Dr.Otman Siregar SpOT.(K)SpineDr.Otman Siregar SpOT.(K)Spine

April 2009

Limb Threatening InjuriesCan be caused by:

� MVA

� Occupational accident

Domestic accident� Domestic accident

� Open injury

� Closed injury

Limb Threatening Injuries� Is an emergency

situation

� Need accurate diagnosis and prompt treatmentand prompt treatment

Limb Threatening Injuries� Fracture

- Open fracture

- Closed Fracture

Vascular Injury� Vascular Injury

� Compartment syndrome

Fracture� Definition:

structural break in continuity weather of a bone, an epiphyseal bone, an epiphyseal plate, or a cartilaginous joint surface

� Fracture also mean soft tissue injury

Fracture� The causative force that produces a fracture may be :

- Direct injury

- Indirect injury

Fracture DiagnosisPatient History, ask about

� Pain

� Deformity

Time of injury

� Mechanism of injury:

- Fall

- Direct blow

- Road accident� Time of injury - Road accident

- Gun Shot Wound

- Often lack of detail

Fracture Diagnosis� Always do Primary Survey (ABC)

� General condition

� Local Condition:

- Look- Look

-Feel

-Move

� Principle: DO NO FURTHER HARM!

Fracture DiagnosisLook:

� Local swelling

� Deformity ( angulations, rotation, discrepancy)rotation, discrepancy)

� Discoloration of the skin

� Open wound (size, margin, depth, contamination)

Fracture DiagnosisFeel

� Sharply localized tenderness

� Aggravation of pain and muscle spasm

Crepitation� not necessary� Crepitation� not necessary

� Neurovascular Condition is important

� Always look and feel for other less apparent injuries

Fracture DiagnosisMove

� Not necessary if the deformity is obvious

� Abnormal movement

Usually ROM limited due to pain� Usually ROM limited due to pain

Fracture DiagnosisSpecial Test and measurement

� Allen test: vascular patency in forearm

� True, apparent, and anatomical length

Drawer test ( is better to do it under anesthesia)� Drawer test ( is better to do it under anesthesia)

Diagnostic Imaging� Immobilized the limb before being

subjected to imaging examination

� Plain X ray

CT Scan� CT Scan

� MRI

� angiography

Diagnostic ImagingX ray : Rules of two

� 2 joint

� 2 projection

2 extremities (paediatric)� 2 extremities (paediatric)

� 2 densities (able to differ hard and soft tissue)

Special projection may be necessary

Diagnostic Imaging� CT Scan and MRI can

provide useful additional data especially for pelvis and spinal injuryand spinal injury

� Angiography is performed if vascular injury is suspected

� Doppler duplex sonogram

Descriptive Term Pertaining to

Fractures� Site

-diaphyseal, metaphyseal, epiphyseal or intraarticular

� Extent

- Complete or incomplete- 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

Descriptive Term Pertaining to

Fractures� Relationship of the

fracture to the external environment

-open or closed-open or closed

� Complications

-uncomplicated or complicated

Complications of Musculoskeletal

InjuriesClassified as :

� Initial (immediate) complications

- Local and Remote

Early� Early

-Local and remote

� Late complications

-Local and remote

Complications of Musculoskeletal

InjuriesInitial Complication:

� Local complication

-Skin injuries (from within or without)

-vascular injuries (artery or vein, division, contusion or -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

Complications of Musculoskeletal

InjuriesEarly Complication

� Local complication

-Skin necrosis, gangrene, compartment syndrome, compartment syndrome, etc

-Joint complication (septic arthritis)

-Bony complications (Osteomyelitis or avascular necrosis)

Complications of Musculoskeletal

InjuriesEarly

� Remote Complications

-Fat embolism

-Pulmonary embolism-Pulmonary embolism

-Pneumonia

-Tetanus

-Delirium Tremens

Complications of Musculoskeletal

InjuriesLate Complications

� Local Complication

-Joint: stiffness, degenerative arthritis

-Bony: abnormal fr healing, growth disturbance, chronic -Bony: abnormal fr healing, growth disturbance, chronic osteomyelitis

-Muscular :myositis ossificans, late rupture tendon

-Neurological : Tardy nerve plasy

Complications of Musculoskeletal

InjuriesLate

� Remote complications

-Renal calculi

-accident neurosis-accident neurosis

An open An open

fracture fracture

indicates …indicates …

… a communications

between the fracture between the fracture

and the external

environment …

Classification

• Gustillo / Anderson 1976

• Oestern & Tscherne 1984

Open Fractures

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• Oestern & Tscherne 1984

Gustillo / AndersonOpen Fx.

