Emergency Medicine: Minor injuries wounds, bites, minor burns, hands and foreign bodies

🩹 Minor injuries — wounds, bites, minor burns, hands and foreign bodies. Minor injuries make up a large share of ED and urgent treatment centre work. Most are simple, but hidden in them are injuries that cause lifelong disability if missed — tendon and nerve damage in hand wounds, fight bites, high-pressure injection injuries, penetrating eye injuries, and button batteries. Fractures are covered in the Musculoskeletal Imaging and Trauma and Orthopaedics pages; major burns in the Major Trauma page.
Your four questions for every minor injury: What was the mechanism — and could there be deeper damage (tendon, nerve, vessel, joint, foreign body)? Is the wound clean, contaminated or a bite? Does the patient need tetanus, antibiotics or rabies prophylaxis? Does this need a specialist (hand, plastics, eye, maxillofacial) today?

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Wound Assessment

• History — mechanism (sharp, crush, bite, high-energy, glass, dirty environment, high-pressure), time since injury, hand dominance and occupation (hand injuries), tetanus status, allergies, anticoagulants, diabetes, immunosuppression, smoking, steroids.
• Types of wound:
  • Incised — clean edges (knife, glass) — risk of deep structure injury despite a small skin wound.
  • Laceration — tearing from blunt force — irregular, bruised edges.
  • Abrasion — graze — risk of tattooing with embedded dirt (clean thoroughly — face).
  • Puncture — deep with a small entry — infection, retained foreign body, tendon sheath and joint penetration.
  • Crush and degloving — tissue devitalisation; compartment syndrome.
  • Bites — always contaminated.
• Examine (before local anaesthetic) — distal neurovascular function (sensation, capillary refill, pulses) and tendon function against resistance; then explore the wound under good light, with a bloodless field (tourniquet on digits) and anaesthesia — look for tendon, nerve, vessel, joint capsule, bone and foreign bodies through the full range of movement (tendons move under the skin).
• X-ray for possible radiopaque foreign bodies (glass — most glass is visible), underlying fractures; ultrasound for wood and plastic.
• Refer — tendon, nerve or vessel injury; joint involvement; complex facial wounds (lip vermilion border, eyelid margin, lacrimal canaliculus, ear cartilage, nose); extensive tissue loss; open fractures; high-pressure injection; most hand wounds with any deep structure involvement.
• Document — size, site (diagram or photograph with consent), depth, structures examined, foreign body exclusion, closure method, follow-up — wounds are a common source of complaints and claims.

Local Anaesthesia for Wounds

• Lidocaine (1% = 10 mg/mL; 2% = 20 mg/mL) — onset 2–5 minutes, duration about 1 hour (2–3 hours with adrenaline).
  • Maximum dose — about 3 mg/kg plain (max 200 mg) and 7 mg/kg with adrenaline (max 500 mg) — check the BNF and local guidance.
  • Example — a 70 kg adult can have up to about 21 mL of 1% plain lidocaine.
• Bupivacaine and levobupivacaine — longer acting (4–8 hours) — nerve blocks; maximum about 2 mg/kg; more cardiotoxic.
• Adrenaline-containing anaesthetic — reduces bleeding and prolongs action; traditionally avoided in digits, nose, ears and penis — evidence suggests low-concentration adrenaline is safe in healthy digits, but follow local guidance; avoid in peripheral vascular disease.
• Reducing injection pain — warm the solution, small needle, inject slowly through the wound edge (not intact skin), buffer with bicarbonate (some units), topical anaesthetic (LAT gel — lidocaine, adrenaline, tetracaine) for children's wounds.
• Ring (digital) block — anaesthetises the finger for nail and fingertip injuries (see ED Procedures page).
• Local anaesthetic systemic toxicity (LAST) — perioral tingling, tinnitus, metallic taste, light-headedness → seizures → arrhythmias and cardiovascular collapse — stop injecting, ABCDE, treat seizures, IV lipid emulsion (Intralipid 20%), prolonged CPR if arrest (AAGBI guideline).
• Allergy to amide local anaesthetics is very rare (reactions are usually vasovagal, adrenaline effects or toxicity).

