Trauma Series - NurseCe4Less.com · 2016. 11. 15. · 1. Differentiate between simple and complex extremity trauma. 2. Describe the symptoms of osseous extremity trauma. 3. Identify

nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com

1

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical

doctor, professor of academic

medicine, and medical author. He

graduated from Ross University

School of Medicine and has completed his clinical clerkship training in various teaching

hospitals throughout New York, including King’s County Hospital Center and Brookdale

Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams,

and has served as a test prep tutor and instructor for Kaplan. He has developed several

medical courses and curricula for a variety of educational institutions. Dr. Jouria has also

served on multiple levels in the academic field including faculty member and Department

Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing

education organizations covering multiple basic medical sciences. He has also developed

several continuing medical education courses covering various topics in clinical medicine.

Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial

Hospital’s Department of Surgery to develop an e-module training series for trauma

patient management. Dr. Jouria is currently authoring an academic textbook on Human

Anatomy & Physiology.

ABSTRACT

Advances in modern medicine have improved both physicians’ abilities to salvage limbs

in cases of extreme trauma and patients’ potential to have a good quality of life when

amputation is a necessary resolution to injury. However, without rapid and appropriate

intervention, extremity trauma has a high incidence of morbidity. Nurses and all

members of the health team play a vital role in the initial treatment and ongoing

management and support of patients with extremity trauma, a role that has a significant

impact on each patient’s recovery and rehabilitation.

Trauma Series:

EXTREMITY

INJURIES


2

Continuing Nursing Education Course Director & Planners

William A. Cook, PhD, NurseCe4Less.com Director

Doug Lawrence, MS, Nurse Ce4Less.com Webmaster Course Planner

Susan DePasquale, CGRN, MSN, Nurse Ce4Less.com Lead Nurse Planner

Accreditation Statement

NurseCe4Less.com is accredited as a provider of continuing nursing education by the American

Nurses Credentialing Center's Commission on Accreditation.

Credit Designation

This educational activity is credited for 6 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Course Author & Planner Disclosure Policy Statements

It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all nursing educational activities. All authors and course

planners participating in the planning or implementation of an educational activity are

expected to disclose to course participants any relevant conflict of interest that may

arise.

Statement of Need

The treatment of individuals with an extremity injury requires that all members of the

health team be familiar with all four components of injury and associated risks. The

mechanisms of injury to an extremity are important clues as to the immediate and

ongoing evaluation and treatment plan. Immobilization and stabilization and the

immediate interventions of pain management, as well as evaluation of potentially

serious and masked injuries, require that nurses and associates be knowledgeable to

provide patients with safe and appropriate assessment and care of an extremity injury.

Course Purpose

This course will provide advanced learning for nurses interested in the management of

the trauma patient with an extremity injury.


3

Learning Objectives

1. Differentiate between simple and complex extremity trauma.

2. Describe the symptoms of osseous extremity trauma.

3. Identify the signs of vascular extremity trauma.

4. List the symptoms of nerve trauma to extremities.

5. Explain the treatment priority for patients with extremity trauma.

6. Identify the treatment goal for patients with extremity trauma.

7. List common risks involved in the treatment of extremity trauma.

8. Describe the role of general surgeons/specialists in treating extremity trauma.

9. Identify the factors that prognosticate limb salvage.

10. Describe risk factors for amputation.

Target Audience Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses,

and Medical Assistants

Course Author & Director Disclosures

Jassin M. Jouria, MD has no disclosures

William S. Cook, PhD has no disclosures

Doug Lawrence, MS has no disclosures

Susan DePasquale, CGRN, MSN has no disclosures

Acknowledgement of Commercial Support:

There is no commercial support for this course.

Activity Review Information:

This course has been peer reviewed by Susan DePasquale, CGRN, MSN. Review

Date: November 3, 2013.

Release Date: November 15, 2013 Termination Date: November 15, 2016


4

INTRODUCTION

Extremity trauma is one of the most common forms of trauma treated in emergency

departments throughout the United States. Extremity trauma can be simple or complex,

as it may cause injuries in only one of the components of the extremity or all of the four

components. The four components of the extremity are the nerves, vessels, bones, and

soft tissue. The most severe cases of extremity trauma will involve more than one of

the components of the extremity and will be difficult to manage and repair. When a

patient experiences injury in three of the four components, he or she has a mangled

injury and is at an increased risk of losing the limb (1).

Treatment for extremity injuries, especially those that are severe, requires a

multifaceted approach that addresses the immediate needs of the patient while

preventing long term damage and salvaging the extremity. This approach typically

requires the involvement of a variety of providers, including but not limited to trauma

surgeons, orthopedic, vascular and plastic surgeons, and rehabilitation specialists. The

focus will be on salvaging the limb while repairing the initial damage (2).

In some instances, the damage will be too severe to salvage the extremity. When this

occurs, the patient will require an amputation of the extremity. In other instances, the

extremity will be amputated as part of the initial injury, and will require treatment and

repair to clean up the damaged area (3). While limb salvage is the primary goal, it must

not take precedence over the health and safety of the patient. If the injured limb poses

a risk to the patient’s survival, it must be amputated as soon as possible.

Extremity injuries are common in both military and civilian trauma situations and can be

caused by a number of different mechanisms. In military situations, most extremity

injuries are the result of penetrating trauma. They are often the result of explosive

devices and landmines (4). In civilian trauma, the majority of extremity injuries are

caused by blunt trauma. They are often the result of motor vehicle accidents and

industrial accidents. However, when penetrating injuries occur in the civilian population,

they are typically the result of gunshot wounds and stabbings (5).


5

Extremity trauma can range in severity and may be life threatening for the patient.

However, advances in modern medicine have improved both physicians’ abilities to

salvage limbs in cases of extreme trauma and patients’ potential to have a good quality

of life when amputation is a necessary resolution to injury. Unfortunately, without rapid

and appropriate intervention, extremity trauma has a high incidence of morbidity.

Nurses and all members of the health team play a vital role in the initial treatment and

ongoing management and support of patients with extremity trauma, a role that has a

significant impact on each patient’s recovery and rehabilitation.

Open versus closed injuries

Open injuries

On open injury is any injury that involves a break in the skin. In all open injuries, the

tissue underneath the skin is exposed. Open injuries can range in severity and some

may appear as a small break in the skin, while others may be deep and wide. There

are different types of open injuries, which are caused by various factors. The following

are the most common types of open injuries (6):

Abrasions & lacerations

Avulsions

Punctures

Traumatic amputation

Crush

Closed Injuries

A closed injury is any injury that occurs underneath the skin, with no open path from the

outside to the injured area. Closed injuries are often the result of blunt trauma and will

range in severity depending on a number of factors including the cause of the injury, the

strength of impact, and the area that is injured. Most closed injuries are not easy to

detect and often require diagnostic imaging for confirmation. The most common types

of closed injuries include the following (7):

Contusion


6

Hematoma

Crush injury

Blunt versus penetrating injuries

Blunt injuries

Blunt injuries occur as the result of blunt force trauma and can range in severity

depending on the mechanism used and the strength of impact. Blunt force trauma is

defined as a severe traumatic episode caused to the body or head with the sudden

introduction of a blunt instrument used with great force (8).

Blunt force trauma can occur as the result of any type of object striking a part of the

body with significant force and can cause a range of injuries. However, while blunt

force trauma is often significant, many patients will not show signs of blunt injuries (9). In

many instances, the blunt injuries will occur internally and will not be noticeable without

the use of diagnostic imaging (10). Additionally, many blunt injuries will produce few

outward symptoms. However, while blunt injuries are not easily detected, they can

have severe consequences. If not detected, a blunt injury can cause death in a patient

within a short period of time (5).

While some blunt injuries may not be apparent upon initial examination, there are some

blunt injuries that produce distinct signs. The following table provides descriptions of

the most common signs of blunt injuries (6):

Sign Description

Bruising Bruising is often a good indicator that there are

broken blood vessels beneath the surface of the

skin. Although there may be some bruising this

cannot always be a definite indicator as to how

much damage has been sustained deeper within

the body.

Abrasions Cuts, grazing of the skin or friction burns, which

can be caused by the victim being beaten,

dragged or kicked. These wounds can sometimes


7

indicate that an individual hit against something or

was hit with something. In instances of assault, it

can be used to measure how much of a struggle a

victim put up against his or her attacker.

Lacerations This is the tearing of tissue underneath the skin.

An individual may have sustained a severe bump

against a stationary object and underneath the

skin (subcutaneous) there may be severe damage

caused to tissue and organs. Visual examinations

do not always show this.

Penetrating Injuries

Although the majority of trauma injuries will be caused by blunt trauma, a number of

patients will experience penetrating trauma and subsequent penetrating injuries.

Penetrating injuries can range in severity depending on the object involved and the site

of injury. Penetrating trauma occurs when an object pierces the patient’s skin. After the

object pierces the skin, it enters the body and causes damage to the internal structures

(11). With penetrating trauma, any of the internal regions can be damaged, including the

bones, tendons, ligaments, nerves and blood vessels (5).

Penetrating injuries are especially common in the extremities and occur in both civilian

and military trauma situations. In most instances, penetrating injuries are not life

threatening. However, vascular injuries do pose a risk of death if untreated, and nerve

and tendon injuries can cause long-term damage and disabilities to the patient.

Penetrating injuries can occur as the result of any object piercing the skin. However the

majority of penetrating injuries are the result of stabbings and gunshots, which are

discussed further below (12).

Stab Wounds:

Stab wounds are one of the most common causes of penetrating trauma. They have

the potential to produce significant amounts of blood loss and can cause extensive

damage to the surrounding areas. The severity of injury produced by stab wounds will

differ depending on the site of injury, the depth of injury, and the type of knife used (13).


8

In many instances, the stab wound will cause trauma through extensive blood loss at

the site of the wound. However, in some instances, the stab wound will result in

significant muscle, vascular and tissue damage in the extremities (12). Since the extent

of the damage is not visible from the outside, the patient will undergo a thorough

assessment, including radiologic imaging, to determine the extent of damage.

Gunshot Wounds:

There are approximately 500,000 gunshot wounds per year in the United States, and

these wounds typically cause severe damage (14). The amount and severity of injury

caused by firearms depends on a number of factors, such as (15):

• Type of weapon/bullet used

• Distance from weapon

• Location and trajectory/path of injury

• Permanent vs. temporary cavity

All firearm injuries are not the same. Injury and trauma level depends on the type of

firearm used. Typically, firearm injuries are categorized as either low velocity injuries or

high velocity injuries, and they are classified based on the type of firearm used and the

projectile impact that is caused (16). Low velocity injuries are primarily caused by

firearms with a muzzle velocity of less than 600 meter per second (m/s). Most low

velocity firearm injuries are caused by handguns and are more prevalent than other

types of injuries (14). High velocity injuries are caused by firearms with a muzzle velocity

of more than 600 meter per second. Most high velocity injuries are caused by military

weapons or high powered hunting rifles (16).

Damage is often dependent on the type of bullet used. Bullets that are encased with

hard shells produce deeper penetration and more significant cavitation. Bullets with soft

or hollow points typically deform or fragment and often ricochet inside the body (16). This

can produce damage to more areas. The actual injuries are influenced by a number of

factors, including the point of entry and the distance that the victim is from the weapon

(39). Some guns, such as shotguns, contain small pellets that spread apart when they

are released from the barrel. This produces a blast that spreads over a larger area and


9

will often cause damage to numerous areas of the body rather than one specific point of

entry (14). However, these produce less damage when fired from a greater distance (14).

TYPES OF INJURIES

There are a variety of injuries that occur in instances of extremity trauma. The types of

injury that occur are broken into categories based upon the structure that they damage.

In instances of extremity trauma, injuries occur in the following regions: soft tissue,

blood vessels, nerves, and bones (17). In some instances, the patient will experience

injuries in more than one region. When injury occurs in three or more regions, it is

considered a mangled extremity and must be treated accordingly. In most instances,

mangled extremities will require amputation. However, when injury occurs in less than

three regions, the risk of amputation is reduced (18). In many instances, the damage can

be repaired and the patient will be able to recover with limited disability or other long

term effects (19).

