Soft Tissue Injury

Injury to muscle, tendon, ligament, or skin without fracture; encompassing sprains (ligament), strains (muscle/tendon), contusions, lacerations, and abrasions. Extremely common; management principles are guided by tissue type and injury grade.

Classified by structure and severity:

• Ligament sprain: Grade I (mild stretch, no instability), Grade II (partial tear, some instability), Grade III (complete tear, gross instability)

• Muscle/tendon strain: similarly graded I-III by extent of fiber disruption

• Wounds: laceration (irregular edges, blunt force), incision (clean edges, sharp), abrasion (superficial, friction), puncture (deep, narrow track; high infection risk)

• Pain, swelling, bruising, reduced range of motion or function at the site

• Ligament injury: joint line tenderness, laxity on stress testing (compare with the contralateral side), effusion if intra-articular

• Complete tendon rupture: palpable gap, loss of specific function; e.g. Achilles rupture, unable to plantarflex against resistance, positive Thompson/Simmonds test (no plantarflexion on calf squeeze)

• Wound assessment: depth, contamination, foreign body, neurovascular or tendon involvement distal to the wound, time since injury (golden period for primary closure ~6-8 hours for non-facial wounds, longer for the face given vascularity)

• Red flags: compartment syndrome in significant crush/contusion injury, signs of underlying fracture (point bony tenderness, inability to weight-bear, apply Ottawa rules), neurovascular compromise, retained foreign body or deep structure involvement

• Primarily clinical assessment
• Ottawa ankle/foot rules: X-ray indicated if pain in the malleolar zone plus either bony tenderness at the posterior tip/edge of either malleolus, or inability to weight-bear 4 steps immediately and in the ED
• Ottawa knee rules: X-ray if age ≥55, isolated patellar tenderness, fibular head tenderness, inability to flex to 90°, or inability to weight-bear 4 steps
• Ultrasound: tendon rupture confirmation, muscle tear grading, foreign body localization
• MRI: definitive assessment of ligament/tendon integrity if surgical planning needed or diagnosis unclear
• Wound exploration under adequate anesthesia: assess for foreign body, tendon/nerve injury, joint penetration

Sprains and strains (Grade I-II):

• RICE: Rest, Ice (15-20 min several times daily for the first 48-72h), Compression, Elevation

• Analgesia: NSAIDs (topical or oral) and/or paracetamol

• Early mobilization once acute pain settles;functional rehabilitation is superior to prolonged immobilization for most sprains, improving outcomes and reducing stiffness

• Physiotherapy for rehabilitation and proprioceptive training, especially ankle sprains (reduces recurrence)

Grade III complete tears/ruptures:

• Immobilize, urgent orthopedic/sports medicine referral ; surgical repair often indicated (ACL rupture in active individuals, Achilles rupture, complete collateral ligament tears with instability)

• Non-operative management (cast/brace) is an option for some complete ruptures depending on patient factors and functional demands

Wound management:

• Irrigation: copious saline irrigation, remove visible debris and foreign material

• Primary closure: sutures/staples/adhesive for clean wounds within the golden period with low contamination risk

• Delayed primary closure or healing by secondary intention: heavily contaminated wounds, bite wounds (except selected facial bites), wounds >12-24 hours old, puncture wounds

• Tetanus prophylaxis: booster if >10 years since last dose (>5 years for tetanus-prone wounds), immunoglobulin plus vaccine if unimmunized or uncertain with a tetanus-prone wound

• Antibiotics: not routine for clean simple lacerations; indicated for bite wounds, heavily contaminated wounds, devitalized tissue, immunocompromised patients, and wounds involving joints/tendons/bone

• Foreign body: remove if identified; X-ray or ultrasound if suspected but not visualized (glass is usually visible on X-ray)

Referral: orthopedics/sports medicine for complete ligament or tendon rupture, plastics/hand surgery for tendon or nerve injury and complex facial/hand lacerations, urgent surgical exploration for suspected joint penetration.