Trauma Series:
EXTREMITY
INJURIES
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical
doctor, professor of academic
medicine, and medical author. He
graduated from Ross University
School of Medicine and has completed his clinical clerkship training in various teaching
hospitals throughout New York, including King’s County Hospital Center and Brookdale
Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams,
and has served as a test prep tutor and instructor for Kaplan. He has developed several
medical courses and curricula for a variety of educational institutions. Dr. Jouria has also
served on multiple levels in the academic field including faculty member and Department
Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing
education organizations covering multiple basic medical sciences. He has also developed
several continuing medical education courses covering various topics in clinical medicine.
Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial
Hospital’s Department of Surgery to develop an e-module training series for trauma
patient management. Dr. Jouria is currently authoring an academic textbook on Human
Anatomy & Physiology.
ABSTRACT
Advances in modern medicine have improved both physicians’ abilities to salvage limbs
in cases of extreme trauma and patients’ potential to have a good quality of life when
amputation is a necessary resolution to injury. However, without rapid and appropriate
intervention, extremity trauma has a high incidence of morbidity.
Nurses and all
members of the health team play a vital role in the initial treatment and ongoing
management and support of patients with extremity trauma, a role that has a significant
impact on each patient’s recovery and rehabilitation.
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Continuing Nursing Education Course Director & Planners
William A. Cook, PhD,
NurseCe4Less.com Director
Doug Lawrence, MS, Nurse Ce4Less.com Webmaster Course Planner
Susan DePasquale, CGRN, MSN, Nurse Ce4Less.com Lead Nurse Planner
Accreditation Statement
NurseCe4Less.com is accredited as a provider of continuing nursing education by the American
Nurses Credentialing Center's Commission on Accreditation.
Credit Designation
This educational activity is credited for 6 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
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It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all nursing educational activities. All authors and course
planners participating in the planning or implementation of an educational activity are
expected to disclose to course participants any relevant conflict of interest that may
arise.
Statement of Need
The treatment of individuals with an extremity injury requires that all members of the
health team be familiar with all four components of injury and associated risks. The
mechanisms of injury to an extremity are important clues as to the immediate and
ongoing evaluation and treatment plan. Immobilization and stabilization and the
immediate interventions of pain management, as well as evaluation of potentially
serious and masked injuries, require that nurses and associates be knowledgeable to
provide patients with safe and appropriate assessment and care of an extremity injury.
Course Purpose
This course will provide advanced learning for nurses interested in the management of
the trauma patient with an extremity injury.
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Learning Objectives
1. Differentiate between simple and complex extremity trauma.
2. Describe the symptoms of osseous extremity trauma.
3. Identify the signs of vascular extremity trauma.
4. List the symptoms of nerve trauma to extremities.
5. Explain the treatment priority for patients with extremity trauma.
6. Identify the treatment goal for patients with extremity trauma.
7. List common risks involved in the treatment of extremity trauma.
8. Describe the role of general surgeons/specialists in treating extremity trauma.
9. Identify the factors that prognosticate limb salvage.
10. Describe risk factors for amputation.
Target Audience
Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses,
and Medical Assistants
Course Author & Director Disclosures
Jassin M. Jouria, MD has no disclosures
William S. Cook, PhD has no disclosures
Doug Lawrence, MS has no disclosures
Susan DePasquale, CGRN, MSN has no disclosures
Acknowledgement of Commercial Support:
There is no commercial support for this course.
Activity Review Information:
This course has been peer reviewed by Susan DePasquale, CGRN, MSN. Review
Date: November 3, 2013.
Release Date: November 15, 2013
Termination Date: November 15, 2016
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INTRODUCTION
Extremity trauma is one of the most common forms of trauma treated in emergency
departments throughout the United States. Extremity trauma can be simple or complex,
as it may cause injuries in only one of the components of the extremity or all of the four
components. The four components of the extremity are the nerves, vessels, bones, and
soft tissue. The most severe cases of extremity trauma will involve more than one of
the components of the extremity and will be difficult to manage and repair. When a
patient experiences injury in three of the four components, he or she has a mangled
injury and is at an increased risk of losing the limb
(1).
Treatment for extremity injuries, especially those that are severe, requires a
multifaceted approach that addresses the immediate needs of the patient while
preventing long term damage and salvaging the extremity. This approach typically
requires the involvement of a variety of providers, including but not limited to trauma
surgeons, orthopedic, vascular and plastic surgeons, and rehabilitation specialists. The
focus will be on salvaging the limb while repairing the initial damage
(2).
In some instances, the damage will be too severe to salvage the extremity. When this
occurs, the patient will require an amputation of the extremity. In other instances, the
extremity will be amputated as part of the initial injury, and will require treatment and
repair to clean up the damaged area
(3).
While limb salvage is the primary goal, it must
not take precedence over the health and safety of the patient. If the injured limb poses
a risk to the patient’s survival, it must be amputated as soon as possible.
Extremity injuries are common in both military and civilian trauma situations and can be
caused by a number of different mechanisms. In military situations, most extremity
injuries are the result of penetrating trauma. They are often the result of explosive
devices and landmines (4). In civilian trauma, the majority of extremity injuries are
caused by blunt trauma. They are often the result of motor vehicle accidents and
industrial accidents. However, when penetrating injuries occur in the civilian population,
they are typically the result of gunshot wounds and stabbings
(5).
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Extremity trauma can range in severity and may be life threatening for the patient.
However, advances in modern medicine have improved both physicians’ abilities to
salvage limbs in cases of extreme trauma and patients’ potential to have a good quality
of life when amputation is a necessary resolution to injury. Unfortunately, without rapid
and appropriate intervention, extremity trauma has a high incidence of morbidity.
Nurses and all members of the health team play a vital role in the initial treatment and
ongoing management and support of patients with extremity trauma, a role that has a
significant impact on each patient’s recovery and rehabilitation.
Open versus closed injuries
Open injuries
On open injury is any injury that involves a break in the skin. In all open injuries, the
tissue underneath the skin is exposed. Open injuries can range in severity and some
may appear as a small break in the skin, while others may be deep and wide. There
are different types of open injuries, which are caused by various factors. The following
are the most common types of open injuries (6):

Abrasions & lacerations

Avulsions

Punctures

Traumatic amputation

Crush
Closed Injuries
A closed injury is any injury that occurs underneath the skin, with no open path from the
outside to the injured area. Closed injuries are often the result of blunt trauma and will
range in severity depending on a number of factors including the cause of the injury, the
strength of impact, and the area that is injured. Most closed injuries are not easy to
detect and often require diagnostic imaging for confirmation. The most common types
of closed injuries include the following (7):

Contusion
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
Hematoma

Crush injury
Blunt versus penetrating injuries
Blunt injuries
Blunt injuries occur as the result of blunt force trauma and can range in severity
depending on the mechanism used and the strength of impact. Blunt force trauma is
defined as a severe traumatic episode caused to the body or head with the sudden
introduction of a blunt instrument used with great force
(8).
Blunt force trauma can occur as the result of any type of object striking a part of the
body with significant force and can cause a range of injuries. However, while blunt
force trauma is often significant, many patients will not show signs of blunt injuries
(9).
In
many instances, the blunt injuries will occur internally and will not be noticeable without
the use of diagnostic imaging (10). Additionally, many blunt injuries will produce few
outward symptoms. However, while blunt injuries are not easily detected, they can
have severe consequences. If not detected, a blunt injury can cause death in a patient
within a short period of time (5).
While some blunt injuries may not be apparent upon initial examination, there are some
blunt injuries that produce distinct signs. The following table provides descriptions of
the most common signs of blunt injuries (6):
Sign
Bruising
Description
Bruising is often a good indicator that there are
broken blood vessels beneath the surface of the
skin. Although there may be some bruising this
cannot always be a definite indicator as to how
much damage has been sustained deeper within
the body.
Abrasions
Cuts, grazing of the skin or friction burns, which
can be caused by the victim being beaten,
dragged or kicked. These wounds can sometimes
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indicate that an individual hit against something or
was hit with something. In instances of assault, it
can be used to measure how much of a struggle a
victim put up against his or her attacker.
Lacerations
This is the tearing of tissue underneath the skin.
An individual may have sustained a severe bump
against a stationary object and underneath the
skin (subcutaneous) there may be severe damage
caused to tissue and organs. Visual examinations
do not always show this.
Penetrating Injuries
Although the majority of trauma injuries will be caused by blunt trauma, a number of
patients will experience penetrating trauma and subsequent penetrating injuries.
Penetrating injuries can range in severity depending on the object involved and the site
of injury. Penetrating trauma occurs when an object pierces the patient’s skin. After the
object pierces the skin, it enters the body and causes damage to the internal structures
(11).
With penetrating trauma, any of the internal regions can be damaged, including the
bones, tendons, ligaments, nerves and blood vessels
(5).
Penetrating injuries are especially common in the extremities and occur in both civilian
and military trauma situations. In most instances, penetrating injuries are not life
threatening. However, vascular injuries do pose a risk of death if untreated, and nerve
and tendon injuries can cause long-term damage and disabilities to the patient.
Penetrating injuries can occur as the result of any object piercing the skin. However the
majority of penetrating injuries are the result of stabbings and gunshots, which are
discussed further below (12).
Stab Wounds:
Stab wounds are one of the most common causes of penetrating trauma. They have
the potential to produce significant amounts of blood loss and can cause extensive
damage to the surrounding areas. The severity of injury produced by stab wounds will
differ depending on the site of injury, the depth of injury, and the type of knife used (13).
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In many instances, the stab wound will cause trauma through extensive blood loss at
the site of the wound. However, in some instances, the stab wound will result in
significant muscle, vascular and tissue damage in the extremities (12). Since the extent
of the damage is not visible from the outside, the patient will undergo a thorough
assessment, including radiologic imaging, to determine the extent of damage.
Gunshot Wounds:
There are approximately 500,000 gunshot wounds per year in the United States, and
these wounds typically cause severe damage (14). The amount and severity of injury
caused by firearms depends on a number of factors, such as
•
Type of weapon/bullet used
•
Distance from weapon
•
Location and trajectory/path of injury
•
Permanent vs. temporary cavity
(15):
All firearm injuries are not the same. Injury and trauma level depends on the type of
firearm used. Typically, firearm injuries are categorized as either low velocity injuries or
high velocity injuries, and they are classified based on the type of firearm used and the
projectile impact that is caused (16). Low velocity injuries are primarily caused by
firearms with a muzzle velocity of less than 600 meter per second (m/s). Most low
velocity firearm injuries are caused by handguns and are more prevalent than other
types of injuries (14). High velocity injuries are caused by firearms with a muzzle velocity
of more than 600 meter per second. Most high velocity injuries are caused by military
weapons or high powered hunting rifles (16).
Damage is often dependent on the type of bullet used. Bullets that are encased with
hard shells produce deeper penetration and more significant cavitation. Bullets with soft
or hollow points typically deform or fragment and often ricochet inside the body (16). This
can produce damage to more areas. The actual injuries are influenced by a number of
factors, including the point of entry and the distance that the victim is from the weapon
(39).
Some guns, such as shotguns, contain small pellets that spread apart when they
are released from the barrel. This produces a blast that spreads over a larger area and
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will often cause damage to numerous areas of the body rather than one specific point of
entry (14). However, these produce less damage when fired from a greater distance
(14).
TYPES OF INJURIES
There are a variety of injuries that occur in instances of extremity trauma. The types of
injury that occur are broken into categories based upon the structure that they damage.
In instances of extremity trauma, injuries occur in the following regions: soft tissue,
blood vessels, nerves, and bones (17). In some instances, the patient will experience
injuries in more than one region. When injury occurs in three or more regions, it is
considered a mangled extremity and must be treated accordingly. In most instances,
mangled extremities will require amputation. However, when injury occurs in less than
three regions, the risk of amputation is reduced (18). In many instances, the damage can
be repaired and the patient will be able to recover with limited disability or other long
term effects (19).
Osseous or Soft Tissue
Soft tissue is one of the most common injuries in extremity trauma and can occur as the
result of direct or indirect trauma to the region. Soft tissue injury, broadly defined, is any
injury that occurs to a non-bony, non-organ area. However, in most instances, soft
tissue injury is any injury that occurs in the muscles, ligaments, and joint capsules (6).
The most common forms of soft tissue trauma are abrasions, lacerations and burns.
However, soft tissue injuries can take many other forms depending on the cause and
location of the injury. The primary mechanisms of soft tissue injury are mechanical and
thermal. Mechanical force includes the following (20):