Osseous or Soft Tissue

Soft tissue is one of the most common injuries in extremity trauma and can occur as the

result of direct or indirect trauma to the region. Soft tissue injury, broadly defined, is any

injury that occurs to a non-bony, non-organ area. However, in most instances, soft

tissue injury is any injury that occurs in the muscles, ligaments, and joint capsules (6).

The most common forms of soft tissue trauma are abrasions, lacerations and burns.

However, soft tissue injuries can take many other forms depending on the cause and

location of the injury. The primary mechanisms of soft tissue injury are mechanical and

thermal. Mechanical force includes the following (20):

Shearing

Tension

Compression

Of these three, compression has the potential to produce the most significant damage

to the tissue and can cause additional complications for damage repair and overall

healing (21).


10

Thermal injuries are caused by the following mechanisms (6):

Radiation

Convection

Conduction

Electricity

Excessive cold

In both types of injury, the mechanism of injury, the material that causes the injury, and

the site of the injury will impact the degree of severity. In addition, the patient’s health

status and other biological factors will impact the body’s response to the injuring agent

(20).

Osseous tissue is the tissue present within bones, and it provides the primary

composition of the bone itself. The two types of osseous tissue are spongy and

compact, and the injury will differ depending on what type of osseous tissue is damaged

(22). Spongy tissue is arranged loosely within the bone and provides space for the bone

marrow. Compact osseous tissue is comprised of tightly packed minerals and can be

found in the outer regions of the bones (23). Osseous injuries often occur in conjunction

with fractures as the tissue is exposed to damage and often swells in response to the

trauma. However, osseous damage can also occur in the absence of fractures.

Osseous injury that is not related to fractures is especially common in instances of blunt

trauma (9).

Symptoms of Osseous/Soft Tissue Injury

Patients may display a variety of symptoms relating to soft tissue/osseous injury. The

specific symptoms the patient experiences will depend on the cause, location and

severity of the injury. However, there are common symptoms that most patients will

experience in conjunction with a soft tissue/osseous injury. The following is a list of the

most common soft tissue/osseous injuries (23):

Pain

Swelling

Discoloration


11

Temperature change

Numbness/tingling

Loss of function

Depending on the cause and type of sift tissue injury, patients may require special

treatment considerations. In some instances, the injury will require special care, while

other injuries may only require standard wound care. The following fact sheet (24)

provides information on special considerations for treating and managing soft tissue

injuries.

Closed Wounds

Suspect underlying fractures

Splint if fracture is suspected

Open Wounds

Expose all wound sites

Clear wounds of loose foreign material

Apply dressings and bandages to all wounds

Control bleeding

Incised Wounds or Lacerations

Edges of the wound may need to be drawn together prior to dressing the wound(s)

Impaled Objects

Stabilize the object

If the object impedes transport then careful shortening (cut) of the object may be required

(object impaled in chest)

Immobilize object securely during shortening effort

Do not remove object unless it interferes with CPR or causes a complete airway obstruction

(e.g. object

Impaled in cheek)

Avulsions

Clean the wound surface


12

Fold the skin flap back to its normal state

Control bleeding with direct pressure

Gun Shot Wounds

If possible, identify the type of weapon and the caliber

Assess the patient carefully for entrance and exit wounds

Expose all wound sites

Treat injuries as per the appropriate Guideline

Clear wounds of loose foreign material

Apply dressings and bandages to all wounds

Control bleeding

Consider internal bleeding, fractures, and injuries to underlying organs and structures

Any additional surveys and treatment should be conducted

Be prepared to manage cardio respiratory distress or arrest

Vascular Trauma

Vascular trauma is defined as any injuries that occur in the vascular regions, including

veins, blood vessels, and arteries. Vascular injuries occur in both blunt and penetrating

trauma, with the majority of injuries caused by penetrating trauma. Approximately 75 –

80% of vascular injuries are the result of penetrating trauma, and approximately 20 –

25% of vascular injuries occur as the result of blunt trauma (25). The severity of the

injury will vary depending on the location of the trauma, as damage to minor blood

vessels will be less traumatic than damage to major arteries. However, vascular trauma

can have long term implications if not treated properly, even when the damage occurs in

minor blood vessels (26).

Vascular trauma can be difficult to detect and identify in initial trauma evaluations,

unless the damage is to a major artery or blood vessel. Some patients will display very

few, or no, signs of vascular trauma, which can be problematic (27). Therefore, the

treating provider will have to conduct a thorough examination to determine the presence

of vascular injuries. The signs for vascular injuries are separated into two categories,

which are used to determine the level and immediacy of required treatment. Hard signs


13

indicate definite injury and require immediate attention, while soft signs indicate

potential injury and require additional evaluation. The following is a list of the different

hard and soft signs for vascular injury.

Hard Signs:

External or pulsate hemorrhage

Rapidly expanding or pulsatile hematoma

Palpable thrill / audible bruit

Ischemic limb (absent pulses, pallor, paraesthesia, pain, paralysis,

poikilothermia)

Soft Signs:

History of arterial bleeding at the scene / in transit, now ceased

Proximity of penetrating wound / blunt injury to an artery

Small non-pulsatile and non-expanding hematoma over an artery

Neurologic deficit originating in a nerve adjacent to a named artery

Reduced pulses

Mechanism (posterior dislocation of knee, anterior dislocation of elbow)

Ankle Brachial Index (ABI) or Arterial Pressure Index (API) <= 0.9 (25)

Patients who do not present with any of the hard or soft signs for vascular injury may

still have damage that is not yet apparent. Therefore, patients should be monitored and

evaluated regularly to determine if any of the above signs appear. If untreated, vascular

injuries can cause significant, life threatening problems (28).

Nerve Trauma

Nerves carry signals and messages to and from the brain and the rest of the body.

There are two types of nerves (29):

Motor Nerves:

These nerves are responsible for carrying messages from the brain to the

muscles to initiate and control movement.


14

Sensory Nerves:

These nerves are responsible for carrying messages to and from the brain and

the rest of the body to signal pain, pressure and temperature.

Injuries to the nerves will range in severity depending on how the nerve is damaged.

When a nerve is stretched or impacted by direct pressure, fibers within the nerve may

break. If this occurs, it will impact the nerve’s ability to send or receive signals (30).

When a nerve is cut, both the nerve and the insulation have the potential to be affected.

In some instances, only the fibers within the nerve will be affected. When this occurs

the end of the nerve that is farthest from the brain will die, while the end of the nerve

that is closest to the brain will remain viable (31). With time, the nerve may heal, but

there is the potential that the nerve will remain damaged permanently. This will depend

on the nerve that is affected as well as the severity of the damage (29). In some

instances, both the nerve and the insulation will be severed. When this occurs, the

nerve will require immediate repair. If the nerve is not repaired immediately, the fibers

have the potential to grow improperly, thereby causing a nerve scar, or neuroma (32).

Nerve damage can occur in instances of both blunt and penetrating trauma. In

instances of blunt trauma, the most common nerve injury is neuropraxia, which is

essentially a stunning of the nerve (33). These injuries have the most potential for

recovery. Penetrating trauma often causes more severe damage to the nerves. In

many penetrating trauma situations, there is a greater potential of complete nerve

transaction. When a transaction occurs, the nerve will experience an immediate loss of

both muscle and sensation function. When this occurs, function will not return unless

the damage is repaired surgically (34). The most common causes of nerve injury include

the following (31):

Laceration

Focal contusion (gunshot wounds)

Stretch/traction injury

Compression

Drug injection injury

Electrical injury


15

It can often be difficult to diagnose a nerve injury, as many patients will exhibit

symptoms that are common with other types of injury as well. Therefore, most

treatment providers will utilize either Seddon’s or Sunderland’s Classification System to

identify and diagnose specific nerve injuries.

Seddon’s Classification System

Seddon’s Classification System breaks nerve injury into three tiers of nerve injury based

on the level of damage. These are outlined and described below (35):

Stage Description

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. 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


16

disruption of the endoneurium. In neurotmesis, the

axon, myelin sheath, and connective tissue

components are damaged, disrupted, or

transected. As with axonotmesis, neurotmesis

initiates Wallerian degeneration, but the prognosis

for nerves is poor. Neurotmesis is commonly seen

after lacerations or ischemic injuries.

Sunderland Classification System

The Sunderland Classification System breaks Seddon’s Classification System into five

categories to further distinguish between severity levels. The stages of this system and

description of each are outlined below (36):

Stage Description

First-degree injury 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.


17

Fifth-degree injury These injuries are usually found in laceration or

severe stretch injuries. The nerve is divided into

two. The only way to repair a fifth-degree injury is

through surgery.

Bone Trauma

Fractures are common extremity injuries and many of the causes of extremity trauma

involve significant impact. In the simplest terms, a fracture is an area of the bone that is

broken. However, there are different types and severity levels of fractures. Depending

on the cause and the impact, an extremity patient may experience any level and type of

fracture (37). Regardless of the level of fracture, most extremity trauma patients will

experience some type of fracture as the result of the accident. In fact, fractures are the

most common extremity trauma injuries. Therefore, bone trauma will be discussed in

greater depth here than the preceding sections on injuries resulting from extremity

trauma.

There are two categories of fractures: closed fractures and compound fractures. A

closed fracture is one in which there is a clean break to the bone. With this type of

fracture, there is no damage to the surrounding tissue and the bone does not tear

through the skin (38). A compound fracture is more complex. With this type of fracture,

the surrounding tissue and skin can be damaged, resulting in significant bruising. A

compound fracture may also involve the bone tearing through the skin (39). Within these

two categories of fractures, there are many different types. The areas they affect, the

damage they inflict, and the cause of the fracture define these fracture types; the types

of fractures are outlined below (38):

Avulsion fracture - a muscle or ligament pulls on the bone, fracturing it.

Comminuted fracture - the bone is shattered into many pieces.

Compression (crush) fracture - generally occurs in the spongy bone in the spine.

For example, the front portion of a vertebra in the spine may collapse due to

osteoporosis.

Fracture dislocation - a joint becomes dislocated, and one of the bones of the

joint has a fracture.


18

Greenstick fracture - the bone partly fractures on one side, but does not break

completely because the rest of the bone can bend; more common among

children, whose bones are softer and more elastic.

Hairline fracture - a partial fracture of the bone. Often this type of fracture is

harder to detect.

Impacted fracture - when the bone is fractured, one fragment of bone goes into

another.

Longitudinal fracture - the break is along the length of the bone.

Oblique fracture - A fracture that is diagonal to a bone's long axis.

Pathological fracture - when an underlying disease or condition has already

weakened the bone, resulting in a fracture (bone fracture caused by an

underlying disease/condition that weakened the bone).

Spiral fracture - A fracture where at least one part of the bone has been twisted.

Stress fracture - more common among athletes. A bone breaks because of

repeated stresses and strains.

Torus (buckle) fracture - bone deforms but does not crack. More common in

children. It is painful but stable.

Transverse fracture - a straight break right across a bone.

When assessing a trauma patient, it is important to identify any present fractures, as

untreated fractures can cause further damage (37). In patients that are unconscious, this

can be difficult as there is no verbal indication of the common fracture symptoms (40).

Therefore, in these instances, X rays will be used to identify fractures and other injuries

in those areas affected by the trauma (41). Examination of different areas will also show

signs of potential fractures, as there may be swelling or bruising. In extreme cases, the

bone will be protruding from the area. When a patient is conscious, it can be easier to

identify fracture sites as the patient can communicate information regarding pain (37).

Fracture symptoms are described below (38):

Fracture Symptoms:

Pain and swelling at the fracture site.


19

Tenderness close to the fracture.

Paleness and deformity (sometimes).

Loss of pulse below the fracture, usually in an extremity (this is an emergency).

Numbness, tingling or paralysis below the fracture (rare; this is an emergency).

Bleeding or bruising at the site.

Weakness and inability to bear weight.

Treatment

Treatment for broken bones involves putting the pieces back into position and

preventing them from moving out of place as they heal. The healing process involves

the broken bone ends “knitting” themselves back together and forming new bone

around the edges of the broken areas (42). In some fracture cases, surgery may be

required (43). Depending on the severity of the break and the location of the injury,

different treatments will be used. The following is a description of the different

treatments that are used to treat fractures (39):

Cast Immobilization

A plaster or fiberglass cast is the most common type of fracture treatment,

because most broken bones can heal successfully once they have been

repositioned and a cast has been applied to keep the broken ends in proper

position while they heal.

