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TRAUMATIC
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 emodule 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 limb salvaging in cases of
extreme trauma and the potential of patients to have a good quality of life
when amputation is a necessary resolution to injury. Without rapid and
appropriate interventions, extremity trauma has a high incidence of
morbidity. All clinicians have a vital role in the initial treatment, ongoing
management, and support of patients with extremity trauma, a role that has
a significant impact on each patient’s recovery and rehabilitation.
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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 3.5 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 clinicians and emergency treatment teams be
knowledgeable to provide patients with safe and appropriate assessment and
care of an extremity injury.
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Course Purpose
This course will provide advanced learning for clinicians 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.
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.
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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
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Introduction
Extremity trauma is one of the most common forms of trauma treated in
emergency departments throughout the United States. Extremity trauma
can be simple or complex, as it may cause injuries in only one of the
components of the extremity or all of the four components. The four
components of the extremity are the nerves, vessels, bones, and soft tissue.
The most severe cases of extremity trauma will involve more than one of the
components of the extremity and will be difficult to manage and repair.
When a patient experiences injury in three of the four components, he or
she has a mangled injury and is at an increased risk of losing the limb.1
Treatment for extremity injuries, especially those that are severe, requires a
multifaceted approach that addresses the immediate needs of the patient
while preventing long term damage and improving the chance to salvage an
extremity. This approach typically requires the involvement of a variety of
clinicians, such as trauma surgeons, orthopedic, vascular and plastic
surgeons, and rehabilitation specialists among some others. 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. 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.
Types Of 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. In civilian
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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. 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 the
patient’s potential to have 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 most common types of open injuries include
those involving abrasions and lacerations, avulsions, punctures, traumatic
amputation and crush.4
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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 contusion, hematoma and crush injury.4
Blunt Versus Penetrating 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.4 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. In many instances, the blunt
injuries will occur internally and will not be noticeable without the use of
diagnostic imaging. Additionally, many blunt injuries will produce few
outward symptoms. However, while blunt injuries are not easily detected,
they can have severe consequences.5,6
If not detected, a blunt injury can cause death in a patient within a short
period of time. 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.
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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
Abrasions involves 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 involves tearing of tissue underneath the skin. An individual
may have sustained a severe bump against a stationary object
and underneath the skin (subcutaneous) there may be severe
damage caused to tissue and organs. Visual examinations do
not always show this.
Penetrating Injuries
Although the majority of trauma injuries will be caused by blunt trauma, a
number of patients will experience penetrating trauma and subsequent
penetrating injuries. Penetrating injuries can range in severity depending on
the object involved and the site of injury. Penetrating trauma occurs when
an object pierces the patient’s skin. After the object pierces the skin, it
enters the body and causes damage to the internal structures. With
penetrating trauma, any of the internal regions can be damaged, including
the bones, tendons, ligaments, nerves and blood vessels.4-6
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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.4-7
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. 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. Since the extent of
the damage is not visible from the outside, the patient will undergo a
thorough assessment, including radiologic imaging, to determine the extent
of damage.8
Gunshot Wounds
The Centers for Disease Control and Prevention (CDC) reported 33,804
gunshot wound related deaths per year in the United States. The amount
and severity of injury caused by firearms depends on a number of factors,
such as the type of weapon/bullet used, distance from the weapon, location
and trajectory/path of injury, and permanent versus temporary cavity.9
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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. 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.
High velocity injuries are caused by firearms with a muzzle velocity of more
than 600 meter per second. Military weapons or high-powered hunting rifles
cause most high velocity injuries.
Damage is often dependent on the type of bullet used. Bullets that are
encased with hard shells produce deeper penetration and more significant
cavitation. Bullets with soft or hollow points typically deform or fragment
and often ricochet inside the body. 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. 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.
Extremity Injury: Soft Tissue, Blood Vessels, Nerve And Bone Tissue
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 vessel, nerve, and bone.4 In some
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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. In many instances,
the damage can be repaired and the patient will be able to recover with
limited disability or other long-term effects.
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.
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
shearing, tension and 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.
Thermal injuries are caused by the following mechanisms:

Radiation

Convection

Conduction

Electricity

Excessive cold
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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.8
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.8 Spongy tissue is arranged loosely within the
bone and provides space for the bone marrow. Compact osseous tissue is
comprised of tightly packed minerals and can be found in the outer regions
of the bones. 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.
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.8 However, there are common
symptoms that most patients will experience in conjunction with a soft
tissue/osseous injury. The most common soft tissue/osseous injuries include
1) Pain, 2) Swelling, 3) Discoloration, 4) Temperature change, 5) Numbness
or tingling and 6) Loss of function.
Depending on the cause and type of soft tissue injury, patients may require
special treatment considerations. In some instances, the injury will require
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special care, while other injuries may only require standard wound care.
Special considerations for treating and managing soft tissue injuries are
highlighted in the table below.
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
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
Treat injuries as per the appropriate Guideline

Clear wounds of loose foreign material

Apply dressings and bandages to all wounds

Control bleeding

Consider internal bleeding, fractures, and injuries to underlying organs and
structures