Shearing

Tension

Compression
Of these three, compression has the potential to produce the most significant damage
to the tissue and can cause additional complications for damage repair and overall
healing (21).
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Thermal injuries are caused by the following mechanisms

Radiation

Convection

Conduction

Electricity

Excessive cold
(6):
In both types of injury, the mechanism of injury, the material that causes the injury, and
the site of the injury will impact the degree of severity. In addition, the patient’s health
status and other biological factors will impact the body’s response to the injuring agent
(20).
Osseous tissue is the tissue present within bones, and it provides the primary
composition of the bone itself. The two types of osseous tissue are spongy and
compact, and the injury will differ depending on what type of osseous tissue is damaged
(22).
Spongy tissue is arranged loosely within the bone and provides space for the bone
marrow. Compact osseous tissue is comprised of tightly packed minerals and can be
found in the outer regions of the bones (23). Osseous injuries often occur in conjunction
with fractures as the tissue is exposed to damage and often swells in response to the
trauma. However, osseous damage can also occur in the absence of fractures.
Osseous injury that is not related to fractures is especially common in instances of blunt
trauma (9).
Symptoms of Osseous/Soft Tissue Injury
Patients may display a variety of symptoms relating to soft tissue/osseous injury. The
specific symptoms the patient experiences will depend on the cause, location and
severity of the injury. However, there are common symptoms that most patients will
experience in conjunction with a soft tissue/osseous injury. The following is a list of the
most common soft tissue/osseous injuries (23):

Pain

Swelling

Discoloration
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
Temperature change

Numbness/tingling

Loss of function
Depending on the cause and type of sift tissue injury, patients may require special
treatment considerations. In some instances, the injury will require special care, while
other injuries may only require standard wound care. The following fact sheet (24)
provides information on special considerations for treating and managing soft tissue
injuries.
Closed Wounds

Suspect underlying fractures

Splint if fracture is suspected
Open Wounds

Expose all wound sites

Clear wounds of loose foreign material

Apply dressings and bandages to all wounds

Control bleeding
Incised Wounds or Lacerations

Edges of the wound may need to be drawn together prior to dressing the wound(s)
Impaled Objects

Stabilize the object

If the object impedes transport then careful shortening (cut) of the object may be required
(object impaled in chest)

Immobilize object securely during shortening effort

Do not remove object unless it interferes with CPR or causes a complete airway obstruction
(e.g. object

Impaled in cheek)
Avulsions

Clean the wound surface
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
Fold the skin flap back to its normal state

Control bleeding with direct pressure
Gun Shot Wounds

If possible, identify the type of weapon and the caliber

Assess the patient carefully for entrance and exit wounds

Expose all wound sites

Treat injuries as per the appropriate Guideline

Clear wounds of loose foreign material

Apply dressings and bandages to all wounds

Control bleeding

Consider internal bleeding, fractures, and injuries to underlying organs and structures

Any additional surveys and treatment should be conducted

Be prepared to manage cardio respiratory distress or arrest
Vascular Trauma
Vascular trauma is defined as any injuries that occur in the vascular regions, including
veins, blood vessels, and arteries. Vascular injuries occur in both blunt and penetrating
trauma, with the majority of injuries caused by penetrating trauma. Approximately 75 –
80% of vascular injuries are the result of penetrating trauma, and approximately 20 –
25% of vascular injuries occur as the result of blunt trauma (25). The severity of the
injury will vary depending on the location of the trauma, as damage to minor blood
vessels will be less traumatic than damage to major arteries. However, vascular trauma
can have long term implications if not treated properly, even when the damage occurs in
minor blood vessels (26).
Vascular trauma can be difficult to detect and identify in initial trauma evaluations,
unless the damage is to a major artery or blood vessel. Some patients will display very
few, or no, signs of vascular trauma, which can be problematic (27). Therefore, the
treating provider will have to conduct a thorough examination to determine the presence
of vascular injuries. The signs for vascular injuries are separated into two categories,
which are used to determine the level and immediacy of required treatment. Hard signs
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indicate definite injury and require immediate attention, while soft signs indicate
potential injury and require additional evaluation. The following is a list of the different
hard and soft signs for vascular injury.
Hard Signs:

External or pulsate hemorrhage

Rapidly expanding or pulsatile hematoma

Palpable thrill / audible bruit

Ischemic limb (absent pulses, pallor, paraesthesia, pain, paralysis,
poikilothermia)
Soft Signs:

History of arterial bleeding at the scene / in transit, now ceased

Proximity of penetrating wound / blunt injury to an artery

Small non-pulsatile and non-expanding hematoma over an artery

Neurologic deficit originating in a nerve adjacent to a named artery

Reduced pulses

Mechanism (posterior dislocation of knee, anterior dislocation of elbow)

Ankle Brachial Index (ABI) or Arterial Pressure Index (API) <= 0.9 (25)
Patients who do not present with any of the hard or soft signs for vascular injury may
still have damage that is not yet apparent. Therefore, patients should be monitored and
evaluated regularly to determine if any of the above signs appear. If untreated, vascular
injuries can cause significant, life threatening problems
(28).
Nerve Trauma
Nerves carry signals and messages to and from the brain and the rest of the body.
There are two types of nerves (29):

Motor Nerves:
These nerves are responsible for carrying messages from the brain to the
muscles to initiate and control movement.
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
Sensory Nerves:
These nerves are responsible for carrying messages to and from the brain and
the rest of the body to signal pain, pressure and temperature.
Injuries to the nerves will range in severity depending on how the nerve is damaged.
When a nerve is stretched or impacted by direct pressure, fibers within the nerve may
break. If this occurs, it will impact the nerve’s ability to send or receive signals (30).
When a nerve is cut, both the nerve and the insulation have the potential to be affected.
In some instances, only the fibers within the nerve will be affected. When this occurs
the end of the nerve that is farthest from the brain will die, while the end of the nerve
that is closest to the brain will remain viable (31). With time, the nerve may heal, but
there is the potential that the nerve will remain damaged permanently. This will depend
on the nerve that is affected as well as the severity of the damage
(29).
In some
instances, both the nerve and the insulation will be severed. When this occurs, the
nerve will require immediate repair. If the nerve is not repaired immediately, the fibers
have the potential to grow improperly, thereby causing a nerve scar, or neuroma
(32).
Nerve damage can occur in instances of both blunt and penetrating trauma. In
instances of blunt trauma, the most common nerve injury is neuropraxia, which is
essentially a stunning of the nerve (33). These injuries have the most potential for
recovery. Penetrating trauma often causes more severe damage to the nerves. In
many penetrating trauma situations, there is a greater potential of complete nerve
transaction. When a transaction occurs, the nerve will experience an immediate loss of
both muscle and sensation function. When this occurs, function will not return unless
the damage is repaired surgically (34). The most common causes of nerve injury include
the following (31):

Laceration

Focal contusion (gunshot wounds)