Cleaning and Closing Wounds

• Irrigation — the most important step in preventing infection — copious tap water or saline under pressure; remove debris; debride devitalised tissue; don't shave eyebrows (they may not grow back — and are landmarks for alignment).
• Timing — most clean wounds can be closed primarily within about 12–24 hours (longer on the face and scalp — good blood supply); contaminated wounds and bites — often left open or delayed primary closure (at 3–5 days), except on the face.
• Closure methods:

  Method	Best for
  Adhesive strips (Steri-Strips)	Small, low-tension wounds; fragile skin (pretibial lacerations, skin tears); children
  Tissue adhesive (glue)	Small, clean, low-tension wounds (face, scalp in children) — not over joints, mucosa, or contaminated wounds; keep out of eyes
  Sutures	Deeper, gaping, high-tension wounds; non-absorbable (nylon — skin) or absorbable (deep layers, lips, children)
  Staples	Scalp wounds — quick
  Hair apposition	Scalp wounds — twisting hair strands across and securing with glue

• Suture removal times (approximate):
  • Face — 3–5 days.
  • Scalp — 7–10 days.
  • Trunk and arms — 7–10 days.
  • Legs and back — 10–14 days.
  • Over joints — 10–14 days.
• Aftercare — keep dry for 24–48 hours, signs of infection, scar care (sun protection, massage), follow-up for removal.
• Antibiotics are not needed for most clean wounds — consider for bites, heavily contaminated wounds, open fractures (within 1 hour), immunosuppressed patients, delayed presentation.
• Special areas — lip vermilion border (align exactly first), eyelid margin and medial canthus (canaliculus — ophthalmology), ear (cover cartilage; drain pinna haematoma), tongue (most heal without sutures), scalp (control bleeding — galeal closure if deep).

Tetanus Prevention

• Tetanus — Clostridium tetani spores (soil, manure) → toxin (tetanospasmin) blocks inhibitory neurones → trismus ("lockjaw"), muscle spasms, opisthotonus, autonomic instability — still occurs in the UK (often older people, injecting drug users, garden injuries).
• Tetanus-prone wounds (UKHSA Green Book):
  • Puncture-type wounds in a contaminated environment (e.g. gardening).
  • Wounds containing foreign bodies; compound fractures; wounds or burns with systemic sepsis; certain animal bites and scratches.
  • High-risk — heavy contamination with material likely to contain spores (soil, manure), and/or extensive devitalised tissue, burns needing surgery that is delayed.
• Management by immunisation status (summary — check the Green Book):

  Status	Clean wound	Tetanus-prone	High-risk tetanus-prone
  Fully immunised (5 doses)	Nothing	Nothing	Consider human tetanus immunoglobulin (HTIG)
  Incomplete or boosters not up to date	Reinforcing vaccine dose	Reinforcing vaccine dose	Vaccine + HTIG
  Unknown or never immunised	Vaccine dose (then complete course)	Vaccine + HTIG	Vaccine + HTIG

• Thorough wound cleaning is essential; tetanus vaccine is given as a combined product (Td/IPV in adults).
• Most UK adults born after 1961 are likely to have had a primary course; older people and migrants may not have.

