Download War Surgery: Limbs Injury – Dr. Abdulwahid

LIMBS INJURY
Dr.AbdulWAHID M Salih
Ph.D. Surgery
WOUNDS OF LIMBS
• 50-75% of all missile wounds and blast injuries
involve the limbs
Fractures
• Should Be Stabilized To Avoid:
1.
Further damage to surrounding tissue,
2.
bleeding
3.
pain.
IMMOBILIZATION of entire limb
INDICATIONS;
1. All severe soft tissue wounds of extremities
2. Fractures should initially be immobilized
METHODS OF IMMOBILIZATION
1. Sling
2. plaster back slabs.
3. application of splints
The leg
• Splinted by binding it
To the good leg
Thomas splint
• Immobilize compound fractures of the femur
and fractures around the knee joint
METHODS OF IMMOBILIZATION
4. Plaster of paris (pop)
5. Skin or skeletal traction
METHODS OF IMMOBILIZATION
6. External fixation
Principles of cast application
1. Slabs or cylinders that have been well split are
the only safe plasters to apply.
2. Never put;
• Complete
• Unsplit
• Unpadded cylinder
• Tight bandages
VASCULAR INJURIES
possible vascular injury ;
• The Position Of The Missile Track,
• The Presence Of A Subfascial Haematoma,
• After Resuscitation, Distal Pulses Remain
Impalpable,
Management of arterial injury
• Urgent surgical exposureas early as circumstances
allow, preferably within six hours of injury.
• “LOOK AND SEE” is wiser than “wait and see”.
• Every effort should be made to repair arterial damage
• After major arterial ligation
the incidence of limb gangrene
is very high
• Fractures should be treated
after vascular surgery
Circulation can be impaired by
1. Complete, unsplit, unpadded cylinder
2. Tight bandages applied to a limb
3. Swelling occurs in a limb within the first 24 – 48
hours after;
Fracture,
severe sprain,
wound or operation;
Signs of compartment syndrome
“7 P’s”:
1. severe pain at rest
2. Pain with passive stretch
3. Parasthesia (tingling and numbness)
4. Paresis (weakness) impaired movement
5. Pulses (diminished pulses in the affected limb)
6. Pallor (loss of normal color)
7. Persistent cold
• Pressure (tense)
A tonometer to directly measure pressure
• indication for fasciotomy;
intracompartmental
pressure >30 mmHg[10]
• <30 mmHg difference
between
intracompartmental
pressure and diastolic
blood pressure
Indications for fasciotomy
1. wounds directly involving the calf;
2. concomitant major venous injuries;
3. clinical compartment compression syndrome in
the immediate postoperative period;
4. when the ischaemic state has existed for longer
than 4-6 hours before arterial surgery;
5. any major arterial injury to the limbs.
The anterior and lateral fascial
compartments
• A single longitudinal incision 15 cm in length
• Placed halfway down the leg,
• 2 cm anterior to the shaft of the fibula.
• Dividing the anterior and lateral compartments,
The two posterior compartments
• Single Longitudinal Incision 15 Cm In Length In The
Distal Part Of The Leg
• 2 Cm Posterior To The Palpable
Posteromedial Edge Of The Tibia.
Fasciotomy
The deep fascia must be incised along the length
of the skin incision
allows wide and deep retraction
left open to allow post-operative oedematous and
congested tissue to swell without tension
exposes the depths of the wound
Fasciotomy
• The wounds should be left
open for delayed closure.
Complications
• Muscle and nerve cell death
• deformity, paralysis, permanent
muscle contraction (Volkmann's
contracture),
• systemic infection (sepsis)
• and renal failure.)
• amputation
TENDON, NERVE
•
No attempt should be made at primary;
• Tendon or nerve repair,
In Grossly contaminated wounds.
Major Artery
An injury to a major artery to the limb:
• must be either repaired
• or replaced by a saphenous vein graft immediately
INJURIES OF PERIPHERAL NERVES
• May be injured alone
• more commonly, in association with vascular
damage or long bone fractures.
Nerve repair
• In multiple injuries, nerve
repair is of the lowest
priority.
• Nerve repairs are performed
when wounds are healthy
and clean, which is generally
at least 6 weeks after injury.
• Repair can safely be deferred
for 3 months but
contractures must not be
permitted to develop.
General indications for Amputation
1. severe damage:
2. no chance of recovery of function of any part
3. mangled, grossly contaminated wounds
4. overwhelming infection
5. established gangrene;
6. continued infection associated
with severe nerve and bone Injury
1. secondary haemorrhage,
uncontrollable by other measures
8. multiple injuries,
GAS GANGRENE
The risk:
1. Foreign bodies in wounds such as clothing,
soil, metal or wood,
2. Prolonged application of tourniquets or tight
plasters
3. Fascial compartment
compression syndromes
1. Delayed treatment
GAS GANGRENE
• The incubation period ; less than three days
• the sudden appearance of pain in the region of the
wound.
• oedematous
• drainage of thin serous or
serosanguinous exudate
• The pulse rate rises markedly
• but the temperature is rarely more than 38° C.
• clinically deteriorates
• within several hours becomes anxious and
frightened
• hypotensive and may vomit in severe cases.
GAS GANGRENE
Immediate surgical intervention is essential