1. Limb Threatening Injuries
Dr.Otman Siregar SpOT.(K)Spine
April 2009

2. Limb Threatening Injuries
Can be caused by:
MVA
Occupational accident
Domestic accident
Open injury
Closed injury

3. Limb Threatening Injuries
Is an emergency situation
Need accurate diagnosis and prompt treatment

4. Limb Threatening Injuries
Fracture
- Open fracture
- Closed Fracture
Vascular Injury
Compartment syndrome

5. Fracture
Definition:
structural break in continuity weather of a bone, an epiphyseal plate, or a cartilaginous joint surface
Fracture also mean soft tissue injury

6. Fracture The causative force that produces a fracture may be :
Direct injury
Indirect injury

7. 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

8. Fracture Diagnosis Always do Primary Survey (ABC) General condition
Local Condition:
- Look
-Feel
-Move
Principle: DO NO FURTHER HARM!

9. Fracture Diagnosis Look: Local swelling
Deformity ( angulations, rotation, discrepancy)
Discoloration of the skin
Open wound (size, margin, depth, contamination)

10. 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

11. Fracture Diagnosis Move Not necessary if the deformity is obvious
Abnormal movement
Usually ROM limited due to pain

12. 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)

13. Diagnostic Imaging Immobilized the limb before being
subjected to imaging examination
Plain X ray
CT Scan
MRI
angiography

14. 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

15. 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

16. 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

17. Descriptive Term Pertaining to Fractures
Relationship of the fracture to the external environment
-open or closed
Complications
-uncomplicated or complicated

18. Complications of Musculoskeletal Injuries
Classified as :
Initial (immediate) complications
Local and Remote
Early
-Local and remote
Late complications

19. 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

20. Complications of Musculoskeletal Injuries
Early Complication
Local complication
-Skin necrosis, gangrene, compartment syndrome, etc
-Joint complication (septic arthritis)
-Bony complications (Osteomyelitis or avascular necrosis)

21. Complications of Musculoskeletal Injuries
Early
Remote Complications
-Fat embolism
-Pulmonary embolism
-Pneumonia
-Tetanus
-Delirium Tremens

22. 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

23. Complications of Musculoskeletal Injuries
Late
Remote complications
-Renal calculi
-accident neurosis

24. Open Fracture

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

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

27. 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

28. 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

29. Gustillo I
AO Courses Jakarta 2008

30. Gustillo III A/B
AO Courses Jakarta 2008

31. Gustillo III C
AO Courses Jakarta 2008

32. 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

33. Vascular Injury

34. 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: , 1988.
Furthermore, 38% of fractures associated with gunshot wounds have arterial injuries. (Gahtan et al., Am Surg 60: , 1994)

35. Presentation of Vascular Injury
First priority is hemorrhage control followed by appropriate diagnostic work-up

36. Presentation of Vascular Injury
Dislocations and displaced or angulated fractures: realigned immediately if vascularity is compromised

37. 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: , 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.”

38. 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: , 1995.

39. 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: , 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: , 1989.
152 injuries from penetrating proximity extremity trauma were studied by either immediate or delayed arteriography 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).

40. 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.

41. 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, Reviewed 1,882 emergency center arteriograms. These arteriograms had a sensitivity of 95.5% and specificity of 97.7% for vascular injury 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)

42. 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.

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

44. Compartment Syndromes

45. 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)

46. 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

47. 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.

48. 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.

49. 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.

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

51. 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

52. 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.

53. Thank You