Stretch/traction injury

Compression

Drug injection injury

Electrical injury
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It can often be difficult to diagnose a nerve injury, as many patients will exhibit
symptoms that are common with other types of injury as well. Therefore, most
treatment providers will utilize either Seddon’s or Sunderland’s Classification System to
identify and diagnose specific nerve injuries.
Seddon’s Classification System
Seddon’s Classification System breaks nerve injury into three tiers of nerve injury based
on the level of damage. These are outlined and described below (35):
Stage
Neurapraxial
Description
This stage involves a reversible conduction block
characterized by local ischemia and selective
demyelination of the axon sheath. The axon's
continuity is retained, and although conduction
across the nerve injury is inhibited, conduction
within the nerve both proximal and distal to the
lesion remains intact. The prognosis for an injured
nerve at this stage is good, and recovery occurs
within weeks to months. Wrist drop secondary to
prolonged external pressure that compresses the
radial nerve at the spiral groove of the humerus is
a clinical example of neurapraxia.
Axonotmesis
This is a more severe stage of injury, with
disruption of not only the myelin sheath, but the
axon as well. The epineurium and perineurium
remain intact, meaning that there is still some
continuity within the nerve. Axonotmesis leads to
Wallerian degeneration, a process whereby the
part of the axon that is separated from the neuronal
cell body disintegrates distal to the injury. The
prognosis for nerves at this stage is fair, and
recovery may require months. Axonotmesis is
commonly seen in crush injuries and displaced
bone fractures.
Neurotmesis
This is the most severe form of nerve injury, is
associated with complete nerve division and
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disruption of the endoneurium. In neurotmesis, the
axon, myelin sheath, and connective tissue
components are damaged, disrupted, or
transected. As with axonotmesis, neurotmesis
initiates Wallerian degeneration, but the prognosis
for nerves is poor. Neurotmesis is commonly seen
after lacerations or ischemic injuries.
Sunderland Classification System
The Sunderland Classification System breaks Seddon’s Classification System into five
categories to further distinguish between severity levels. The stages of this system and
description of each are outlined below (36):
Stage
First-degree injury
Description
A reversible local conduction block at the site of the
injury. This injury does not require surgical
intervention and usually will recover within a matter
hours to a few weeks.
Second-degree injury
There is a loss of continuity of the axons or
electrical wires within the nerve. If this kind of injury
can be confirmed through pre-operative nerve
testing, surgical intervention is usually not required.
Third-degree injury
There is damage to the axons and their supporting
structures within the nerve. In this case, recovery is
variable. Intra-operative nerve conduction studies
are often able to help predict outcome and need for
simple cleaning of the nerve (neurolysis) or a more
extensive repair with grafting.
Fourth-degree injury
In this case, there is damage to the axons and the
surrounding tissues sufficient to create scarring
that prevents nerve regeneration. Intra-operative
electrical testing confirms that no electrical energy
can be passed along the neural pathways in this
injured nerve. Surgical intervention with nerve
grafting is necessary to repair the damage.
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Fifth-degree injury
These injuries are usually found in laceration or
severe stretch injuries. The nerve is divided into
two. The only way to repair a fifth-degree injury is
through surgery.
Bone Trauma
Fractures are common extremity injuries and many of the causes of extremity trauma
involve significant impact. In the simplest terms, a fracture is an area of the bone that is
broken. However, there are different types and severity levels of fractures. Depending
on the cause and the impact, an extremity patient may experience any level and type of
fracture (37). Regardless of the level of fracture, most extremity trauma patients will
experience some type of fracture as the result of the accident. In fact, fractures are the
most common extremity trauma injuries. Therefore, bone trauma will be discussed in
greater depth here than the preceding sections on injuries resulting from extremity
trauma.
There are two categories of fractures: closed fractures and compound fractures. A
closed fracture is one in which there is a clean break to the bone. With this type of
fracture, there is no damage to the surrounding tissue and the bone does not tear
through the skin (38). A compound fracture is more complex. With this type of fracture,
the surrounding tissue and skin can be damaged, resulting in significant bruising. A
compound fracture may also involve the bone tearing through the skin
(39).
Within these
two categories of fractures, there are many different types. The areas they affect, the
damage they inflict, and the cause of the fracture define these fracture types; the types
of fractures are outlined below (38):

Avulsion fracture - a muscle or ligament pulls on the bone, fracturing it.

Comminuted fracture - the bone is shattered into many pieces.

Compression (crush) fracture - generally occurs in the spongy bone in the spine.
For example, the front portion of a vertebra in the spine may collapse due to
osteoporosis.

Fracture dislocation - a joint becomes dislocated, and one of the bones of the
joint has a fracture.
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
Greenstick fracture - the bone partly fractures on one side, but does not break
completely because the rest of the bone can bend; more common among
children, whose bones are softer and more elastic.

Hairline fracture - a partial fracture of the bone. Often this type of fracture is
harder to detect.

Impacted fracture - when the bone is fractured, one fragment of bone goes into
another.

Longitudinal fracture - the break is along the length of the bone.

Oblique fracture - A fracture that is diagonal to a bone's long axis.

Pathological fracture - when an underlying disease or condition has already
weakened the bone, resulting in a fracture (bone fracture caused by an
underlying disease/condition that weakened the bone).

Spiral fracture - A fracture where at least one part of the bone has been twisted.

Stress fracture - more common among athletes. A bone breaks because of
repeated stresses and strains.

Torus (buckle) fracture - bone deforms but does not crack. More common in
children. It is painful but stable.

Transverse fracture - a straight break right across a bone.
When assessing a trauma patient, it is important to identify any present fractures, as
untreated fractures can cause further damage (37). In patients that are unconscious, this
can be difficult as there is no verbal indication of the common fracture symptoms
(40).
Therefore, in these instances, X rays will be used to identify fractures and other injuries
in those areas affected by the trauma
(41).
Examination of different areas will also show
signs of potential fractures, as there may be swelling or bruising. In extreme cases, the
bone will be protruding from the area. When a patient is conscious, it can be easier to
identify fracture sites as the patient can communicate information regarding pain (37).
Fracture symptoms are described below (38):
Fracture Symptoms:

Pain and swelling at the fracture site.
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
Tenderness close to the fracture.

Paleness and deformity (sometimes).

Loss of pulse below the fracture, usually in an extremity (this is an emergency).

Numbness, tingling or paralysis below the fracture (rare; this is an emergency).

Bleeding or bruising at the site.

Weakness and inability to bear weight.
Treatment
Treatment for broken bones involves putting the pieces back into position and
preventing them from moving out of place as they heal. The healing process involves
the broken bone ends “knitting” themselves back together and forming new bone
around the edges of the broken areas (42). In some fracture cases, surgery may be
required (43). Depending on the severity of the break and the location of the injury,
different treatments will be used. The following is a description of the different
treatments that are used to treat fractures (39):

Cast Immobilization
A plaster or fiberglass cast is the most common type of fracture treatment,
because most broken bones can heal successfully once they have been
repositioned and a cast has been applied to keep the broken ends in proper
position while they heal.

Functional Cast or Brace
The cast or brace allows limited or "controlled" movement of nearby joints. This
treatment is desirable for some, but not all, fractures.

Traction
Traction is usually used to align a bone or bones by a gentle, steady pulling
action.

External Fixation
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In this type of operation, metal pins or screws are placed into the broken bone
above and below the fracture site. The pins or screws are connected to a metal
bar outside the skin. This device is a stabilizing frame that holds the bones in the
proper position while they heal. In cases where the skin and other soft tissues
around the fracture are badly damaged, an external fixator may be applied until
surgery can be tolerated.

Open Reduction and Internal Fixation
During this operation, the bone fragments are first repositioned (reduced) in their
normal alignment, and then held together with special screws or by attaching
metal plates to the outer surface of the bone. Inserting rods down through the
marrow space in the center of the bone may also hold the fragments together.
Complications of Fracture Repair and Fractures
It is important to properly treat and repair fractures as soon as possible to prevent the
patient from experiencing any further damage as well as any repair related
complications. In some instances, repair related complications may be unavoidable
(13).
However, repairing the fracture early and properly can prevent others. It is important to
understand the pathophysiology and predisposing factors of fracture repair
complications to adequately prevent them. When a complication is unavoidable, it is
important to diagnose it early and provide the appropriate treatment so that it does not
cause further damage (42).
While some complications can be a direct result of fracture repair, other complications
occur as a result of the fracture itself. Complications are categorized as either acute or
delayed, and they range in severity from minimal to life threatening
(37).
Acute
complications occur as a direct result of the trauma sustained and can include damage
to vascular structures, nerves, or soft tissue (37). Delayed complications may occur after
initial treatment or in response to treatment
(44).
As part of the trauma treatment
process, it is important to identify and treat any fracture related complications to prevent
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further damage (42). In addition, reevaluation at regular intervals during healing is
necessary to monitor progress and identify any complications that may arise
(43).
The following complications are common in fracture repair or as the direct result of a
fracture (45):

Life-Threatening Conditions
In some instances, a patient will experience a life threatening complication as the
result of a fracture. These conditions include the following:
o Femur fractures - disrupt the femoral artery or its branches and are
potentially fatal.
o Hip fractures - may prevent ambulation, resulting in potentially lifethreatening complications, such as pneumonia, thromboembolic disease,
and possibly rhabdomyolysis, if there is a prolonged period of immobility

Arterial Injury
Some patients may experience immediate or delayed arterial injuries as the
result of fractures or dislocations. These complications include:
Immediate:
o Laceration of the vessel, either partial or complete
o Occlusion, either partial or complete, which may be due to:

Angulation

Extrinsic compression

Intimal tears and dissection with an intact adventitia

Stretching

Spasm
Delayed:
o False aneurysms
o AV fistula
o Thrombosis of the vessel following reconstructive surgery
o Ischemic muscle contractures.
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
Nerve Injury
Nerve injuries and vessel injuries are common complications with some types of
fractures. Due to the location of many nerves and vessels, they are prone to
injury. The most vulnerable nerves and vessels are those that lie in close
proximity to the bone. These injuries are common in both closed and open
fractures. However, the injury is often more severe with an open fracture. Of the
two, nerve injuries are more commonly complications of fractures

(35).
Compartment Syndrome
Compartment syndrome is the direct result of swelling and bleeding within a
compartment. When this occurs, the fascia does not stretch, thereby causing
increased pressure on the capillaries, nerves and muscles. This increased
pressure disrupts blood flow to the muscles and nerve cells. When this occurs,
the supply of oxygen is reduced, which damages nerve and muscle cells. There
are two types of compartment syndrome:
o Acute – This type results in permanent disability and tissue death unless
the pressure is relieved quickly.
o Chronic (exertional) –This type does not typically result in permanent
disability and tissue death.
Compartment syndrome is most common in the anterior compartment of the
lower leg, as well as other compartments in the leg. However, it can also occur
in the arms, hands, feet and buttocks (46).

Venous Thromboembolism
Venous thromboembolism (VTE) is a term that describes a condition that occurs
when clots or thrombi develop in the vein from red blood cells, fibrin and other
components that clump and form a mass. VTE is the result of at least one of
three underlying etiologic factors: damage to endothelial lining of the blood
vessel, stasis or slowing of the blood flow, and hypercoagulability or increased
clotting of the blood.
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Venous thromboembolism consists of two related conditions: deep vein
thrombosis (DVT) that commonly occurs in leg veins, and pulmonary embolism
(PE) that occurs when a segment of a clot, within the deep venous system
detaches from the vessel, travels to the lungs, and lodges within the pulmonary
arteries (47).