Any additional surveys and treatment should be conducted

Be prepared to manage cardio respiratory distress or arrest
Vascular Trauma
Vascular trauma is defined as any injuries that occur in the vascular regions,
including veins, blood vessels, and arteries. Vascular injuries occur in both
blunt and penetrating trauma, with the majority of injuries caused by
penetrating trauma. Approximately 75–80% of vascular injuries are the
result of penetrating trauma, and approximately 20–25% of vascular injuries
occur as the result of blunt trauma.6,8 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.4-8
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. Therefore, the treating clinician will have to conduct a thorough
examination to determine the presence of vascular injuries. The signs for
vascular injuries are separated into two categories, which are used to
determine the level and immediacy of required treatment. Hard signs
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indicate definite injury and require immediate attention, while soft signs
indicate potential injury and require additional evaluation. The following is a
list of the different hard and soft signs for vascular injury.6,8
Hard Signs:

External or pulsate hemorrhage

Rapidly expanding or pulsatile hematoma

Palpable thrill/audible bruit

Ischemic limb (absent pulses, pallor, paresthesia, 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.
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Nerve Trauma
Nerves carry signals and messages to and from the brain and the rest of the
body. There are two types of nerves:

Motor Nerves:
These nerves are responsible for carrying messages from the brain to
the muscles to initiate and control movement.

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. 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.8 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. 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. 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.
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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. These injuries have the most
potential for recovery. Penetrating trauma often causes more severe damage
to the nerves. In many penetrating trauma situations, there is a greater
potential of complete nerve transaction. When a transaction occurs, the
nerve will experience an immediate loss of both muscle and sensation
function. When this occurs, function will not return unless the damage is
repaired surgically. The most common causes of nerve injury include the
following:

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 clinicians will utilize either Seddon’s or
Sunderland’s Classification System to identify and diagnose specific nerve
injuries.4-6
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:
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Stage
Neurapraxial
Description
This stage involves a reversible conduction block characterized
by local ischemia and selective demyelination of the axon
sheath. The axon's continuity is retained, and although
conduction across the nerve injury is inhibited, conduction
within the nerve both proximal and distal to the lesion remains
intact.
The prognosis for an injured nerve at this stage is good, and
recovery occurs within weeks to months. Wrist drop secondary
to prolonged external pressure that compresses the radial
nerve at the spiral groove of the humerus is a clinical example
of neurapraxia.
Axonotmesis
This is a more severe stage of injury, with disruption of not
only the myelin sheath, but the axon as well. The epineurium
and perineurium remain intact, meaning that there is still some
continuity within the nerve.
Axonotmesis leads to Wallerian degeneration, a process
whereby the part of the axon that is separated from the
neuronal cell body disintegrates distal to the injury. The
prognosis for nerves at this stage is fair, and recovery may
require months. Axonotmesis is commonly seen in crush
injuries and displaced bone fractures.
Neurotmesis
This is the most severe form of nerve injury, is associated with
complete nerve division and 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.
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Sunderland Classification System
The Sunderland Classification System breaks Seddon’s Classification System
into five categories to further distinguish between severity levels.
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.
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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.6,7 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.
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. 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. 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:4-6

Avulsion fracture - a muscle or ligament pulls on the bone, fracturing it.

Comminuted fracture - the bone is shattered into many pieces.

Compression (crush) fracture - generally occurs in the spongy bone in the
spine. For example, the front portion of a vertebra in the spine may
collapse due to osteoporosis.

Fracture dislocation - a joint becomes dislocated, and one of the bones of
the joint has a fracture.
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
Greenstick fracture - the bone partly fractures on one side, but does not
break completely because the rest of the bone can bend; more common
among children, whose bones are softer and more elastic.

Hairline fracture - a partial fracture of the bone. Often this type of
fracture is harder to detect.

Impacted fracture - when the bone is fractured, one fragment of bone
goes into another.

Longitudinal fracture - the break is along the length of the bone.

Oblique fracture - A fracture that is diagonal to a bone's long axis.

Pathological fracture - when an underlying disease or condition has
already weakened the bone, resulting in a fracture (bone fracture caused
by an underlying disease/condition that weakened the bone).

Spiral fracture - A fracture where at least one part of the bone has been
twisted.

Stress fracture - more common among athletes. A bone breaks because
of repeated stresses and strains.

Torus (buckle) fracture - bone deforms but does not crack. More common
in children. It is painful but stable.

Transverse fracture - a straight break right across a bone.
When assessing a trauma patient, it is important to identify any present
fractures, as untreated fractures can cause further damage. In patients that
are unconscious, this can be difficult as there is no verbal indication of the
common fracture symptoms. In these instances, X-rays will be used to
identify fractures and other injuries in those areas affected by the trauma.8
Examination of different areas will also show signs of potential fractures, as
there may be swelling or bruising. In extreme cases, the bone will be
protruding from the area. When a patient is conscious, it can be easier to
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identify fracture sites as the patient can communicate information regarding
pain. Fracture symptoms are described below:
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 Of Fractured Bones
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.10 In some
fracture cases, surgery may be required. Depending on the severity of the
break and the location of the injury, different treatments will be used. The
following highlights the different treatments that are used to treat fractures.

Cast Immobilization
A plaster or fiberglass cast is the most common type of fracture
treatment, because most broken bones can heal successfully once they
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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.
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Complications of Fractures and Fracture Repair
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. 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.6-8,10
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. Delayed complications may occur after initial
treatment or in response to treatment.10,11
As part of the trauma treatment process, it is important to identify and treat
any fracture related complications to prevent further damage. In addition,
reevaluation at regular intervals during healing is necessary to monitor
progress and identify any complications that may arise. The following
complications are common in fracture repair or as the direct result of a
fracture.12-22
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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:

Femur fractures - disrupt the femoral artery or its branches and are
potentially fatal.

