Extremity Injuries CPT James R. Rice, PA-C Program Manager Tactical Combat Medical Care

Why Should You Care?  Wounds incurred by U.S. Army Seventh Corps in Desert Storm – Extremities only 65.0% – Extremities + other 22.4%  “Most treatable soldiers who died in the hospital did so from blood loss from extremity wounds.”

Wound Distribution

Armored Vehicle Blast Patterns

Physical Examination  Level of Consciousness  Inspection  Palpation  Range of Motion  Neurovascular Exam

Physical Exam- LOC  Altered LOC due to shock, head trauma, pain medication, alcohol – Unable to respond to painful stimulus – Requires more systematic and diligent search for injuries

P.E.- Inspection and Palpation  Don’t be distracted by obvious injuries!

P.E.- Inspection and Palpation  Inspection – Completely disrobe patient – Log Roll to look at back and backs of arms/legs – Note all deformities, bruising, abrasions, lacerations  Palpation – Crepitus, tenderness

P.E.- ROM and Neurovascular  ROM – Place all joints through complete arc of motion » Notice any crepitus, resistance or complaint of pain  Neurovascular – Color, pulse, capillary refill – Light touch sensation » Grossly intact or not – Motor exam

Initial Management  Dislocations – Reduce with in-line traction » Large joints making evac impossible » Vascular compromise  Fractures – Splint  Soft Tissues – Skin – Edema – Nerve Injuries – Vascular Injuries

Dislocations  Shoulder – Pain with motion, resistance to motion, palpable mass anterior or inferior, axillary nerve palsy, reduction maneuvers, sling

 Elbow – Difficult to differentiate from fracture, vascular injuries, compartment syndrome  Reduction maneuvers – Immobilize in enough flexion to maintain reduction Dislocations

 Wrist – Careful palpation assists with diagnosis, traction and direct pressure, splint in neutral

Dislocations  Fingers – Usually obvious, easily reduce with traction, may do digital block, buddy tape

Dislocations  Hip – Flexion, adduction, internal rotation for posterior – Flexion, abduction and external rotation for anterior » Traction in line with thigh Knee immobilizer or abduction pillow – Often associated acetabular fx or loose body in joint » Orthopedic Emergency! » May be unstable » Traction if available

Dislocations  Knee – Gross deformity, usually posterior, direct pressure and traction – Evaluate pulses » Carefully and repeatedly » For at least 24 hours – Splint in slight flexion

Dislocations  Ankle – Almost always with bi/trimalleolar fractures  May be difficult to retain reduction in splint  Tend to fall posterior or lateral

Dislocations- Subtalar

 Subtalar – Gross deformity – Looks like a club-foot – Tenting of skin will result in large area of necrosis without expedient reduction – Usually stable post reduction, splint

Dislocations  Foot/toes  Foot dislocations will be unstable and likely require fixation to hold  Maximal elevation in well-padded splint  Treat toes like fingers

Fractures  General Principles – Realign with gentle in-line traction – Pulse before and after any manipulation – Splint for comfort and ease of transport » Plaster, wood, prefabs, pillows, body parts – Elevate

Fractures- Long Bones  Radius/Ulna – Reduction may be difficult – Splint and elevate  Femur – Blood loss – Increase in mortality with delay in stabilization – Traction device works very well  Tibia – Beware compartment syndrome

Vascular Injuries  Well perfused extremity with absent pulse less of an emergency  Pulse will often return after reduction of Fx or dislocation  Repeat exams of utmost importance

Skin  Any laceration or deep abrasion near a fracture should be treated as an open fracture – Look for fat droplets  Antibiotic Coverage – Cephalosporin – +/- Aminoglycocide – +/- Penicillin  Tetanus prophylaxis

Skin  Wash away gross contamination  Dress wound and leave alone until OR

Open Fracture  Principles of Treatment – Reallignment – Re-Assess Vascular Status – Stabilization – Antibiotics – Pain Management – Evacuate

Edema  Compartment syndrome most common in forearm and lower leg – May also occur in arm, thigh, foot, hand  5 P’s – PAIN out of proportion – Pallor – Pulselessness – Paraesthesias – Paralysis  Release early and widely

 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

Fasciotomy  Indications – After all field revascularizations – When compartment pressure is above 30-40mm Hg – Injured extremity in a head injured or neurologically impaired patient?

Compartment Syndrome  Lower Extremity – Gluteal – Thigh – Lower leg – Foot  Upper Extremity – Deltoid – Arm – Forearm – Hand

Questions ?