Animal and Human Bites

• Dog bites — commonest — crush and tear injuries; infection with Pasteurella, Capnocytophaga (severe sepsis in asplenic people and alcohol excess), streptococci, staphylococci, anaerobes; children — face and neck (refer to plastics).
• Cat bites — deep puncture wounds — high infection risk (Pasteurella multocida — rapid cellulitis within 24 hours), tendon sheath and joint infections (hands); cat scratch disease (Bartonella).
• Human bites — clenched-fist injury ("fight bite") over a knuckle — tooth penetrates the MCP joint — high risk of septic arthritis and tenosynovitis — explore and wash out (hand surgeons); Eikenella corrodens; blood-borne virus risk (hepatitis B and C, HIV — risk assessment, hepatitis B vaccine and PEP as needed).
• Management (NICE NG184):
  • Irrigate thoroughly; debride; leave open or loosely closed (except the face — close after thorough cleaning).
  • Prophylactic antibiotics (3 days) — co-amoxiclav — for: cat bites that break the skin; dog or other animal bites that draw blood if in a high-risk area (hand, foot, face, genitals, skin over joints, cartilage) or high-risk person (diabetes, asplenia, immunosuppression, cirrhosis, prosthetic valve); human bites that draw blood.
  • Penicillin allergy — doxycycline plus metronidazole (adults).
  • Treatment of infected bites — co-amoxiclav for 5 days (longer if severe; IV if systemically unwell).
  • Tetanus — animal bites can be tetanus-prone.
  • X-ray for fractures and teeth fragments; hand bites — hand surgeons.
• Rabies:
  • Any bat bite or scratch in the UK — European bat lyssavirus — seek advice from UKHSA for post-exposure prophylaxis.
  • Animal bites abroad in rabies-endemic countries (dogs, monkeys, bats) — urgent UKHSA risk assessment — wound washing for 15 minutes with soap and water, rabies vaccine course ± rabies immunoglobulin (infiltrated around the wound) depending on risk and prior vaccination.
  • Rabies is almost always fatal once symptoms start.
• Dangerous dogs — consider safeguarding (children); the police may need to be informed.

Pretibial Lacerations and Skin Tears

• Who — older people with thin, fragile skin (ageing, long-term steroids, anticoagulants) — minor knocks against furniture or wheelchairs cause flap wounds over the shin.
• Problems — poor blood supply over the tibia, flap necrosis, slow healing, can progress to chronic leg ulcers; haematoma under the flap.
• Management:
  • Clean, remove haematoma, lay the flap back carefully (it acts as a biological dressing) without tension.
  • Adhesive strips (not sutures — skin tears through) with gaps; non-adherent dressing; light compression bandage if arterial supply adequate (check pulses or ABPI); elevation.
  • Review in a few days (nurse-led wound clinic); plastic surgery for large or necrotic flaps (debridement and grafting).
  • Tetanus status.
• Skin tears (ISTAP classification) — similar principles; mark the flap direction on the dressing to avoid lifting it when changed.
• Also consider why they fell — falls assessment in older people.

Abscesses and Paronychia

• Skin abscess — fluctuant, tender, red swelling — Staphylococcus aureus (including PVL-producing strains — recurrent abscesses in household contacts, sports teams — screen and decolonise).
• Treatment — incision and drainage (local or general anaesthetic), break loculations, irrigate, pack only if large (packing is painful and often unnecessary); antibiotics only if surrounding cellulitis, systemic features, immunosuppression, diabetes, or sites where drainage is incomplete.
• Caution:
  • Groin swelling in people who inject drugs — could be a femoral artery pseudoaneurysm — ultrasound before incision (catastrophic bleeding risk).
  • Perianal abscess — usually needs surgical drainage (fistula risk; Crohn's).
  • Breast abscess — ultrasound-guided aspiration (breast team).
  • Pilonidal abscess — surgical drainage.
  • Facial abscesses in the "danger triangle" — cavernous sinus thrombosis risk.
  • Diabetes — check glucose; deep infection.
• Paronychia (nail fold infection) — acute: Staph aureus — warm soaks; drain pus by lifting the nail fold (digital block); antibiotics if cellulitis; chronic paronychia — candida, wet work, eczema.
• Felon — pulp space infection of the fingertip — tense, very painful — surgical drainage.
• Herpetic whitlow (HSV) — vesicles on the finger — don't incise (spreads infection) — aciclovir if early.

