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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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Continuing Nursing Education Course Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Course Purpose This course will provide advanced learning for nurses interested in the management of the trauma patient with an extremity injury. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Activity Review Information Reviewed by Susan DePasquale, MSN, FPMHNP-BC Release Date: 3/1/2016 Termination Date: 11/15/2016 Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. The most common types of closed injuries include: a. b. c. d. Contusion Hematoma Crush All of the above 2. Which following type of fracture poses the greatest risk of nonunion: a. b. c. d. Wrist (carpus) fractures Femur fractures Facial fractures Spinal fractures 3. Life threatening extremity injuries include: a. b. c. d. Pelvic disruption with massive hemorrhage Severe arterial hemorrhage irrespective of mechanism Multiple long bone fractures (blood loss into the compartments) All of the above 4. True or False. 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. a. True b. False 5. Type IIIA fracture classification involves: a. b. c. d. Severe tissue injury with open bone exposed Fracture to upper and/or lower extremity limbs Low contamination with infection rate less than 2 % None of the above nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 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 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 Extremity Injuries 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 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 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 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. 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 and lacerations Avulsions nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 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 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 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:15 • Type of weapon/bullet used • Distance from weapon • Location and trajectory/path of injury • Permanent versus temporary cavity 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 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 will often cause damage to numerous areas of the body rather than one specific point of entry. 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 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 Thermal injuries are caused by the following mechanisms:6 Radiation Convection Conduction Electricity Excessive cold 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 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 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 sheet24 provides information on special considerations for treating and managing soft tissue injuries. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 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 (i.e., object impaled in cheek) Avulsions Clean the wound surface 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 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 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.25 Hard Signs: External or pulsate hemorrhage Rapidly expanding or pulsatile hematoma Palpable thrill/audible bruit nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 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 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 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 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. The classifications 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 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 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 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. 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 Fracture dislocation - a joint becomes dislocated, and one of the bones of the joint has a fracture. 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 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. 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 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 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 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. 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 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 life-threatening 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 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. 