Functional Cast or Brace

The cast or brace allows limited or "controlled" movement of nearby joints. This

treatment is desirable for some, but not all, fractures.

Traction

Traction is usually used to align a bone or bones by a gentle, steady pulling

action.

External Fixation


20

In this type of operation, metal pins or screws are placed into the broken bone

above and below the fracture site. The pins or screws are connected to a metal

bar outside the skin. This device is a stabilizing frame that holds the bones in the

proper position while they heal. In cases where the skin and other soft tissues

around the fracture are badly damaged, an external fixator may be applied until

surgery can be tolerated.

Open Reduction and Internal Fixation

During this operation, the bone fragments are first repositioned (reduced) in their

normal alignment, and then held together with special screws or by attaching

metal plates to the outer surface of the bone. Inserting rods down through the

marrow space in the center of the bone may also hold the fragments together.

Complications of Fracture Repair and Fractures

It is important to properly treat and repair fractures as soon as possible to prevent the

patient from experiencing any further damage as well as any repair related

complications. In some instances, repair related complications may be unavoidable (13).

However, repairing the fracture early and properly can prevent others. It is important to

understand the pathophysiology and predisposing factors of fracture repair

complications to adequately prevent them. When a complication is unavoidable, it is

important to diagnose it early and provide the appropriate treatment so that it does not

cause further damage (42).

While some complications can be a direct result of fracture repair, other complications

occur as a result of the fracture itself. Complications are categorized as either acute or

delayed, and they range in severity from minimal to life threatening (37). Acute

complications occur as a direct result of the trauma sustained and can include damage

to vascular structures, nerves, or soft tissue (37). Delayed complications may occur after

initial treatment or in response to treatment (44). As part of the trauma treatment

process, it is important to identify and treat any fracture related complications to prevent


21

further damage (42). In addition, reevaluation at regular intervals during healing is

necessary to monitor progress and identify any complications that may arise (43).

The following complications are common in fracture repair or as the direct result of a

fracture (45):

Life-Threatening Conditions

In some instances, a patient will experience a life threatening complication as the

result of a fracture. These conditions include the following:

o Femur fractures - disrupt the femoral artery or its branches and are

potentially fatal.

o Hip fractures - may prevent ambulation, resulting in potentially life-

threatening complications, such as pneumonia, thromboembolic disease,

and possibly rhabdomyolysis, if there is a prolonged period of immobility

Arterial Injury

Some patients may experience immediate or delayed arterial injuries as the

result of fractures or dislocations. These complications include:

Immediate:

o Laceration of the vessel, either partial or complete

o Occlusion, either partial or complete, which may be due to:

Angulation

Extrinsic compression

Intimal tears and dissection with an intact adventitia

Stretching

Spasm

Delayed:

o False aneurysms

o AV fistula

o Thrombosis of the vessel following reconstructive surgery

o Ischemic muscle contractures.


22

Nerve Injury

Nerve injuries and vessel injuries are common complications with some types of

fractures. Due to the location of many nerves and vessels, they are prone to

injury. The most vulnerable nerves and vessels are those that lie in close

proximity to the bone. These injuries are common in both closed and open

fractures. However, the injury is often more severe with an open fracture. Of the

two, nerve injuries are more commonly complications of fractures (35).

Compartment Syndrome

Compartment syndrome is the direct result of swelling and bleeding within a

compartment. When this occurs, the fascia does not stretch, thereby causing

increased pressure on the capillaries, nerves and muscles. This increased

pressure disrupts blood flow to the muscles and nerve cells. When this occurs,

the supply of oxygen is reduced, which damages nerve and muscle cells. There

are two types of compartment syndrome:

o Acute – This type results in permanent disability and tissue death unless

the pressure is relieved quickly.

o Chronic (exertional) –This type does not typically result in permanent

disability and tissue death.

Compartment syndrome is most common in the anterior compartment of the

lower leg, as well as other compartments in the leg. However, it can also occur

in the arms, hands, feet and buttocks (46).

Venous Thromboembolism

Venous thromboembolism (VTE) is a term that describes a condition that occurs

when clots or thrombi develop in the vein from red blood cells, fibrin and other

components that clump and form a mass. VTE is the result of at least one of

three underlying etiologic factors: damage to endothelial lining of the blood

vessel, stasis or slowing of the blood flow, and hypercoagulability or increased

clotting of the blood.


23

Venous thromboembolism consists of two related conditions: deep vein

thrombosis (DVT) that commonly occurs in leg veins, and pulmonary embolism

(PE) that occurs when a segment of a clot, within the deep venous system

detaches from the vessel, travels to the lungs, and lodges within the pulmonary

arteries (47).

Osteomyelitis

Osteomyelitis is an infection that occurs in the bone. Typically, various microbial

agents, such as staphylococcus aureus, cause osteomyelitis. In addition,

osteomyelitis can occur during the following situations:

o An open injury to the bone, such as an open fracture with the bone ends

piercing the skin.

o An infection from elsewhere in the body, such as pneumonia or a urinary

tract infection that has spread to the bone through the blood (bacteremia,

sepsis).

o A minor trauma, which can lead to a blood clot around the bone and then

a secondary infection from seeding of bacteria.

o Bacteria in the bloodstream bacteremia (poor dentition), which is

deposited in a focal (localized) area of the bone. This bacterial site in the

bone then grows, resulting in destruction of the bone. However, new bone

often forms around the site.

o A chronic open wound or soft tissue infection can eventually extend down

to the bone surface, leading to a secondary bone infection (48).

Malunion

In a malunion, the bone heals in a position that is considered unacceptable and

which may cause significant impairment. In some instances, the bone heals in a

bent angle. This is called an angulated heal. In other instances, the bone can be

rotated out of position or can have overlapping fractured ends, which may cause

bone shortening (39).

o Malunion is typically caused by the following factors (40):

o Inadequate immobilization of the fracture


24

o Misalignment at the time of immobilization

o Premature removal of the cast or other immobilizer

Nonunion

A nonunion occurs when a fracture fails to heal after a number of months; it

often is caused by the following factors (37):

The broken ends of bone may be separated too much (overdistraction)

There could have been excessive motion at the fracture site, either from

inadequate immobilization after the injury or from having a cast removed

prematurely

Muscle or other tissue caught between the fracture fragments also can

prevent healing, as can the presence of infection or inadequate blood

supply to the fracture site

Bone disease (e.g., bone cancer) also can prevent healing

The two types of nonunions include (44):

Fibrous nonunion – fractures that heal through the formation of fiber tissue

rather than the formation of new bone

False joint (pseudarthrosis) –continuous movement of the fracture

fragments result in the development of a false joint

The following types of fractures pose the greatest risk of nonunion (39):

Fractures of the wrist (carpus), including scaphoid bone

Certain fractures of the foot, including navicular fractures and Jones

(diaphyseal) fractures of the fifth metatarsal

Shoulder long bone fractures (proximal humerus fractures)

Shin bone (tibial) fractures

Complex Regional Pain Syndrome (CRPS)

Complex regional pain syndrome is common in injuries that damage the

peripheral and central nervous systems. CRPS is characterized by chronic pain


25

that affects one of the limbs (arms, legs, hands or feet), which occurs after there

has been a trauma to the area (37).

Symptoms of CRPS include the following (49):

o Prolonged or excessive pain

o Mild or dramatic changes in skin color, temperature, and/or swelling in the

affected area

There are two types of CRPS (49):

o CRPS-I – patients do not have confirmed nerve injuries

o CRPS-II – patients do have confirmed nerve injuries

Both types of CRPS produce the same symptoms. Patients will experience a

range of symptom severity and duration depending in the type of injury (37). Most

CRPS cases are mild and resolve completely over time. However, in some

instances, patients will present with a severe case, which may result in delayed

recovery and long term disability (49).

Fat Embolism Syndrome

Some patients may develop fat embolism syndrome as the result of fractures to

the long bones and pelvis. These fractures may result in the development of fat

globules in the peripheral circulation and lung parenchyma of the patient. Fat

embolism syndrome is a common occurrence, and affects almost all patients who

experience a long bone or pelvic fracture. It is most common in closed fractures.

In fact, Patients with a single long bone fracture have a 1 to 3 percent chance of

developing the syndrome, and this increases in correlation with the number of

fractures (50).

Post-Traumatic Arthritis

"Arthritis" is defined as inflammation of a joint. The most common cause is

wearing out of joint surface cartilage (osteoarthritis). The wearing out of a joint

that has had any kind of physical injury causes post-traumatic arthritis. The injury

could be from sports, a vehicle accident, a fall, a military injury, or any other


26

source of physical trauma. Such injuries can damage the cartilage and/or the

bone, changing the mechanics of the joint and making it wear out more quickly.

The wearing-out process is accelerated by continued injury and excess body

weight (51).

Fractures are common injuries and must be treated accordingly. Although fractures are

rarely life threatening, it is important to assess and treat them during the initial

emergency treatment stage to prevent further damage. Fractures can range in severity

from minor cracks to complete breaks that cause trauma to the surrounding tissue and

skin. Therefore, practitioners must identify the extent of injury and provide the

appropriate care to minimize further damage.

DIAGNOSIS AND TREATMENT

Patient stabilization is the primary objective when a patient is admitted with extremity

trauma. The emergency team will begin working to stabilize the patient immediately,

while assessing the patient and identifying any additional injuries. Once the patient is

stabilized, more focused treatment will be administered (13). Extremity trauma patient

stabilization includes three primary components:

Airway

Breathing

Circulation

Early Stabilization

When a patient presents with extremity trauma, the emergency team will immediately

begin working on the three components listed above. It is important to note that these

three components of stabilization serve as both assessments and treatment. The three

areas are assessed for immediate damage, and any necessary treatment is

administered (52).

As soon as the patient arrives in the emergency department, he or she will receive a

rapid primary survey to assess and identify any immediate problems (53). The first area


27

to receive treatment is the airway. If a patient requires intubation, it is initiated

immediately. Once an airway has been established, patients who require breathing

assistance will receive the appropriate treatment (38).

The second stage in patient stabilization involves the patient’s breathing. It is important

to assess the patient’s breathing and provide the necessary treatment. The goal is to

determine if the patient’s breathing is sufficient and provide breathing support if it is not

sufficient.

The next stage in patient care involves the circulatory system. An initial assessment of

the circulatory system is conducted to determine if the patient has experienced

circulatory collapse (39). This can be caused by hypovolemia from hemorrhage.

Immediate treatment is necessary to prevent further blood loss and assist with patient

resuscitation (8).

Evaluation and identification of extremity injury

Once the patient has been stabilized, the focus will shift to identifying and treating the

extremity injuries. As part of the initial examination, the treating provider will attempt to

determine the mechanism that caused the injuries as well as any other relevant

information, such as the time of the injury, the patient’s medical history, and any

underlying issues (17).

Once the provider has established the patient’s history and mechanism of injury, he or

she will conduct a thorough examination of the extremities to assess the damage. Early

evaluation and identification of extremity injuries is crucial to minimizing the damage

and, in many instances, salvaging the injured extremities. In some instances, extremity

injuries can be life threatening, while other injuries will pose a risk of limb loss.

However, with proper treatment, these problems may be prevented.

The following is a list of life threatening extremity injuries (54):

Pelvic disruption with massive hemorrhage

Severe arterial hemorrhage irrespective of mechanism


28

Hemorrhagic shock from multiple long bone fractures (blood loss into the

compartments)

Crush syndrome

Some injuries are not life threatening, yet they do pose a risk for limb loss. These

injuries are considered to be limb-threatening injuries. The following is a list of the limb

threatening extremity injuries (18):

Mangled extremity

Complex open fractures and / or dislocations

Degloving injuries

Severe vascular injury

Traumatic amputation

Compartment syndrome (as a consequence of the injury)

Neurological compromise of the limb

A thorough examination of the extremities will enable the treatment provider to identify

damage early and provide the appropriate treatment. The following table provides

detailed guidelines for the examination of extremities in extremity trauma situations (55).

