1. Dr.AbdulWAHID M Salih Ph.D. Surgery
LIMBS INJURY
Dr.AbdulWAHID M Salih
Ph.D. Surgery

2. WOUNDS OF LIMBS
50-75% of all missile wounds and blast injuries involve the limbs

3. Fractures Should Be Stabilized To Avoid:
Further damage to surrounding tissue,
bleeding
pain.

4. IMMOBILIZATION of entire limb
INDICATIONS;
All severe soft tissue wounds of extremities
Fractures should initially be immobilized

5. METHODS OF IMMOBILIZATION
Sling
plaster back slabs.
application of splints

6. The leg
Splinted by binding it
To the good leg

7. Thomas splint
Immobilize compound fractures of the femur and fractures around the knee joint

8. METHODS OF IMMOBILIZATION
4. Plaster of paris (pop) 5. Skin or skeletal traction

9. METHODS OF IMMOBILIZATION
6. External fixation  

10. Principles of cast application
Slabs or cylinders that have been well split are the only safe plasters to apply.
Never put;
Complete
Unsplit
Unpadded cylinder
Tight bandages

11. VASCULAR INJURIES possible vascular injury ;
The Position Of The Missile Track,
The Presence Of A Subfascial Haematoma,
After Resuscitation, Distal Pulses Remain Impalpable,

12. Management of arterial injury
Urgent surgical exposureas early as circumstances allow, preferably within six hours of injury.
“LOOK AND SEE” is wiser than “wait and see”.
Every effort should be made to repair arterial damage
After major arterial ligation
the incidence of limb gangrene
is very high
Fractures should be treated
after vascular surgery

13. Circulation can be impaired by
Complete, unsplit, unpadded cylinder
Tight bandages applied to a limb 
Swelling occurs in a limb within the first 24 – 48 hours after;
Fracture,
severe sprain,
wound or operation;

16. Signs of compartment syndrome
“7 P’s”:
severe pain at rest
Pain with passive stretch
Parasthesia (tingling and numbness)
Paresis (weakness) impaired movement
Pulses (diminished pulses in the affected limb)
Pallor (loss of normal color)
Persistent cold
Pressure (tense)

17. A tonometer to directly measure pressure
indication for fasciotomy; intracompartmental pressure >30 mmHg[10]
<30 mmHg difference between intracompartmental pressure and diastolic blood pressure

18. Indications for fasciotomy
wounds directly involving the calf;
concomitant major venous injuries;
clinical compartment compression syndrome in the immediate postoperative period;
when the ischaemic state has existed for longer than 4-6 hours before arterial surgery;
any major arterial injury to the limbs.

19. The anterior and lateral fascial compartments
A single longitudinal incision 15 cm in length
Placed halfway down the leg,
2 cm anterior to the shaft of the fibula.
Dividing the anterior and lateral compartments,

20. The two posterior compartments
Single Longitudinal Incision 15 Cm In Length In The Distal Part Of The Leg
2 Cm Posterior To The Palpable
Posteromedial Edge Of The Tibia.

23. Fasciotomy exposes the depths of the wound
The deep fascia must be incised along the length of the skin incision
allows wide and deep retraction
left open to allow post-operative oedematous and congested tissue to swell without tension
exposes the depths of the wound

24. Fasciotomy
The wounds should be left
open for delayed closure.

25. Complications Muscle and nerve cell death
deformity, paralysis, permanent muscle contraction (Volkmann's contracture),
systemic infection (sepsis)
and renal failure.)
amputation

27. TENDON, NERVE No attempt should be made at primary;
Tendon or nerve repair,
In Grossly contaminated wounds.

28. Major Artery An injury to a major artery to the limb:
must be either repaired
or replaced by a saphenous vein graft immediately

29. INJURIES OF PERIPHERAL NERVES
May be injured alone
more commonly, in association with vascular damage or long bone fractures.

30. Nerve repair
In multiple injuries, nerve repair is of the lowest priority.
Nerve repairs are performed when wounds are healthy and clean, which is generally at least 6 weeks after injury.
Repair can safely be deferred for 3 months but contractures must not be permitted to develop.

31. General indications for Amputation
severe damage:
no chance of recovery of function of any part
mangled, grossly contaminated wounds
overwhelming infection
established gangrene;
continued infection associated
with severe nerve and bone Injury
secondary haemorrhage,
uncontrollable by other measures
8. multiple injuries,

33. GAS GANGRENE
The risk:
Foreign bodies in wounds such as clothing, soil, metal or wood,
Prolonged application of tourniquets or tight plasters
Fascial compartment
compression syndromes
Delayed treatment

34. GAS GANGRENE hypotensive and may vomit in severe cases. oedematous
The incubation period ; less than three days
the sudden appearance of pain in the region of the wound.
oedematous
drainage of thin serous or
serosanguinous exudate
The pulse rate rises markedly
but the temperature is rarely more than 38° C.
clinically deteriorates
within several hours becomes anxious and frightened
hypotensive and may vomit in severe cases.

35. GAS GANGRENE
Immediate surgical intervention is essential