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:48 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 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. 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 Inadequate immobilization of the fracture Misalignment at the time of immobilization 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 (i.e., bone cancer) also can prevent healing nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 problems.53 The first area 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 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 • 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 Lower limb The dorsalis pedis 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 through setting up a central venous or arterial pressure monitor and attaching it to a needle that is then inserted into the compartment to be measured. All 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 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, 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 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:62 Injection of an anticoagulant Thrombolysis Embolectomy Surgical revascularization Amputation 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 blood flow to the ischemic tissue can cause problems if not managed properly.57 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) nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 Bone disease (i.e., 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42 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 Angiography nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 43 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.69,70,71 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 X-rays. 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 Xrays that penetrate the tissues. The soft tissues in the body (such as blood, skin, fat, and muscle) allow most of the X-ray 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44 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 as infection, arthritis, tendinitis, bone spurs, tumors, or congenital abnormalities. X-rays 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. 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 non-arthrographic 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 45 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. 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 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 46 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. 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 47 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:75,76 Contrast CT: 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 CT: The CT scan is conducted without the use of any solution. CT scans are used frequently in instances of spinal trauma as they provide thorough views of nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48 the brain and the spine. A CT scan is especially useful for detecting the following injuries in spinal trauma patients where there has been: • 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49 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-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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 50 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 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 versus epidural NSAIDS Opioids – Peripheral and/or central NMDA receptor agonists Ketamine/Methadone/dextromethorphan Anticonvulsants – Gabapentin/Lyrica nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 51 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 52 Treatment by General or Trauma Surgeon and Other 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 53 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, nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 54 irreparable damage. This is especially true in military trauma situations and accidents that crush or mangle the extremity.2 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 55 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 (i.e., limbs being blown off during an explosive accident), or they can 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:97 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 56 additional parts of the limb so that the loss occurs within one of the predetermined 