Limb Threatening Injuries 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 Pain Deformity Time of injury Mechanism of injury: Fall Direct blow 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

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

Open Fracture

An open fracture indicates … … a communications between the fracture and the external environment …

Classification Gustillo / Anderson 1976 Oestern & Tscherne 1984 Open Fractures Classification Gustillo / Anderson 1976 Oestern & Tscherne 1984 AO Courses Jakarta 2008

Gustillo / Anderson Gustillo I Gustillo II skin lesion < 1cm 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 Gustillo RB (1984) J Trauma;24:742-6

Gustillo / Anderson Gustillo III A Gustillo III B Gustillo III C 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 AO Courses Jakarta 2008

Gustillo III A/B AO Courses Jakarta 2008

Gustillo III C AO Courses Jakarta 2008

Erfurt algorithm remove wound dressing only in OR foto documentation management of open fx. 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

Vascular Injury

Mechanisms of Vascular Injury in the Extremities Gunshot wound – 54% Stab wound – 15% Shotgun wound – 12% Blunt trauma – 15% Iatrogenic – 3% Feliciano DV, Herskowitz K, O’Gormon RB, et al: Management of vascular injuries to the lower extremities. J Trauma 28: 319-328, 1988. Furthermore, 38% of fractures associated with gunshot wounds have arterial injuries. (Gahtan et al., Am Surg 60: 123-127, 1994)

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 Modrall JG, Weaver FA and Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emergency Medicine Clinics of North America, 16: 129-144, 1998. “Frequently nonocclusive arterial injuries are surrounded by a contained hematoma. If the hematoma is disrupted, exigent hemorrhage may ensue. Local wound exploration is therefore ill advised.”

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) The presence of one or more hard signs is an indication for immediate surgical exploration. Frykberg ER. Advances in the diagnosis and treatment of extremity vascular trauma. Surgical Clinics of North America 75: 207-223, 1995.

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 In general, soft signs may indicate the need for further evaluation. Their significance is controversial and their presence alone do not constitute an indication for surgical intervention. Proximity refers to penetrating wounds less than 1 cm to a major vessel. Proximity is very controversial. Some centers now rely on non-invasive methods to initially evaluate injuries less than 1 cm from a major vessel. Modrall JG, Weaver FA and Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emergency Medicine Clinics of North America, 16: 129-144, 1998. “Recent studies have demonstrated that in the absence of objective clinical findings (e.g., fracture, hematoma, nerve injury), arteriograms performed for proximity alone demonstrate an arterial injury in only 6 to 9% of patients. More significantly, the injuries that are clinically occult but detected only by arteriography are invariably insignificant and do not require surgical repair.” Frykberg ER, Crump JM, Vines FS, McLellan GL, Dennis JW, Brunner RG, Alexander RH. A reassessment of the role of arteriography in penetrating proximity extremity trauma: a prospective study. J Trauma, 29: 1041-50, 1989. 152 injuries from penetrating proximity extremity trauma were studied by either immediate or delayed arteriography. 27 radiographic abnormalities found with 16 in major vessels. 1 acute AV fistula was immediately repaired. The remaining 15 were observed (7 cases of segmental narrowing, 6 intimal flaps and two small pseudoaneurysms). One pseudoaneurysm enlarged and underwent repair at 10 weeks. The remaining 14 were successfully managed non-operatively (9 resolved, 2 improved and 3 unchanged) over an average of 2.7 months. Conclusions: 1. The natural history of clinically occult arterial injuries was predominantly benign, 2. Arteriogram could be safely delayed up to 24 hours, 3. “soft” signs were not clinically useful predictors of vascular injury, 4. Arteriography not a cost-effective modality for screening proximity injuries (a possible exception is shotgun wounds because this mechanism was found to have the greatest risk of significant injury).

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) Rutherford RB (ed.) Vascular Surgery (3rd ed.). W.B. Sanders Co., 1989.

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. Formal departmental arteriograms may not be readily available during peak trauma times and may significantly prolong the time to intervention while not changing management when compared to operating room arteriograms. In most cases of penetrating trauma with hard signs of vascular injury, delaying surgical exploration in order to get an arteriogram could potentially compromise limb salvage. The delay of 1 to 3 hours is unwarranted in most instances. Itani KM, Burch JM, Spjut-Patrinely V, Richardson R, Martin RR, Mattox KL. J Trauma, 1992. Reviewed 1,882 emergency center arteriograms. These arteriograms had a sensitivity of 95.5% and specificity of 97.7% for vascular injury. 196 of 305 injuries required operative intervention. These results approach the results of formal, departmental arteriograms in detecting vascular injuries. (Proximity was the only indication for arteriogram in 91% of the patients)

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 Other indications for arteriography that do not apply to acute presentation are: intraoperative arteriogram (completion of repair), delayed diagnosis, follow-up of nonoperatively managed arterial injuries. The reason patients with chronic vascular disease might warrant arteriogram is that they may have longstanding pulse deficits that predispose them to false-positive non-invasive evaluation. The reason that extensive bone or soft tissue injury may warrant an arteriogram is that the extent of the injury may cause hard signs without vascular injury. Thoracic outlet wounds sometimes benefit from an arteriogram in order to plan the surgical approach which varies with the exact site of the injury.