The general examination of the extremities includes:

Inspection

• Deformity – closed fracture, dislocation

• Open fracture – deformity, presence of an open wound, condition of the overlying skin defect, bony

involvement, degree of soft tissue involvement, contamination

• Mangled extremity

• Active bleeding, expansile hematoma

• Location of wound – proximity to an artery, location with regards to the clavicle and inguinal canal

(transition points where proximal control of extremity vascular injury becomes difficult)

• Degloving injury

• Amputation – site(s), condition of skin, soft tissue and bone of stump and amputated appendage

Palpation

• Crepitus


29

• Hematoma – pulsatile, palpable thrill

• Swelling / firmness of the compartment involved, response to passive movement if compartment

syndrome suspected

Neurovascular status

• Pulses

• Warmth of periphery

• Paraesthesia

• Paralysis

Investigations

General:

ECG: Evidence of hyperkalaemia / arrhythmia

VBG: rapid pH status, electrolytes (K, Ca++), Hb, lactate

Arterial Pressure Index (API) or Ankle Brachial Index (ABI):

Performed when vascular injury is suspected in the absence of hard signs.

The ratio of the systolic blood pressure in the injured extremity distal to the injury (ankle or forearm) to

the systolic blood pressure in an uninjured extremity (usually the brachial artery)

API = Injured SBP / Uninjured SBPa

Lower limb:

The dorsalis paedis or posterior tibial pulse is found with Doppler. A BP cuff is placed below the site of

the injury and inflated to 20mmHg higher than the pressure at which the Doppler sound disappears.

The cuff is released until the Doppler sound is clearly heard and the BP is recorded (SBP). The

process is repeated on either the uninjured lower extremity or the brachial artery of an uninjured upper

extremity.

Upper limb:

The same technique is used except that the two upper limbs are compared.

Note: the cuff needs to be placed below the site of the wound on the injured limb. A ratio of 0.9 is used

to rule out the need for diagnostic imaging with a sensitivity and specificity as high as 95%. Patients

with soft signs and an API 0.9 may be observed (although ultimately there will be a delayed operative

rate of 1-4%). Patients with soft signs and a ratio of < 0.9 require further investigation as the

prevalence of vascular injury requiring surgery is 3-25% depending.

Compartment Pressure Measurement:

Compartment pressure may be measured by setting up a central venous or arterial pressure monitor

and attaching it to a needle that is then inserted into the compartment that you want to measure. All


30

compartments at the level of the injury should be measured.

Laboratory:

• CK - rhabdomyolysis

• Creatinine – renal insult secondary to hypoperfusion, rhabdomyolysis

• Electrolytes – K, calcium, uric acid, phosphate – Crush / Compartment Syndrome

• Hemoglobin (normal Hb does not exclude hemorrhage)

• Urine – myoglobinuria – marker of rhabdomyolysis

• G&H and CXM - transfusion

Imaging:

• Identifies fractures, skeletal deficits, foreign bodies, soft tissue defects, subcutaneous emphysema

• Amputation – x-ray stump and amputated appendage

CTA

• Up to 100% sensitive and specific in detecting all clinically significant arterial injuries

• Allow for interrogation of the vascular system as well as surrounding skeletal and soft tissue

structures

• Standard teaching is that CTA should only be performed in patients who are hemodynamically stable

to stratify injuries in patients with soft signs of vascular injury

The goal with assessing and treating extremity injuries is to prevent amputation and

repair the injured extremity. If an injury is identified and treated early, amputation can

often be prevented. Patients who do not receive early treatment have an increased risk

of amputation and morbidity (56).

Risks

Patients who present with extremity injuries are at risk of developing additional

complications. These complications are often the result of improper, or insufficient,

treatment and can be prevent with appropriate care.

Ischemia

Ischemia is the restriction of blood supply to the tissue. When this occurs, the

restriction will cause a shortage of oxygen and glucose, which is needed to keep the

tissue alive. After a period without oxygen and glucose, the tissue will die (57). In fact,


31

damage can occur in as little as 3 – 4 minutes after oxygen supply is blocked.

Subsequent damage will occur in other regions of the body, including the kidneys and

tissue. After a few hours, the problems will become more severe and will typically

cause tissue necrosis and gangrene (58). Eventually, the patient will experience

paralysis in the affected area, which is a sign that the nerves supplying the extremity

have died. The paralysis may be reversed if treated quickly, but in many instances it

can be permanent (59). Ischemia frequently occurs when a patient experiences vascular

trauma (60).

Ischemia typically produces specific symptoms in the patient. These include the

following (61):

Pain

Pallor

Pulselessness

Paresthesia

Paralysis

Poikilothermia

Ischemia must be reversed quickly to prevent long-term damage to the tissue and

organs. Without early treatment, the patient has an increased risk of losing the limb.

The most common treatment methods for ischemia include (62):

Injection of an anticoagulant

Thrombolysis

Embolectomy

Surgical revascularization

Amputation

Early treatment is essential to keep the affected limb viable. While early treatment is

imperative when attempting to salvage the limb, the treatment provider must proceed

with caution. In most instances, reintroduction of blood flow to the ischemic tissue can

cause problems if not managed properly (57).


32

Wound infection

Wound infections are common in instances of extremity trauma, especially when the

patient experiences penetrating extremity trauma (63). Wound infections are commonly

caused by bacteria, but other microorganisms can cause infections as well (52).

Infections can be problematic in patients as they can delay healing or cause more

severe damage and long-term problems in the patient.

The most common form of bacteria that causes wound infections is staphylococcus

aureus, as well as other forms of staphylococci. These bacteria are especially prevalent

in health care facilities and can cause extensive damage to the patient in a relatively

short period of time. In most instances, a patient will develop a wound infection within

24 – 72 hours of the initial trauma (64). However, some infections may develop over a

longer period of time, or may occur as the result of external factors not related to the

initial trauma. Treatment providers should monitor the patient and any wounds carefully

so that infections can be detected and treated immediately, thereby preventing more

severe damage.

The following is a list of the most common signs of wound infection (63):

Pus or cloudy fluid draining from the wound

Pimple or yellow crust formed on the wound (impetigo)

Scab has increased in size

Increasing redness around the wound (cellulitis)

Red streak is spreading from the wound toward the heart (lymphangitis)

Wound has become extremely tender

Pain or swelling increasing after 48 hours since the wound occurred

Wound has developed blisters or black dead tissue (gangrene and

myonecrosis)

Lymph node draining that area of skin may become large and tender

(lymphadenitis)

Onset of widespread bright red sunburn-like rash

Onset of fever


33

Wound hasn't healed within 10 days after the injury

Malunion, Delayed union, or nonunion

In instances of fractures, there is a risk that the bones will not heal properly, or at all.

This risk is greater with more complex fractures and can impact the outcome for the

patient.

Malunion:

In a malunion, the bone heals in a position that is considered unacceptable and which

may cause significant impairment. In some instances, the bone heals in a bent angle.

This is called an angulated heal. In other instances, the bone can be rotated out of

position or can have overlapping fractured ends, which may cause bone shortening (39).

Malunion is typically caused by the following factors (40):

Inadequate immobilization of the fracture

Misalignment at the time of immobilization

Premature removal of the cast or other immobilizer

Delayed Union:

Fracture repair requires time. In most instances, a bone will require a certain amount of

time to complete the healing process and establish a solid union. Delayed union occurs

when a bone has not healed over an appropriate amount of time. In these instances,

the bone remains separated or fractured, even after a significant and appropriate period

of time (7). Delayed unions often occur as the result of the following factors (38):

Inadequate reduction

Inadequate immobilization

Distraction

Loss of blood supply

Infection


34

Sometimes, a delayed union will eventually transition to a successful union. However,

in other instances, the delayed union may become a nonunion (7). With appropriate

treatment and intervention, the patient will have the potential for a successful outcome.

Nonunion:

A nonunion occurs when a fracture fails to heal after a number of months. A nonunion

is often caused by the following factors (37):

The broken ends of bone may be separated too much (overdistraction)

There could have been excessive motion at the fracture site, either from

inadequate immobilization after the injury or from having a cast removed

prematurely

Muscle or other tissue caught between the fracture fragments also can prevent

healing, as can the presence of infection or inadequate blood supply to the

fracture site

Bone disease (e.g., bone cancer) also can prevent healing

The two types of nonunions include (44):

Fibrous nonunion – fractures that heal through the formation of fiber tissue rather

than the formation of new bone

False joint (pseudarthrosis) – continuous movement of the fracture fragments

result in the development of a false joint

The following types of fractures pose the greatest risk of nonunion (39):

Fractures of the wrist (carpus), including scaphoid bone

Certain fractures of the foot, including navicular fractures and Jones (diaphyseal)

fractures of the fifth metatarsal

Shoulder long bone fractures (proximal humerus fractures)

Shin bone (tibial) fractures

Loss of muscle function

In many instances extensive tissue and muscle damage occurs as the result of

extremity trauma. This damage will have an impact on the function of the extremity, and


35

can result in permanent damage or death to the region (12). In some instances, the

patient will only experience minor or temporary loss of function. However, in more

severe cases, the patient will experience significant, long-term loss of function (1). Most

patients will require surgical intervention to repair and reconstruct the affected area (65).

Inability to achieve skin closure

In some patients, it will be difficult to achieve skin closure during the repair process. In

some instances, this will occur because of damage and destruction of significant

portions of the skin. When this occurs, the remaining viable skin will not be sufficient for

closure and wound coverage. In these instances, other means must be employed. If

possible, skin from other areas of the body may be grafted and used for wound closure

(66).

Chronic pain

Many patients will experience chronic pain as the result of traumatic injuries to the

extremities. In fact, a approximately sixty percent of extremity trauma patients report

moderate to severe pain one year after experiencing trauma, with many of those

patients experiencing similar levels of pain for approximately 5 – 7 years after the initial

trauma (67). In many instances, this chronic pain will cause disability, post traumatic

stress disorder, and depression in patients (68).

Radiologic Imaging and Surgical Evaluation

It is common for practitioners and emergency treatment providers to use a number of

imaging techniques to identify and diagnose extremity injuries. In addition, surgical

evaluation may be used to conduct an in-depth examination of the patient’s injuries. In

many instances, the surgical evaluation is conducted in conjunction with diagnostic

imaging (17).

Trauma of the extremities is typically assessed using the three following diagnostic

imaging techniques:

X Rays

Arthrography


36

Angiography

CT scans and MRI’s ore occasionally used, but they are typically reserved for use in

complex trauma. They are also useful for diagnosing soft tissue damage. An MRI will

also be used in instances where it is necessary to obtain images of large nerves,

tendons, and cartilage.

The following chart provides detailed information on the three most common diagnostic

imaging techniques used to identify and assess extremity trauma.

Technique Description

X Rays X-rays use invisible electromagnetic energy beams to produce images of internal

tissues, bones, and organs on film. Standard X-rays are performed for many

reasons, including diagnosing tumors or bone injuries.

X-rays are made by using external radiation to produce images of the body, its

organs, and other internal structures for diagnostic purposes. X-rays pass through

body structures onto specially treated plates (similar to camera film) and a

"negative" type picture is made (the more solid a structure is, the whiter it appears

on the film). Instead of film, using computers and digital media may also make X-

rays.

When the body undergoes X-rays, different parts of the body allow varying

amounts of the X-ray beams to pass through. Images are produced in degrees of

light and dark, depending on the amount of 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


37

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 (69).

Arthrography

Arthrography is medical imaging to evaluate conditions of joints. It can either be

indirect or direct.

Indirect arthrography is a medical imaging technique in which contrast material is

injected into the blood stream, which will eventually absorb into the joint. With

direct arthrography, the contrast material is injected directly into the joint. Direct

arthrography is the preferred method because it is better for distending or enlarging

the joint and imaging small internal structures to allow for better evaluation of

diseases or conditions within the joint. It, however, is often performed only if a non-

arthrographic exam is felt to be inadequate.

There are several methods to perform direct arthrography:

Conventional direct arthrography of a joint uses a special form of x-ray called

fluoroscopy after an injection of contrast material containing iodine is administered

directly into the joint. Alternate methods of direct arthrography examinations may

use magnetic resonance imaging (MRI) or computed tomography (CT) following

the various contrast material injections into the joint.