• Gustillo I

• skin lesion < 1cm

• skin perforation inside out

• minimal muscle contusion

• simple fracture pattern• simple fracture pattern

• Gustillo II

• skin lesion > 1cm

• limited soft tissue damage

• no degloving

• simple fracture pattern

Gustillo RB (1984) J Trauma;24:742-6

Gustillo / AndersonOpen Fx.

• Gustillo III A• Extensive soft tissue damage (skin, muscles,

neurovascular strucures) with still sufficient

bone coverage (periosteum)

• Gustillo III B• 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

Gustillo I

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Gustillo III A/B

AO Courses Jakarta 2008

Gustillo III C

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Erfurt algorithm

• remove wound dressing only in OR

• foto documentation

• debridement

management of open fx.

• fracture fixation (FixEx)

• leave the wound open or

• temporary wound coverage by

� skin substitute or

� vacuum therapy

Mechanisms of Vascular Injury in

the Extremities

� Gunshot wound – 54%

� Stab wound – 15%

� Shotgun wound – 12%� Shotgun wound – 12%

� Blunt trauma – 15%

� Iatrogenic – 3%

Presentation of Vascular Injury

� First priority is hemorrhage control followed by control followed by appropriate diagnostic work-up

Presentation of Vascular Injury� Dislocations and

displaced or angulated fractures: realigned realigned immediately if vascularity is compromised

Evaluation for Vascular Injury� Physical Examination� Doppler Flowmeter� Duplex Ultrasonography� Arteriogram� Local wound exploration should not be � Local wound exploration should not be

done in an uncontrolled setting� Close coordination with a general or

vascular surgeon recommended

Physical Examination

Hard Signs

� Absent or diminished distal pulses

� Active hemorrhage

� Large, expanding or pulsatile hematomaLarge, expanding or pulsatile hematoma

� Bruit or thrill

� Distal ischemia (pain, pallor, paralysis, paresthesias, coolness)

Physical Examination

Soft Signs

� Small, stable hematoma

� Injury to anatomically related nerveInjury to anatomically related nerve

� Unexplained hypotension

� History of hemorrhage no longer present

� Proximity of injury to major vessel

Doppler Examination

� Non-invasive adjunct to physical examination� Small, hand-held (non-directional) Doppler

flowmeter provides for subjective interpretation of flowmeter provides for subjective interpretation of audible signal

� Useful as modality for determining the Ankle-Brachial Index (ABI)

Arteriography� Gold standard for evaluation of peripheral vascular

injuries

� Formal arteriograms done in radiology may cause critical delays in diagnosis or interventioncritical 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.

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� Extensive bone or soft tissue injury� Thoracic outlet wounds� Evaluation of equivocal results from non-invasive

tests� Proximity (gsw, knife wound) (controversial)� ABI < .9

Single-shot Arteriogram in the

Emergency or Operating Room

Compartment SyndromeDefinition

� Elevated tissue pressure within a closed fascial space

� Reduces tissue perfusion� Reduces tissue perfusion

� Results in cell death

� Pathogenesis

� Too much inflow (edema, hemorrhage)

� Decreased outflow (venous obstruction, tight dressing/cast)

Compartment SyndromeHistorical Review

� Late complications of ischemic contracture� Volkmann, 1881

� Ischemia of forearm

venous stasis leading

to irreversible contracture to irreversible contracture

� Ellis, 1958; Seddon, 1966� Lower extremity

� Retrospective reviews � Advised the early recognition of the syndrome and

fasciotomies of the affected limbs

Compartment SyndromeTissue Survival

� Muscle� 3-4 hours - reversible changes

� 6 hours - variable damage� 6 hours - variable damage

� 8 hours - irreversible changes

� Nerve � 2 hours - looses nerve conduction

� 4 hours - neuropraxia

� 8 hours - irreversible changes

Compartment SyndromeEtiology

� Fractures-closed and open

� Blunt trauma

� Exertional states

� GSW

� Temp vascular occlusion

� Cast/dressing

� Closure of fascial defects

� Burns/electrical

� IV/A-lines

� Hemophiliac/coag

� Intraosseous IV(infant)

� Snake bite

� Arterial injury

Compartment SyndromeDiagnosis

� Pain out of proportion

� Palpably tense compartment

� Pain with passive stretch� Pain with passive stretch

� Paresthesia/hypoesthesia

� Paralysis

� Pulselessness/pallor

Compartment SyndromeDifferential diagnosis

� Arterial occlusion

� Peripheral nerve injury

� Muscle rupture

Compartment SyndromeEmergent Treatment

� Remove cast or dressing

� Place at level of heart

(DO NOT ELEVATE to optimize (DO NOT ELEVATE to optimize perfusion)

� Alert OR and Anesthesia

� Bedside procedure

� Medical treatment

Compartment SyndromeSurgical Treatment

� Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma.

� Fracture care – rigidstabilization

� Ex-fix

� IM Nail