Single-shot Arteriogram in the Emergency or Operating Room Single-shot arteriogram showing complete transection of the popliteal artery.

Compartment Syndromes

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 The classic descriptions of late complications of ischemic contractures of the extremities due to compartment syndrome are described in the retrospective reviews of Seddon, Owen and Tsimboukis. They recognized the need for early recognition, surgical decompression and found the classic signs of physical exam were unreliable in compartment syndrome. Volkmann is credited with the description of ischemic contracture of the upper extremity associated with compartment syndrome without treatment

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 Studies have shown that nerve tissue is the most sensitive to ischemic changes. Nerve conduction is lost in 1-2 hours of total ischemia and survive up to 4 hrs with only neuropraxia changes, while axonotmesis and irreversible changes occur after 8 hrs. Muscle may survive up to 4 hours with reversible changes, variable damage occurs by 6 hrs, and irreversible changes after 8 hrs under conditions of warm ischemia.

Compartment Syndrome Etiology Fractures-closed and open Blunt trauma Temp vascular occlusion Cast/dressing Closure of fascial defects Burns/electrical Exertional states GSW IV/A-lines Hemophiliac/coag Intraosseous IV(infant) Snake bite Arterial injury Causes range from minor trauma to major injuries and interosseous infusion of IV fluids. Open fractures can have a 9% incidence of Compartment Syndrome-(Brumback et al). The incidence of CS in electrical injuries is proportional to the amount of voltage the patient was exposed to: minimal risk with low voltage (normal household current) and can be as high as 40% in higher voltage. Most burn literature uses the loss of pulses to decide when to perform escharotomies, however, tissue perfusion may still be compromised. Temporary vascular occlusion can occur in obtunded states(drug abuse), operative positioning (hemi and full lithotomy), and prolonged tourniquet use. If compartment syndrome is suspected, tissue pressures measurement is warranted and fasciotomies performed as indicated and supported in the literature.

Compartment Syndrome Diagnosis Pain out of proportion Palpably tense compartment Pain with passive stretch Paresthesia/hypoesthesia Paralysis Pulselessness/pallor These physical findings have been described as the clinical hallmarks of CS. They are not very sensitive and if seen in the later stages it may be too late to change the underlying pathology. CS may be present with good pulses and no pallor and loss of pulses rarely occur unless arterial damage is present. Pain out of proportion and pain with passive stretch of a muscle in the compartment in question may be the most sensitive clinical finding before the onset of ischemic dysfunction of the nerves and muscles. These findings are useful only in a conscious cooperative patient and once paresthesia begin the pain may decrease. One important point to make is of CS is a possibility then regional anesthesia, continuous epidurals and PCA intravenous opiate analgesia should be avoided since they may mask the symptoms of compartment syndrome. Otherwise monitoring of the tissue pressure is warranted. There exist reports of missed compartment syndrome in tibia fracture and other surgical patients at risk managed postoperatively with these techniques and therefore they are generally avoided.

Compartment Syndrome Differential diagnosis Arterial occlusion Peripheral nerve injury Muscle rupture These are in the differential but CS must be ruled out first

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 Initial steps in treating an extremity with elevated pressures or evolving CS. Because tissue viability depends on arterial inflow, elevating the extremity will decrease the inflow and time to prevent the secondary effects of CS. Although ideally performed in the OR, fasciotomy may have to be performed at the bedside after appropriate surgical prep. Animal studies have show some efficacy of extending muscle ischemia tolerance with the use of anticoagulants, steroids and hypothermia. Clinically most pharmacological agents are ineffective unless perfusion to the muscle tissue has been reestablished. Hypothermia may be useful to extend the time period until reperfusion or fasciotomies can be performed

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 Surgical decompression does not reverse the damage present but can prevent secondary sequella of the CS. Fasciotomies destabilize any long bone or extremity fracture. Studies have shown ex-fix and URN in tibias may provide temporary or permanent fixation for treatment of the fracture.

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