MANAGEMENT OF LIMB INJURIES

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MANAGEMENT OF LIMB INJURIES

• Dr K. Bougoulias

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Objectives

• ATLS
• Scoring system
• Soft tissue trauma
• Joint injuries
• Fracture management

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Advanced Trauma Life Support

• Primary and secondary surveys
• Primary ABCDE
• Identify life threatening injuries
• Identify limb threatening injuries

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Scoring systems

• Limb ischaemia
• 1/ pulse reduced/ absent- perfusion normal
• 2/ Pulseless, parasthesia,diminished capillary
  refill
• 3/ Cool, paralyzed,insensate numb
• Score is doubled for ischaemia gt 6h

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Amputation

• Ischaemia time more than 6 h,
• non- reconstructable defect,
• limp salvage attempt would threaten patients life

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Soft tissue Trauma

• Vascular trauma
• Early evaluation
• Distal pulses
• Arterial disruption caused by penetrating
  trauma, dislocations, blunt trauma

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Frykmans signs of arterial damage

• Hard signs pulselessness, massive bleeding at
  injury, rapidly expanding haematoma, pulsatile
  haematoma
• Soft signs history of arterial bleeding at
  scene, proximity of wound to the artery in
  question, non- pulsatile haematoma over an
  artery,
• One hard or two and more soft signs suggest
  severe arterial injury

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Arterial repair

• One artery is enough for the limb
• Repair should be coordinated with skeletal
  stability fasciotomies distally
• Surgical emergency
• Definitive evaluation requires angiogram

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Compartment syndrome

• End capillary perfusion less than
  intracompartmental pressure
• Pressure greater than 30mmHg (lower threshold in
  hypotensive patients- 20mmHg
• Pulselessnes, pallor, excruciate pain,
  paresthesia, paralysis

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Muscle viability

• Color
• Consistency
• Contractility
• Capacity to bleed

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Nerve injury

• Neuropraxia (nerve contusion)
• Axonotemesis (partial destruction of axon
  myelin sheaths, epineurium intact)
• Neurotmesis (complete disruption)
• Seddon, 1943

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Nerve injury

• After repair, return rate 1mm/day in adults and
  3-5mm/day in children
• Prognosis better lt30y of age
• distal than
  proximal
• sharp lacerations
• early repair (time
  limit
• 18 months)

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Joint Injuries

• Dislocations
• Documentation of neurovascular status before
  reduction
• Always attempt a closed reduction
• Open reduction if necessary
• Documentation neurovascular status again
• Splinting, bringing ex fix, traction

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Fracture management

• FRACTURE a break in the continuity of bony
  structure or.
• Open bone exposed to the air
• Local sterile irrigation, sterile cover dressing,
  iv antibiotics, tetanus cover, surgical
  debridement, skeletal stabilization, soft tissue
  cover

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Classification of open fractures

• Gustilo Anderson, 1984

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Classification of closed fractures with soft
tissue damage

• Tscherne et al, 1982

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Fracture management

• Closed fractures
• Reduce- immobilize- rehabilitate

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THANK YOU