Limb injuries following trauma are extremely common ED presentations.
Some limb injuries can be life threatening
Other limb injuries are “limb” threatening
Note that in polytrauma patients, a seemingly “minor” missed injury (eg: base of thumb fracture) can lead to significant long term disability.
Hence a thorough secondary and tertiary survey is essential after life and limb threats have been identified and treated.
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) https://www.narescue.com/combat-application-tourniquet-c-a-t-instructions.html
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
AT MIDDLEMORE HOSPITAL – if a tourniquet is required for haemorrhage control a RED BLANKET should be initiated in consultation with the on-call Vascular and/or Plastic/Hands (forearm, wrist or hand) 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 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 release limb) or have ongoing sequelae from release.
Initial management of crush syndrome
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. All upper limb mangled extremities that not in extremis (dying) need urgent discussion with the Hands/Plastics service at Middlemore hospital for consideration of salvage/replant. Severely mangled feet and distal tibiae can be assessed and potentially primarily amputated by the nearest Orthopaedic service in the first instance. They should have a low threshold for discussion with the on call Orthopaedic and Plastic surgical consultants at Middlemore Hospital for consideration of salvage. All other proximal lower leg injuries require referral to the appropriate service/destination (see below)
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 of the upper limb
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 (Hands/Plastics service)
Following trauma, all limbs should have their neurovascular status assessed after reduction of fracture, warming and resuscitation.
This involves checking
The clinician should be aware of injury patterns that are associated with various limb injuries eg:
Open (Compound) fractures
Compound (aka: open) fractures place the patient at risk of infection, repeat operation, eventual amputation and chronic disability due to communication of the fracture site with the outside world.
CMH Open Fracture Antibiotic Guideline
This table outlines empiric antibiotic coverage for immediate management of open fractures
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 also occur as a result. Long term complications include ischaemic contractures and disability.
In terms of crush injuries, the risk of traumatic rhabdomyolysis leading to myoglobinuria and acute kidney injury (and even sudden cardiac death) 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.
The presence of an open fracture does not exclude compartment syndrome occurring.
Causes of compartment syndrome include
Symptoms and signs of compartment syndrome (the “P”s)
Degloving injuries occur when the skin and soft tissues is 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). It is also common in mangled lower legs.
The wounds should be irrigated and covered 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.
It is possible to have a closed degloving injury where the overlying skin is still intact. They present with swelling, tenderness and fluctuance, but often little bruising. There is a risk of skin necrosis proportional to the size of the area affected and energy imparted. If no underlying fractures, it can be observed locally by the orthopaedic service and conservatively managed but can be discussed non-emergently as an acute referral with the on call Plastics referral.
Definitive destination will depend on the site and type of injury. Critical ischaemia of a limb is the most emergent element of an injury and takes precedence.
Soft tissue defects in lower limb fractures: