Extremity trauma

Limb injuries following trauma are extremely common ED presentations.

 

Some limb injuries can be life threatening

  • External exsanguination from arterial bleeding
  • “internal bleeding” from femoral or other long bone fractures
    • an adult can bleed 1.5L from a single femoral fracture
  • crush syndrome

 

Other limb injuries are “limb” threatening

  • mangled limbs and amputations
  • neurovascular injuries
  • compound fractures
  • compartment syndrome from crush injures, fractures, burns
  • degloving injuries

 

Note that in multitrauma patients, a seemingly “minor” missed injury (eg: base of thumb fracture) can lead to significant morbidity and may prevent the patient from returning to full capacity.

This is why a thorough secondary and tertiary survey is essential after life and limb threats have been identified and treated.

 

Principles of management

 

Address immediate life-threatening injuries

 

External exsanguination

Exsanguinating haemorrhage from extremity trauma should be managed as a priority during the primary survey.

Many trauma providers advocate a “CABC” approach with the first “C” being – control external exsanguination.

 

If extremity bleeding cannot be stopped with firm direct pressure, a tourniquet should be applied. The most commonly utilised tourniquet in the Northern Region is the “CAT” (combat application tourniquet) http://www.combattourniquet.com/

 

Principles of tourniquet application

  • cut off clothes from the affected limb
  • apply a few centimetres proximal to the wound
  • don’t apply over a joint
  • tighten until bleeding is controlled
  • note the time of application
  • if still bleeding – place a 2nd tourniquet proximally

 

A tourniquet should only be left on for 2 hours before it needs to be released to allow perfusion of the distal limb.

Be prepared to apply direct pressure to the bleeding area after release of the tourniquet.

Provided that direct pressure can adequately control any bleeding, the tourniquet should be kept off for 20 minutes.

The tourniquet can be reapplied if bleeding is an ongoing concern.

 

At MIDDLEMORE HOSPITAL: If a tourniquet is  required for haemorrhage control a RED BLANKET should be initiated in consultation with the on-call Vascular & Plastic Surgeon.

Long bone fractures

Early reduction of long bone fractures will decrease bleeding by bringing the bony ends together. In terms of volume of blood loss, this is most important for femoral fractures. Various traction devices are available. Reduction of fractures is extremely painful – give adequate analgesia/sedation and consider utilising regional nerve blocks (eg: femoral nerve block)

 

Treat crush syndrome

Crush syndrome (aka: “release syndrome”) occurs when a body part is released after a period of entrapment. In general, one limb needs to be crushed for 1 hour for this to occur.

Release causes the circulation to be flooded with lactate, potassium and vasoactive oxygen free radicals from the injured cells and can trigger lethal cardiac dysrhythmias and hypovolaemic shock. Release of myoglobin can cause acute kidney injury.

Treating crush syndrome will usually be a pre-hospital consideration (immediately after the affected area is released) but patients may arrive to ED following extrication with limb tourniquet in situ (placed pre-hospital to limit the effects of crush syndrome from a released limb) or have ongoing sequelae from release.

 

Initial management of crush syndrome

  • IV fluids to maintain urine output 2-3ml/kg/hr
  • Treat hyperkalaemia
    • 10ml 10% calcium gluconate boluses over 2-5 minutes
    • 10U actrapid insulin in 500ml 10% dextrose (or 50ml 50% dextrose)
    • Salbutamol nebulisers 5mg
    • Sodium bicarbonate 1 mmol/kg

 

Address limb threatening injuries

 

Mangled limbs and amputation

Mangled limbs can be defined as “any extremity sustaining sufficiently severe injury to a combination of vascular, bony, soft tissue and/or nerve structure that results in subsequent concern for viability of the limb”1

Mangled limbs need to be assessed for viability and urgently referred to an appropriate facility after other life threats have been addressed (see Mangled limbs – destination guidelines)

Amputations can be partial or complete. Some upper limb complete amputations can be replanted – in general there is a 6 hour “cold ischaemia” window to reattach (though may be longer in some circumstances). Incomplete amputations are more time sensitive than complete amputations.

 

Management of complete amputations

Handle the amputated part with care – do not debride. Irrigate with normal saline and wrap loosely in saline soaked gauze. Place in a water tight bag then put bag into an ice slurry. Ice should never contact the amputated part directly. Label the part and the bag.

The stump portion should have bleeding controlled (may require a tourniquet), be irrigated and covered in saline soaked gauze. Treat with patient with antibiotics (as per “compound fractures – see below) and update tetanus as required.

After life threats have been identified and managed, refer as soon as possible to the appropriate surgical service.

 

Neurovascular injury

Following trauma, all limbs should have their neurovascular status assessed after resuscitation, warming and fracture reduction.