Fluoroscopy makes it possible to see bones, joints and internal organs in motion.

When iodine contrast is injected into the joint, it fills the entire joint and becomes

clearly visible during x-ray evaluation, allowing the radiologist to assess the

anatomy and function of the joint. Although the injection is typically monitored by

fluoroscopy, the examination also involves taking radiographs for documentation.

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.


38

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 (70)

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 (71).


39

While the three techniques included in the table above are the most common diagnostic

imaging techniques, it is important to understand the role that CT Scans and MRI’s have

in diagnosing extremity trauma.

CT Scan

Computed tomography (CT scan) is a diagnostic imaging procedure that produces

horizontal, or axial, images of the body. These images are often called “slices” (72). The

CT scan uses a combination of X Ray imaging and computer technology to obtain the

images in a noninvasive format (73). A CT scan is an important diagnostic tool as it is

able to provide detailed images of different parts of the body. It is especially useful in

obtaining images of the bones, muscles, fat and organs (74).

CT scans are used more frequently than standard X Rays because the images are

more detailed (41). Standard X Rays use a single beam of energy that is aimed at the

specific body part being analyzed. The image is captured on a plate that is placed

behind the body, once the beam of light passes through the various body parts (skin,

bone, muscle, and tissue) (10). X Rays are limited in their ability to provide detailed

imaging, as they cannot capture images of internal organs and other structures of the

body. Therefore, a CT scan is often the primary assessment used. A CT scan uses a

moving X Ray beam to capture the images. The beam circles around the body, thereby

capturing a number of different views of the same body part. The information is

transmitted to a computer, which then interprets the data and creates a two dimensional

form. The form is displayed on a monitor, which is then reviewed by the radiologist (41).

CT scans are conducted in two ways, as described below:

Contrast: Patients ingest a substance orally, or receive an injection intravenously. The

contrast solution enables the radiologist to view the specific body part or region more

clearly.

Non-Contrast: The CT scan is conducted without the use of any solution (75).


40

CT scans are used frequently in instances of spinal trauma as they provide thorough

views of the brain and the spine. A CT scan is especially useful for detecting the

following injuries in spinal trauma patients (76):

• Bone fractures

• Bleeding

• Spinal stenosis

CT scans are less useful in detecting injuries to the spinal cord or any ligament injuries

associated with an unstable spine (77).

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) is a radiologic scan that produces images of

various body structures using a combination of magnetism, radio waves and computer

technology. The MRI is conducted using a large circular magnet that surrounds a

scanner tube (10). Placing the patient on a movable surface and inserting him or her into

the magnetic tube is done to obtain images. Once the patient is in the tube, a strong

magnetic field is created. This magnetic field aligns the protons of the hydrogen atoms.

Once the hydrogen atoms are aligned, they are exposed to a beam of radio waves. The

radio waves impact the protons within the body, causing them to spin, thereby

producing a faint signal, which is easily detected by the MRI receiver. The information

obtained by the scanner is sent to a computer, where it is processed to produce an

image (75).

An MRI utilizes high resolution technology, which allows it to produce highly detailed

images that will show changes in many of the structures in the body (78). In some

instances, additional agents will be used to enhance the accuracy of the images. It is

most common to use contrast agents such as gadolinium (79). Due to the MRI’s high

level of sensitivity, it is able to detect many injuries that are undetectable using other

methods (75).

While an MRI and CT scan both use the slicing technique for obtaining images, the

process is different for each. The MRI uses a magnetic field while the CT scan uses X


41

Rays (76). As a result, the MRI provides more detailed images than a CT scan and is

able to detect damage that is as small as 1 – 2 mm. A CT scan cannot detect damage

this small (80).

Reperfusion

Many patients will experience a reperfusion injury when blood supply is returned after a

period of ischemia. Damage from reperfusion occurs in the tissue surrounding the

impacted area (57). If reperfusion is not properly managed, the restoration of blood flow

will cause inflammation and oxygen related damage to the area, which will cause

additional complications for the patient (81). Reperfusion is characterized by the

following (61):

Cellular edema

Intracellular calcium ion (Ca2+) overload

Activation of Ca2+- dependent autolytic enzymes

Disruption of lipid membranes

Changes in mitochondrial structure and function

To prevent reperfusion injury, the treating provider will have to manage the restoration

of blood flow so that it does not overwhelm the patient’s system. This can be

accomplished using a variety of techniques, including but not limited to a tourniquet (57).

Analgesia

Patients who experience extremity trauma typically present with significant pain, which

can negatively impact the assessment and treatment of the patient. In addition,

extreme pain can cause physiologic problems with trauma patients.

The physiologic impact of pain in trauma is listed below as the following (82):

Accentuates stress response

Accentuates catabolic processes

Slows restoration of function

Increases sympathetic outflow

Hemostatic response with altered levels of platelets/fibrin and coagulation


42

Patients should receive, when appropriate, analgesics as soon as possible to minimize

pain. In most instances, analgesics will be administered intravenously. However, some

patients may receive oral analgesics (83). In most instances, the treatment provider will

take a multimodal approach to analgesic administration.

Multimodal Treatment

Multimodal treatment options may include the following (84):

Regional – Local anesthetic blocks/infusions

Neuraxial – Intrathecal vs. epidural

NSAIDS

Opioids – Peripheral and/or central

NMDA receptor agonists –

Ketamine/Methadone/dextromethorphan

Anticonvulsants – Gabapentin/Lyrica

The goal is to reduce or eliminate pain so that assessment and treatment will be

successful and so that the patient will be comfortable. However, while analgesics do

help reduce the patient’s pain, there are potential risks associated with the use of some

analgesics. Therefore, the treatment provider must consider the potential

consequences when prescribing analgesics (83).

Antibiotics

All extremity wounds have the potential to become infected. Therefore, many provides

will utilize prophylactic antibiotics to prevent infection. In many instances, antibiotics will

be used for a duration of five days to two weeks, depending on the type of injury and the

antibiotic used (85). In some cases, patients will receive additional antibiotic treatment

after the initial period if there is still a risk of infection (86). In most instances, initial

antibiotics are delivered intravenously, with additional dosing administered orally for the

duration of treatment. Generally speaking, the antibiotics used as prophylactics will be

broad antibiotics that will treat multiple types of bacteria and infection (63).


43

Antibiotics will also be used to treat patients after they develop an infection. In these

instances, the patient will receive antibiotics to eliminate an infection that has occurred

as a complication of the initial trauma. Infections may not appear for days or weeks, so

the provider must rely on information from the patient to identify and manage these

infections (64). When antibiotics are prescribed to treat specific infections, they will be

selected based upon the specific treatment needs of the patient. In these instances, the

antibiotics will be bacteria and infection specific (85).

Treatment by general or trauma surgeon with involvement from specialists

Many patients will require advanced treatment beyond the scope of the initial

emergency provider or treating physician. If the situation warrants, patients will receive

treatment from a general or trauma surgeon, along with involvement and assistance

from various specialists. The specific specialists will be selected based upon the

mechanism and type of injury, the affected areas, any potential complications, and the

presence of any underlying conditions (13).

PROGNOSTIC FACTORS FOR LIMB SALVAGE

The primary goal with extremity trauma is limb salvage. In most instances, the treating

provider will utilize a variety of treatment options to prevent amputation and repair the

damage to the extremities. However, in some instances, the extremity is too damaged

to salvage. This is especially common when a patient experiences a mangled

extremity, which is a limb injury that damages at least three of the four systems in the

extremity. While mangled extremities can still be salvaged, the risk of amputation is

greater and it is more difficult to repair the damage (2).

In some instances, the treating provider will use scoring systems to assess the damage

and determine if amputation is necessary. However, many of the scoring systems are

unreliable and do not accurately predict whether amputation is necessary. Therefore,

providers will often assess other factors when making a determination (87).


44

Of utmost concern is the safety of the patient. If a damaged limb poses a life

threatening risk, the patient’s needs will come before the need to salvage the limb (88).

Once the patient’s viability has been assessed, the focus will shift to other factors. The

primary factor to consider when determining limb viability is the severity of the damage

to the soft tissue. The more extensive the damage, the greater likelihood that the

patient will require amputation (89). Other factors that may cause the surgeon to

consider amputation include (90):

High grade open fracture

Severe vascular injury

Significant nerve damage

Inevitability of amputation after failed salvage

In addition to the primary factors listed above, surgeons and treatment providers will

consider a variety of other factors as well. The decision is not made lightly and

providers must take all factors into consideration before making the decision. It is

especially important for treatment providers to consider the following factors when

determining whether or not to amputate.

Time

The potential to salvage a limb decreases as more time passes from the onset of injury.

Untreated damage to any of the systems that comprise the extremity will worsen over

time and can cause tissue death and unrepairable damage to the extremities.

Therefore, surgeons will consider the amount of time that has passed when determining

whether or not to amputate (91).

Mechanism

The mechanism of injury will have an impact on the potential for limb salvage. In some

instances, the mechanism of injury will cause extensive, irreparable damage. This is

especially true in military trauma situations and accidents that crush or mangle the

extremity (2).


45

In military trauma situations, explosive devices that destroy portions of the extremities

often injure patients. In these situations, the damage is too extensive to repair. The

same is true with civilian trauma that causes similar damage, which is especially

common in motor vehicle crashes (92).

Anatomy

The region of the extremity that is damaged will be a determining factor in the

salvageability of the limb. In some instances, the damage will occur in a region that

cannot be repaired easily, which will increase the likelihood that the limb will have to be

amputated (93).

In addition to the factors listed above, the treating physician and surgeon will also

consider other factors when determining limb salvagibility. These factors include the

following (18):

Associated injuries

Age and physiologic health

Clinical presentation

Environmental circumstances

Limb salvage is one of the primary goals when working with patients who have

experienced extremity trauma. However, the factors listed above may reduce the

potential for limb salvage. As part of the assessment and treatment process, physicians

and surgeons will utilize all resources to salvage the limb. In some instances, however,

limb salvage will not be possible. In these instances, the patient will experience a limb

loss, either through amputation or as part of the initial injuries (94).

AMPUTATION AND LIMB LOSS

Limb loss, which is defined as the loss of part of the arm or the leg, can be a common

injury during extremity trauma situations as many of the accidents that cause extremity

trauma are severely damaging to the individual’s body. Limb loss can occur directly

during the trauma (e.g. limbs being blown off during an explosive accident), or they can


46

occur through amputation after the accident as a treatment measure. According to the

Center for Disease Control, approximately two million people in the United States are

living with limb loss (95).

When limbs are amputated in response to specific injuries sustained during an accident,

there are specific amputation locations that are called amputation levels. The treatment

team will determine where to amputate the limb based on the severity of the injury and

the areas affected (96). The following is a list of the different amputation levels (97):

Partial Foot or Toe(s) (incl. Symes)

Below Knee (incl. Rotationplasty)

Above Knee (incl. Knee Disarticulation)

Hip Disarticulation or Hemipelvectomy

Bilateral Lower Limb Loss

Partial Hand or Finger(s)

Below Elbow (incl. Wrist Disarticulation)

Above Elbow (incl. Elbow Disarticulation)

Shoulder Disarticulation or Forequarter

Bilateral Upper Limb Loss

When limbs are blown off during an explosive accident or are torn from the body as part

of another type of accident, it is often necessary to remove additional parts of the limb

so that the loss occurs within one of the pre-determined amputation levels (98). Limb

loss and damage that is a direct result of an explosion or accident is typically very

uneven and includes an abundance of damaged, unsalvageable tissue, bone and

ligaments. Therefore, the treatment team will most likely need to “clean up” the area

and remove the additional damaged tissue, bone and ligaments (99). This ensures a

smooth amputation and ensures that the loss site is clean and can be fitted for a

prosthetic device (if one is deemed necessary and/or appropriate) (100).

In many instances, a body part will sustain significant damage as a result of the

accident. However, the limb will not be detached from the body in any way. This often

occurs when significant tissue damage occurs (95). In these instances, the emergency


47

treatment team will either have to provide treatment that will salvage the extremity, or

they will have to amputate the extremity (96). This decision is not made lightly.