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 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) nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 57 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 include: 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 Degree Mild component; simple oblique fracture; fracture dislocation of joint Muscle Comminuted fracture over 2-5 cm Moderate Comminuted fracture >5 cm; or segmental loss Severe Laceration of one or more muscles in a single Mild compartment; no significant crush component Laceration of one or more muscles in 2 Moderate compartments; crush-revulsion component Laceration of one or more muscles in 3 or 4 Severe compartments nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 58 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:101 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59 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 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 soft tissue caliber gunshot wounds) injury Medium energy (open or multiple level fractures, dislocations, Points 1 2 moderate crush injuries) High energy (shotgun blast at close range, high velocity 3 gunshot wound) Shock 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 1 responsive to intravenous fluids) Prolonged hypotension (systolic blood pressure <90 mm Hg in 2 field and 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, 2 parenthesis, diminished motor activity) Severe (pulseless, cool, paralyzed, numb, without capillary 3 refill) nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 60 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 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 61 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 Points 0 (pseudo-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 1 popliteal vessels without palpable pedal pulses Complete occlusion of femoral or popliteal vessels with no distal 2 runoff available Complete occlusion of 3 shank vessels with no distal runoff 2 available Nerve 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/tibial nerve 1 Complete transection or avulsion of sciatic nerve 2 Complete transection or avulsion of both peroneal and tibial 2 nerves Bone Closed fracture at 1 or 2 sites 0 Open fracture with comminution or with minimal displacement 0 Closed dislocation without fracture 0 Open joint without foreign body 0 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 62 Fibula fracture 0 Closed fracture at 3 or more sites on same extremity 1 Open fracture with comminution or moderate to large 1 displacement 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 2 stripping, 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 0 return is intact Superficial vein injury 0 Complete laceration, avulsion or thrombosis with no alternative 1 route of venous return Warm <6 hours 0 ischemia 6−9 hours 1 time 9−12 hours 2 12−15 hours 3 >15 hours 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 63 Where: Shank is the lower leg. Bone loss was <3 cm or >3 cm in the table. I assigned = 3 cm as 2 points. 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 64 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, 1 femoral nerve injury Ischemia Plantar partial Tibial nerve injury 2 Plantar complete Sciatic nerve injury 3 None Good to fair pulses, no ischemia 0 Mild ≤ 6 hours Reduced pulses but perfusion normal 1 Moderate ≤ 6 hours No pulse; prolonged capillary refill; 2 Doppler pulses present Severe ≤ 6 hours Pulseless, cool, ischemic, no Doppler 3 pulses Soft tissue Mild >6 hours 2 Moderate >6 hours 4 Severe >6 hours 6 Low Minimal to no contusion, no 0 contamination Medium Moderate injury, low velocity gunshot 1 wound, moderate contamination, minimal crush High Moderate crush, deglove, high velocity 2 gunshot, injury may require soft tissue flap, considerable contamination nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 65 Severe Massive crush, farm injury, severe 3 deglove, severe contamination Skeletal Low energy Spiral fracture, oblique fracture, no or 0 minimal displacement Medium energy Transverse fracture, minimal 1 comminution, small caliber gunshot wound High energy Moderate displacement, moderate 2 comminution, high velocity gunshot wound, butterfly fragments Severe energy Segmental, severe comminution, severe 3 bone loss Shock Age Normotensive Always >90 mm Hg systolic 0 Transient hypotension Transient 1 Persistent hypotension Persistent hypotension despite fluids 2 <30 years Young 0 30−50 years Middle age 1 >50 years Older 2 NISSSA score = SUM (points for all 6 parameters) Interpretation: Minimum score: 0 Maximum score: 19 The higher the score, the more severe the injury:104 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 66 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 67 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:105 A score ≥ 11 indicates significant trauma, with amputation recommended. 