Minor Burns and When to Refer

• First aid — stop the burning; cool running water for 20 minutes (effective up to 3 hours after injury); remove jewellery and clothing (unless stuck); cover with cling film (loosely — not wrapped round limbs); keep the patient warm; analgesia.
• Assess — mechanism (scald, flame, contact, chemical, electrical), time, size (% total body surface area), depth, special areas, inhalation injury, safeguarding.
• Size — Lund and Browder chart (most accurate — adjusts for children's larger heads); the patient's palm with fingers ≈ 1% TBSA (small or patchy burns); Rule of Nines (adults — rough). Don't include simple erythema (epidermal burns).
• Depth:

  Depth	Appearance	Sensation and healing
  Epidermal (superficial)	Red, dry, no blisters (sunburn)	Painful; heals in about 7 days
  Superficial partial thickness	Pink, moist, blisters, blanches with brisk refill	Very painful; heals in about 2 weeks without scarring
  Deep partial thickness	Blotchy red or pale, may blister, sluggish or absent refill	Reduced sensation; slow healing, scarring — often needs grafting
  Full thickness	White, waxy, leathery, brown or charred; no blanching	Painless; won't heal without grafting (except very small)

• Refer to a burns service (National Burn Care Referral Guidance) — e.g.:
  • Partial-thickness burns of 3% TBSA or more in adults or 2% or more in children; any full-thickness burn over 1%.
  • Special areas — face, hands, feet, genitalia, perineum, major joints; circumferential burns.
  • Chemical, electrical (high voltage) and inhalation injuries; burns with trauma.
  • Extremes of age, significant comorbidity, pregnancy, burns not healed in 2 weeks.
  • Suspected non-accidental injury — immersion scalds with clear "glove and stocking" margins, cigarette burns, pattern contact burns.
• Minor burn care — clean, leave small blisters intact (deroof large or tense blisters per local policy), non-adherent dressing, review at 48 hours (depth becomes clearer); analgesia; tetanus; no routine antibiotics.
• Major burns (fluid resuscitation over 15% in adults and 10% in children, airway burns, escharotomy) — see the Major Trauma and Burns page.

Hand Injuries

• History — hand dominance, occupation and hobbies (musicians, manual workers), mechanism (glass, knife, crush, bite, high-pressure gun), time.
• Examine systematically (before anaesthesia):
  • Posture — a finger out of the normal flexion cascade suggests a flexor tendon injury.
  • Flexor digitorum profundus — flex the DIP joint with the PIP held straight.
  • Flexor digitorum superficialis — flex the PIP with the other fingers held in extension.
  • Extensor tendons — extension against resistance (partial tears can still move).
  • Digital nerves — light touch and two-point discrimination on each side of the finger pulp (normal under 6 mm); sweating (a cut nerve leaves dry skin).
  • Median, ulnar and radial nerves — motor and sensory; vascular — colour, capillary refill, Allen's test.
• Refer to hand surgery — tendon, nerve or arterial injury; open fractures; fight bites; joint penetration; flexor sheath infection; high-pressure injection; amputations (keep the amputated part wrapped in saline-moistened gauze in a sealed bag on ice — not directly on ice).
• Fingertip injuries — small pulp loss (under 1 cm², no bone exposed) heals by secondary intention with dressings; larger or bone exposed — hand surgeons.
• Nail bed injuries — subungual haematoma (painful) — trephine (heated paperclip or needle) if the nail is intact and adherent, regardless of size; nail avulsion or disrupted nail fold — nail bed repair (hand surgeons); underlying tuft fracture is an open fracture (antibiotics).
• Mallet finger — extensor tendon avulsion at the DIP (finger "drop") — continuous extension splint for 6–8 weeks (never remove it, even to wash — support the finger flat); X-ray for bony fragment.
• Ring removal — swollen fingers — string technique or ring cutter (before swelling worsens and threatens circulation).
• Boxer's fracture (fifth metacarpal neck) — check rotation (fingers should point to the scaphoid on flexion — scissoring indicates malrotation) and for fight bite wounds.

