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Extremity Trauma


Investigation for extremity injuries is a critical portion of the trauma evaluation. During these examinations, the surgeon must look for fractures, dislocations, soft tissue damage, vascular injuries, and neurologic deficits. Upon completion of the tertiary survey, the patient should have undergone a complete and systematic evaluation of every body part. This chapter outlines the keys to diagnosing and managing common extremity injuries seen in the trauma patient.

I

Evaluation of the Injured Limb

A

General Points

  • 1.

    Examination should proceed, if possible, by comparing injured side to uninjured side.

  • 2.

    Immediate reduction of fractures and dislocations improves pain and limits neurovascular injury.

B

Evaluation of Fractures and Dislocations

Each identified fracture can be classified by the following scheme. The following descriptors determine the prognosis of a given fracture and are extremely useful when orthopedic consultation is required.

  • 1.

    Open or closed fracture

  • 2.

    Name of fractured bone

  • 3.

    Location of fracture

    • a.

      Diaphyseal (shaft) versus metaphyseal (near the articular surface)

    • b.

      Intraarticular versus extraarticular

  • 4.

    Status of the soft tissue

    • a.

      Presence of any bullae, ecchymosis, swelling, or multiple abrasions (“road rash”)

    • b.

      Laceration or degloving injury overlying fracture (suggests an open fracture)

    • c.

      Associated neurovascular deficits

  • 5.

    Descriptors (tell about the energy of injury)

    • a.

      Pattern (transverse, oblique, spiral, comminuted; Fig. 18.1 )

      FIG. 18.1, Fracture patterns.

    • b.

      Displacement or angulation

    • c.

      Rotation

    • d.

      Length (presence of limb shortening)

II

Open Fractures

A

Definition

  • 1.

    Fracture in which a break in the skin communicates directly with a fractured bone or the surrounding hematoma. An archaic synonym is a “compound fracture.”

B

Complications of Open Fractures

  • 1.

    Delayed union or nonunion

  • 2.

    Infection (soft tissue or osteomyelitis)

    • a.

      All open fractures are contaminated.

  • 3.

    Compartment syndrome

  • 4.

    Amputation

  • 5.

    Death (sepsis, multiple organ dysfunction syndrome [MODS], effects of polytrauma)

C

Gustilo-Anderson Classification System ( Table 18.1 )

  • 1.

    Determined by size of skin defect, mechanism, and presence of contamination. Increasing score correlates with higher rates of complications.

    TABLE 18.1
    Gustilo-Anderson Classification System
    Grade Wound
    Type I <1 cm laceration, clean
    Type II 1–10 cm laceration with limited soft tissue damage
    Type III >10 cm laceration, amputation, gunshot, farm injury, crush, >6 h after injury or marked contamination
    Type IIIa Soft tissue injury with adequate tissue for coverage
    Type IIIb Soft tissue injury with inadequate tissue for coverage
    Type IIIc Any open injury with arterial injury requiring repair

D

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