Dr.Otman Siregar SpOT.

(K)Spine
April 2009
Limb Threatening Injuries
Can be caused by:
 MVA
 Occupational accident
 Domestic accident

 Open injury
 Closed injury
Limb Threatening Injuries
 Is an emergency
situation
 Need accurate diagnosis
and prompt treatment
Limb Threatening Injuries
 Fracture
- Open fracture
- Closed Fracture
 Vascular Injury
 Compartment syndrome
Fracture
 Definition:
structural break in
continuity weather of a
bone, an epiphyseal
plate, or a cartilaginous
joint surface

 Fracture also mean soft

tissue injury
Fracture
 The causative force that produces a fracture may be :
- Direct injury
- Indirect injury
Fracture Diagnosis
Patient History, ask about  Mechanism of injury:
 Pain - Fall
 Deformity - Direct blow
 Time of injury - Road accident
- Gun Shot Wound
- Often lack of detail
Fracture Diagnosis
 Always do Primary Survey (ABC)
 General condition
 Local Condition:
- Look
-Feel
-Move
 Principle: DO NO FURTHER HARM!
Fracture Diagnosis
Look:
 Local swelling
 Deformity ( angulations,
rotation, discrepancy)
 Discoloration of the skin
 Open wound (size,
margin, depth,
contamination)
Fracture Diagnosis
Feel
 Sharply localized tenderness
 Aggravation of pain and muscle spasm
 Crepitation not necessary
 Neurovascular Condition is important
 Always look and feel for other less apparent injuries
Fracture Diagnosis
Move
 Not necessary if the deformity is obvious
 Abnormal movement
 Usually ROM limited due to pain
Fracture Diagnosis
Special Test and measurement
 Allen test: vascular patency in forearm
 True, apparent, and anatomical length
 Drawer test ( is better to do it under anesthesia)
Diagnostic Imaging
 Immobilized the limb before being
subjected to imaging examination
 Plain X ray
 CT Scan
 MRI
 angiography
Diagnostic Imaging
X ray : Rules of two
 2 joint
 2 projection
 2 extremities (paediatric)
 2 densities (able to differ
hard and soft tissue)
Special projection may be
necessary
Diagnostic Imaging
 CT Scan and MRI can
provide useful additional
data especially for pelvis
and spinal injury
 Angiography is
performed if vascular
injury is suspected
 Doppler duplex
sonogram
Descriptive Term Pertaining to
Fractures
 Site
-diaphyseal, metaphyseal, epiphyseal or intraarticular
 Extent
- Complete or incomplete
 Configuration
-transverse, oblique or spiral
-comminuted or segmental
 Relationship of the fracture fragments to each other
-translated,angulated,rotated,distracted,overriding,
impacted
Descriptive Term Pertaining to
Fractures
 Relationship of the
fracture to the external
environment
-open or closed
 Complications
-uncomplicated or
complicated
Complications of Musculoskeletal
Injuries
Classified as :
 Initial (immediate) complications
- Local and Remote
 Early
-Local and remote
 Late complications
-Local and remote
Complications of Musculoskeletal
Injuries
Initial Complication:
 Local complication
-Skin injuries (from within or without)
-vascular injuries (artery or vein, division, contusion or
spasm)
-neurological injuries (brain, spinal cord, peripheral nerve)
-muscular
-visceral
 Remote complication
-multiple injuries and hemorrhagic shock
Complications of Musculoskeletal
Injuries
Early Complication
 Local complication
-Skin necrosis, gangrene,
compartment syndrome,
etc
-Joint complication (septic
arthritis)
-Bony complications
(Osteomyelitis or
avascular necrosis)
Complications of Musculoskeletal
Injuries
Early
 Remote Complications
-Fat embolism
-Pulmonary embolism
-Pneumonia
-Tetanus
-Delirium Tremens
Complications of Musculoskeletal
Injuries
Late Complications
 Local Complication
-Joint: stiffness, degenerative arthritis
-Bony: abnormal fr healing, growth disturbance, chronic
osteomyelitis
-Muscular :myositis ossificans, late rupture tendon
-Neurological : Tardy nerve plasy
Complications of Musculoskeletal
Injuries
Late
 Remote complications
-Renal calculi
-accident neurosis
 An open
fracture
indicates …

… a communications
between the fracture
and the external
environment …
Open Fractures

Classification

• Gustillo / Anderson 1976

• Oestern & Tscherne 1984

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Open Fx.

Gustillo / Anderson

• Gustillo I
• skin lesion < 1cm
• skin perforation inside out
• minimal muscle contusion
• simple fracture pattern

• Gustillo II
• skin lesion > 1cm
• limited soft tissue damage
• no degloving
• simple fracture pattern
Gustillo RB (1984) J Trauma;24:742-6
Open Fx.