Hand Infections and High-pressure Injection

• Flexor tendon sheath infection — a surgical emergency (tendon necrosis, spread to palm) — Kanavel's signs:
  • Fusiform (sausage-shaped) swelling of the finger.
  • Finger held in slight flexion.
  • Tenderness along the flexor sheath.
  • Pain on passive extension (the most sensitive sign).
  — IV antibiotics (flucloxacillin, or co-amoxiclav after bites), elevation, urgent hand surgery for washout.
• Deep palmar space infection and septic arthritis — surgery.
• Fight bite — wound over MCP joint from a punch — assume joint penetration — X-ray, washout in theatre, co-amoxiclav.
• High-pressure injection injury (paint guns, grease guns, hydraulic lines, diesel injectors):
  • Small, innocent-looking entry wound but material tracks widely along tissue planes → chemical inflammation, ischaemia, infection — high amputation rates if treatment is delayed.
  • Emergency hand surgical referral for urgent debridement — don't be falsely reassured by the small wound or lack of initial pain; X-ray may show radiopaque material or air; no digital blocks with adrenaline; elevate, analgesia, antibiotics, tetanus.
• Necrotising fasciitis of the hand or arm (injecting drug users, diabetes) — pain out of proportion — emergency surgery.
• Orf and milker's nodules (sheep and cattle handlers) — self-limiting viral nodules.

⚠️ Safety Pearl: Three hand injuries look trivial and are not — a small cut over a knuckle after a punch (fight bite), a tiny puncture from a paint or grease gun (high-pressure injection), and a swollen, flexed, tender finger that hurts when straightened (flexor sheath infection). All three need same-day hand surgery.

Sprains and Soft Tissue Injuries

• Sprain — ligament injury (grade I stretch, II partial tear, III complete); strain — muscle or tendon injury.
• Ankle sprain — commonest — inversion injury of the lateral ligaments (anterior talofibular); Ottawa ankle rules decide on X-ray; check the proximal fibula (Maisonneuve), base of the fifth metatarsal, Achilles tendon; syndesmosis ("high ankle") sprains heal more slowly.
• Management of soft tissue injury:
  • PRICE (or POLICE — Protection, Optimal Loading, Ice, Compression, Elevation) in the first 48–72 hours; avoid HARM (Heat, Alcohol, Running, Massage) early.
  • Early mobilisation and weight-bearing as tolerated; functional support (tubigrip has little evidence; brace for severe sprains); physiotherapy for recurrent instability.
  • Analgesia — paracetamol, topical or oral NSAIDs (short course).
  • Recovery — 2–6 weeks for most ankle sprains; longer for severe injuries.
• Achilles tendon rupture — sudden pain like being kicked in the heel, during sport; palpable gap; Simmonds' (Thompson's) test positive (squeezing the calf doesn't plantarflex the foot) — weak plantarflexion may still be possible — immobilise in equinus (boot with wedges) and refer to fracture clinic; risk with fluoroquinolones and steroids.
• Knee injuries — rapid effusion within hours (haemarthrosis) — ACL tear, fracture, patellar dislocation; slow effusion over a day — meniscal tear; locking — meniscus; Ottawa knee rules; knee immobiliser short term, crutches, fracture or soft tissue knee clinic follow-up; MRI later.
• Muscle injuries — hamstring tears, calf "tennis leg" (medial gastrocnemius) — exclude DVT if uncertain.
• Compartment syndrome — pain out of proportion, pain on passive stretch — can follow crush injuries, fractures, tight casts, prolonged lie — emergency fasciotomy.

Foreign Bodies

• Nose (children) — unilateral foul-smelling discharge suggests a retained foreign body; removal — "parent's kiss" (positive pressure via the mouth while blocking the other nostril), suction, hooks or forceps; button batteries and magnets in the nose are urgent (septal necrosis).
• Ear — insects (drown with olive oil first), beads, cotton wool — removal under direct vision with hooks or suction; avoid pushing deeper; button batteries — urgent ENT (don't irrigate).
• Swallowed foreign bodies:
  • Button batteries — oesophageal impaction is an emergency (caustic burns within 2 hours — perforation, aortic fistula) — X-ray ("halo" or double ring), urgent endoscopic removal; give honey (children over 1 year) en route if swallowed within 12 hours (if it won't delay removal).
  • Multiple magnets (or magnet plus metal) — can attract across bowel walls — perforation — urgent surgical review.
  • Coins — usually pass if beyond the oesophagus; oesophageal coins need removal (persistent symptoms, over 24 hours).
  • Sharp objects and long objects — endoscopy or surgical review.
  • Food bolus obstruction (unable to swallow saliva) — urgent endoscopy within 24 hours (sooner if complete obstruction) — underlying eosinophilic oesophagitis or stricture; IV hyoscine or glucagon has little evidence.
  • Body packers — CT; never remove packets endoscopically (rupture); toxicity — surgery.
• Inhaled foreign body (children, older people with dysphagia) — choking episode, unilateral wheeze, recurrent pneumonia — chest X-ray (often normal; hyperinflation on the affected side) — bronchoscopy; choking — back blows and abdominal (or chest) thrusts.
• Soft tissue foreign bodies — glass (usually radiopaque — X-ray), metal, wood (ultrasound) — remove if accessible, causing symptoms, or near joints and tendons; ultrasound-guided removal.
• Rectal and vaginal foreign bodies — sensitive approach; X-ray; perforation risk; surgical or gynaecological removal; tampons — toxic shock.
• Fish hooks — advance-and-cut or string-yank techniques.