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 68 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 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69 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%) 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%) nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 70 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 versus 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. Summary Extremity trauma is one of the most common forms of trauma treated in emergency departments throughout the United States. Extremity trauma nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 71 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 72 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. 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. Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 73 1. The most common types of closed injuries include: a. b. c. d. 2. Which following type of fracture poses the greatest risk of nonunion: a. b. c. d. 3. Wrist (carpus) fractures Femur fractures Facial fractures Spinal fractures Life threatening extremity injuries include: a. b. c. d. 4. Contusion Hematoma Crush All of the above Pelvic disruption with massive hemorrhage Severe arterial hemorrhage irrespective of mechanism Multiple long bone fractures (blood loss into the compartments) All of the above True or False. 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. a. True b. False 5. Type IIIA fracture classification involves: a. b. c. d. 6. Severe tissue injury with open bone exposed Fracture to upper and/or lower extremity limbs Low contamination with infection rate less than 2 % None of the above In a malunion, the bone heals a. b. c. d. in a position that may cause significant impairment. in a bent angle, also called an angulated heal. rotated out of position or have overlapping fractured ends. *All of the above. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 74 7. True or False. While mangled extremities can still be salvaged, the risk of amputation is greater and it is more difficult to repair the damage. a. *True. b. False. 8. The primary factor to consider when determining limb viability is the a. b. c. d. 9. *severity of the damage to the soft tissue. severity of vascular damage and blood loss. degree of muscle damage. Both b and c above. Factors that may cause the surgeon to consider amputation include: a. b. c. d. high grade open fracture. severe vascular injury and significant nerve damage. inevitability of amputation after failed salvage. *All of the above. 10. Compartment pressure may be measured through setting up a _____________________________________. a. b. c. d. neuro check every 2 hours. *CVP or pressure monitor. blood pressure cuff to the limb. None of the above. 11. Approximately ________ percent of extremity trauma patients report moderate to severe pain one year after experiencing trauma. a. b. c. d. 20 40 *60 77 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 75 12. Ischemia typically produces specific symptoms in the patient. These may include: a. b. c. d. Pain Pallor Paresthesia *All of the above. 13. The primary mechanisms of soft tissue injury are mechanical and thermal. Mechanical force includes: a. b. c. d. *Shearing, tension, compression Laceration, hematoma, acute edema Burn, hematoma, pain Pressure wound, pain, serous drainage. 14. Reperfusion injury occurs when blood supply is returned after a. b. c. d. *a period of ischemia. acute blood loss putting the arm up. use of hot and cold. 15. Multimodal treatment options may include a. b. c. d. Regional – Local anesthetic blocks/infusion Neuraxial – Intrathecal versus epidural NSAIDS and opioids. *All of the Above. 16. True or False. Muscle or other tissue caught between bone fracture fragments can prevent healing. a. *True. b. False. 17. Life threatening fractures include the following: a. b. c. d. femur fractures hip fractures arm/shoulder fractures *Both a and b above. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 76 18. The most vulnerable nerves and vessels are those that a. b. c. d. *lie in close proximity to the bone. lie in far proximity to the bone. are affected in both closed and open fractures. are at the distal digits. 19. The following types of fractures pose the greatest risk of nonunion: a. b. c. d. *fractures of the wrist (carpus), including scaphoid bone certain fractures of the thigh short bone fractures both b and c above. 20. True or False. In the trauma setting, the patient may receive interventions from multiple specialists other than the emergency MD. a. *True. b. False. Correct Answers: 1. d 11. c 2. a 12. d 3. d 13. a 4. a 14. a 5. d 15. d 6. d 16. a 7. a 17. d 8. a 18. a 9. d 19. a 10. b 20. a nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 77 References Section The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text. 1. Kloen P, Helfet DL, Prasarn ML. Management of the mangled extremity. Strateg. Trauma Limb Reconstr. 2012. p. 57–66. 2. Wolinsky PR, Webb LX, Harvey EJ, Tejwani NC. The mangled limb: salvage versus amputation. Instr. Course Lect. 2011 Jan;60:27–34. 3. Akula M, Gella S, Shaw CJ, McShane P, Mohsen AM. A meta-analysis of amputation versus limb salvage in mangled lower limb injuries—The patient perspective. Injury. 2011;42(11):1194–7. 4. Jeffery SLA. Advanced wound therapies in the management of severe military lower limb trauma: a new perspective. Eplasty. 2009 Jan;9:e28. 5. Manthey DE, Nicks BA. Penetrating Trauma to the Extremity. J. Emerg. Med. 2008;34(2):187–93. 6. Tu Y-K, On Tong G, Wu C-H, Sananpanich K, Kakinoki R. Soft-tissue injury in orthopaedic trauma. Injury. 2008 Oct;39 Suppl 4:3–17. 7. Pape H-C, Sanders R, Borrelli, J, editors. The Poly-Traumatized Patient with Fractures. Berlin, Heidelberg: Springer Berlin Heidelberg; 2011. 8. Stone WM, Fowl RJ, Money SR. Upper extremity trauma: current trends in management. J. Cardiovasc. Surg. (Torino). 2007;48:551–5. 9. Wolf JM, Athwal GS, Shin AY, Dennison DG. Acute trauma to the upper extremity: what to do and when to do it. Instr. Course Lect. 2010 Jan;59:525–38. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 78 10. Harris & Harris’ Radiology of Emergency Medicine. Lippincott Williams & Wilkins; 2012. p. 1048. 11. Penetrating Trauma Wounds Challenge EMS Providers - Patient Care @ JEMS.com [Internet]. Available from: http://www.jems.com/article/patient-care/penetrating-trauma-woundschallenge-ems 12. Tibbles CD, Newton EJ, Love J. Acute Complications of Extremity Trauma. Emerg. Med. Clin. North Am. 2007;25(3):751–61. 13. Hildebrand F, Giannoudis P, Kretteck C, Pape H-C. Damage control: extremities. Injury. 2004 Jul;35(7):678–89. 14. Philipp L, Reiner O, Marcel B, Rene W, Hans-Christoph P, Philipp K. A civilian perspective on ballistic trauma and gunshot injuries. Scand. J. Trauma. Resusc. Emerg. Med. 18. 15. Sadjadi J, Cureton EL, Dozier KC, Kwan RO, Victorino GP. Expedited Treatment of Lower Extremity Gunshot Wounds. J. Am. Coll. Surg. 2009;209(6):740–5. 16. Brevard SB, Champion H KD. Weapons Effects [Internet]. Available from: http://www.cs.amedd.army.mil/borden/book/ccc/UCLAchp2.pdf 17. Assessment of Extremity Injuries - EMSWorld.com [Internet]. Available from: http://www.emsworld.com/article/10336473/assessment-ofextremity-injuries 18. Korompilias A V, Beris AE, Lykissas MG, Vekris MD, Kontogeorgakos VA, Soucacos PN. The mangled extremity and attempt for limb salvage. J. Orthop. Surg. Res. 2009 Jan;4(1):4. 19. Stone WM, Fowl RJ, Money SR. Upper extremity trauma: Current trends in management. J. Cardiovasc. Surg. (Torino). 2007;48:551–5. 20. Sloan J. Soft tissue injuries: introduction and basic principles. Emerg Med J. 2008;25:33–7. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 79 21. Grivas TB, Koufopoulos GE, Vasiliadis E, Polyzois VD. The management of lower extremity soft tissue and tendon trauma. Clin. Podiatr. Med. Surg. 2006;23:257–282, v. 22. Geeslin AG, LaPrade RF. Location of bone bruises and other osseous injuries associated with acute grade III isolated and combined posterolateral knee injuries. Am. J. Sports Med. 2010 Dec;38(12):2502–8. 23. Frank J, Daecke W, Marzi I. Reconstruction of Lower Extremity Fractures with Soft Tissue Defects. Eur. J. Trauma Emerg. Surg. 2007. p. 24–32. 24. Soft Tissue Injuries [Internet]. Available from: http://www.gov.mb.ca/health/ems/guidelines/docs/T1.05.06.pdf 25. Halvorson JJ, Anz A, Langfitt M, Deonanan JK, Scott A, Teasdall RD, et al. Vascular injury associated with extremity trauma: initial diagnosis and management. J. Am. Acad. Orthop. Surg. American Academy of Orthopaedic Surgeons; 2011 Aug 1;19(8):495–504. 