Osteomyelitis
Osteomyelitis is an infection that occurs in the bone. Typically, various microbial
agents, such as staphylococcus aureus, cause osteomyelitis. In addition,
osteomyelitis can occur during the following situations:
o An open injury to the bone, such as an open fracture with the bone ends
piercing the skin.
o An infection from elsewhere in the body, such as pneumonia or a urinary
tract infection that has spread to the bone through the blood (bacteremia,
sepsis).
o A minor trauma, which can lead to a blood clot around the bone and then
a secondary infection from seeding of bacteria.
o Bacteria in the bloodstream bacteremia (poor dentition), which is
deposited in a focal (localized) area of the bone. This bacterial site in the
bone then grows, resulting in destruction of the bone. However, new bone
often forms around the site.
o A chronic open wound or soft tissue infection can eventually extend down
to the bone surface, leading to a secondary bone infection

(48).
Malunion
In a malunion, the bone heals in a position that is considered unacceptable and
which may cause significant impairment. In some instances, the bone heals in a
bent angle. This is called an angulated heal. In other instances, the bone can be
rotated out of position or can have overlapping fractured ends, which may cause
bone shortening (39).
o Malunion is typically caused by the following factors (40):
o Inadequate immobilization of the fracture
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o Misalignment at the time of immobilization
o Premature removal of the cast or other immobilizer

Nonunion
A nonunion occurs when a fracture fails to heal after a number of months; it
often is caused by the following factors (37):

The broken ends of bone may be separated too much (overdistraction)

There could have been excessive motion at the fracture site, either from
inadequate immobilization after the injury or from having a cast removed
prematurely

Muscle or other tissue caught between the fracture fragments also can
prevent healing, as can the presence of infection or inadequate blood
supply to the fracture site

Bone disease (e.g., bone cancer) also can prevent healing
The two types of nonunions include

(44):
Fibrous nonunion – fractures that heal through the formation of fiber tissue
rather than the formation of new bone

False joint (pseudarthrosis) –continuous movement of the fracture
fragments result in the development of a false joint
The following types of fractures pose the greatest risk of nonunion
(39):

Fractures of the wrist (carpus), including scaphoid bone

Certain fractures of the foot, including navicular fractures and Jones
(diaphyseal) fractures of the fifth metatarsal


Shoulder long bone fractures (proximal humerus fractures)

Shin bone (tibial) fractures
Complex Regional Pain Syndrome (CRPS)
Complex regional pain syndrome is common in injuries that damage the
peripheral and central nervous systems. CRPS is characterized by chronic pain
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that affects one of the limbs (arms, legs, hands or feet), which occurs after there
has been a trauma to the area (37).
Symptoms of CRPS include the following (49):
o Prolonged or excessive pain
o Mild or dramatic changes in skin color, temperature, and/or swelling in the
affected area
There are two types of CRPS (49):
o CRPS-I – patients do not have confirmed nerve injuries
o CRPS-II – patients do have confirmed nerve injuries
Both types of CRPS produce the same symptoms. Patients will experience a
range of symptom severity and duration depending in the type of injury
(37).
Most
CRPS cases are mild and resolve completely over time. However, in some
instances, patients will present with a severe case, which may result in delayed
recovery and long term disability (49).

Fat Embolism Syndrome
Some patients may develop fat embolism syndrome as the result of fractures to
the long bones and pelvis. These fractures may result in the development of fat
globules in the peripheral circulation and lung parenchyma of the patient. Fat
embolism syndrome is a common occurrence, and affects almost all patients who
experience a long bone or pelvic fracture. It is most common in closed fractures.
In fact, Patients with a single long bone fracture have a 1 to 3 percent chance of
developing the syndrome, and this increases in correlation with the number of
fractures (50).

Post-Traumatic Arthritis
"Arthritis" is defined as inflammation of a joint. The most common cause is
wearing out of joint surface cartilage (osteoarthritis). The wearing out of a joint
that has had any kind of physical injury causes post-traumatic arthritis. The injury
could be from sports, a vehicle accident, a fall, a military injury, or any other
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source of physical trauma. Such injuries can damage the cartilage and/or the
bone, changing the mechanics of the joint and making it wear out more quickly.
The wearing-out process is accelerated by continued injury and excess body
weight (51).
Fractures are common injuries and must be treated accordingly. Although fractures are
rarely life threatening, it is important to assess and treat them during the initial
emergency treatment stage to prevent further damage. Fractures can range in severity
from minor cracks to complete breaks that cause trauma to the surrounding tissue and
skin. Therefore, practitioners must identify the extent of injury and provide the
appropriate care to minimize further damage.
DIAGNOSIS AND TREATMENT
Patient stabilization is the primary objective when a patient is admitted with extremity
trauma. The emergency team will begin working to stabilize the patient immediately,
while assessing the patient and identifying any additional injuries. Once the patient is
stabilized, more focused treatment will be administered (13). Extremity trauma patient
stabilization includes three primary components:

Airway

Breathing

Circulation
Early Stabilization
When a patient presents with extremity trauma, the emergency team will immediately
begin working on the three components listed above. It is important to note that these
three components of stabilization serve as both assessments and treatment. The three
areas are assessed for immediate damage, and any necessary treatment is
administered (52).
As soon as the patient arrives in the emergency department, he or she will receive a
rapid primary survey to assess and identify any immediate problems (53). The first area
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to receive treatment is the airway. If a patient requires intubation, it is initiated
immediately. Once an airway has been established, patients who require breathing
assistance will receive the appropriate treatment
(38).
The second stage in patient stabilization involves the patient’s breathing. It is important
to assess the patient’s breathing and provide the necessary treatment. The goal is to
determine if the patient’s breathing is sufficient and provide breathing support if it is not
sufficient.
The next stage in patient care involves the circulatory system. An initial assessment of
the circulatory system is conducted to determine if the patient has experienced
circulatory collapse (39). This can be caused by hypovolemia from hemorrhage.
Immediate treatment is necessary to prevent further blood loss and assist with patient
resuscitation (8).
Evaluation and identification of extremity injury
Once the patient has been stabilized, the focus will shift to identifying and treating the
extremity injuries. As part of the initial examination, the treating provider will attempt to
determine the mechanism that caused the injuries as well as any other relevant
information, such as the time of the injury, the patient’s medical history, and any
underlying issues (17).
Once the provider has established the patient’s history and mechanism of injury, he or
she will conduct a thorough examination of the extremities to assess the damage. Early
evaluation and identification of extremity injuries is crucial to minimizing the damage
and, in many instances, salvaging the injured extremities. In some instances, extremity
injuries can be life threatening, while other injuries will pose a risk of limb loss.
However, with proper treatment, these problems may be prevented.
The following is a list of life threatening extremity injuries (54):

Pelvic disruption with massive hemorrhage

Severe arterial hemorrhage irrespective of mechanism
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
Hemorrhagic shock from multiple long bone fractures (blood loss into the
compartments)

Crush syndrome
Some injuries are not life threatening, yet they do pose a risk for limb loss. These
injuries are considered to be limb-threatening injuries. The following is a list of the limb
threatening extremity injuries (18):

Mangled extremity

Complex open fractures and / or dislocations

Degloving injuries

Severe vascular injury

Traumatic amputation

Compartment syndrome (as a consequence of the injury)

Neurological compromise of the limb
A thorough examination of the extremities will enable the treatment provider to identify
damage early and provide the appropriate treatment. The following table provides
detailed guidelines for the examination of extremities in extremity trauma situations
(55).
The general examination of the extremities includes:
Inspection
• Deformity – closed fracture, dislocation
• Open fracture – deformity, presence of an open wound, condition of the overlying skin defect, bony
involvement, degree of soft tissue involvement, contamination
• Mangled extremity
• Active bleeding, expansile hematoma
• Location of wound – proximity to an artery, location with regards to the clavicle and inguinal canal
(transition points where proximal control of extremity vascular injury becomes difficult)
• Degloving injury
• Amputation – site(s), condition of skin, soft tissue and bone of stump and amputated appendage
Palpation
• Crepitus
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• Hematoma – pulsatile, palpable thrill
• Swelling / firmness of the compartment involved, response to passive movement if compartment
syndrome suspected
Neurovascular status
• Pulses
• Warmth of periphery
• Paraesthesia
• Paralysis
Investigations
General:
ECG: Evidence of hyperkalaemia / arrhythmia
VBG: rapid pH status, electrolytes (K, Ca++), Hb, lactate
Arterial Pressure Index (API) or Ankle Brachial Index (ABI):
Performed when vascular injury is suspected in the absence of hard signs.
The ratio of the systolic blood pressure in the injured extremity distal to the injury (ankle or forearm) to
the systolic blood pressure in an uninjured extremity (usually the brachial artery)
API = Injured SBP / Uninjured SBPa
Lower limb:
The dorsalis paedis or posterior tibial pulse is found with Doppler. A BP cuff is placed below the site of
the injury and inflated to 20mmHg higher than the pressure at which the Doppler sound disappears.
The cuff is released until the Doppler sound is clearly heard and the BP is recorded (SBP). The
process is repeated on either the uninjured lower extremity or the brachial artery of an uninjured upper
extremity.
Upper limb:
The same technique is used except that the two upper limbs are compared.
Note: the cuff needs to be placed below the site of the wound on the injured limb. A ratio of 0.9 is used
to rule out the need for diagnostic imaging with a sensitivity and specificity as high as 95%. Patients
with soft signs and an API 0.9 may be observed (although ultimately there will be a delayed operative
rate of 1-4%). Patients with soft signs and a ratio of < 0.9 require further investigation as the
prevalence of vascular injury requiring surgery is 3-25% depending.
Compartment Pressure Measurement:
Compartment pressure may be measured by setting up a central venous or arterial pressure monitor
and attaching it to a needle that is then inserted into the compartment that you want to measure. All
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compartments at the level of the injury should be measured.
Laboratory:
• CK - rhabdomyolysis
• Creatinine – renal insult secondary to hypoperfusion, rhabdomyolysis
• Electrolytes – K, calcium, uric acid, phosphate – Crush / Compartment Syndrome
• Hemoglobin (normal Hb does not exclude hemorrhage)
• Urine – myoglobinuria – marker of rhabdomyolysis
• G&H and CXM - transfusion
Imaging:
• Identifies fractures, skeletal deficits, foreign bodies, soft tissue defects, subcutaneous emphysema
• Amputation – x-ray stump and amputated appendage
CTA
• Up to 100% sensitive and specific in detecting all clinically significant arterial injuries
• Allow for interrogation of the vascular system as well as surrounding skeletal and soft tissue
structures
• Standard teaching is that CTA should only be performed in patients who are hemodynamically stable
to stratify injuries in patients with soft signs of vascular injury
The goal with assessing and treating extremity injuries is to prevent amputation and
repair the injured extremity. If an injury is identified and treated early, amputation can
often be prevented. Patients who do not receive early treatment have an increased risk
of amputation and morbidity (56).
Risks
Patients who present with extremity injuries are at risk of developing additional
complications. These complications are often the result of improper, or insufficient,
treatment and can be prevent with appropriate care.
Ischemia
Ischemia is the restriction of blood supply to the tissue. When this occurs, the
restriction will cause a shortage of oxygen and glucose, which is needed to keep the
tissue alive. After a period without oxygen and glucose, the tissue will die
(57).
In fact,
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damage can occur in as little as 3 – 4 minutes after oxygen supply is blocked.
Subsequent damage will occur in other regions of the body, including the kidneys and
tissue. After a few hours, the problems will become more severe and will typically
cause tissue necrosis and gangrene (58). Eventually, the patient will experience
paralysis in the affected area, which is a sign that the nerves supplying the extremity
have died. The paralysis may be reversed if treated quickly, but in many instances it
can be permanent (59). Ischemia frequently occurs when a patient experiences vascular
trauma (60).
Ischemia typically produces specific symptoms in the patient. These include the
following (61):