This involves checking

  • Pulses
    • If not immediately palpable, check using doppler
    • Note that a palpable pulse does not exclude arterial injury. Certain injury patterns (eg: knee dislocation – popliteal artery injury) should spark a high index of suspicion and further tests (eg: CTA run off) should be considered
  • Capillary return
  • Sensation
  • Motor power

 

The clinician should be aware of injury patterns that are associated with various neurovascular injuries eg:

  • Knee dislocation: popliteal artery injury.
  • Mid-shaft Humerus #: radial nerve injury

Compound fractures

Compound (aka: open) fractures place the patient at risk of osteomyelitis due to communication of the fracture site with the skin and soft tissues.

Management

  • Control haemorrhage
  • Reduce, washout and splint (with adequate analgesia/sedation)
  • Assess and document neurovascular status
  • Cover wound with moist dressing – please photograph first to avoid repeated exposure/innoculation
  • Antimicrobial cover as per local guidelines (the following is the draft antimicrobial guidelines from CMDHB)
MMH abx

 

  • Give tetanus toxin or immunoglobulin as indicated (open fractures are tetanus prone wounds)
  • Arrange operative washout and debridement
    • A 6 hour target time to theatre has traditionally been cited, but the window of safety may be longer (up to 24h) 2

 

Compartment syndrome

High pressures within a limb muscular compartment bound by fascia can lead to decreased tissue perfusion with subsequent irreversible nerve injury and muscle necrosis. Rhabdomyolysis and acute kidney injury can occur. Long term complications include ischaemic contractures.

In terms of crush injuries, the risk of traumatic rhabdomyolysis leading to myoglobinuria and acute kidney injury (and even sudden cardiac death on lifting off the offending item at the scene) is directly proportional to the number of limbs crushed. Central crushes have a high mortality. The treatment of myoglobinuria is fluids aiming for a urine output of 2-3ml/kg/hr. Haemodialysis may be required if the patient develops a severe AKI with persistent metabolic disturbance.

 

Causes of compartment syndrome include

  • Fractures (especially lower limb and forearm)
  • Crush injuries
  • Penetrating trauma
  • Burns (high voltage electrical)
  • Minor injuries in patients with bleeding diatheses or on anticoagulants

 

Symptoms and signs of compartment syndrome (the “P”s – note: not all need to be present to diagnose compartment syndrome)

  • Pain out of proportion to the apparent injury
    • The affected compartment usually feels “woody” and tense
    • This is the most sensitive sign, but beware of the ‘inaccessible patient’ eg: altered GCS/obtunded or intellectually impaired/non communicable patients
  • Pain on passive extension
    • an important early sign
  • Parasthesias (late)
  • Pallor and cool peripheries (late)
  • Diminished pulses (late)
  • Paralysis (late)

Investigations

  • Diagnosis is clinical but can be confirmed by measuring intracompartment pressures (eg: using a “Stryker” pressure gauge)
  • Check FBC, UEC, CK and urine myoglobin

Management

  • Remove constricting dressings
  • Reduce fractures
  • Treat pain
  • Elevate limb
  • Fasciotomy of the affected compartment is the definitive management

 

Degloving injuries

Degloving injuries occur when the skin and soft tissues are peeled away off the underlying fascia exposing the underlying structures (like taking off a glove). A common example is finger degloving caused by a ring which catches on a structure and pulls the skin away (eg: from swinging on a bar).

Note that it is possible to have a closed degloving injury (skin has been pulled off the underlying tissues but remains in situ)

The wounds should be irrigated and cloved in saline soaked gauze.

Antibiotics should be administered and tetanus updated.

Gently irrigate any detached skin and wrap in saline soaked gauze

Replantation of the skin might be possible – early referral to plastic surgery is essential (after other life threats have been identified and managed). Some patients may require grafts, flaps or amputation.

 

Disposition – interhospital transfer guidelines

 

Definitive destination will depend on the site and type of injury

 

k boi d

 

Whangarei

 

mmh

 

NSH WTH

 

ACH

 

References

  1. Scalea, T. M., DuBose, J., Moore, E. E., et al. (2012). Western Trauma Association Critical Decisions in Trauma: Management of the mangled extremity. J. Trauma, 72(1), 86-93.
  2. Srour M, Inaba K, Okoye O, Chan C, Skiada D, Schnüriger B, Trump M, Lam L, Demetriades D. Prospective evaluation of treatment of open fractures: effect of time to irrigation and debridement. JAMA surgery. 2015 Apr 1;150(4):332-6.

 

About this guideline

Published: February 2018

Updated: September 2018

Author: Emma Batistich

Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB

Review due: 2 years