Minor Eye Injuries and Chemical Splashes

• Visual acuity first — every eye injury (unless a chemical injury — irrigate first).
• Chemical injury — emergency:
  • Irrigate immediately with at least 1–2 litres of saline or water (topical anaesthetic first, lid speculum, evert the lids, sweep the fornices) until pH is 7–7.5 (check 5 minutes after stopping); remove particles.
  • Alkalis (cement, plaster, oven cleaner, ammonia) penetrate deeply and cause worse damage than acids.
  • Same-day ophthalmology — limbal ischaemia (white eye) is a bad sign.
• Corneal abrasion — pain, watering, foreign body sensation, photophobia — fluorescein staining; chloramphenicol ointment (prophylaxis), analgesia; no eye patch; heals in 24–72 hours; contact lens wearers — antipseudomonal drops (quinolone) and stop lens wear; vertical linear abrasions — look for a foreign body under the upper lid (evert it).
• Corneal foreign body — remove under the slit lamp with a needle or burr after topical anaesthetic; rust ring — remove (same day or within 24 hours); chloramphenicol; follow-up.
• Penetrating eye injury — suspect with high-velocity fragments (hammering metal on metal, grinding without goggles), sharp objects — signs: reduced vision, teardrop or peaked pupil, shallow anterior chamber, positive Seidel test (aqueous leak dilutes fluorescein), visible prolapse — shield the eye (no pressure), no drops, nil by mouth, antiemetic, IV antibiotics, tetanus, CT orbits (not MRI if metal) — emergency ophthalmology.
• Arc eye (UV keratitis — welders, sunbeds, snow) — severe pain and photophobia 6–12 hours after exposure, both eyes, punctate staining — analgesia, lubricants, cycloplegic; heals in 24–48 hours; don't give topical anaesthetic to take home.
• Hyphaema (blood in the anterior chamber after blunt trauma) — ophthalmology (raised IOP, rebleeding, sickle cell).
• Orbital blowout fracture and retrobulbar haemorrhage (proptosis, tense orbit, reduced vision, RAPD after trauma — lateral canthotomy within 90 minutes) — see Ophthalmology.
• Lid lacerations through the margin or near the medial canthus — ophthalmology repair.

Dental Injuries

• Avulsed permanent tooth — a dental emergency (outcome depends on time out of the socket):
  • Hold by the crown (not the root).
  • If dirty, rinse briefly in milk, saline or cold running water (don't scrub).
  • Replant immediately into the socket (the right way round) and have the patient bite on gauze or a handkerchief.
  • If replanting isn't possible, store in milk (or saliva — in the cheek of a cooperative adult, or saline) — not water.
  • See a dentist as soon as possible (ideally within 60 minutes) — splinting; antibiotics and tetanus.
• Primary (baby) teeth — don't replant (risk of damaging the permanent tooth bud); dental review.
• Fractured teeth — pink or bleeding pulp exposure — urgent dentist; small enamel chips — routine.
• Missing teeth or fragments — consider aspiration (chest X-ray) or embedded in the lip (soft tissue X-ray).
• Dental abscess — dental treatment; antibiotics (phenoxymethylpenicillin or amoxicillin, metronidazole) if spreading or systemic; Ludwig's angina (floor of mouth swelling, raised tongue, drooling, trismus) — airway emergency.
• Mandible fractures — malocclusion, step, numb lip (inferior alveolar nerve) — OPG X-ray; maxillofacial surgery (open if through tooth sockets — antibiotics).
• Temporomandibular joint dislocation — mouth stuck open — manual reduction.