Pain

Pallor

Pulselessness

Paresthesia

Paralysis

Poikilothermia
Ischemia must be reversed quickly to prevent long-term damage to the tissue and
organs. Without early treatment, the patient has an increased risk of losing the limb.
The most common treatment methods for ischemia include

Injection of an anticoagulant

Thrombolysis

Embolectomy

Surgical revascularization

Amputation
(62):
Early treatment is essential to keep the affected limb viable. While early treatment is
imperative when attempting to salvage the limb, the treatment provider must proceed
with caution. In most instances, reintroduction of blood flow to the ischemic tissue can
cause problems if not managed properly (57).
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Wound infection
Wound infections are common in instances of extremity trauma, especially when the
patient experiences penetrating extremity trauma
(63).
Wound infections are commonly
caused by bacteria, but other microorganisms can cause infections as well
(52).
Infections can be problematic in patients as they can delay healing or cause more
severe damage and long-term problems in the patient.
The most common form of bacteria that causes wound infections is staphylococcus
aureus, as well as other forms of staphylococci. These bacteria are especially prevalent
in health care facilities and can cause extensive damage to the patient in a relatively
short period of time. In most instances, a patient will develop a wound infection within
24 – 72 hours of the initial trauma (64). However, some infections may develop over a
longer period of time, or may occur as the result of external factors not related to the
initial trauma. Treatment providers should monitor the patient and any wounds carefully
so that infections can be detected and treated immediately, thereby preventing more
severe damage.
The following is a list of the most common signs of wound infection (63):

Pus or cloudy fluid draining from the wound

Pimple or yellow crust formed on the wound (impetigo)

Scab has increased in size

Increasing redness around the wound (cellulitis)

Red streak is spreading from the wound toward the heart (lymphangitis)

Wound has become extremely tender

Pain or swelling increasing after 48 hours since the wound occurred

Wound has developed blisters or black dead tissue (gangrene and
myonecrosis)

Lymph node draining that area of skin may become large and tender
(lymphadenitis)

Onset of widespread bright red sunburn-like rash

Onset of fever
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
Wound hasn't healed within 10 days after the injury
Malunion, Delayed union, or nonunion
In instances of fractures, there is a risk that the bones will not heal properly, or at all.
This risk is greater with more complex fractures and can impact the outcome for the
patient.
Malunion:
In a malunion, the bone heals in a position that is considered unacceptable and which
may cause significant impairment. In some instances, the bone heals in a bent angle.
This is called an angulated heal. In other instances, the bone can be rotated out of
position or can have overlapping fractured ends, which may cause bone shortening
(39).
Malunion is typically caused by the following factors (40):

Inadequate immobilization of the fracture

Misalignment at the time of immobilization

Premature removal of the cast or other immobilizer
Delayed Union:
Fracture repair requires time. In most instances, a bone will require a certain amount of
time to complete the healing process and establish a solid union. Delayed union occurs
when a bone has not healed over an appropriate amount of time. In these instances,
the bone remains separated or fractured, even after a significant and appropriate period
of time (7). Delayed unions often occur as the result of the following factors (38):

Inadequate reduction

Inadequate immobilization

Distraction

Loss of blood supply

Infection
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Sometimes, a delayed union will eventually transition to a successful union. However,
in other instances, the delayed union may become a nonunion
(7).
With appropriate
treatment and intervention, the patient will have the potential for a successful outcome.
Nonunion:
A nonunion occurs when a fracture fails to heal after a number of months. A nonunion
is often caused by the following factors (37):

The broken ends of bone may be separated too much (overdistraction)

There could have been excessive motion at the fracture site, either from
inadequate immobilization after the injury or from having a cast removed
prematurely

Muscle or other tissue caught between the fracture fragments also can prevent
healing, as can the presence of infection or inadequate blood supply to the
fracture site

Bone disease (e.g., bone cancer) also can prevent healing
The two types of nonunions include

(44):
Fibrous nonunion – fractures that heal through the formation of fiber tissue rather
than the formation of new bone

False joint (pseudarthrosis) – continuous movement of the fracture fragments
result in the development of a false joint
The following types of fractures pose the greatest risk of nonunion
(39):

Fractures of the wrist (carpus), including scaphoid bone

Certain fractures of the foot, including navicular fractures and Jones (diaphyseal)
fractures of the fifth metatarsal

Shoulder long bone fractures (proximal humerus fractures)

Shin bone (tibial) fractures
Loss of muscle function
In many instances extensive tissue and muscle damage occurs as the result of
extremity trauma. This damage will have an impact on the function of the extremity, and
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can result in permanent damage or death to the region
(12).
In some instances, the
patient will only experience minor or temporary loss of function. However, in more
severe cases, the patient will experience significant, long-term loss of function (1). Most
patients will require surgical intervention to repair and reconstruct the affected area
(65).
Inability to achieve skin closure
In some patients, it will be difficult to achieve skin closure during the repair process. In
some instances, this will occur because of damage and destruction of significant
portions of the skin. When this occurs, the remaining viable skin will not be sufficient for
closure and wound coverage. In these instances, other means must be employed. If
possible, skin from other areas of the body may be grafted and used for wound closure
(66).
Chronic pain
Many patients will experience chronic pain as the result of traumatic injuries to the
extremities. In fact, a approximately sixty percent of extremity trauma patients report
moderate to severe pain one year after experiencing trauma, with many of those
patients experiencing similar levels of pain for approximately 5 – 7 years after the initial
trauma (67). In many instances, this chronic pain will cause disability, post traumatic
stress disorder, and depression in patients (68).
Radiologic Imaging and Surgical Evaluation
It is common for practitioners and emergency treatment providers to use a number of
imaging techniques to identify and diagnose extremity injuries. In addition, surgical
evaluation may be used to conduct an in-depth examination of the patient’s injuries. In
many instances, the surgical evaluation is conducted in conjunction with diagnostic
imaging (17).
Trauma of the extremities is typically assessed using the three following diagnostic
imaging techniques:

X Rays

Arthrography
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
Angiography
CT scans and MRI’s ore occasionally used, but they are typically reserved for use in
complex trauma. They are also useful for diagnosing soft tissue damage. An MRI will
also be used in instances where it is necessary to obtain images of large nerves,
tendons, and cartilage.
The following chart provides detailed information on the three most common diagnostic
imaging techniques used to identify and assess extremity trauma.
Technique
X Rays
Description
X-rays use invisible electromagnetic energy beams to produce images of internal
tissues, bones, and organs on film. Standard X-rays are performed for many
reasons, including diagnosing tumors or bone injuries.
X-rays are made by using external radiation to produce images of the body, its
organs, and other internal structures for diagnostic purposes. X-rays pass through
body structures onto specially treated plates (similar to camera film) and a
"negative" type picture is made (the more solid a structure is, the whiter it appears
on the film). Instead of film, using computers and digital media may also make Xrays.
When the body undergoes X-rays, different parts of the body allow varying
amounts of the X-ray beams to pass through. Images are produced in degrees of
light and dark, depending on the amount of X-rays that penetrate the tissues. The
soft tissues in the body (such as blood, skin, fat, and muscle) allow most of the Xray to pass through and appear dark gray on the film. A bone or a tumor, which is
denser than the soft tissues, allows few of the X-rays to pass through and appears
white on the X-ray. At a break in a bone, the X-ray beam passes through the
broken area and appears as a dark line in the white bone.
X-rays of the extremities are often used as the first step in diagnosing injuries of
the extremities, but may also be used to evaluate other problems involving the
bones and/or soft tissues.
X-rays of the extremities (such as the arm, leg, hand, foot, ankle, shoulder, knee,
hip or hand) may be performed to assess the bones of the extremity for injuries,
such as fractures or broken bones, or evidence of other injuries or conditions, such
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as infection, arthritis, tendinitis, bone spurs, tumors, or congenital abnormalities. Xrays of the extremities may also be used to evaluate bone growth and development
in children.
X-rays of joints may be done to evaluate damage to soft tissues, such as cartilage,
muscle, tendons, or ligaments, and to assess for the presence of fluid in the joint,
and other abnormalities of the joint such as bone spurs, narrowing of the joint, and
changes in the structure of the joint (69).
Arthrography
Arthrography is medical imaging to evaluate conditions of joints. It can either be
indirect or direct.
Indirect arthrography is a medical imaging technique in which contrast material is
injected into the blood stream, which will eventually absorb into the joint. With
direct arthrography, the contrast material is injected directly into the joint. Direct
arthrography is the preferred method because it is better for distending or enlarging
the joint and imaging small internal structures to allow for better evaluation of
diseases or conditions within the joint. It, however, is often performed only if a nonarthrographic exam is felt to be inadequate.
There are several methods to perform direct arthrography:
Conventional direct arthrography of a joint uses a special form of x-ray called
fluoroscopy after an injection of contrast material containing iodine is administered
directly into the joint. Alternate methods of direct arthrography examinations may
use magnetic resonance imaging (MRI) or computed tomography (CT) following
the various contrast material injections into the joint.
Fluoroscopy makes it possible to see bones, joints and internal organs in motion.
When iodine contrast is injected into the joint, it fills the entire joint and becomes
clearly visible during x-ray evaluation, allowing the radiologist to assess the
anatomy and function of the joint. Although the injection is typically monitored by
fluoroscopy, the examination also involves taking radiographs for documentation.
The images are most often stored and viewed electronically.
Direct MR arthrography involves the injection of a contrast material into the joint.
The contrast material used for MR evaluation is different from that used for x-ray; it
contains gadolinium, which affects the local magnetic field within the joint. As in
conventional direct arthrography, the contrast material outlines the structures within
the joint, such as cartilage, ligaments and bones and allows them to be evaluated
by the radiologist after the MR images are produced.
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CT direct arthrography uses the same type of contrast material as conventional
direct arthrography and may be supplemented by air to produce a double contrast
CT arthrogram. CT makes cross sectional images processed by a computer using
x-rays.
Arthrography may be performed on a joint when there has been persistent and
unexplained pain, discomfort, and/or dysfunction in the joint. Other reasons to
perform arthrography may include, but are not limited to, the following:

To identify abnormalities (for example, acute and chronic tears) in the soft
tissues of the joint, such as ligaments, cartilage, and joint capsules
Angiography

To evaluate damage from recurrent dislocations of the joint

To visualize synovial cysts (70)
Angiography is the imaging of blood vessels using water-soluble ionic or nonionic
X ray contrast media injected into the blood stream of arteries (arteriography) or
veins (venography). For lymph vessels, oily contrast media are used.
Angiography serves to investigate normal and pathological states of the vessel
system particularly luminal narrowing and obstruction or aneurismal widening.
Furthermore tumor conditions, arteriovenous malformations (AVM) and
arteriovenous fistulae (AVF) or sources of bleeding are investigated with
angiography. Complications are low but differ somewhat according to vessel
access.
Images are taken mainly with digital subtraction techniques (digital subtraction
angiography DSA), however, single shot or fast series may also be taken with rapid
film changers, in cine mode (cine angiography for coronary arteries) or as digital
video recordings directly from the image intensifier screen.
Injection of contrast material into arteries and veins is performed either directly via
a needle puncture or using a percutaneously inserted angiographic catheter most
commonly made from polyethylene, polyurethane or nylon. Contrast injection is
done by hand (mainly in direct needle puncture or in small caliber arteries) or with
a power injector.
Angiographic studies are routinely performed under local anesthesia. After
infiltration of the skin and the tissue around the artery or vein to be punctured, a
small skin incision is made, and the artery is punctured with an angiographic
needle. For percutaneous catheter insertion, the Seldinger technique is used (71).
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While the three techniques included in the table above are the most common diagnostic
imaging techniques, it is important to understand the role that CT Scans and MRI’s have
in diagnosing extremity trauma.
CT Scan
Computed tomography (CT scan) is a diagnostic imaging procedure that produces
horizontal, or axial, images of the body. These images are often called “slices” (72). The
CT scan uses a combination of X Ray imaging and computer technology to obtain the
images in a noninvasive format (73). A CT scan is an important diagnostic tool as it is
able to provide detailed images of different parts of the body. It is especially useful in
obtaining images of the bones, muscles, fat and organs (74).
CT scans are used more frequently than standard X Rays because the images are
more detailed (41). Standard X Rays use a single beam of energy that is aimed at the
specific body part being analyzed. The image is captured on a plate that is placed
behind the body, once the beam of light passes through the various body parts (skin,
bone, muscle, and tissue) (10). X Rays are limited in their ability to provide detailed
imaging, as they cannot capture images of internal organs and other structures of the
body. Therefore, a CT scan is often the primary assessment used. A CT scan uses a
moving X Ray beam to capture the images. The beam circles around the body, thereby
capturing a number of different views of the same body part. The information is
transmitted to a computer, which then interprets the data and creates a two dimensional
form. The form is displayed on a monitor, which is then reviewed by the radiologist (41).
CT scans are conducted in two ways, as described below:
Contrast: Patients ingest a substance orally, or receive an injection intravenously. The
contrast solution enables the radiologist to view the specific body part or region more
clearly.
Non-Contrast: The CT scan is conducted without the use of any solution (75).
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CT scans are used frequently in instances of spinal trauma as they provide thorough
views of the brain and the spine. A CT scan is especially useful for detecting the
following injuries in spinal trauma patients (76):
•
Bone fractures
•
Bleeding
•
Spinal stenosis
CT scans are less useful in detecting injuries to the spinal cord or any ligament injuries
associated with an unstable spine
(77).
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Imaging (MRI) is a radiologic scan that produces images of
various body structures using a combination of magnetism, radio waves and computer
technology. The MRI is conducted using a large circular magnet that surrounds a
scanner tube (10). Placing the patient on a movable surface and inserting him or her into
the magnetic tube is done to obtain images. Once the patient is in the tube, a strong
magnetic field is created. This magnetic field aligns the protons of the hydrogen atoms.
Once the hydrogen atoms are aligned, they are exposed to a beam of radio waves. The
radio waves impact the protons within the body, causing them to spin, thereby
producing a faint signal, which is easily detected by the MRI receiver. The information
obtained by the scanner is sent to a computer, where it is processed to produce an
image (75).
An MRI utilizes high resolution technology, which allows it to produce highly detailed
images that will show changes in many of the structures in the body (78). In some
instances, additional agents will be used to enhance the accuracy of the images. It is
most common to use contrast agents such as gadolinium (79). Due to the MRI’s high
level of sensitivity, it is able to detect many injuries that are undetectable using other
methods (75).
While an MRI and CT scan both use the slicing technique for obtaining images, the
process is different for each. The MRI uses a magnetic field while the CT scan uses X
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Rays (76). As a result, the MRI provides more detailed images than a CT scan and is
able to detect damage that is as small as 1 – 2 mm. A CT scan cannot detect damage
this small (80).
Reperfusion
Many patients will experience a reperfusion injury when blood supply is returned after a
period of ischemia. Damage from reperfusion occurs in the tissue surrounding the
impacted area (57). If reperfusion is not properly managed, the restoration of blood flow
will cause inflammation and oxygen related damage to the area, which will cause
additional complications for the patient (81). Reperfusion is characterized by the
following (61):

Cellular edema

Intracellular calcium ion (Ca2+) overload

Activation of Ca2+- dependent autolytic enzymes

Disruption of lipid membranes

Changes in mitochondrial structure and function
To prevent reperfusion injury, the treating provider will have to manage the restoration
of blood flow so that it does not overwhelm the patient’s system. This can be
accomplished using a variety of techniques, including but not limited to a tourniquet
(57).
Analgesia
Patients who experience extremity trauma typically present with significant pain, which
can negatively impact the assessment and treatment of the patient. In addition,
extreme pain can cause physiologic problems with trauma patients.
The physiologic impact of pain in trauma is listed below as the following (82):

Accentuates stress response

Accentuates catabolic processes

Slows restoration of function

Increases sympathetic outflow

Hemostatic response with altered levels of platelets/fibrin and coagulation
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Patients should receive, when appropriate, analgesics as soon as possible to minimize
pain. In most instances, analgesics will be administered intravenously. However, some
patients may receive oral analgesics (83). In most instances, the treatment provider will
take a multimodal approach to analgesic administration.
Multimodal Treatment
Multimodal treatment options may include the following (84):

Regional – Local anesthetic blocks/infusions

Neuraxial – Intrathecal vs. epidural

NSAIDS

Opioids – Peripheral and/or central

NMDA receptor agonists –

Ketamine/Methadone/dextromethorphan

Anticonvulsants – Gabapentin/Lyrica
The goal is to reduce or eliminate pain so that assessment and treatment will be
successful and so that the patient will be comfortable. However, while analgesics do
help reduce the patient’s pain, there are potential risks associated with the use of some
analgesics. Therefore, the treatment provider must consider the potential
consequences when prescribing analgesics (83).
Antibiotics
All extremity wounds have the potential to become infected. Therefore, many provides
will utilize prophylactic antibiotics to prevent infection. In many instances, antibiotics will
be used for a duration of five days to two weeks, depending on the type of injury and the
antibiotic used (85). In some cases, patients will receive additional antibiotic treatment
after the initial period if there is still a risk of infection (86). In most instances, initial
antibiotics are delivered intravenously, with additional dosing administered orally for the
duration of treatment. Generally speaking, the antibiotics used as prophylactics will be
broad antibiotics that will treat multiple types of bacteria and infection
(63).
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Antibiotics will also be used to treat patients after they develop an infection. In these
instances, the patient will receive antibiotics to eliminate an infection that has occurred
as a complication of the initial trauma. Infections may not appear for days or weeks, so
the provider must rely on information from the patient to identify and manage these
infections (64). When antibiotics are prescribed to treat specific infections, they will be
selected based upon the specific treatment needs of the patient. In these instances, the
antibiotics will be bacteria and infection specific
(85).
Treatment by general or trauma surgeon with involvement from specialists
Many patients will require advanced treatment beyond the scope of the initial
emergency provider or treating physician. If the situation warrants, patients will receive
treatment from a general or trauma surgeon, along with involvement and assistance
from various specialists. The specific specialists will be selected based upon the
mechanism and type of injury, the affected areas, any potential complications, and the
presence of any underlying conditions (13).
PROGNOSTIC FACTORS FOR LIMB SALVAGE
The primary goal with extremity trauma is limb salvage. In most instances, the treating
provider will utilize a variety of treatment options to prevent amputation and repair the
damage to the extremities. However, in some instances, the extremity is too damaged
to salvage. This is especially common when a patient experiences a mangled
extremity, which is a limb injury that damages at least three of the four systems in the
extremity. While mangled extremities can still be salvaged, the risk of amputation is
greater and it is more difficult to repair the damage
(2).
In some instances, the treating provider will use scoring systems to assess the damage
and determine if amputation is necessary. However, many of the scoring systems are
unreliable and do not accurately predict whether amputation is necessary. Therefore,
providers will often assess other factors when making a determination
(87).
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Of utmost concern is the safety of the patient. If a damaged limb poses a life
threatening risk, the patient’s needs will come before the need to salvage the limb
(88).
Once the patient’s viability has been assessed, the focus will shift to other factors. The
primary factor to consider when determining limb viability is the severity of the damage
to the soft tissue. The more extensive the damage, the greater likelihood that the
patient will require amputation (89). Other factors that may cause the surgeon to
consider amputation include (90):