Hip fractures - may prevent ambulation, resulting in potentially lifethreatening complications, such as pneumonia, thromboembolic disease,
and possibly rhabdomyolysis, if there is a prolonged period of immobility
Arterial Injury
Some patients may experience immediate or delayed arterial injuries as the
result of fractures or dislocations. These complications include:
Immediate:

Laceration of the vessel, either partial or complete

Occlusion, either partial or complete, which may be due to:
 Angulation
 Extrinsic compression
 Intimal tears and dissection with an intact adventitia
 Stretching
 Spasm
Delayed:

False aneurysms

AV fistula

Thrombosis of the vessel following reconstructive surgery

Ischemic muscle contractures.
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Nerve Injury
Nerve injuries and vessel injuries are common complications with some
types of fractures. Due to the location of many nerves and vessels, they are
prone to injury. The most vulnerable nerves and vessels are those that lie in
close proximity to the bone. These injuries are common in both closed and
open fractures. However, the injury is often more severe with an open
fracture. Of the two, nerve injuries are more commonly complications of
fractures.
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:

Acute – This type results in permanent disability and tissue death
unless the pressure is relieved quickly.

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.
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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.
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:

An open injury to the bone, such as an open fracture with the bone
ends piercing the skin.

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).

A minor trauma, which can lead to a blood clot around the bone and
then a secondary infection from seeding of bacteria.

Bacteria in the bloodstream bacteremia (poor dentition), which is
deposited in a focal (localized) area of the bone. This bacterial site in
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the bone then grows, resulting in destruction of the bone. However,
new bone often forms around the site.

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 that 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. Malunion is typically caused by
inadequate immobilization of the fracture, misalignment at the time of
immobilization, and 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:

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
The two types of nonunions include 1) fibrous nonunion, fractures that heal
through the formation of fiber tissue rather than the formation of new bone;
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and, 2) false joint (pseudarthrosis), continuous movement of the fracture
fragments that result in the development of a false joint.
The following types of fractures pose the greatest risk of nonunion:
•
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
Complex regional pain syndrome (CRPS) 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. Symptoms of CRPS
include prolonged or excessive pain and mild or dramatic changes in skin
color, temperature, and/or swelling in the affected area. There are two types
of CRPS: 1) CRPS-I, where patients do not have confirmed nerve injuries,
and 2) CRPS-II, which includes patients that do have confirmed nerve
injuries.
Both types of CRPS produce the same symptoms. Patients will experience a
range of symptom severity and duration depending on the type of injury.
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.
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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. Patients with a single
long bone fracture have a 1% to 3% chance of developing the syndrome,
and this increases in correlation with the number of fractures.
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 sports-related or from a vehicle accident, fall, 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.
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, clinicians must
identify the extent of injury and provide the appropriate care to minimize
further damage.
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Diagnosis And Stabilization Of Extremity Trauma
Patient stabilization is the primary objective when admission involving an
extremity trauma has occurred. 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. Extremity trauma patient stabilization
includes three primary components: 1) Airway, 2) Breathing, and 3) Circulation.
Early Stabilization
When a patient presents with extremity trauma, the emergency team will
immediately begin working on the three primary 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. As soon
as the patient arrives in the emergency department, he or she will receive a
rapid primary survey to assess and identify any immediate problems. 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.
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 to 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. This can be caused by hypovolemia from hemorrhage.
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Immediate treatment is necessary to prevent further blood loss and to assist
with patient resuscitation.
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
clinician 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.
Once the clinician 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 minimize the damage and, in many instances, salvage the
injured extremities. In some instances, extremity injuries can be life
threatening, while other injuries will pose a risk of limb loss. However, with
proper treatment, these problems may be prevented.
The following is a list of life threatening extremity injuries:

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:
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
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 team to
identify damage early on and to provide the appropriate treatment. The
following table provides detailed guidelines for the examination of
extremities in extremity trauma situations.
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
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Neurovascular status:
• Pulses
• Warmth of periphery
• Paraesthesia
• Paralysis
Investigations
General
ECG: Evidence of hyperkalaemia / arrhythmia
VBG: rapid pH status, electrolytes (K, Ca++), Hb, lactate
Arterial Pressure Index (API) or Ankle Brachial Index (ABI):
Performed when vascular injury is suspected in the absence of hard signs.
The ratio of the systolic blood pressure in the injured extremity distal to the injury (ankle
or forearm) to the systolic blood pressure in an uninjured extremity (usually the brachial
artery)
API = Injured SBP / Uninjured SBPa
Lower limb
The dorsalis 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.
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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
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.
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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 prevented 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. 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
gangrene. 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. Ischemia frequently occurs when a patient experiences vascular
trauma. Ischemia typically produces specific symptoms in the patient. These
include:

Pain

Pallor

Pulselessness

Paresthesia

Paralysis

Poikilothermia
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Ischemia must be reversed quickly to prevent long-term damage to the
tissue and organs. Without early treatment, the patient has an increased risk
of losing the limb. The most common treatment methods for ischemia
include:

Injection of an anticoagulant

Thrombolysis

Embolectomy

Surgical revascularization

Amputation
Early treatment is essential to keep the affected limb viable. While early
treatment is imperative when attempting to salvage the limb, the treating
clinician must proceed with caution. In most instances, reintroduction of
blood flow to the ischemic tissue can cause problems if not managed
properly.
Wound Infection
Wound infections are common in instances of extremity trauma, especially
when the patient experiences penetrating extremity trauma. Bacteria
commonly cause wound infections, but other microorganisms can cause
infections as well. 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
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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. 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. Clinicians 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.

