the cornea under slit lamp guidance. This is a valuable procedural skill to master if you intend to work in emergency medicine.

However, before attempting this yourself, you should ask someone competent in performing the procedure to guide you through it.

Irrigation following chemical exposure

Chemical injuries to the eye can be very painful and may require irrigation with copious amounts of saline (sometimes up to several litres). You should look up all chemical exposures on TOXBASE, the National Poisons Information Service’s toxicology database.¹⁰ Your department will have a TOXBASE username and password. It is an indispensable resource when it comes to drug overdoses and chemical exposures.

Highly alkali solutions such as ammonia can rapidly penetrate the anterior chamber of the eye, and prompt irrigation is the cornerstone of treatment. The eye should be irrigated with copious amounts of normal saline until a neutral pH is achieved (tested by dabbing the inside of the lower lid with litmus paper).

Irrigation can be painful, and offering topical anaesthetic eye drops is good practice when performing this.

Irrigation should be performed by sitting the patient with their head over a sink and irrigating with a giving set attached to a saline bag. Some departments may use a Morgan lens which is a firm contact lens-like device with irrigating tubing attached.

All significant eye injuries and chemical exposures should be discussed with the on-call ophthalmology team.

Other eye problems

Not all eye problems presenting to minors will result from an injury. Patients may present with an atraumatic red painful eye, floaters or visual loss for example. The differential diagnosis is broad. A thorough history and examination are needed, including discussion with senior ED or ophthalmology team members.

For more information, see the Geeky Medics guides to ophthalmic history taking, the painless red eye and the painful red eye.

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Escalating your concerns

Although this guide relates to minor injuries only, you should be aware that medical and surgical patients are also triaged to minors. These are often well patients with minor conditions that can be dealt with outside of the majors area.

However, more and more patients are being triaged to minors as departments become busier. You should, therefore, remain vigilant for unwell patients who may be sitting in the waiting room. 

If you are concerned about a patient who has been triaged to minors, you should discuss this with the doctor or nurse in charge with a view to moving the patient to a more appropriate area, such as majors or results.

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Conclusion

This guide has covered common minor injuries ranging from simple sprains to eye injuries. This is not an exhaustive list, but offers a flavour of the diversity of presentations you will encounter.

Treating minor injuries can be very rewarding, and you should approach your time spent in the department as an opportunity to develop a range of key clinical skills. Enjoy!

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References

1. Guthrie, K. Life in the Fast Lane. Another ankle sprain. 03/11/2020. Available from: [LINK]
2. Stiell, I. MD+ Calc. Ottawa ankle rules. Accessed Nov. 2023. Available from: [LINK]
3. Stiell, I. MD+ Calc. Ottawa knee rule. Accessed Nov. 2023. Available from: [LINK]
4. The UK Health Security Agency. The Green Book: tetanus (chapter 30). Updated 01/06/22. Available from: [LINK]
5. Stewart, B.T. UpToDate. Epidemiology, risk factors, and prevention of burn injuries. 02/11/22. Available from: [LINK]
6. Atwal, R. and Matthews, J. RCEMLearning. Major trauma – burns. 11/02/21. Available from: [LINK]
7. National network for burn care. British Burn Association. National burn care referral guidance. Feb. 2012. Available from: [LINK]
8. Whittaker, J. RCEMLearning. Epistaxis. 10/02/20. Available from: [LINK]
9. Whittaker, J. RCEMLearning. Initial assessment of the eye. 29/03/21. Available from: [LINK]
10. National Poisons Information Service. TOXBASE. Available from: [LINK]

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