Lower extremity and degloving injury

Vascular assessment and radiologic evaluation

The evaluation of the patient’s vascular status is critical. External bleeding from the extremity, in addition to bleeding from a junctional segment such as the common femoral artery, is life-threatening and should be controlled as soon as possible. A tourniquet or direct clamping of visible vessels can be used to control lower extremity vascular injury. Examination of pulses should include common femoral, popliteal, dorsalis pedis, and posterior tibial arteries to identify asymmetry of pulses or the absence of palpable pulses. In the setting of shock or the presence of joint dislocation or angulated fracture, the pulse assessment should be reported after resuscitation and/or reduction of deformity. It has been shown that blood flow to the lower extremity may be reestablished following resuscitation and limb stabilization.

Patients with hard signs of arterial injury should be taken emergently to the operating room (OR) for surgical repair of the injured artery. The hard signs include (1) active hemorrhage, (2) expanding or pulsatile hematoma, (3) bruit or thrill over wound, (4) absent distal pulses, and (5) extremity ischemia. Intraoperatively the area of injury should be extensively explored, and an arteriography can be used to clarify the arterial anatomy.

In contrast, if the patient does not have any hard signs of vascular injury, further vascular evaluation must be performed. The patient will need ankle-brachial index (ABI) or arterial pressure index (API) performed of the injured extremity. With an ABI of >0.9, the patient can be observed or managed without immediate vascular imaging, whereas an ABI of <0.9 or absent distal pulse may be indicative of an occult vascular injury, and advanced imaging is indicated. Computed tomographic arteriography (CTA) should be obtained. In older patients who may have preexisting vascular disease, the ABI or API can be compared with the uninjured side. If there is variation between the injured and uninjured side, vascular injury may be present. When dividing the injured side API or ABI by noninjured, >0.9 can still be used at cutoff or a difference of ≥0.1.

After the patient is hemodynamically stable and bleeding is controlled, standard anteroposterior and lateral radiographs of the injured lower extremity, including the joint above and below, should be obtained. Penetrating injuries are best evaluated with entrance and exit site markers. Further evaluation of fractures, specifically of articular injuries, is afforded by obtaining a computed tomography (CT) of the affected joint. CT can also assess for penetrating traumatic joint arthrotomy, ruling out the presence of air within the joint of concern. CT typically is performed for preoperative planning and rarely is emergently obtained. Magnetic resonance image (MRI) can be obtained of the area of concern for soft tissue injury not noted on CT, specifically for possible tendon and ligament and cartilage injury. Generally, MRI is obtained on an outpatient basis but rarely is obtained in the acute setting.

Fractures

Historically, Early Total Care (ETC) with immediate fixation of long bones was popularized in the 1980s, with the thoughts that these traumatized patients were “too sick not to operate.” This exacerbated some critically ill patients by creating a “second hit” phenomenon, by creating more physiologic trauma to underresuscitated patients. Therefore by the early 2000s, a shift had occurred to perform Damage Control Orthopedics (DCO). This involves delaying definitive fracture fixation and instead using methods including temporary external fixation and skeletal traction for immediate and temporary fracture stabilization until adequate resuscitation can be achieved. This method is used for polytraumatized patients with severe injuries, especially extremity injuries with significant soft tissue involvement that will require multiple surgical debridements and interventions. For traumatized patients who are adequately resuscitated, Early Appropriate Care (EAC) is now the accepted treatment algorithm. This involves fixating pelvis, acetabulum, femur, and spine fractures within 36 hours of injury to improve overall outcomes and decrease patient complication rates. Of note, this section is not a how-to discussion, but rather provides recommendations for immediate and knowledgeable collaboration with an experienced orthopedic traumatologist in treating severe lower extremity injuries. Specific details of management for musculoskeletal injuries are treated only briefly (and thus arbitrarily) here. Several acceptable alternative treatments exist for many fractures. Differences of opinion are thus unavoidable.

Skeletal injuries cannot be managed safely in isolation. The treating physician must always think beyond the broken bone and assess associated soft tissue trauma, the status of the entire injured limb, and the whole patient. Other associated injuries, age and anticipated activity level, preexisting musculoskeletal conditions, and chances for meaningful participation in a rehabilitation program must also be considered. The choice of management for fractures and joint injuries may depend on whether an injury is isolated or is one of several problems in a patient with multiple injuries. Treatment is also affected by the resources available to the surgeon. It is critical to have a well-equipped OR, effective radiographic monitoring, and an experienced surgical team to ensure best outcomes possible.

Early care of musculoskeletal injuries

Extremity injuries may be obvious or occult. Initial care of obvious injuries includes control of bleeding with pressure dressings, splinting unstable injuries in an acceptable anatomical reduced position, and urgent identification and treatment of arterial occlusion.

Once the patient is resuscitated or stable, a thorough and systematic search must be made for more occult injuries. All skin surfaces, from digits to trunk, must be inspected for deformity, swelling, ecchymosis, and laceration. Any areas of suspected injury should be imaged. Skin abrasions are significant. If they are present in the region of a musculoskeletal injury, any needed operation must be done promptly or delayed until the abrasion heals. Palpate each bone and joint for swelling, deformity, and tenderness. Manually stress each one to confirm stability. Move each joint to demonstrate normal passive range of motion and instability. When emergency surgery is a part of the resuscitation or early care of a trauma patient, examination of the extremity should always be completed before terminating the anesthetic. Confirm the presence of peripheral pulses. Obtain radiographs of all abnormal areas.

When the patient is conscious and able to cooperate, active voluntary motion of each joint must be assessed to check motor nerve and myotendinous integrity. Check sensation in the isolated sensory area of each major peripheral nerve. For critically ill patients who are unable to cooperate initially, completion of this evaluation may take several days. Such follow-through is mandatory to avoid missing injuries. Critical resuscitation of patients with multiple injuries necessarily places diagnosis and treatment of musculoskeletal conditions at a relatively low priority in comparison with cardiovascular, pulmonary, and neurologic status. Many injuries are not initially appreciated. Repeated examinations during the early recovery period are frequently rewarded by the discovery of additional injuries in time for effective treatment.

Open fractures