Pus or cloudy fluid draining from the wound

Pimple or yellow crust formed on the wound (impetigo)

Scab has increased in size

Increasing redness around the wound (cellulitis)

Red streak is spreading from the wound toward the heart
(lymphangitis)

Wound has become extremely tender

Pain or swelling increasing after 48 hours since the wound occurred

Wound has developed blisters or black dead tissue (gangrene and
myonecrosis)

Lymph node draining that area of skin may become large and
tender (lymphadenitis)

Onset of widespread bright red sunburn-like rash

Onset of fever

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.
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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. Malunion is typically caused by the
following factors:

Inadequate immobilization of the fracture

Misalignment at the time of immobilization

Premature removal of the cast or other immobilizer
Delayed Union:
Fracture repair will require 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. Delayed
unions often occur as the result of the following factors:

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.
With appropriate treatment and intervention, the patient will have the
potential for a successful outcome.
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Nonunion:
A nonunion occurs when a fracture fails to heal after a number of months. A
nonunion is often caused by the following factors:

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
The two types of nonunions include:

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:

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
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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. 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.
Inability to Achieve Skin Closure
In some patients, it will be difficult to achieve skin closure during the repair
process. In some instances, this will occur because of damage and
destruction of significant portions of the skin. When this occurs, the
remaining viable skin will not be sufficient for closure and wound coverage.
In these instances, other means must be employed. If possible, skin from
other areas of the body may be grafted and used for wound closure.23,24
Chronic Pain
Many patients will experience chronic pain as the result of traumatic injuries
to the extremities. In fact, approximately 60% 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. In many instances, this chronic pain will
cause disability, posttraumatic stress disorder, and depression in patients.
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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. Trauma of
the extremities is typically assessed using the three diagnostic imaging
techniques of 1) X-Rays, 2) Arthrography, and 3) Angiography. CT scans and
MRI’s are 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.25,26
The following chart provides detailed information on the three most common
diagnostic imaging techniques used to identify and assess extremity trauma.
Technique
X Rays
Description
X-rays use invisible electromagnetic energy beams to produce images of
internal tissues, bones, and organs on film. Standard X-rays are
performed for many reasons, including diagnosing tumors or bone
injuries. X-rays are made by using external radiation to produce images
of the body, its organs, and other internal structures for diagnostic
purposes. X-rays pass through body structures onto specially treated
plates (similar to camera film) and a "negative" type picture is made (the
more solid a structure is, the whiter it appears on the film). Instead of
film, using computers and digital media may also make X-rays.
When the body undergoes X-rays, different parts of the body allow
varying amounts of the X-ray beams to pass through.
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Images are produced in degrees of light and dark, depending on the
amount of X-rays that penetrate the tissues. The soft tissues in the body
(such as blood, skin, fat, and muscle) allow most of the 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.
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:
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Conventional direct arthrography of a joint uses a special form of x-ray
called fluoroscopy after an injection of contrast material containing iodine
is administered directly into the joint. Alternate methods of direct
arthrography examinations may use magnetic resonance imaging (MRI)
or computed tomography (CT) following the various contrast material
injections into the joint.
Fluoroscopy makes it possible to see bones, joints and internal organs in
motion. When iodine contrast is injected into the joint, it fills the entire
joint and becomes clearly visible during x-ray evaluation, allowing the
radiologist to assess the anatomy and function of the joint. Although the
injection is typically monitored by fluoroscopy, the examination also
involves taking radiographs for documentation.
The images are most often stored and viewed electronically. Direct MR
arthrography involves the injection of a contrast material into the joint.
The contrast material used for MR evaluation is different from that used
for x-ray; it contains gadolinium, which affects the local magnetic field
within the joint. As in conventional direct arthrography, the contrast
material outlines the structures within the joint, such as cartilage,
ligaments and bones and allows them to be evaluated by the radiologist
after the MR images are produced.
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