Gustillo / Anderson

• Gustillo III A
• Extensive soft tissue damage (skin, muscles,
neurovascular strucures) with still sufficient
bone coverage (periosteum)

• Gustillo III B
• Extensive soft tissue damage with periosteal
detachment and exposed bone
• Massive contomination of the wound

• Gustillo III C
• Vascular injury to be reconstructed
 Gustillo I

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 Gustillo III A/B

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 Gustillo III C

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management
of open fx. Erfurt algorithm

• remove wound dressing only in OR

• foto documentation
• debridement
• fracture fixation (FixEx)
• leave the wound open or
• temporary wound coverage by
 skin substitute or
 vacuum therapy
Mechanisms of Vascular Injury in
the Extremities
 Gunshot wound – 54%
 Stab wound – 15%
 Shotgun wound – 12%
 Blunt trauma – 15%
 Iatrogenic – 3%
Presentation of Vascular Injury
 First priority is
hemorrhage
control followed by
appropriate
diagnostic work-up
Presentation of Vascular Injury
 Dislocations and
displaced or
angulated fractures:
realigned
immediately if
vascularity is
compromised
Evaluation for Vascular Injury
 Physical Examination
 Doppler Flowmeter
 Duplex Ultrasonography
 Arteriogram
 Local wound exploration should not be
done in an uncontrolled setting
 Close coordination with a general or
vascular surgeon recommended
Physical Examination
Hard Signs

 Absent or diminished distal pulses

 Active hemorrhage
 Large, expanding or pulsatile hematoma
 Bruit or thrill
 Distal ischemia (pain, pallor, paralysis,
paresthesias, coolness)
Physical Examination
Soft Signs

 Small, stable hematoma

 Injury to anatomically related nerve
 Unexplained hypotension
 History of hemorrhage no longer present
 Proximity of injury to major vessel
Doppler Examination
 Non-invasive adjunct to physical examination
 Small, hand-held (non-directional) Doppler
flowmeter provides for subjective interpretation of
audible signal
 Useful as modality for determining the Ankle-
Brachial Index (ABI)
Arteriography
 Gold standard for evaluation of peripheral vascular
injuries
 Formal arteriograms done in radiology may cause
critical delays in diagnosis or intervention
 Single-shot arteriograms done in the emergency
room or operating room should be considered in
cases where arteriography is indicated.
Indications for Arteriography
 Multiple potential sites of injury (shotgun wounds)
 Missile track parallels vessel over long distance
 Blunt trauma with signs of vascular trauma
 Chronic vascular disease
 Extensive bone or soft tissue injury
 Thoracic outlet wounds
 Evaluation of equivocal results from non-invasive
tests
 Proximity (gsw, knife wound) (controversial)
 ABI < .9
Single-shot Arteriogram in the
Emergency or Operating Room
Compartment Syndrome
Definition
 Elevated tissue pressure within a closed
fascial space
 Reduces tissue perfusion
 Results in cell death
 Pathogenesis
 Too much inflow (edema, hemorrhage)

 Decreased outflow (venous obstruction, tight

dressing/cast)
Compartment Syndrome
Historical Review

 Late complications of ischemic contracture

 Volkmann, 1881
 Ischemia of forearm
venous stasis leading
to irreversible contracture
 Ellis, 1958; Seddon, 1966
 Lower extremity

 Retrospective reviews
 Advised the early recognition of the syndrome and
fasciotomies of the affected limbs
Compartment Syndrome
Tissue Survival

 Muscle
 3-4 hours - reversible changes
 6 hours - variable damage
 8 hours - irreversible changes
 Nerve
 2 hours - looses nerve conduction
 4 hours - neuropraxia
 8 hours - irreversible changes
Compartment Syndrome
Etiology

 Fractures-closed and open  Exertional states

 Blunt trauma  GSW
 Temp vascular  IV/A-lines
occlusion  Hemophiliac/coag
 Cast/dressing  Intraosseous IV(infant)
 Closure of fascial  Snake bite
defects  Arterial injury
 Burns/electrical
Compartment Syndrome
Diagnosis
 Pain out of proportion
 Palpably tense compartment
 Pain with passive stretch
 Paresthesia/hypoesthesia
 Paralysis
 Pulselessness/pallor
Compartment Syndrome
Differential diagnosis

 Arterial occlusion

 Peripheral nerve injury

 Muscle rupture
Compartment Syndrome
Emergent Treatment

 Remove cast or dressing

 Place at level of heart
(DO NOT ELEVATE to optimize
perfusion)
 Alert OR and Anesthesia
 Bedside procedure
 Medical treatment
 Compartment Syndrome
Surgical Treatment
 Fasciotomy - prophylactic release of
pressure before permanent damage
occurs. Will not reverse injury from
trauma.
 Fracture care – rigid
stabilization
 Ex-fix
 IM Nail