26. Dua A, Desai SS, Holcomb JB, Burgess AR, Freischlag JA, editors. Clinical Review of Vascular Trauma. Berlin, Heidelberg: Springer Berlin Heidelberg; 2014. 27. Brown K V, Ramasamy A, Tai N, MacLeod J, Midwinter M, Clasper JC. Complications of extremity vascular injuries in conflict. J. Trauma. 2009;66:S145–S149. 28. Doody O, Given MF, Lyon SM. Extremities--indications and techniques for treatment of extremity vascular injuries. Injury. 2008;39:1295– 303. 29. Gosk J, Rutowski R. Penetrating injuries to the nerves of the lower extremity: principles of diagnosis and treatment. Ortop. Traumatol. Rehabil. 2005;7:651–5. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 80 30. Kerns JM. The microstructure of peripheral nerves. Tech. Reg. Anesth. Pain Manag. 2008;12:127–33. 31. Taylor CA, Braza D, Rice JB, Dillingham T. The incidence of peripheral nerve injury in extremity trauma. Am. J. Phys. Med. Rehabil. 2008;87:381–5. 32. Robinson LR. Traumatic injury to peripheral nerves. Muscle Nerve. 2000;23:863–73. 33. Gosk J, Rutowski R, Rabczyński J. The lower extremity nerve injuries own experience in surgical treatment. Folia Neuropathol. 2005;43:148– 52. 34. Ruch DS, Vallee J, Li Z, Smith BP, Holden M, Koman LA. The acute effect of peripheral nerve transection on digital thermoregulatory function. J. Hand Surg. Am. 2003 May;28(3):481–8. 35. Pathophysiology of Peripheral Nerve Injury: A Brief Review: Nerve Injury Classification [Internet]. Available from: http://www.medscape.com/viewarticle/480071_3 36. Management of Nerve Injuries: Grades of Nerve Injury [Internet]. Available from: http://www.medscape.com/viewarticle/774686_3 37. Pape H-C, Sanders RW, Borrelli J. The Poly-Traumatized Patient with Fractures: A Multi-Disciplinary Approach. Springer; 2011. 38. What Is A Fracture? What Are Broken Bones? [Internet]. [cited 2013 Oct 1]. Available from: http://www.medicalnewstoday.com/articles/173312.php 39. Fractures (Broken Bones)-OrthoInfo - AAOS [Internet]. [cited 2013 Oct 1]. Available from: http://orthoinfo.aaos.org/topic.cfm?topic=a00139 40. Howe AS. The Spectrum of Polytrauma. A Pragmatic Approach for the Musculo-Skeletal Surgeon [Internet]. [cited 2013 Oct 1]. Available from: http://www.uptodate.com/contents/general-principles-offracture-management-early-and-late-complications nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 81 41. Bittle MM, Gunn ML, Gross JA, Stern EJ. Trauma Radiology Companion: Methods, Guidelines, and Imaging Fundamentals. Lippincott Williams & Wilkins; 2012. p. 432. 42. Nicholas B, Toth L, van Wessem K, Evans J, Enninghorst N, Balogh ZJ. Borderline femur fracture patients: early total care or damage control orthopaedics? ANZ J. Surg. 2011 Mar;81(3):148–53. 43. Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J. Bone Joint Surg. Am. 2006 Dec;88(12):2739–48. 44. Giannoudis P V, Giannoudi M, Stavlas P. Damage control orthopaedics: lessons learned. Injury. 2009 Nov;40 Suppl 4:S47–52. 45. Joshi V, Harding GEJ, Bottoni DA, Lovell MB, Forbes TL. Determination of functional outcome following upper extremity arterial trauma. Vasc. Endovascular Surg. 2007 Jan 1;41(2):111–4. 46. Murdock M, Murdoch MM. Compartment syndrome: a review of the literature. Clin. Podiatr. Med. Surg. 2012;29:301–10, viii. 47. Arcelus JI, Kudrna JC, Caprini JA. Venous thromboembolism following major orthopedic surgery: what is the risk after discharge? Orthopedics. 2006 Jun;29(6):506–16. 48. Osteomyelitis [Internet]. Available from: http://my.clevelandclinic.org/orthopaedics-rheumatology/diseasesconditions/hic-osteomyelitis.aspx 49. Complex Regional Pain Syndrome Fact Sheet: National Institute of Neurological Disorders and Stroke (NINDS) [Internet]. Available from: http://www.ninds.nih.gov/disorders/reflex_sympathetic_dystrophy/det ail_reflex_sympathetic_dystrophy.htm 50. Stein PD, Yaekoub AY, Matta F, Kleerekoper M. Fat embolism syndrome. Am. J. Med. Sci. 2008;336:472–7. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 82 51. Post-Traumatic Arthritis [Internet]. Available from: http://my.clevelandclinic.org/disorders/arthritis/hic-post-traumaticarthritis.aspx 52. Keel M, Trentz O. Pathophysiology of polytrauma. Injury. 2005 Jun;36(6):691–709. 53. Hoffmeyer P, Peter R. The Spectrum of Polytrauma. A Pragmatic Approach for the Musculo-Skeletal Surgeon. Bentley G, editor. Berlin, Heidelberg: Springer Berlin Heidelberg; 2012. 