To evaluate damage from recurrent dislocations of the joint

To visualize synovial cysts
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Angiography
Angiography is the imaging of blood vessels using water-soluble ionic or
nonionic X ray contrast media injected into the blood stream of arteries
(arteriography) or veins (venography). For lymph vessels, oily contrast
media are used.
Angiography serves to investigate normal and pathological states of the
vessel system particularly luminal narrowing and obstruction or
aneurismal widening. Furthermore tumor conditions, arteriovenous
malformations (AVM) and arteriovenous fistulae (AVF) or sources of
bleeding are investigated with angiography.
Complications are low but differ somewhat according to vessel access.
Images are taken mainly with digital subtraction techniques (digital
subtraction angiography DSA), however, single shot or fast series may
also be taken with rapid film changers, in cine mode (cine angiography
for coronary arteries) or as digital video recordings directly from the
image intensifier screen.
Injection of contrast material into arteries and veins is performed either
directly via a needle puncture or using a percutaneously inserted
angiographic catheter most commonly made from polyethylene,
polyurethane or nylon. Contrast injection is done by hand (mainly in
direct needle puncture or in small caliber arteries) or with a power
injector.
Angiographic studies are routinely performed under local anesthesia.
After infiltration of the skin and the tissue around the artery or vein to be
punctured, a small skin incision is made, and the artery is punctured with
an angiographic needle. For percutaneous catheter insertion, the
Seldinger technique is used.
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.
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Computed Tomography 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”. The CT scan uses a combination of X Ray imaging and
computer technology to obtain the images in a noninvasive format. A CT
scan is an important diagnostic tool as it is able to provide detailed images
of different parts of the body. It is especially useful to obtain images of the
bones, muscles, fat and organs. CT scans are used more frequently than
standard X Rays because the images are more detailed.8
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).8 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 a radiologist.8 CT scans
are conducted in two ways, as described below:
Contrast CT:
Patients ingest a substance orally, or receive an injection intravenously for a
contrast CT. The contrast solution enables the radiologist to view the specific
body part or region more clearly.
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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
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 and spinal stenosis. CT scans are less useful in detecting
injuries to the spinal cord or any ligament injuries associated with an
unstable spine.26,27
Magnetic Resonance Imaging
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.26 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.26
An MRI utilizes high-resolution technology that allows it to produce highly
detailed images that will show changes in many of the structures in the
body.26 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
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gadolinium. Due to the MRI’s high level of sensitivity, it is able to detect
many injuries that are undetectable using other methods.26
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. 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.8,25
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.28 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.28 Reperfusion is characterized by the following:

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 clinician 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.28
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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:29

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. In most
instances, the clinician will take a multimodal approach to analgesic
administration.
Multimodal Treatment
Multimodal treatment options may include the following:

Regional – Local anesthetic blocks/infusions

Neuraxial – Intrathecal versus epidural

Nonsteroidal anti-inflammatory drugs (NSAIDS)

Opioids – Peripheral and/or central

NMDA receptor agonists

Ketamine/Methadone/dextromethorphan

Anticonvulsants – Gabapentin
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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 clinician must
consider the potential consequences when prescribing analgesics.
Antibiotics
All extremity wounds have the potential to become infected. Therefore,
many clinicians 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.30 In some
cases, patients will receive additional antibiotic treatment after the initial
period if there is still a risk of infection.31 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.
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 clinician must rely on information
from the patient to identify and manage these infections. 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.30
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Treatment by General or Trauma Surgeon and Other Specialists
Many patients will require advanced treatment beyond the scope of the
initial emergency or treating clinician. 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.
Prognostic Factors For Limb Salvage
The primary goal with extremity trauma is limb salvage. In most instances,
the treating clinician 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 clinician 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, clinicians will often assess other factors
when making a determination. Of utmost concern is the safety of the
patient. If a damaged limb poses a life threatening risk, the patient’s
survival needs will come before the need to salvage the limb.
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
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severity of the damage to the soft tissue. The more extensive the damage,
the greater likelihood the patient will require amputation. Other factors that
may cause the surgeon to consider amputation include:

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
clincians 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 clinician to consider the
following factors when determining whether or not to amputate.32-35
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.
Mechanism
The mechanism of injury will have an impact on the potential for limb
salvage. In some instances, the mechanism of injury will cause extensive,
irreparable damage. This is especially true in military trauma situations and
accidents that crush or mangle the extremity.
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In military trauma situations, explosive devices that destroy portions of the
extremities often injure patients. In these situations, the damage is too
extensive to repair. The same is true with civilian trauma that causes similar
damage, which is especially common in motor vehicle crashes.
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.33 In addition to the factors listed above,
the treating clinician and surgeon will also consider other factors when
determining limb salvageability. These factors include 1) associated injuries,
2) age and physiologic health, 3) clinical presentation, and 4) 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.33 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.
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
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the accident as a treatment measure. According to the Centers for Disease
Control and Prevention, approximately two million people in the United
States are living with limb loss.34
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. The
following is a list of the different amputation levels:35

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
additional parts of the limb so that the loss occurs within one of the predetermined amputation levels. 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.36 This
ensures a smooth amputation and ensures that the loss site is clean and can
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be fitted for a prosthetic device (if one is deemed necessary and/or
appropriate).
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.35 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. 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.36
There are a number of assessment tools that emergency clinicians 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.4 The following are the
available scoring systems:

Predictive Salvage Index (PSI)

Mangled Extremity Severity Score (MESS)

Limb Salvage Index (LSI)

Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and
Age (NISSSA) Score

Hannover Fracture Scale-98 (HFS-98)
Each scoring system uses different criteria to determine extremity damage
and viability.4
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Predictive Salvage Index
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, and 4) Interval from injury until arrival in the
operating room.37
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
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)
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Interpretation:
Minimum score: 3 (based on the point assignments; if no vascular, bone or
muscle injury then the score could reach 1, but then it would not be a
seriously injured limb).
Maximum score: 13
The higher the score the worse the chances for a successful limb salvage.
Mangled Extremity Severity Score
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
include 1) Extent of skeletal and soft tissue injury, 2) Patient’s blood
pressure, 3) Duration and extent of limb hypoperfusion, and 4) Age of the
patient.38
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)
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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)
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.
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Limb Salvage Index (LSI)
The Limb Salvage Index (LSI) is used to evaluate a severely injured lower
extremity.39
Parameters include the:
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
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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
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/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
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Warm
<6 hours
0
ischemia
6−9 hours
1
time
9−12 hours
2
12−15 hours
3
>15 hours
4
Note: 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.
Limb Salvage Index
Outcome
0−5
Limb salvage successful (51 of 51)
6−14
Amputation (19 of 19)
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Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock,
and Age (NISSSA) Score
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.40 The parameters include:
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
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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
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: A score ≥ 7 was 100%
sensitive for amputation, but with specificity of 46%.
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A score ≥ 11 had a 100% specificity and positive predictive value for
amputation.
Hannover Fracture Scale-98 (HFS-98)
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.41 The parameters include:
1. extent of fracture bone loss
2. skin injury as percent of limb circumference
3. muscle injury as percent of limb circumference
4. wound contamination
5. deperiostation
6. local circulation
7. systolic blood pressure (systemic circulation)
8. neurologic findings
Parameter
Extent of bone loss
Skin injury
Muscle injury
Finding
Points
None
0
0.1 to 1.9 cm
1
≥ 2.0 cm
2
None
0
1−24% of circumference
1
25−50% of circumference
2
51−75% of circumference
3
76−100% of circumference
4
None
0
1−24% of circumference
1
25−50% of circumference
2
51−75% of circumference
3
76−100% of circumference
4
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Wound contamination
Deperiostation
Local circulation
Systolic blood pressure
Palmar-plantar sensibility
Finger-toe active motion
None
0
Partial
1
Massive
2
No
0
Yes
1
Normal
0
Capillary pulse
1
Ischemia <4 hours
2
Ischemia 4 to 8 hours
3
Ischemia >8 hours
4
Constantly >100 mm Hg
0
<100 until admission
1
<100 until surgery
2
Constantly <100 mm Hg
3
Yes
0
No
1
Yes
0
No
1
Hannover Fracture Scale Score = SUM (points for all 8 parameters)
Interpretation:
Minimum score: 0
Maximum score: 22
The higher the score the worse the injury:
A score ≥ 11 indicates significant trauma, with amputation
recommended.
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
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is damaged. Each scoring system is reliable. However, no system is 100%
reliable. Therefore, clinicians should use the scoring system as an initial
guide when making a determination regarding whether to amputate a
damaged limb. However, clinicians 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.35
Risk Factors for Amputation
As mentioned earlier, the primary goal with extremity trauma is limb
salvage; and, the treating clinician 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. The treating clinician 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
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fracture is classified as a Type IIIC injury, the patient is at an increased risk
of requiring amputation.42 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:
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%).
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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. However, there are a number of other factors
that will increase the risk of amputation if present in the patient. These
include the following:43