Minor Injuries at a Glance

Injury	Key management
Simple laceration	Examine nerves and tendons, irrigate, explore, close (glue, strips, sutures); remove sutures — face 3–5, scalp and trunk 7–10, legs 10–14 days
Lidocaine	Max about 3 mg/kg plain, 7 mg/kg with adrenaline; LAST — Intralipid
Tetanus	Vaccine if not up to date; HTIG for tetanus-prone wounds if unknown status, or high-risk wounds
Cat bite or human bite	Irrigate; co-amoxiclav prophylaxis 3 days
Bat bite (UK) or animal bite abroad	Rabies — UKHSA advice, vaccine ± immunoglobulin
Fight bite	Hand surgeons — washout; co-amoxiclav
Pretibial laceration	Steri-Strips, lay flap back, compression, elevation
Abscess	Incision and drainage; antibiotics only if cellulitis or systemic; groin in IDU — ultrasound first
Minor burn	Cool running water 20 minutes; cling film; refer 3%+ adult, 2%+ child, special areas, full thickness
Flexor sheath infection	Kanavel's signs — IV antibiotics, urgent surgery
High-pressure injection	Emergency hand surgery
Mallet finger	Continuous extension splint 6–8 weeks
Subungual haematoma	Trephine
Ankle sprain	Ottawa rules; POLICE; early mobilisation
Achilles rupture	Simmonds' test; equinus boot; fracture clinic
Button battery	Oesophageal — remove within 2 hours; honey en route (over 1 year)
Chemical eye injury	Irrigate first — until pH 7–7.5
Penetrating eye injury	Shield, no pressure, CT orbits, emergency ophthalmology
Avulsed adult tooth	Replant now or store in milk; dentist within 60 minutes

Spot the Diagnosis

Clue	Diagnosis
Glass cut on the palm; can't bend the fingertip with the middle joint held straight	Flexor digitorum profundus division
Knife cut on the side of a finger with dry, numb skin on one side of the pulp	Digital nerve injury
Small cut over the 4th knuckle after a pub fight	Fight bite — joint penetration likely
Swollen, flexed index finger that hurts when straightened	Flexor tendon sheath infection
Tiny wound on the fingertip from a paint spray gun; little pain	High-pressure injection injury
Fingertip drooping after the finger was hit by a ball	Mallet finger
Throbbing black nail after shutting a finger in a door	Subungual haematoma — trephine
Rapidly spreading cellulitis 12 hours after a cat bite	Pasteurella multocida
Bat bit a man in his loft in Yorkshire	Bat lyssavirus — rabies PEP via UKHSA
Flap laceration on the shin of an 85-year-old on prednisolone	Pretibial laceration — strips and compression
Fluctuant groin swelling in a man who injects drugs	Possible pseudoaneurysm — ultrasound before incising
Painful vesicles on a nurse's fingertip	Herpetic whitlow — don't incise
Toddler scald with sharp "glove" margins on both hands	Immersion injury — safeguarding
White, leathery, painless burn on the forearm	Full-thickness burn — refer
Felt like a kick to the heel while playing squash; calf squeeze doesn't move the foot	Achilles tendon rupture
Knee swollen within 1 hour after a twisting injury	Haemarthrosis — ACL tear
Child with unilateral smelly nasal discharge	Nasal foreign body
Double-ring opacity on the chest X-ray of a toddler	Button battery
Welder with both eyes very painful the night after work	Arc eye (UV keratitis)
Teardrop pupil after hammering metal	Penetrating eye injury
Cement splashed in the eye	Alkali injury — irrigate immediately

Exam-style Scenarios

1. A 25-year-old man punched someone in the mouth 2 days ago. He now has a red, swollen right hand with a 5 mm wound over the 3rd MCP joint.
Answer: Infected fight bite with probable MCP joint involvement.