54. Sanches JEA, Pereira de Godoy JM, Baitello AL, Chueire AG. Mortality associated with extremity injuries compared with other types of trauma. Int. J. Gen. Med. 2011;4:273–5. 55. Major Extremity Trauma [Internet]. Available from: http://www.emergpa.net/wp/wp-content/uploads/Major-ExtremityTrauma-Module.pdf 56. Newton EJ, Love J. Acute complications of extremity trauma. Emerg. Med. Clin. North Am. 2007;25:751–761, iv. 57. Eltzschig HK, Eckle T. Ischemia and reperfusion--from mechanism to translation. Nat. Med. Nature Publishing Group, a division of Macmillan Publishers Limited. All Rights Reserved.; 2011 Jan;17(11):1391–401. 58. Lumsden AB, Davies MG, Peden EK. Medical and endovascular management of critical limb ischemia. J. Endovasc. Ther. 2009 Apr 31;16(2 Suppl 2):II31–62. 59. Fernandez N, McEnaney R, Marone LK, Rhee RY, Leers S, Makaroun M, et al. Predictors of failure and success of tibial interventions for critical limb ischemia. J. Vasc. Surg. 2010;52(4):834–42. 60. Semenza GL. Vascular responses to hypoxia and ischemia. Arterioscler. Thromb. Vasc. Biol. 2010 Apr 1;30(4):648–52. 61. Varu VN, Hogg ME, Kibbe MR. Critical limb ischemia. J. Vasc. Surg. 2010;51(1):230–41. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 83 62. White CJ, Jaff MR, Dattilo PB, Casserly IP. Critical Limb Ischemia: Endovascular Strategies for Limb Salvage. Prog. Cardiovasc. Dis. 2011;54(1):47–60. 63. Treatment of Infections in Penetrating Traumatic Injury: Infections of the Extremities [Internet]. Available from: http://www.medscape.com/viewarticle/738854_5 64. Eardley WGP, Watts SA, Clasper JC. Extremity trauma, dressings, and wound infection: should every acute limb wound have a silver lining? Int. J. Low. Extrem. Wounds. 2012 Sep;11(3):201–12. 65. Rush RM, Arrington ED, Hsu JR. Management of complex extremity injuries: tourniquets, compartment syndrome detection, fasciotomy, and amputation care. Surg. Clin. North Am. 2012;92:987–1007, ix. 66. Crist BD, Ferguson T, Murtha YM, Lee MA. Surgical timing of treating injured extremities: an evolving concept of urgency. Instr. Course Lect. 2013;62:17–28. 67. Castillo RC, MacKenzie EJ, Wegener ST, Bosse MJ. Prevalence of chronic pain seven years following limb threatening lower extremity trauma. Pain. 2006;124(3):321–9. 68. MacKenzie EJ, Bosse MJ. Factors Influencing Outcome Following LimbThreatening Lower Limb Trauma: Lessons Learned From the Lower Extremity Assessment Project (LEAP). J. Am. Acad. Orthop. Surg. 2006 Sep 1;14(10):S205–210. 69. X-rays of the Extremities | Johns Hopkins Medicine Health Library [Internet]. Available from: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopa edic/x-rays_of_the_extremities_92,P07646/ 70. Arthrography [Internet]. Available from: http://www.radiologyinfo.org/en/info.cfm?pg=arthrog nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 84 71. The Scientific Basis of Urology, Second Edition. Taylor & Francis; 2004. p. 684. 72. Marik PE, Varon J, Trask T. CT of head trauma. Neuroimaging Clin. N. Am. 2002;122:525–39. 73. Understanding Brain Injury Diagnostic Tests (CT/MRI/DTI/SPECT/EEG) [Internet]. [cited 2013 Oct 1]. Available from: http://www.braininjury.com/diagnostics.shtml 74. Gakhal MS, Sartip KA. CT angiography signs of lower extremity vascular trauma. AJR. Am. J. Roentgenol. American Roentgen Ray Society; 2009 Jul 23;193(1):W49–57. 75. Gasiorowski KL. Trauma Radiology Companion: Methods, Guidelines, and Imaging Fundamentals. AORN J. Elsevier; 2012;96(4):457. 76. Watkins D. A–Z of Musculoskeletal and Trauma Radiology. J. Trauma Inj. Infect. Crit. Care. 2009. p. 960. 77. Shaftan GW. How interventional radiology changed the practice of a trauma surgeon. Injury. 2008;39:1229–31. 78. Jones RG. Introduction to interventional radiology in trauma. Trauma. 2011. p. 145–53. 79. Gay D, Miles R. Use of imaging in trauma decision-making. J R Army Med Corps. 2011;157:S289–92. 80. Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA. Detecting vascular injury in lower-extremity orthopedic trauma: the role of CT angiography. Orthopedics. 2008;31:761. 81. Percival TJ, Rasmussen TE. Reperfusion strategies in the management of extremity vascular injury with ischaemia. Br. J. Surg. 2012 Jan;99 Suppl 1:66–74. 82. Wranze E, Greb I, Wulf H, Hartmann H, Kill C. Analgesia for extremity trauma by rescue paramedics. Notfall + Rettungsmedizin. 2011. p. 135–42. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 85 83. Cander B, Girisgin S, Koylu R, Gul M, Koçak S. The effectiveness of analgesics in traumatic injuries of the extremities. Adv. Ther. 2005 Sep;22(5):462–6. 