High grade open fracture

Severe vascular injury

Significant nerve damage

Inevitability of amputation after failed salvage
In addition to the primary factors listed above, surgeons and treatment providers will
consider a variety of other factors as well. The decision is not made lightly and
providers must take all factors into consideration before making the decision. It is
especially important for treatment providers to consider the following factors when
determining whether or not to amputate.
Time
The potential to salvage a limb decreases as more time passes from the onset of injury.
Untreated damage to any of the systems that comprise the extremity will worsen over
time and can cause tissue death and unrepairable damage to the extremities.
Therefore, surgeons will consider the amount of time that has passed when determining
whether or not to amputate (91).
Mechanism
The mechanism of injury will have an impact on the potential for limb salvage. In some
instances, the mechanism of injury will cause extensive, irreparable damage. This is
especially true in military trauma situations and accidents that crush or mangle the
extremity (2).
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In military trauma situations, explosive devices that destroy portions of the extremities
often injure patients. In these situations, the damage is too extensive to repair. The
same is true with civilian trauma that causes similar damage, which is especially
common in motor vehicle crashes (92).
Anatomy
The region of the extremity that is damaged will be a determining factor in the
salvageability of the limb. In some instances, the damage will occur in a region that
cannot be repaired easily, which will increase the likelihood that the limb will have to be
amputated (93).
In addition to the factors listed above, the treating physician and surgeon will also
consider other factors when determining limb salvagibility. These factors include the
following (18):

Associated injuries

Age and physiologic health

Clinical presentation

Environmental circumstances
Limb salvage is one of the primary goals when working with patients who have
experienced extremity trauma. However, the factors listed above may reduce the
potential for limb salvage. As part of the assessment and treatment process, physicians
and surgeons will utilize all resources to salvage the limb. In some instances, however,
limb salvage will not be possible. In these instances, the patient will experience a limb
loss, either through amputation or as part of the initial injuries
(94).
AMPUTATION AND LIMB LOSS
Limb loss, which is defined as the loss of part of the arm or the leg, can be a common
injury during extremity trauma situations as many of the accidents that cause extremity
trauma are severely damaging to the individual’s body. Limb loss can occur directly
during the trauma (e.g. limbs being blown off during an explosive accident), or they can
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occur through amputation after the accident as a treatment measure. According to the
Center for Disease Control, approximately two million people in the United States are
living with limb loss (95).
When limbs are amputated in response to specific injuries sustained during an accident,
there are specific amputation locations that are called amputation levels. The treatment
team will determine where to amputate the limb based on the severity of the injury and
the areas affected (96). The following is a list of the different amputation levels

Partial Foot or Toe(s) (incl. Symes)

Below Knee (incl. Rotationplasty)

Above Knee (incl. Knee Disarticulation)

Hip Disarticulation or Hemipelvectomy

Bilateral Lower Limb Loss

Partial Hand or Finger(s)

Below Elbow (incl. Wrist Disarticulation)

Above Elbow (incl. Elbow Disarticulation)

Shoulder Disarticulation or Forequarter

Bilateral Upper Limb Loss
(97):
When limbs are blown off during an explosive accident or are torn from the body as part
of another type of accident, it is often necessary to remove additional parts of the limb
so that the loss occurs within one of the pre-determined amputation levels (98). Limb
loss and damage that is a direct result of an explosion or accident is typically very
uneven and includes an abundance of damaged, unsalvageable tissue, bone and
ligaments. Therefore, the treatment team will most likely need to “clean up” the area
and remove the additional damaged tissue, bone and ligaments
(99).
This ensures a
smooth amputation and ensures that the loss site is clean and can be fitted for a
prosthetic device (if one is deemed necessary and/or appropriate)
(100).
In many instances, a body part will sustain significant damage as a result of the
accident. However, the limb will not be detached from the body in any way. This often
occurs when significant tissue damage occurs (95). In these instances, the emergency
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treatment team will either have to provide treatment that will salvage the extremity, or
they will have to amputate the extremity (96). This decision is not made lightly.
Salvaging the limb is always the preferred option if the limb function can be restored or
maintained, or if the severity of the injury will not cause further damage to the patient.
In many instances, the tissue damage is so severe that the limb cannot be salvaged
(98).
There are a number of assessment tools that emergency providers can use to
determine the severity of the injury to the extremity and the potential for repair and
restoration. The data obtained from these assessments is used to make a final
determination regarding amputation. The following are the available scoring systems:

Predictive Salvage Index (PSI)

Mangled Extremity Severity Score (MESS)

Limb Salvage Index (LSI)

Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age
(NISSSA) Score

Hannover Fracture Scale-98 (HFS-98)
Each scoring system uses different criteria to determine extremity damage and viability.
Predictive Salvage Index
Overview:
The Predictive Salvage Index (PSI) is used to evaluate severity of a lower extremity that
has undergone trauma with orthopedic and vascular injuries.
Parameters:
1. Level of arterial injury
2. Degree of bone injury
3. Degree of muscle injury
4. Interval from injury until arrival in the operating room
Tissue Injury
Bone
Findings
Transverse fracture with possible butterfly component;
Degree
Mild
simple oblique fracture; fracture dislocation of joint
Comminuted fracture over 2-5 cm
Moderate
Comminuted fracture >5 cm; or segmental loss
Severe
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Muscle
Laceration of one or more muscles in a single
Mild
compartment; no significant crush component
Laceration of one or more muscles in 2 compartments;
Moderate
crush-revulsion component
Laceration of one or more muscles in 3 or 4
Severe
compartments
Parameter
Findings
Points
Level of arterial
Suprapopliteal
1
injury
Popliteal
2
Infrapopliteal
3
Degree of bone
Mild
1
injury
Moderate
2
Severe
3
Degree of muscle
Mild
1
injury
Moderate
2
Severe
3
Interval before
<6 hours
0
surgery
6−12 hours
2
>12 hours
4
Predictive Salvage Index = SUM (points for all 4 parameters)
Interpretation:
Minimum score: 3 (based on the point assignments; if no vascular, bone or muscle
injury then the score could reach 1, but then it would not be a seriously injured limb)
Maximum score: 13
The higher the score the worse the chances for a successful limb salvage.
(101)
Mangled Extremity Severity Score
Overview:
The Mangled Extremity Severity Score can be used to evaluate patients with lower
extremity trauma with vascular compromise. It can help to decide whether to attempt
limb salvage or to perform amputation.
Parameters:
1. Extent of skeletal and soft tissue injury
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2. Patient’s blood pressure
3. Duration and extent of limb hypoperfusion
4. Age of patient
Group
Finding
Skeletal and
Low energy (stab wounds, simple closed fractures, small caliber
soft tissue
gunshot wounds)
injury
Medium energy (open or multiple level fractures, dislocations, moderate
Points
1
2
crush injuries)
Shock
High energy (shotgun blast at close range, high velocity gunshot wound)
3
Massive crush injury (logging, railroad or oil rig accidents)
4
Normotensive (blood pressure stable in field and in OR)
0
Transiently hypotensive (blood pressure unstable in field but responsive
1
to intravenous fluids)
Prolonged hypotension (systolic blood pressure <90 mm Hg in field and
2
responsive to intravenous fluid only in the OR)
Ischemia
None (pulsatile limb without signs of ischemia)
0
(≤ 6 hours)
Mild (diminished pulses without signs of ischemia)
1
Moderate (no pulse by Doppler, sluggish capillary refill, parenthesis,
2
diminished motor activity)
Severe (pulseless, cool, paralyzed, numb, without capillary refill)
3
Ischemia
None (as above)
0
(>6 hours)
Mild (as above)
2
Moderate (as above)
4
Severe (as above)
6
< 30 years of age
0
≥ 30 and <50 years of age
1
≥ 50 years of age
2
Age
Where: Scores for ischemia >6 hours are twice those of ≤ 6 hours.
Mangled Extremity Severity Score = (points for skeletal and soft tissue injury)
+ (points for blood pressure)
+ (points for ischemia, depending on duration of ischemia)
+ (points for age)
Interpretation:
Minimum score 1
Maximum score 14
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A score ≥ 7 is 100% predictive for amputation in the study population.
A score <7 can usually be salvaged (102).
Limb Salvage Index (LSI)
Overview:
The Limb Salvage Index (LSI) is used to evaluate a severely injured lower extremity.
Parameters:
1. artery
2. nerve
3. bone
4. skin
5. muscle
6. deep vein
7. warm ischemia time
Parameter
Artery
Finding
Artery contusion, intimal tear, partial laceration or avulsion (pseudo-
Points
0
aneurysm) with no distal thrombosis and palpable pedal pulses
Complete occlusion of 1 of 3 shank vessels or profunda
0
Occlusion of 2 or more shank vessels
1
Complete laceration, avulsion, or thrombosis of femoral or popliteal
1
vessels without palpable pedal pulses
Complete occlusion of femoral or popliteal vessels with no distal
2
runoff available
Nerve
Bone
Complete occlusion of 3 shank vessels with no distal runoff available
2
Contusion or stretch injury
0
Minimal clean laceration of femoral, peroneal or tibial nerve
0
Partial transection or avulsion of sciatic nerve
1
Complete or partial transection of femoral, peroneal or tibial nerve
1
Complete transection or avulsion of sciatic nerve
2
Complete transection or avulsion of both peroneal and tibial nerves
2
Closed fracture at 1 or 2 sites
0
Open fracture with comminution or with minimal displacement
0
Closed dislocation without fracture
0
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Open joint without foreign body
0
Fibula fracture
0
Closed fracture at 3 or more sites on same extremity
1
Open fracture with comminution or moderate to large displacement
1
Segmental fracture
1
Fracture dislocation
1
Open joint with foreign body
1
Bone loss <3 cm
1
Bone loss ≥ 3 cm
2
Type III-B or III-C fracture (open fracture with periosteal stripping,
2
gross contamination, extensive soft tissue injury or loss)
Skin
Muscle
Deep vein
Clean laceration, single or multiple
0
Small avulsion injury with primary closure
0
First degree burn
0
Delayed closure due to contamination
1
Large avulsion requiring split thickness skin graft or flap closure
1
Second and third degree burn
1
Laceration or avulsion involving a single compartment
0
Laceration or avulsion involving a single tendon
0
Laceration or avulsion involving 2 or more compartments
1
Complete laceration or avulsion of 2 or more tendons
1
Crush injury
2
Contusion, partial laceration, or partial avulsion
0
Complete laceration or avulsion if alternative route of venous return is
0
intact
Superficial vein injury
0
Complete laceration, avulsion or thrombosis with no alternative route
1
of venous return
Warm
<6 hours
0
ischemia time
6−9 hours
1
9−12 hours
2
12−15 hours
3
>15 hours
4
Where:
Shank is the lower leg.
Bone loss was <3 cm or >3 cm in the table. I assigned = 3 cm as 2 points.
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Points for each category = maximum single point assignment
Limb Salvage Index = SUM (points for all 7 parameters)
Interpretation:
Minimum score: 0
Maximum score: 14
The higher the score the more severe the injury (103).
Limb Salvage Index
Outcome
0−5
Limb salvage successful (51 of 51)
6−14
Amputation (19 of 19)
Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age (NISSSA)
Score
Overview:
The NISSSA score is used for grading the severity of an open fracture of the lower
extremity. It is a modification of the MESS, with addition of an evaluation of nerve injury.
Parameters:
1. N = nerve injury
2. I = ischemia
3. S = soft tissue contamination
4. S = skeletal injury
5. S = shock
6. A = age of the patient
Parameter
Nerve
Finding
Description
Points
Sensate
No major nerve injury
0
Dorsal
Deep or superficial peroneal nerve, femoral nerve
1
injury
Plantar partial
Tibial nerve injury
2
Plantar
Sciatic nerve injury
3
Good to fair pulses, no ischemia
0
complete
Ischemia
None
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Mild ≤ 6 hours
Reduced pulses but perfusion normal
1
Moderate ≤ 6
No pulse; prolonged capillary refill; Doppler pulses
2
hours
present
Severe ≤ 6
Pulseless, cool, ischemic, no Doppler pulses
3
hours
Mild >6 hours
2
Moderate >6
4
hours
Severe >6
6
hours
Soft tissue
Low
Minimal to no contusion, no contamination
0
Medium
Moderate injury, low velocity gunshot wound,
1
moderate contamination, minimal crush
High
Moderate crush, deglove, high velocity gunshot,
2
injury may require soft tissue flap, considerable
contamination
Severe
Massive crush, farm injury, severe deglove, severe
3
contamination
Skeletal
Low energy
Spiral fracture, oblique fracture, no or minimal
0
displacement
Medium energy Transverse fracture, minimal comminution, small
1
caliber gunshot wound
High energy
Moderate displacement, moderate comminution,
2
high velocity gunshot wound, butterfly fragments
Shock
Severe energy
Segmental, severe comminution, severe bone loss
3
Normotensive
Always >90 mm Hg systolic
0
Transient
Transient
1
Persistent hypotension despite fluids
2
<30 years
Young
0
30−50 years
Middle age
1
>50 years
Older
2
hypotension
Persistent
hypotension
Age
NISSSA score = SUM (points for all 6 parameters)
Interpretation:
Minimum score: 0
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Maximum score: 19
The higher the score, the more severe the injury.
A score ≥ 7 was 100% sensitive for amputation, but with specificity of 46%.
A score ≥ 11 had a 100% specificity and positive predictive value for amputation
(104).
Hannover Fracture Scale-98 (HFS-98)
Overview:
The Hannover Fracture Scale '98 is an update to the Hannover Fracture Scale that was
developed in 1983. It is a simpler instrument yet reliable measure of limb salvage.
Parameters:
1. extent of fracture bone loss
2. skin injury as percent of limb circumference
3. muscle injury as percent of limb circumference
4. wound contamination
5. deperiostation
6. local circulation
7. systolic blood pressure (systemic circulation)
8. neurologic findings
Parameter
Extent of bone loss
Skin injury
Muscle injury
Finding
Points
None
0
0.1 to 1.9 cm
1
≥ 2.0 cm
2
None
0
1−24% of circumference
1
25−50% of circumference
2
51−75% of circumference
3
76−100% of circumference
4
None
0
1−24% of circumference
1
25−50% of circumference
2
51−75% of circumference
3
76−100% of circumference
4
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Wound contamination
Deperiostation
Local circulation
Systolic blood pressure
Palmar-plantar sensibility
Finger-toe active motion
None
0
Partial
1
Massive
2
No
0
Yes
1
Normal
0
Capillary pulse
1
Ischemia <4 hours
2
Ischemia 4 to 8 hours
3
Ischemia >8 hours
4
Constantly >100 mm Hg
0
<100 until admission
1
<100 until surgery
2
Constantly <100 mm Hg
3
Yes
0
No
1
Yes
0
No
1
Hannover Fracture Scale Score = SUM (points for all 8 parameters)
Interpretation:
Minimum score: 0
Maximum score: 22
The higher the score the worse the injury.
A score ≥ 11 indicates significant trauma, with amputation recommended
(105).
When assessing the damage caused to an extremity, emergency treatment personnel
will use the scoring systems listed above. A determination regarding which system to
use will be made based on the specific area that is damaged
(106).
Each scoring system
is reliable. However, no system is 100% reliable. Therefore, practitioners should use
the scoring system as an initial guide when making a determination regarding whether
to amputate a damaged limb. However, practitioners should also exercise caution when
relying completely on the score. In some instances, the score will not accurately
determine whether a limb should be amputated or salvaged
(97).
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Risk factors for amputation
As mentioned earlier, the primary goal with extremity trauma is limb salvage; and, the
treating provider will often utilize a variety of treatment options to prevent amputation
and repair the damage to the extremities. In the case of a mangled extremity, which is a
limb injury that damages at least three of the four systems in the extremity, the extremity
may be too damaged to salvage. While mangled extremities can still be salvaged, the
risk of amputation is greater and it is more difficult to repair the damage
(2).
In some
instances, the damage and destruction to the extremity will make it apparent
immediately that amputation is necessary. However, in many instances, it will be
difficult to determine immediately if the injured extremity will require amputation
(93).
The
treating provider will have to consider various factors when making the determination.
There are many reasons why a patient may require an amputation. However, some risk
factors will increase the likelihood that a patient will require an amputation.
Gustilo III-C injuries
When a patient experiences an open fracture as the result of extremity trauma, he or
she may be at an increased risk of requiring amputation. The level of fracture injury
often determines the risk of amputation. When a fracture is classified as a Type IIIC
injury, the patient is at an increased risk of requiring amputation (107).
To determine the level of injury, providers use the Gustilo-Anderson classification
system, which classifies open fractures based on the level and severity of soft tissue
injury; the higher the level the greater the risk of amputation. The following is the
different fracture classification levels according to the Gustilo-Anderson Classification
System (108):
Type I:
Wound < 1cm, wound is clean without evidence of contamination; usually simple
transverse / oblique fractures (infection risk 0-2%)
Type II:
Wound > 1cm with moderate soft tissue injury and moderate contamination; (infection
risk 2-5%)
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Type IIIA:
Severe soft tissue injury but bone adequately covered irrespective of the size of the
wound; highly contaminated; usually more complex fractures - segmental or severely
comminuted fractures (infection risk 5-10%)
Type IIIB:
Extensive soft tissue loss, exposed bone, periosteal stripping, massive contamination
(infection risk 10-50%)
Type IIIC:
Extensive fracture associated with arterial injury requiring repair (infection risk 25-50%)
The Gustilo-Anderson Classification System is one of the most reliable indicators of
amputation risk (109). However, there are a number of other factors that will increase the
risk of amputation if present in the patient. These include the following (110):

Nerve transaction

Prolonged ischemia/muscle necrosis

Crush or destructive soft tissue injury

Significant wound contamination

Multiple/severely comminuted fractures/segmental bone loss

Old age/severe comorbidity

Lower vs. upper extremity

Apparent futility of revascularization
It is important for treatment providers to thoroughly assess the patient to determine the
presence of any amputation risk factors. In some instances the patient’s limb can still
be salvaged. It is crucial that all risk be addressed and remedied as soon as possible;
the longer the patient experiences risk factors, the greater the chance of amputation.
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SUMMARY
Extremity trauma is one of the most common forms of trauma treated in emergency
departments throughout the United States. Extremity trauma can be simple or complex,
as it may cause injuries in only one of the components of the extremity or all of the four
components. The four components of the extremity are the nerves, vessels, bones, and
soft tissue. The most severe cases of extremity trauma will involve more than one of
the components of the extremity and can be difficult to manage and repair. When a
patient experiences injury in three of the four components, he or she has a mangled
injury and is at an increased risk of losing the limb.
Treatment for extremity injuries, especially those that are severe, requires a
multifaceted approach that addresses the immediate needs of the patient while
preventing long term damage and salvaging the extremity. This approach typically
requires the involvement of a variety of providers, including but not limited to trauma
surgeons, orthopedic, vascular and plastic surgeons, and rehabilitation specialists. The
focus will be on salvaging the limb while repairing the initial damage.
In some instances, the damage will be too severe to salvage the extremity. When this
occurs, the patient will require an amputation of the extremity. In other instances, the
extremity will be amputated as part of the initial injury, and will require treatment and
repair to clean up the damaged area. While limb salvage is the primary goal, it must not
take precedence over the health and safety of the patient. If the injured limb poses a
risk to the patient’s survival, it must be amputated as soon as possible.
Extremity injuries are common in both military and civilian trauma situations and can be
caused by a number of different mechanisms. In military situations, most extremity
injuries are the result of penetrating trauma. They are often the result of explosive
devices and landmines. In civilian trauma, the majority of extremity injuries are caused
by blunt trauma. They are often the result of motor vehicle accidents and industrial
accidents. However, when penetrating injuries occur in the civilian population, they are
typically the result of gunshot wounds and stabbings.
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Extremity trauma can range in severity and may be life threatening for the patient.
However, advances in modern medicine have improved both physicians’ abilities to
salvage limbs in cases of extreme trauma and patients’ potential to have a good quality
of life when amputation is a necessary resolution to injury. Unfortunately, without rapid
and appropriate intervention, extremity trauma has a high incidence of morbidity.
Nurses and all members of the health team play a vital role in the initial treatment and
ongoing management and support of patients with extremity trauma, a role that has a
significant impact on each patient’s recovery and rehabilitation.
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