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 clinicians 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.4 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
can be simple or complex, as it may cause injuries in only one of the
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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 clinicians,
including but not limited to emergency physicians, trauma surgeons,
orthopedic, vascular and plastic surgeons, and rehabilitation specialists. The
focus will be on salvaging the limb while repairing the initial damage.
In some instances, the damage will be too severe to salvage the extremity.
When this occurs, the patient will require an amputation of the extremity. In
other instances, the extremity will be amputated as part of the initial injury,
and will require treatment and repair to clean up the damaged area. While
limb salvage is the primary goal, it must not take precedence over the
health and safety of the patient. If the injured limb poses a risk to the
patient’s survival, it must be amputated as soon as possible.
Extremity injuries are common in both military and civilian trauma situations
and can be caused by a number of different mechanisms. In military
situations, most extremity injuries are the result of penetrating trauma.
They are often the result of explosive devices and landmines. In civilian
trauma, the majority of extremity injuries are caused by blunt trauma. They
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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. All
members of the health team play a vital role in the initial treatment and
ongoing management and support of patients with extremity trauma, a role
that has a significant impact on each patient’s recovery and rehabilitation.
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1. The most common types of closed injuries include
a.
b.
c.
d.
contusion.
hematoma.
crush.
All of the above
2. Which of the following types of fractures 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.
mangled extremity.
complex open fractures and/or dislocations.
crush syndrome.
severe vascular injury.
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.
simple transverse/oblique fractures.
segmental or severely comminuted fractures.
moderate soft tissue injury and moderate contamination.
6. 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
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7. According to the Gustilo-Anderson Classification System, a Type
____ fracture carries the highest risk of infection.
a.
b.
c.
d.
I
II
IIIA
IIIC
8. 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
9. The primary factor to consider when determining limb viability is
the
a.
b.
c.
d.
severity of the damage to the soft tissue.
severity of vascular damage and blood loss.
degree of muscle damage.
significant nerve damage.
10. 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
11. Compartment pressure may be measured through setting up a
a.
b.
c.
d.
neuro check every 2 hours.
CVP or arterial pressure monitor.
blood pressure cuff to the limb.
None of the above
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12. Approximately ____ percent of extremity trauma patients report
moderate to severe pain one year after experiencing trauma.
a.
b.
c.
d.
20
40
60
77
13. True or False: A tourniquet should never be used to prevent a
reperfusion injury.
a. True
b. False
14. Ischemia typically produces specific symptoms in the patient.
These may include
a.
b.
c.
d.
pain.
pallor.
paresthesia.
All of the above
15. 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.
16. Reperfusion injury occurs when blood supply is returned after
a.
b.
c.
d.
a period of ischemia.
acute blood loss.
raising the limb.
use of hot and cold.
17. Multimodal treatment options for analgesic administration may
include
a.
b.
c.
d.
Regional – Local anesthetic blocks/infusion.
Neuraxial – Intrathecal versus epidural.
NSAIDS and opioids.
All of the above
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18. True or False: Muscle or other tissue caught between bone
fracture fragments can prevent healing.
a.True
b. False
19. Pneumonia may be a life-threatening complication associated with
__________ fractures.
a.
b.
c.
d.
rib
hip
arm
shoulder
20. The most vulnerable nerves and vessels are those that
a.
b.
c.
d.
lie in close proximity to the bone.
lie within and in close proximity to the skin.
affect ambulation.
are connected to the distal interphalangeal joints.
21. Compartment syndrome is the direct result of ______________
within a compartment.
a.
b.
c.
d.
muscle or other tissue caught
use of a tourniquet to manage blood flow
short bone fractures
swelling and bleeding
22. True or False: Nerve injuries are more common complications of
fractures than vessel injuries.
a. True
b. False
23. Chronic compartment syndrome typically results
a.
b.
c.
d.
in permanent disability.
in tissue death.
from physical exertion.
from immobility.
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24. An extremity is considered “mangled” when injuries occur to
____________ of the regions (soft tissue, blood vessels, nerves
and bones).
a.
b.
c.
d.
all
two or more
any
three or more
25. Under Seddon’s Classification System on nerve damage, which
of the following describes a neurapraxial injury?
a.
b.
c.
d.
Local ischemia and selective demyelination of the axon sheath
Disruption of the myelin sheath and the axon.
Wallerian degeneration
Complete nerve division and disruption of the endoneurium
26. ________________ 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.
a.
b.
c.
d.
Neuropraxia
Osteoporosis
Axonotmesis
Neurotmesis
27. Which of the following statement correctly describes osseous
injuries?
a.
b.
c.
d.
They always occur in conjunction with fractures
Swelling is rarely present in osseous injuries
Blunt trauma is common in osseous injuries without fractures
Osseous injuries without fractures involve only spongy tissue
28. This stage of nerve injury, known as the __________ stage,
involves a reversible conduction block and the axon's continuity
is retained.
a.
b.
c.
d.
axonotmesis
neurapraxial
Wallerian
Seddon
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29. A soft tissue injury is broadly defined as any injury that occurs
to
a.
b.
c.
d.
a non-bony area or to an organ.
a non-bony area or to non-ligaments.
spongy tissue.
a non-bony, non-organ area.
30. True or False: Prophylactic use of antibiotics to prevent infection in
extremity trauma patients is contraindicated.
a. True
b. False
31. Which of the following extremity injuries is limb-threatening but not
considered life-threatening?
a.
b.
c.
d.
Pelvic disruption with massive hemorrhage
Severe arterial hemorrhage
Severe vascular injury
Hemorrhagic shock from multiple long bone fractures
32. _______________ fracture occurs when a muscle or ligament pulls on
the bone, fracturing it.
a.
b.
c.
d.
An avulsion
A greenstick
A compression
An oblique
33. With a hairline fracture the fracture is described as defined as
a.
b.
c.
d.
a partial fracture of the bone.
a bone that is partly fractured on one side.
one fragment of a bone going into another.
a break along the length of a bone.
34. _________________ fracture is more common among children,
whose bones are softer and more elastic.
a.
b.
c.
d.
A longitudinal
An avulsion
A transverse
A greenstick
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35. True or False: Wallerian degeneration, a process whereby the part of
the axon that is separated from the neuronal cell body, is exclusively a
condition present in the axonotmesis stage.
a. True
b. False
CORRECT ANSWERS:
1. The most common types of closed injuries include
a.
b.
c.
d.
contusion.
hematoma.
crush.
All of the above [correct answer]
“The most common types of closed injuries include the following:
Contusion; Hematoma; Crush injury.”
2. Which of the following types of fractures poses the greatest risk of
nonunion?
a. Wrist (carpus) fractures
“The following types of fractures pose the greatest risk of nonunion:
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.”
3. Life-threatening extremity injuries include
c. crush syndrome.
“The following is a list of life-threatening extremity injuries: 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.”
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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
“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.”
5. Type IIIA fracture classification involves
c. segmental or severely comminuted fractures.
“Type I: … usually simple transverse/oblique fractures … Type II:
Wound >1cm with moderate soft tissue injury and moderate
contamination … 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 … Type IIIB: Extensive soft tissue
loss, exposed bone, periosteal stripping, massive contamination …
Type IIIC: Extensive fracture associated with arterial injury