Salvaging the limb is always the preferred option if the limb function can be restored or

maintained, or if the severity of the injury will not cause further damage to the patient.

In many instances, the tissue damage is so severe that the limb cannot be salvaged (98).

There are a number of assessment tools that emergency providers can use to

determine the severity of the injury to the extremity and the potential for repair and

restoration. The data obtained from these assessments is used to make a final

determination regarding amputation. The following are the available scoring systems:

Predictive Salvage Index (PSI)

Mangled Extremity Severity Score (MESS)

Limb Salvage Index (LSI)

Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age

(NISSSA) Score

Hannover Fracture Scale-98 (HFS-98)

Each scoring system uses different criteria to determine extremity damage and viability.

Predictive Salvage Index

Overview:

The Predictive Salvage Index (PSI) is used to evaluate severity of a lower extremity that

has undergone trauma with orthopedic and vascular injuries.

Parameters:

1. Level of arterial injury

2. Degree of bone injury

3. Degree of muscle injury

4. Interval from injury until arrival in the operating room

Tissue Injury Findings Degree

Bone Transverse fracture with possible butterfly component;

simple oblique fracture; fracture dislocation of joint

Mild

Comminuted fracture over 2-5 cm Moderate

Comminuted fracture >5 cm; or segmental loss Severe


48

Muscle Laceration of one or more muscles in a single

compartment; no significant crush component

Mild

Laceration of one or more muscles in 2 compartments;

crush-revulsion component

Moderate

Laceration of one or more muscles in 3 or 4

compartments

Severe

Parameter Findings Points

Level of arterial

injury

Suprapopliteal 1

Popliteal 2

Infrapopliteal 3

Degree of bone

injury

Mild 1

Moderate 2

Severe 3

Degree of muscle

injury

Mild 1

Moderate 2

Severe 3

Interval before

surgery

<6 hours 0

6−12 hours 2

>12 hours 4

Predictive Salvage Index = SUM (points for all 4 parameters)

Interpretation:

Minimum score: 3 (based on the point assignments; if no vascular, bone or muscle

injury then the score could reach 1, but then it would not be a seriously injured limb)

Maximum score: 13

The higher the score the worse the chances for a successful limb salvage. (101)

Mangled Extremity Severity Score

Overview:

The Mangled Extremity Severity Score can be used to evaluate patients with lower

extremity trauma with vascular compromise. It can help to decide whether to attempt

limb salvage or to perform amputation.

Parameters:

1. Extent of skeletal and soft tissue injury


49

2. Patient’s blood pressure

3. Duration and extent of limb hypoperfusion

4. Age of patient

Group Finding Points

Skeletal and

soft tissue

injury

Low energy (stab wounds, simple closed fractures, small caliber

gunshot wounds)

1

Medium energy (open or multiple level fractures, dislocations, moderate

crush injuries)

2

High energy (shotgun blast at close range, high velocity gunshot wound) 3

Massive crush injury (logging, railroad or oil rig accidents) 4

Shock Normotensive (blood pressure stable in field and in OR) 0

Transiently hypotensive (blood pressure unstable in field but responsive

to intravenous fluids)

1

Prolonged hypotension (systolic blood pressure <90 mm Hg in field and

responsive to intravenous fluid only in the OR)

2

Ischemia

(≤ 6 hours)

None (pulsatile limb without signs of ischemia) 0

Mild (diminished pulses without signs of ischemia) 1

Moderate (no pulse by Doppler, sluggish capillary refill, parenthesis,

diminished motor activity)

2

Severe (pulseless, cool, paralyzed, numb, without capillary refill) 3

Ischemia

(>6 hours)

None (as above) 0

Mild (as above) 2

Moderate (as above) 4

Severe (as above) 6

Age < 30 years of age 0

≥ 30 and <50 years of age 1

≥ 50 years of age 2

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


50

A score ≥ 7 is 100% predictive for amputation in the study population.

A score <7 can usually be salvaged (102).

Limb Salvage Index (LSI)

Overview:

The Limb Salvage Index (LSI) is used to evaluate a severely injured lower extremity.

Parameters:

1. artery

2. nerve

3. bone

4. skin

5. muscle

6. deep vein

7. warm ischemia time

Parameter Finding Points

Artery Artery contusion, intimal tear, partial laceration or avulsion (pseudo-

aneurysm) with no distal thrombosis and palpable pedal pulses

0

Complete occlusion of 1 of 3 shank vessels or profunda 0

Occlusion of 2 or more shank vessels 1

Complete laceration, avulsion, or thrombosis of femoral or popliteal

vessels without palpable pedal pulses

1

Complete occlusion of femoral or popliteal vessels with no distal

runoff available

2

Complete occlusion of 3 shank vessels with no distal runoff available 2

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 or tibial nerve 1

Complete transection or avulsion of sciatic nerve 2

Complete transection or avulsion of both peroneal and tibial nerves 2

Bone Closed fracture at 1 or 2 sites 0

Open fracture with comminution or with minimal displacement 0

Closed dislocation without fracture 0


51

Open joint without foreign body 0

Fibula fracture 0

Closed fracture at 3 or more sites on same extremity 1

Open fracture with comminution or moderate to large displacement 1

Segmental fracture 1

Fracture dislocation 1

Open joint with foreign body 1

Bone loss <3 cm 1

Bone loss ≥ 3 cm 2

Type III-B or III-C fracture (open fracture with periosteal stripping,

gross contamination, extensive soft tissue injury or loss)

2

Skin 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

Muscle 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

Deep vein Contusion, partial laceration, or partial avulsion 0

Complete laceration or avulsion if alternative route of venous return is

intact

0

Superficial vein injury 0

Complete laceration, avulsion or thrombosis with no alternative route

of venous return

1

Warm

ischemia time

<6 hours 0

6−9 hours 1

9−12 hours 2

12−15 hours 3

>15 hours 4

Where:

Shank is the lower leg.

Bone loss was <3 cm or >3 cm in the table. I assigned = 3 cm as 2 points.


52

Points for each category = maximum single point assignment

Limb Salvage Index = SUM (points for all 7 parameters)

Interpretation:

Minimum score: 0

Maximum score: 14

The higher the score the more severe the injury (103).

Limb Salvage Index Outcome

0−5 Limb salvage successful (51 of 51)

6−14 Amputation (19 of 19)

Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age (NISSSA)

Score

Overview:

The NISSSA score is used for grading the severity of an open fracture of the lower

extremity. It is a modification of the MESS, with addition of an evaluation of nerve injury.

Parameters:

1. N = nerve injury

2. I = ischemia

3. S = soft tissue contamination

4. S = skeletal injury

5. S = shock

6. A = age of the patient

Parameter Finding Description Points

Nerve Sensate No major nerve injury 0

Dorsal Deep or superficial peroneal nerve, femoral nerve

injury

1

Plantar partial Tibial nerve injury 2

Plantar

complete

Sciatic nerve injury 3

Ischemia None Good to fair pulses, no ischemia 0


53

Mild ≤ 6 hours Reduced pulses but perfusion normal 1

Moderate ≤ 6

hours

No pulse; prolonged capillary refill; Doppler pulses

present

2

Severe ≤ 6

hours

Pulseless, cool, ischemic, no Doppler pulses 3

Mild >6 hours 2

Moderate >6

hours

4

Severe >6

hours

6

Soft tissue Low Minimal to no contusion, no contamination 0

Medium Moderate injury, low velocity gunshot wound,

moderate contamination, minimal crush

1

High Moderate crush, deglove, high velocity gunshot,

injury may require soft tissue flap, considerable

contamination

2

Severe Massive crush, farm injury, severe deglove, severe

contamination

3

Skeletal Low energy Spiral fracture, oblique fracture, no or minimal

displacement

0

Medium energy Transverse fracture, minimal comminution, small

caliber gunshot wound

1

High energy Moderate displacement, moderate comminution,

high velocity gunshot wound, butterfly fragments

2

Severe energy Segmental, severe comminution, severe bone loss 3

Shock Normotensive Always >90 mm Hg systolic 0

Transient

hypotension

Transient 1

Persistent

hypotension

Persistent hypotension despite fluids 2

Age <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


54

Maximum score: 19

The higher the score, the more severe the injury.

A score ≥ 7 was 100% sensitive for amputation, but with specificity of 46%.

A score ≥ 11 had a 100% specificity and positive predictive value for amputation (104).

Hannover Fracture Scale-98 (HFS-98)

Overview:

The Hannover Fracture Scale '98 is an update to the Hannover Fracture Scale that was

developed in 1983. It is a simpler instrument yet reliable measure of limb salvage.

Parameters:

1. extent of fracture bone loss

2. skin injury as percent of limb circumference

3. muscle injury as percent of limb circumference

4. wound contamination

5. deperiostation

6. local circulation

7. systolic blood pressure (systemic circulation)

8. neurologic findings

Parameter Finding Points

Extent of bone loss None 0

0.1 to 1.9 cm 1

≥ 2.0 cm 2

Skin injury None 0

1−24% of circumference 1




Muscle injury None 0






55

Wound contamination None 0

Partial 1

Massive 2

Deperiostation No 0

Yes 1

Local circulation Normal 0

Capillary pulse 1

Ischemia <4 hours 2

Ischemia 4 to 8 hours 3

Ischemia >8 hours 4

Systolic blood pressure Constantly >100 mm Hg 0

<100 until admission 1

<100 until surgery 2

Constantly <100 mm Hg 3

Palmar-plantar sensibility Yes 0

No 1

Finger-toe active motion Yes 0

No 1

Hannover Fracture Scale Score = SUM (points for all 8 parameters)

Interpretation:

Minimum score: 0

Maximum score: 22

The higher the score the worse the injury.

A score ≥ 11 indicates significant trauma, with amputation recommended (105).

When assessing the damage caused to an extremity, emergency treatment personnel

will use the scoring systems listed above. A determination regarding which system to

use will be made based on the specific area that is damaged (106). Each scoring system

is reliable. However, no system is 100% reliable. Therefore, practitioners should use

the scoring system as an initial guide when making a determination regarding whether

to amputate a damaged limb. However, practitioners should also exercise caution when

relying completely on the score. In some instances, the score will not accurately

determine whether a limb should be amputated or salvaged (97).


56

Risk factors for amputation

As mentioned earlier, the primary goal with extremity trauma is limb salvage; and, the

treating provider will often utilize a variety of treatment options to prevent amputation

and repair the damage to the extremities. In the case of a mangled extremity, which is a

limb injury that damages at least three of the four systems in the extremity, the extremity

may be too damaged to salvage. While mangled extremities can still be salvaged, the

risk of amputation is greater and it is more difficult to repair the damage (2). In some

instances, the damage and destruction to the extremity will make it apparent

immediately that amputation is necessary. However, in many instances, it will be

difficult to determine immediately if the injured extremity will require amputation (93). The

treating provider will have to consider various factors when making the determination.

There are many reasons why a patient may require an amputation. However, some risk

factors will increase the likelihood that a patient will require an amputation.

Gustilo III-C injuries

When a patient experiences an open fracture as the result of extremity trauma, he or

she may be at an increased risk of requiring amputation. The level of fracture injury

often determines the risk of amputation. When a fracture is classified as a Type IIIC

injury, the patient is at an increased risk of requiring amputation (107).

To determine the level of injury, providers use the Gustilo-Anderson classification

system, which classifies open fractures based on the level and severity of soft tissue

injury; the higher the level the greater the risk of amputation. The following is the

different fracture classification levels according to the Gustilo-Anderson Classification

System (108):

Type I:

Wound < 1cm, wound is clean without evidence of contamination; usually simple

transverse / oblique fractures (infection risk 0-2%)

Type II:

Wound > 1cm with moderate soft tissue injury and moderate contamination; (infection

risk 2-5%)


57

Type IIIA:

Severe soft tissue injury but bone adequately covered irrespective of the size of the

wound; highly contaminated; usually more complex fractures - segmental or severely

comminuted fractures (infection risk 5-10%)

Type IIIB:

Extensive soft tissue loss, exposed bone, periosteal stripping, massive contamination

(infection risk 10-50%)

Type IIIC:

Extensive fracture associated with arterial injury requiring repair (infection risk 25-50%)

The Gustilo-Anderson Classification System is one of the most reliable indicators of

amputation risk (109). However, there are a number of other factors that will increase the

risk of amputation if present in the patient. These include the following (110):

Nerve transaction

Prolonged ischemia/muscle necrosis

Crush or destructive soft tissue injury

Significant wound contamination

Multiple/severely comminuted fractures/segmental bone loss

Old age/severe comorbidity

Lower vs. upper extremity

Apparent futility of revascularization

It is important for treatment providers to thoroughly assess the patient to determine the

presence of any amputation risk factors. In some instances the patient’s limb can still

be salvaged. It is crucial that all risk be addressed and remedied as soon as possible;

the longer the patient experiences risk factors, the greater the chance of amputation.


