West Indies wicketkeeper Shane Dowrich was replaced by Joshua Da Silva after taking a blow to the face on day three as England strengthened their grip on the decisive third Test.
Jason Holder (46) and Dowrich (47) ensured the Windies avoided the follow-on, but Stuart Broad (6-31) took all four wickets in the morning session to dismiss them for 197.
There was more pain for the tourists after England started their second innings with a lead of 162 at Old Trafford, Holder the first to be in pain after being struck on the thumb.
The captain was able to continue, but Dowrich went off the field after a short delivery from Shannon Gabriel went through his gloves and appeared to hit him in the face.
Shai Hope initially took the gloves before the uncapped Da Silva, who will not be able to bat in the second innings, came on to take his place and soon missed a chance to stump Rory Burns.
England were 50 without loss in the afternoon session, leading by 222 runs as they bid to regain the Wisden Trophy, knowing rain is likely to wipe out day four.