Extremities trauma

Section: Trauma Curriculum: Curriculum, page 81

Basics

• If unstable - Surgery
• If not and suspicious - Image

Management

• Life saving
  • Pressure bandage or tourniquet - Ongoing external bleeding
  • Detect other sources of bleeding
• Limb saving
  • Assess limb injuries - note distal perfusion
  • Early ortho and plastics involvement
  • Fasciotomy
  • Restore impaired circulation
  • Cover open wounds with sterile dressing
  • Abx and tetanus
  • Debridement of devitalised tissue
  • Restore skeletal stability
  • Temporary wound closure
  • Rehabilitation
• Successful limb salvage
  • Defined by patient - overall satisfaction and functionality

Extremity Vascular Injury

• Steps
  • Ischaemia initial assessment
  • Exploration of the vessels
  • Fasciotomy - if needed or if there is doubt
  • Temporary stenting of vein and artery
  • Temporary orthopaedic fixation of skeletal damage
  • Definitive repair of vascular damage
• Options to manage vascular damage
  • Repair
  • Replace - graft
  • Shunt
  • Stent
  • Ligate and bypass
• Signs of Vascular Compromise
  • Hard signs (warrant exploration without imaging)
    • Loss of distal pulse (pulse deficit)
    • Pulsatile bleeding
    • Expanding haematoma
    • Bruit
    • Thrill
    • Unilateral cool and pale peripheries
  • Soft signs
    • Pulsatile haematoma
    • False aneurysm
    • Continuous murmurs of AVF
    • Progressive swelling of an extremity
    • Unexplained ischaemia or dysfunction
• Assessment/Imaging
  • ABPI
  • Doppler USS
  • Duplex USS
  • CT angiogram

Mangled Limb Severity Score

• = MESS (MISA)
• Score stratifies risk of need for amputation vs limb salvage
• Ischaemia of limb with double points for duration

• 7 = Highly likely need amputation

Management

• Direct pressure
• Torniquet
• Clamping
• Abx
• Tetanus
• Surgery

Open Fractures

• Risk Factors for Infection
  • Severity of injury
  • Type of contamination
  • Delay from injury to surgical care (> 6hrs)
  • Failure to use prophylactic abx
  • Inappropriate wound toilet
  • Lack of coverage of bony structures
  • Inappropriate wound closure (e.g. primary closure in contaminated/contused wounds)
  • Open fracture wounds that are more likely to get infected

Gustilo Classification of Open Fractures

• Grades are from 1-3 with 3 being divided into A,B,C
• Higher grade correlates with a more severe open fracture which is more challenging to manage, may require more invasive management and has a higher risk of morbidity/loss of limb

• Antibiotics
  • Just Staph cover for Grade 1 and 2
  • Grade 3 need broader cover
• Skeletal Fixation Timing in Polytrauma
  • Weak evidence that earlier fixation has better outcomes overall
  • Other option is ex fix and definitive surgery later (DCS/DCO)
• Scores
  • Many scores exist to grade mangled limbs
  • They focus largely on patient stability, age, comorbidities, and limb information
  • Injuries to bone, vessel, soft tissue, nerve
  • Scores should not be the mainstay of mx decisions

Compartment Syndrome

• 5 P’s are all late signs
  • Pain on passive flexion, pulseless, pallor, paraesthesia, paralysis (poikilothermia)
• Difficult to assess in ICU pts - Can measure compartment pressure

  • 30mmHg = Compartment syndrome

  • Have a low index of suspicion to dx and treat with fasciotomy
• Fasciotomy should be first done while trying repair vessel
  • Fasciotomy
    • Lower leg = 2 incision and 4 compartment
      • Lateral
        • 2cm below Fibula Head (anterolateral) all the way down to Lateral Malleolus
        • Need to open the anterior and lateral compartments on either side of the septum
        • Avoid the Common Peroneal Nerve at Fibula head
      • Medial
        • 2cm medial and below Tibial Tuberosity to 2cm above the Medial Malleolus
        • Need to open deep and superficial compartments
        • Avoid the Great Saphenous Vein

Complications of major limb injury

• Skin/soft tissue - Scarring, infection, need for grafts, compartment syndrome
• Bone - Mal-union, non-union, delayed union, infection
• Nerve - Direct or ischaemic injury with functional loss
• Vascular - DVT
• Joint - Poor mobility, arthritis
• Other - Chronic pain, psych