• X-ray (fracture, tooth fragment, gas); bloods if systemically unwell.
• Urgent hand surgery — exploration and washout in theatre.
• IV co-amoxiclav; elevation; tetanus; blood-borne virus risk assessment.

2. A 40-year-old painter has a 2 mm puncture wound on his index finger from a high-pressure paint gun 1 hour ago. He has minimal pain.
Answer: High-pressure injection injury.

• Emergency hand surgery referral — urgent debridement (high amputation risk if delayed).
• Elevate, analgesia (avoid digital block with adrenaline), X-ray, IV antibiotics, tetanus.
• Don't discharge with follow-up "if it gets worse".

3. A 4-year-old was bitten on the cheek by the family dog. There is a 2 cm laceration through the skin.
Answer: Facial dog bite in a child.

• Thorough irrigation; close primarily (face) — often by plastics (cosmetic outcome, possible sedation or GA).
• Co-amoxiclav prophylaxis (high-risk site); tetanus check.
• Consider safeguarding and dog safety advice; police notification if dangerous dog.

4. A builder got wet cement in his right eye 15 minutes ago. The eye is red and painful.
Answer: Alkali chemical injury — emergency.

• Immediate irrigation (topical anaesthetic, at least 1–2 L of saline, evert lids, remove particles) until pH 7–7.5 — check pH 5 minutes after stopping.
• Then visual acuity and fluorescein examination.
• Same-day ophthalmology (limbal ischaemia, corneal damage).

5. A 30-year-old woman has a 6 cm clean laceration on her forearm from a kitchen knife. Neurovascular and tendon function are normal. She had her last tetanus vaccine at school and has had 4 doses in total.
Answer: Simple laceration; tetanus primary course incomplete.

• Lidocaine (within maximum dose), irrigation, exploration through range of movement, closure with interrupted sutures.
• Clean wound with incomplete immunisation — give a reinforcing tetanus vaccine dose (Td/IPV) and arrange completion of the course.
• Suture removal at 7–10 days; wound care advice and infection safety-netting.

Key Points

• Examine nerves, tendons and circulation before local anaesthetic; explore wounds through full range of movement.
• X-ray for glass; ultrasound for wood and plastic.
• Lidocaine max about 3 mg/kg (7 mg/kg with adrenaline); treat LAST with lipid emulsion.
• Irrigation prevents infection; most clean wounds don't need antibiotics.
• Know tetanus-prone wounds and the Green Book table — vaccine and HTIG.
• Bites — irrigate, leave open (except face), co-amoxiclav for cat bites, human bites and high-risk dog bites.
• Bat bites in the UK and animal bites abroad — rabies advice from UKHSA.
• Pretibial lacerations — strips, not sutures; compression and elevation.
• Abscesses — incision and drainage; beware groin pseudoaneurysms in IDUs; don't incise herpetic whitlows.
• Burns — cool running water 20 minutes; refer 3%+ adult, 2%+ child, special areas, full thickness, chemical, electrical, NAI.
• Fight bites, high-pressure injection and flexor sheath infection need same-day hand surgery.
• Mallet finger — continuous extension splint 6–8 weeks.
• Button batteries in the oesophagus — remove within 2 hours.
• Chemical eye injury — irrigate before anything else; penetrating injury — shield and CT.
• Avulsed permanent tooth — replant or store in milk; never replant baby teeth.

Guidelines and Further Reading

• UKHSA: Immunisation against infectious disease (Green Book) — chapter 30 (tetanus) and chapter 27 (rabies); rabies post-exposure treatment guidance
• NICE NG184: Human and animal bites — antimicrobial prescribing
• British Burn Association / National Network for Burn Care: National burn care referral guidance; first aid for burns
• British Society for Surgery of the Hand (BSSH): Hand injury standards; BOAST open fractures
• Royal College of Emergency Medicine: Best practice guidance — wound management, button batteries, eye injuries
• Association of Anaesthetists: Management of severe local anaesthetic toxicity
• International Association of Dental Traumatology: Guidelines for avulsed teeth
• BNF — for current doses