requiring repair.”
6. 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
“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.”
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7. According to the Gustilo-Anderson Classification System, a Type
____ fracture carries the highest risk of infection.
d. IIIC
“The following is the different fracture classification levels according
to the Gustilo-Anderson Classification System: Type I: … infection
risk 0-2% … Type II: … infection risk 2-5% … Type IIIA: … infection
risk 5-10% … Type IIIB: … infection risk 10-50% … Type IIIC: …
infection risk 25-50%.”
8. 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
“… 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.”
9. The primary factor to consider when determining limb viability is
the
a. severity of the damage to the soft tissue.
“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. Other factors that may cause the surgeon to consider
amputation include: High grade open fracture; Severe vascular
injury; Significant nerve damage; Inevitability of amputation after
failed salvage.”
10. Secondary 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 [correct answer]
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“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. Other factors that may cause the surgeon to consider
amputation include: High grade open fracture; Severe vascular
injury; Significant nerve damage; Inevitability of amputation after
failed salvage.”
11. Compartment pressure may be measured through setting up a
b. CVP or arterial pressure monitor.
“Compartment pressure may be measured through setting up a
central venous (CVP) 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.”
12. Approximately ____ percent of extremity trauma patients report
moderate to severe pain one year after experiencing trauma.
c. 60
“… 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.”
13. True or False: A tourniquet should never be used to prevent a
reperfusion injury.
b. False
“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.”
14. Ischemia typically produces specific symptoms in the patient.
These may include
a.
b.
c.
d.
pain.
pallor.
paresthesia.
All of the above [correct answer]
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“Ischemia typically produces specific symptoms in the patient.
These include the following: Pain; Pallor; Pulselessness;
Paresthesia; Paralysis; Poikilothermia.”
15. The primary mechanisms of soft tissue injury are mechanical
and thermal. Mechanical force includes
a. shearing, tension, compression.
“The primary mechanisms of soft tissue injury are mechanical and
thermal. Mechanical force includes the following: Shearing; Tension;
Compression.”
16. Reperfusion injury occurs when blood supply is returned after
a. a period of ischemia.
“Many patients will experience a reperfusion injury when blood
supply is returned after a period of ischemia.”
17. Multimodal treatment options for analgesic administration may
include
a.
b.
c.
d.
Regional – Local anesthetic blocks/infusion.
Neuraxial – Intrathecal versus epidural.
NSAIDS and opioids.
All of the above [correct answer]
“Multimodal treatment options may include the following: Regional
– Local anesthetic blocks/infusions; Neuraxial – Intrathecal versus
epidural; NSAIDS; Opioids – Peripheral and/or central; NMDA
receptor agonists; Ketamine/Methadone/dextromethorphan;
Anticonvulsants – Gabapentin/Lyrica.”
18. True or False: Muscle or other tissue caught between bone
fracture fragments can prevent healing.
a. True
“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.”
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19. Pneumonia may be a life-threatening complication associated with
__________ fractures.
b. hip
“In some instances, a patient will experience a life-threatening
complication as the result of a fracture. These conditions include the
following: … 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.”
20. The most vulnerable nerves and vessels are those that
a. lie in close proximity to the bone.
“The most vulnerable nerves and vessels are those that lie in close
proximity to the bone.”
21. Compartment syndrome is the direct result of ______________
within a compartment.
d. swelling and bleeding
“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.”
22. True or False: Nerve injuries are more common complications of
fractures than vessel injuries.
a. True
“Nerve injuries are more common complications of fractures than vessel
injuries.”
23. Chronic compartment syndrome typically results
c. from physical exertion.
“There are two types of compartment syndrome: Acute – This type results
in permanent disability and tissue death unless the pressure is relieved
quickly. Chronic (exertional) –This type does not typically result in
permanent disability and tissue death.
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24. An extremity is considered “mangled” when injuries occur to
____________ of the regions (soft tissue, blood vessels, nerves and
bones).
d. three or more
“In instances of extremity trauma, injuries occur in the following regions:
soft tissue, blood vessels, nerves, and bones. 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.”
25. Under Seddon’s Classification System on nerve damage, which of the
following describes a neurapraxial injury?
a. Local ischemia and selective demyelination of the axon sheath
“Neurapraxial. 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.”
26. ________________ 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.
c. Axonotmesis
“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.”
27. Which of the following statement correctly describes osseous injuries?
c. Blunt trauma is common in osseous injuries without fractures.
“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.”
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28. This stage of nerve injury, known as the __________ stage, involves a
reversible conduction block and the axon's continuity is retained.
b. neurapraxial
“Neurapraxial. 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.”
29. A soft tissue injury is broadly defined as any injury that occurs to
d. a non-bony, non-organ area.
“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.”
30. True or False: Prophylactic use of antibiotics to prevent infection in
extremity trauma patients is contraindicated.
b. False
“All extremity wounds have the potential to become infected. Therefore,
many provides will utilize prophylactic antibiotics to prevent infection.”
31. Which of the following extremity injuries is limb-threatening but not
considered life-threatening?
c. Severe vascular injury
“The following is a list of life-threatening extremity injuries: 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….
Severe vascular injury.”
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32. _______________ fracture occurs when a muscle or ligament pulls on
the bone, fracturing it.
a. An avulsion
“Avulsion fracture - a muscle or ligament pulls on the bone, fracturing it.”
33. With a hairline fracture the fracture is described as defined as
a. a partial fracture of the bone.
“Hairline fracture - a partial fracture of the bone. Often this type of
fracture is harder to detect.”
34. _________________ fracture is more common among children,
whose bones are softer and more elastic.
d. A greenstick
“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.”
35. True or False: Wallerian degeneration, a process whereby the part of
the axon that is separated from the neuronal cell body, is exclusively a
condition present in the axonotmesis stage.
b. False
“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…. As with axonotmesis, neurotmesis
initiates Wallerian degeneration, but the prognosis for nerves is poor.”
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References Section
The References below include published works and in-text citations of
published works that are intended as helpful material for your further
reading.
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Cannon, J.W. and Rasmussen, T.E. (2016). Severe extremity injury in
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Cannon, J.W. and Rasmussen, T.E. (2016). Surgical management of
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6. Pape H-C, Sanders R, Borrelli, J, editors. The Poly-Traumatized Patient
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Howe AS. The Spectrum of Polytrauma. A Pragmatic Approach for the
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Methods, Guidelines, and Imaging Fundamentals. Lippincott Williams &
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Nicholas B, Toth L, van Wessem K, Evans J, Enninghorst N, Balogh ZJ.
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injuries: tourniquets, compartment syndrome detection, fasciotomy,
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