58

SUMMARY

Extremity trauma is one of the most common forms of trauma treated in emergency

departments throughout the United States. Extremity trauma can be simple or complex,

as it may cause injuries in only one of the components of the extremity or all of the four

components. The four components of the extremity are the nerves, vessels, bones, and

soft tissue. The most severe cases of extremity trauma will involve more than one of

the components of the extremity and can be difficult to manage and repair. When a

patient experiences injury in three of the four components, he or she has a mangled

injury and is at an increased risk of losing the limb.

Treatment for extremity injuries, especially those that are severe, requires a

multifaceted approach that addresses the immediate needs of the patient while

preventing long term damage and salvaging the extremity. This approach typically

requires the involvement of a variety of providers, including but not limited to trauma

surgeons, orthopedic, vascular and plastic surgeons, and rehabilitation specialists. The

focus will be on salvaging the limb while repairing the initial damage.

In some instances, the damage will be too severe to salvage the extremity. When this

occurs, the patient will require an amputation of the extremity. In other instances, the

extremity will be amputated as part of the initial injury, and will require treatment and

repair to clean up the damaged area. While limb salvage is the primary goal, it must not

take precedence over the health and safety of the patient. If the injured limb poses a

risk to the patient’s survival, it must be amputated as soon as possible.

Extremity injuries are common in both military and civilian trauma situations and can be

caused by a number of different mechanisms. In military situations, most extremity

injuries are the result of penetrating trauma. They are often the result of explosive

devices and landmines. In civilian trauma, the majority of extremity injuries are caused

by blunt trauma. They are often the result of motor vehicle accidents and industrial

accidents. However, when penetrating injuries occur in the civilian population, they are

typically the result of gunshot wounds and stabbings.


59

Extremity trauma can range in severity and may be life threatening for the patient.

However, advances in modern medicine have improved both physicians’ abilities to

salvage limbs in cases of extreme trauma and patients’ potential to have a good quality

of life when amputation is a necessary resolution to injury. Unfortunately, without rapid

and appropriate intervention, extremity trauma has a high incidence of morbidity.

Nurses and all members of the health team play a vital role in the initial treatment and

ongoing management and support of patients with extremity trauma, a role that has a

significant impact on each patient’s recovery and rehabilitation.

References:

1. Kloen P, Helfet DL, Prasarn ML. Management of the mangled extremity. Strateg.

Trauma Limb Reconstr. 2012. p. 57–66.

2. Wolinsky PR, Webb LX, Harvey EJ, Tejwani NC. The mangled limb: salvage

versus amputation. Instr. Course Lect. 2011 Jan;60:27–34.

3. Akula M, Gella S, Shaw CJ, McShane P, Mohsen AM. A meta-analysis of

amputation versus limb salvage in mangled lower limb injuries—The patient

perspective. Injury. 2011;42(11):1194–7.

4. Jeffery SLA. Advanced wound therapies in the management of severe military

lower limb trauma: a new perspective. Eplasty. 2009 Jan;9:e28.

5. Manthey DE, Nicks BA. Penetrating Trauma to the Extremity. J. Emerg. Med.

2008;34(2):187–93.

6. Tu Y-K, On Tong G, Wu C-H, Sananpanich K, Kakinoki R. Soft-tissue injury in

orthopaedic trauma. Injury. 2008 Oct;39 Suppl 4:3–17.

7. Pape H-C, Sanders R, Borrelli, J, editors. The Poly-Traumatized Patient with

Fractures. Berlin, Heidelberg: Springer Berlin Heidelberg; 2011.

8. Stone WM, Fowl RJ, Money SR. Upper extremity trauma: current trends in

management. J. Cardiovasc. Surg. (Torino). 2007;48:551–5.

9. Wolf JM, Athwal GS, Shin AY, Dennison DG. Acute trauma to the upper

extremity: what to do and when to do it. Instr. Course Lect. 2010 Jan;59:525–38.


60

10. Harris & Harris’ Radiology of Emergency Medicine. Lippincott Williams & Wilkins;

2012. p. 1048.

11. Penetrating Trauma Wounds Challenge EMS Providers - Patient Care - @

JEMS.com [Internet]. Available from: http://www.jems.com/article/patient-

care/penetrating-trauma-wounds-challenge-ems

12. Tibbles CD, Newton EJ, Love J. Acute Complications of Extremity Trauma.

Emerg. Med. Clin. North Am. 2007;25(3):751–61.

13. Hildebrand F, Giannoudis P, Kretteck C, Pape H-C. Damage control: extremities.

Injury. 2004 Jul;35(7):678–89.

14. Philipp L, Reiner O, Marcel B, Rene W, Hans-Christoph P, Philipp K. A civilian

perspective on ballistic trauma and gunshot injuries. Scand. J. Trauma. Resusc.

Emerg. Med. 18.

15. Sadjadi J, Cureton EL, Dozier KC, Kwan RO, Victorino GP. Expedited Treatment

of Lower Extremity Gunshot Wounds. J. Am. Coll. Surg. 2009;209(6):740–5.

16. Brevard SB, Champion H KD. Weapons Effects [Internet]. Available from:

http://www.cs.amedd.army.mil/borden/book/ccc/UCLAchp2.pdf

17. Assessment of Extremity Injuries - EMSWorld.com [Internet]. Available from:

http://www.emsworld.com/article/10336473/assessment-of-extremity-injuries

18. Korompilias A V, Beris AE, Lykissas MG, Vekris MD, Kontogeorgakos VA,

Soucacos PN. The mangled extremity and attempt for limb salvage. J. Orthop.

Surg. Res. 2009 Jan;4(1):4.

19. Stone WM, Fowl RJ, Money SR. Upper extremity trauma: Current trends in

management. J. Cardiovasc. Surg. (Torino). 2007;48:551–5.

20. Sloan J. Soft tissue injuries: introduction and basic principles. Emerg Med J.

2008;25:33–7.

21. Grivas TB, Koufopoulos GE, Vasiliadis E, Polyzois VD. The management of lower

extremity soft tissue and tendon trauma. Clin. Podiatr. Med. Surg. 2006;23:257–

282, v.

22. Geeslin AG, LaPrade RF. Location of bone bruises and other osseous injuries

associated with acute grade III isolated and combined posterolateral knee injuries.

Am. J. Sports Med. 2010 Dec;38(12):2502–8.


61

23. Frank J, Daecke W, Marzi I. Reconstruction of Lower Extremity Fractures with

Soft Tissue Defects. Eur. J. Trauma Emerg. Surg. 2007. p. 24–32.

24. Soft Tissue Injuries [Internet]. Available from:

http://www.gov.mb.ca/health/ems/guidelines/docs/T1.05.06.pdf

25. Halvorson JJ, Anz A, Langfitt M, Deonanan JK, Scott A, Teasdall RD, et al.

Vascular injury associated with extremity trauma: initial diagnosis and

management. J. Am. Acad. Orthop. Surg. American Academy of Orthopaedic

Surgeons; 2011 Aug 1;19(8):495–504.

26. Dua A, Desai SS, Holcomb JB, Burgess AR, Freischlag JA, editors. Clinical

Review of Vascular Trauma. Berlin, Heidelberg: Springer Berlin Heidelberg; 2014.

27. Brown K V, Ramasamy A, Tai N, MacLeod J, Midwinter M, Clasper JC.

Complications of extremity vascular injuries in conflict. J. Trauma. 2009;66:S145–

S149.

28. Doody O, Given MF, Lyon SM. Extremities--indications and techniques for

treatment of extremity vascular injuries. Injury. 2008;39:1295–303.

29. Gosk J, Rutowski R. Penetrating injuries to the nerves of the lower extremity:

principles of diagnosis and treatment. Ortop. Traumatol. Rehabil. 2005;7:651–5.

30. Kerns JM. The microstructure of peripheral nerves. Tech. Reg. Anesth. Pain

Manag. 2008;12:127–33.

31. Taylor CA, Braza D, Rice JB, Dillingham T. The incidence of peripheral nerve

injury in extremity trauma. Am. J. Phys. Med. Rehabil. 2008;87:381–5.

32. Robinson LR. Traumatic injury to peripheral nerves. Muscle Nerve. 2000;23:863–

73.

33. Gosk J, Rutowski R, Rabczyński J. The lower extremity nerve injuries - own

experience in surgical treatment. Folia Neuropathol. 2005;43:148–52.

34. Ruch DS, Vallee J, Li Z, Smith BP, Holden M, Koman LA. The acute effect of

peripheral nerve transection on digital thermoregulatory function. J. Hand Surg.

Am. 2003 May;28(3):481–8.

35. Pathophysiology of Peripheral Nerve Injury: A Brief Review: Nerve Injury

Classification [Internet]. Available from:

http://www.medscape.com/viewarticle/480071_3


62

36. Management of Nerve Injuries: Grades of Nerve Injury [Internet]. Available from:


37. Pape H-C, Sanders RW, Borrelli J. The Poly-Traumatized Patient with Fractures:

A Multi-Disciplinary Approach. Springer; 2011.

38. What Is A Fracture? What Are Broken Bones? [Internet]. [cited 2013 Oct 1].

Available from: http://www.medicalnewstoday.com/articles/173312.php

39. Fractures (Broken Bones)-OrthoInfo - AAOS [Internet]. [cited 2013 Oct 1].

Available from: http://orthoinfo.aaos.org/topic.cfm?topic=a00139

40. Howe AS. The Spectrum of Polytrauma. A Pragmatic Approach for the Musculo-

Skeletal Surgeon [Internet]. [cited 2013 Oct 1]. Available from:

http://www.uptodate.com/contents/general-principles-of-fracture-management-

early-and-late-complications

41. Bittle MM, Gunn ML, Gross JA, Stern EJ. Trauma Radiology Companion:

Methods, Guidelines, and Imaging Fundamentals. Lippincott Williams & Wilkins;

2012. p. 432.

42. Nicholas B, Toth L, van Wessem K, Evans J, Enninghorst N, Balogh ZJ.

Borderline femur fracture patients: early total care or damage control

orthopaedics? ANZ J. Surg. 2011 Mar;81(3):148–53.

43. Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical

analysis. J. Bone Joint Surg. Am. 2006 Dec;88(12):2739–48.

44. Giannoudis P V, Giannoudi M, Stavlas P. Damage control orthopaedics: lessons

learned. Injury. 2009 Nov;40 Suppl 4:S47–52.

45. Joshi V, Harding GEJ, Bottoni DA, Lovell MB, Forbes TL. Determination of

functional outcome following upper extremity arterial trauma. Vasc. Endovascular

Surg. 2007 Jan 1;41(2):111–4.

46. Murdock M, Murdoch MM. Compartment syndrome: a review of the literature.

Clin. Podiatr. Med. Surg. 2012;29:301–10, viii.

47. Arcelus JI, Kudrna JC, Caprini JA. Venous thromboembolism following major

orthopedic surgery: what is the risk after discharge? Orthopedics. 2006

Jun;29(6):506–16.


63

48. Osteomyelitis [Internet]. Available from: http://my.clevelandclinic.org/orthopaedics-

rheumatology/diseases-conditions/hic-osteomyelitis.aspx

49. Complex Regional Pain Syndrome Fact Sheet: National Institute of Neurological

Disorders and Stroke (NINDS) [Internet]. Available from:

http://www.ninds.nih.gov/disorders/reflex_sympathetic_dystrophy/detail_reflex_sy

mpathetic_dystrophy.htm

50. Stein PD, Yaekoub AY, Matta F, Kleerekoper M. Fat embolism syndrome. Am. J.

Med. Sci. 2008;336:472–7.