84. Abbuhl FB, Reed DB. Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance. Prehosp. Emerg. Care. 7(4):445–7. 85. Lane JC, Mabvuure NT, Hindocha S, Khan W. Current concepts of prophylactic antibiotics in trauma: a review. Open Orthop. J. 2012 Jan;6:511–7. 86. Barton C, Osler T, Crookes B, Bartlett C, McMillian W. Compliance with the Eastern Association for the Surgery of Trauma guidelines for prophylactic antibiotics after open extremity fracture. Int. J. Crit. Illn. Inj. Sci. 2012. p. 57. 87. Shanmuganathan R. The utility of scores in the decision to salvage or amputation in severely injured limbs. Indian J. Orthop. 2008 Oct;42(4):368–76. 88. MacKenzie EJ, Bosse MJ. Factors influencing outcome following limbthreatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP). J. Am. Acad. Orthop. Surg. 2006;14:S205–S210. 89. Sánchez Perales MC, García Cortés MJ, Borrego Utiel FJ, Viedma G, Gil JM, Pérez del Barrio P, et al. [Incidence and risk factors for nontraumatic lower extremity amputation in hemodialysis patients]. Nefrologia. 2005 Jan;25(4):399–406. 90. Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J. Orthop. Trauma. 2007 Jan;21(1):70–6. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 86 91. Mills JL, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI). J. Vasc. Surg. 2013; 92. Conroy C, Schwartz A, Hoyt DB, Brent Eastman A, Pacyna S, Holbrook TL, et al. Upper extremity fracture patterns following motor vehicle crashes differ for drivers and passengers. Injury. 2007;38:350–7. 93. Russell WL, Sailors DM, Whittle TB, Fisher DF, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann. Surg. 1991 May;213(5):473–80; discussion 480–1. 94. Fodor L, Sobec R, Sita-Alb L, Fodor M, Ciuce C. Mangled lower extremity: can we trust the amputation scores? Int. J. Burns Trauma. 2012 Jan;2(1):51–8. 95. Limb Loss Awareness|Features|NCBDDD|CDC. 96. Pasquina PF, Bryant PR, Huang ME, Roberts TL, Nelson VS, Flood KM. Advances in amputee care. Arch. Phys. Med. Rehabil. 2006 Mar;87(3 Suppl 1):S34–43; quiz S44–5. 97. Reiber GE, McFarland L V, Hubbard S, Maynard C, Blough DK, Gambel JM, et al. Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings. J. Rehabil. Res. Dev. 2010 Jan;47(4):275–97. 98. Dougherty PJ, McFarland L V, Smith DG, Esquenazi A, Blake DJ, Reiber GE. Multiple traumatic limb loss: a comparison of Vietnam veterans to OIF/OEF servicemembers. J. Rehabil. Res. Dev. 2010 Jan;47(4):333– 48. 99. Paradigm shift for VA amputation care [Internet]. Available from: http://www.rehab.research.va.gov/jour/10/474/sigford.html nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 87 100. Devlin M, Pauley T, Head K, Garfinkel S. Houghton Scale of prosthetic use in people with lower-extremity amputations: Reliability, validity, and responsiveness to change. Arch. Phys. Med. Rehabil. 2004 Aug;85(8):1339–44. 101. Predictive Salvage Index (PSI) [Internet]. Available from: http://www.mymedal.org/index.php?n=Military.293703 102. Mangled Extremity Severity Score (MESS) [Internet]. Available from: http://www.mymedal.org/index.php?n=Military.293701 103. Limb Salvage Index (LSI) [Internet]. Available from: http://www.mymedal.org/index.php?n=Military.293704 104. NISSSA Score of McNamara et al for Open Fracture of the Lower Extremity [Internet]. Available from: http://www.mymedal.org/index.php?n=Military.293705 105. Hannover Fracture Scale ’98 (HFS '98) [Internet]. Available from: http://www.mymedal.org/index.php?n=Military.293707 106. Brown K V, Ramasamy A, McLeod J, Stapley S, Clasper JC. Predicting the need for early amputation in ballistic mangled extremity injuries. J. Trauma. 2009 Apr;66(4 Suppl):S93–7; discussion S97–8. 107. Papakostidis C, Kanakaris NK, Pretel J, Faour O, Morell DJ, Giannoudis P V. Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo–Anderson classification. Injury. 2011;42(12):1408– 15. 108. Rajasekaran S, Naresh Babu J, Dheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, et al. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. J. Bone Joint Surg. Br. 2006 Oct 1;88(10):1351–60. 109. Ly T V, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J. Bone Joint Surg. Am. 2008;90:1738–43. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 88 110. Tintle SM, Baechler MF, Nanos GP, Forsberg JA, Potter BK. Traumatic and trauma-related amputations: Part II: Upper extremity and future directions. J. Bone Joint Surg. Am. 2010;92:2934–45. The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. 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