51. Post-Traumatic Arthritis [Internet]. Available from:

http://my.clevelandclinic.org/disorders/arthritis/hic-post-traumatic-arthritis.aspx

52. Keel M, Trentz O. Pathophysiology of polytrauma. Injury. 2005 Jun;36(6):691–

709.

53. Hoffmeyer P, Peter R. The Spectrum of Polytrauma. A Pragmatic Approach for

the Musculo-Skeletal Surgeon. Bentley G, editor. Berlin, Heidelberg: Springer

Berlin Heidelberg; 2012.

54. Sanches JEA, Pereira de Godoy JM, Baitello AL, Chueire AG. Mortality

associated with extremity injuries compared with other types of trauma. Int. J.

Gen. Med. 2011;4:273–5.

55. Major Extremity Trauma [Internet]. Available from:

http://www.emergpa.net/wp/wp-content/uploads/Major-Extremity-Trauma-

Module.pdf

56. Newton EJ, Love J. Acute complications of extremity trauma. Emerg. Med. Clin.

North Am. 2007;25:751–761, iv.

57. Eltzschig HK, Eckle T. Ischemia and reperfusion--from mechanism to translation.

Nat. Med. Nature Publishing Group, a division of Macmillan Publishers Limited. All

Rights Reserved.; 2011 Jan;17(11):1391–401.

58. Lumsden AB, Davies MG, Peden EK. Medical and endovascular management of

critical limb ischemia. J. Endovasc. Ther. 2009 Apr 31;16(2 Suppl 2):II31–62.

59. Fernandez N, McEnaney R, Marone LK, Rhee RY, Leers S, Makaroun M, et al.

Predictors of failure and success of tibial interventions for critical limb ischemia. J.

Vasc. Surg. 2010;52(4):834–42.


64

60. Semenza GL. Vascular responses to hypoxia and ischemia. Arterioscler. Thromb.

Vasc. Biol. 2010 Apr 1;30(4):648–52.

61. Varu VN, Hogg ME, Kibbe MR. Critical limb ischemia. J. Vasc. Surg.

2010;51(1):230–41.

62. White CJ, Jaff MR, Dattilo PB, Casserly IP. Critical Limb Ischemia: Endovascular

Strategies for Limb Salvage. Prog. Cardiovasc. Dis. 2011;54(1):47–60.

63. Treatment of Infections in Penetrating Traumatic Injury: Infections of the

Extremities [Internet]. Available from:


64. Eardley WGP, Watts SA, Clasper JC. Extremity trauma, dressings, and wound

infection: should every acute limb wound have a silver lining? Int. J. Low. Extrem.

Wounds. 2012 Sep;11(3):201–12.

65. Rush RM, Arrington ED, Hsu JR. Management of complex extremity injuries:

tourniquets, compartment syndrome detection, fasciotomy, and amputation care.

Surg. Clin. North Am. 2012;92:987–1007, ix.

66. Crist BD, Ferguson T, Murtha YM, Lee MA. Surgical timing of treating injured

extremities: an evolving concept of urgency. Instr. Course Lect. 2013;62:17–28.

67. Castillo RC, MacKenzie EJ, Wegener ST, Bosse MJ. Prevalence of chronic pain

seven years following limb threatening lower extremity trauma. Pain.

2006;124(3):321–9.

68. MacKenzie EJ, Bosse MJ. Factors Influencing Outcome Following Limb-

Threatening Lower Limb Trauma: Lessons Learned From the Lower Extremity

Assessment Project (LEAP). J. Am. Acad. Orthop. Surg. 2006 Sep

1;14(10):S205–210.

69. X-rays of the Extremities | Johns Hopkins Medicine Health Library [Internet].

Available from:

http://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/x-

rays_of_the_extremities_92,P07646/

70. Arthrography [Internet]. Available from:

http://www.radiologyinfo.org/en/info.cfm?pg=arthrog

71. The Scientific Basis of Urology, Second Edition. Taylor & Francis; 2004. p. 684.


65

72. Marik PE, Varon J, Trask T. CT of head trauma. Neuroimaging Clin. N. Am.

2002;122:525–39.

73. Understanding Brain Injury Diagnostic Tests (CT/MRI/DTI/SPECT/EEG) [Internet].

[cited 2013 Oct 1]. Available from: http://www.braininjury.com/diagnostics.shtml

74. Gakhal MS, Sartip KA. CT angiography signs of lower extremity vascular trauma.

AJR. Am. J. Roentgenol. American Roentgen Ray Society; 2009 Jul

23;193(1):W49–57.

75. Gasiorowski KL. Trauma Radiology Companion: Methods, Guidelines, and

Imaging Fundamentals. AORN J. Elsevier; 2012;96(4):457.

76. Watkins D. A–Z of Musculoskeletal and Trauma Radiology. J. Trauma Inj. Infect.

Crit. Care. 2009. p. 960.

77. Shaftan GW. How interventional radiology changed the practice of a trauma

surgeon. Injury. 2008;39:1229–31.

78. Jones RG. Introduction to interventional radiology in trauma. Trauma. 2011. p.

145–53.

79. Gay D, Miles R. Use of imaging in trauma decision-making. J R Army Med Corps.

2011;157:S289–92.

80. Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA. Detecting vascular injury in

lower-extremity orthopedic trauma: the role of CT angiography. Orthopedics.

2008;31:761.

81. Percival TJ, Rasmussen TE. Reperfusion strategies in the management of

extremity vascular injury with ischaemia. Br. J. Surg. 2012 Jan;99 Suppl 1:66–74.

82. Wranze E, Greb I, Wulf H, Hartmann H, Kill C. Analgesia for extremity trauma by

rescue paramedics. Notfall + Rettungsmedizin. 2011. p. 135–42.

83. Cander B, Girisgin S, Koylu R, Gul M, Koçak S. The effectiveness of analgesics in

traumatic injuries of the extremities. Adv. Ther. 2005 Sep;22(5):462–6.

84. Abbuhl FB, Reed DB. Time to analgesia for patients with painful extremity injuries

transported to the emergency department by ambulance. Prehosp. Emerg. Care.

7(4):445–7.

85. Lane JC, Mabvuure NT, Hindocha S, Khan W. Current concepts of prophylactic

antibiotics in trauma: a review. Open Orthop. J. 2012 Jan;6:511–7.


66

86. Barton C, Osler T, Crookes B, Bartlett C, McMillian W. Compliance with the

Eastern Association for the Surgery of Trauma guidelines for prophylactic

antibiotics after open extremity fracture. Int. J. Crit. Illn. Inj. Sci. 2012. p. 57.

87. Shanmuganathan R. The utility of scores in the decision to salvage or amputation

in severely injured limbs. Indian J. Orthop. 2008 Oct;42(4):368–76.

88. MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening

lower limb trauma: lessons learned from the Lower Extremity Assessment Project

(LEAP). J. Am. Acad. Orthop. Surg. 2006;14:S205–S210.

89. Sánchez Perales MC, García Cortés MJ, Borrego Utiel FJ, Viedma G, Gil JM,

Pérez del Barrio P, et al. [Incidence and risk factors for non-traumatic lower

extremity amputation in hemodialysis patients]. Nefrologia. 2005 Jan;25(4):399–

406.

90. Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M. Complex limb

salvage or early amputation for severe lower-limb injury: a meta-analysis of

observational studies. J. Orthop. Trauma. 2007 Jan;21(1):70–6.

91. Mills JL, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, et al.

The Society for Vascular Surgery Lower Extremity Threatened Limb Classification

System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI). J.

Vasc. Surg. 2013;

92. Conroy C, Schwartz A, Hoyt DB, Brent Eastman A, Pacyna S, Holbrook TL, et al.

Upper extremity fracture patterns following motor vehicle crashes differ for drivers

and passengers. Injury. 2007;38:350–7.

93. Russell WL, Sailors DM, Whittle TB, Fisher DF, Burns RP. Limb salvage versus

traumatic amputation. A decision based on a seven-part predictive index. Ann.

Surg. 1991 May;213(5):473–80; discussion 480–1.

94. Fodor L, Sobec R, Sita-Alb L, Fodor M, Ciuce C. Mangled lower extremity: can we

trust the amputation scores? Int. J. Burns Trauma. 2012 Jan;2(1):51–8.

95. Limb Loss Awareness|Features|NCBDDD|CDC.

96. Pasquina PF, Bryant PR, Huang ME, Roberts TL, Nelson VS, Flood KM.

Advances in amputee care. Arch. Phys. Med. Rehabil. 2006 Mar;87(3 Suppl

1):S34–43; quiz S44–5.


67

97. Reiber GE, McFarland L V, Hubbard S, Maynard C, Blough DK, Gambel JM, et al.

Servicemembers and veterans with major traumatic limb loss from Vietnam war

and OIF/OEF conflicts: survey methods, participants, and summary findings. J.

Rehabil. Res. Dev. 2010 Jan;47(4):275–97.

98. Dougherty PJ, McFarland L V, Smith DG, Esquenazi A, Blake DJ, Reiber GE.

Multiple traumatic limb loss: a comparison of Vietnam veterans to OIF/OEF

servicemembers. J. Rehabil. Res. Dev. 2010 Jan;47(4):333–48.

99. Paradigm shift for VA amputation care [Internet]. Available from:

http://www.rehab.research.va.gov/jour/10/474/sigford.html

100. Devlin M, Pauley T, Head K, Garfinkel S. Houghton Scale of prosthetic use in

people with lower-extremity amputations: Reliability, validity, and responsiveness

to change. Arch. Phys. Med. Rehabil. 2004 Aug;85(8):1339–44.

101. Predictive Salvage Index (PSI) [Internet]. Available from:

http://www.mymedal.org/index.php?n=Military.293703

102. Mangled Extremity Severity Score (MESS) [Internet]. Available from:


103. Limb Salvage Index (LSI) [Internet]. Available from:


104. NISSSA Score of McNamara et al for Open Fracture of the Lower Extremity

[Internet]. Available from: http://www.mymedal.org/index.php?n=Military.293705

105. Hannover Fracture Scale ’98 (HFS '98) [Internet]. Available from:


106. Brown K V, Ramasamy A, McLeod J, Stapley S, Clasper JC. Predicting the need

for early amputation in ballistic mangled extremity injuries. J. Trauma. 2009

Apr;66(4 Suppl):S93–7; discussion S97–8.

107. Papakostidis C, Kanakaris NK, Pretel J, Faour O, Morell DJ, Giannoudis P V.

Prevalence of complications of open tibial shaft fractures stratified as per the

Gustilo–Anderson classification. Injury. 2011;42(12):1408–15.

108. Rajasekaran S, Naresh Babu J, Dheenadhayalan J, Shetty AP, Sundararajan SR,

Kumar M, et al. A score for predicting salvage and outcome in Gustilo type-IIIA


68

and type-IIIB open tibial fractures. J. Bone Joint Surg. Br. 2006 Oct

1;88(10):1351–60.

109. Ly T V, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ. Ability of lower-

extremity injury severity scores to predict functional outcome after limb salvage. J.

Bone Joint Surg. Am. 2008;90:1738–43.

110. Tintle SM, Baechler MF, Nanos GP, Forsberg JA, Potter BK. Traumatic and

trauma-related amputations: Part II: Upper extremity and future directions. J.

Bone Joint Surg. Am. 2010;92:2934–45.

The information presented in this course is intended solely for the use of healthcare professionals taking

this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in addressing issues

associated with healthcare.

The information provided in this course is general in nature, and is not designed to address any specific

situation. This publication in no way absolves facilities of their responsibility for the appropriate

orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own orientation processes

should review the contents of this publication to ensure accuracy and compliance before using this

publication.

Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold

NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from

liability resulting from the use of this publication.

The contents of this publication may not be reproduced without written permission from

NurseCe4Less.com.

Trauma Series - NurseCe4Less.com · 2016. 11. 15. · 1. Differentiate between simple and complex extremity trauma. 2. Describe the symptoms of osseous extremity trauma. 3. Identify

Documents