dr.

Otman Siregar, SpOT, (K)Spine

Ilmu Bedah Orthopaedi FK-USU/RSUP HAM
2010
Limb Threatening Injuries
Can be caused by:
MVA ( Motor Vehicle
Accident )
Occupational accident
Domestic accident

Open injury
Closed injury
Limb Threatening Injuries
Is an emergency
situation
Need accurate diagnosis
and prompt treatment
Limb Threatening Injuries
Fracture
- Open fracture
- Closed Fracture
Vascular Injury
Compartment syndrome
Fracture
Definition:
structural break in
continuity weather of a
bone, an epiphyseal
plate, or a cartilaginous
joint surface

Fracture also mean soft

tissue injury
Fracture
The causative force that produces a fracture may be :
- Direct injury
- Indirect injury
Fracture Diagnosis
Patient History, ask about Mechanism of injury:
Pain - Fall
Deformity - Direct blow
Time of injury - Road accident
- Gun Shot Wound
- Often lack of detail
Fracture Diagnosis
Always do Primary Survey (ABC)
General condition
Local Condition:
- Look
- Feel
- Move
Principle: DO NO FURTHER HARM!
Fracture Diagnosis
Look:
Local swelling
Deformity ( angulations,
rotation, discrepancy)
Discoloration of the skin
Open wound (size,
margin, depth,
contamination)
Fracture Diagnosis
Feel
Sharply localized tenderness
Aggravation of pain and muscle spasm
Crepitation not necessary
Neurovascular Condition is important
Always look and feel for other less apparent injuries
Fracture Diagnosis
Move
Not necessary if the deformity is obvious
Abnormal movement
Usually ROM limited due to pain
Fracture Diagnosis
Special Test and measurement
Allen test: vascular patency in forearm
True, apparent, and anatomical length
Drawer test ( is better to do it under anesthesia)
Diagnostic Imaging
Immobilized the limb before being
subjected to imaging examination
Plain X ray
CT Scan
MRI
angiography
Diagnostic Imaging
X ray : Rules of two
2 joint
2 projection
2 extremities
(paediatric)
2 densities (able to differ
hard and soft tissue)
Special projection may be
necessary
Diagnostic Imaging
CT Scan and MRI can
provide useful additional
data especially for pelvis
and spinal injury
Angiography is
performed if vascular
injury is suspected
Doppler duplex
sonogram
Descriptive Term Pertaining to
Fractures
Site
-diaphyseal, metaphyseal, epiphyseal or intraarticular
Extent
- Complete or incomplete
Configuration
-transverse, oblique or spiral
-comminuted or segmental
Relationship of the fracture fragments to each other
-translated,angulated,rotated,distracted,overriding,
impacted
Descriptive Term Pertaining to
Fractures
Relationship of the
fracture to the external
environment
-open or closed
Complications
-uncomplicated or
complicated
Complications of Musculoskeletal
Injuries
Classified as :
Initial (immediate) complications
- Local and Remote
Early
-Local and remote
Late complications
-Local and remote
Complications of Musculoskeletal
Injuries
Initial Complication:
Local complication
-Skin injuries (from within or without)
-vascular injuries (artery or vein, division, contusion or
spasm)
-neurological injuries (brain, spinal cord, peripheral nerve)
-muscular
-visceral
Remote complication
-multiple injuries and hemorrhagic shock
Complications of Musculoskeletal
Injuries
Early Complication
Local complication
-Skin necrosis, gangrene,
compartment syndrome,
etc
-Joint complication (septic
arthritis)
-Bony complications
(Osteomyelitis or
avascular necrosis)
Complications of Musculoskeletal
Injuries
Early
Remote Complications
-Fat embolism
-Pulmonary embolism
-Pneumonia
-Tetanus
-Delirium Tremens
Complications of Musculoskeletal
Injuries
Late Complications
Local Complication
-Joint: stiffness, degenerative arthritis
-Bony: abnormal fr healing, growth disturbance,
chronic osteomyelitis
-Muscular :myositis ossificans, late rupture tendon
-Neurological : Tardy nerve plasy
Complications of Musculoskeletal
Injuries
Late
Remote complications
- Renal calculi
- Accident neurosis
 An open
fracture
indicates …

… a communications
between the fracture
and the external
environment …
Open Fractures

Classification

• Gustillo / Anderson 1976

• Oestern & Tscherne 1984

AO Courses Jakarta 2008

Open Fx.

Gustillo / Anderson

• Gustillo I
• skin lesion < 1cm
• skin perforation inside out
• minimal muscle contusion
• simple fracture pattern

• Gustillo II
• skin lesion > 1cm
• limited soft tissue damage
• no degloving
• simple fracture pattern
Gustillo RB (1984) J Trauma;24:742-6
Open Fx.

Gustillo / Anderson

• Gustillo III A
• Extensive soft tissue damage (skin, muscles,
neurovascular strucures) with still sufficient
bone coverage (periosteum)

• Gustillo III B
• Extensive soft tissue damage with periosteal
detachment and exposed bone
• Massive contomination of the wound

• Gustillo III C
• Vascular injury to be reconstructed
AO Courses Jakarta 2008
AO Courses Jakarta 2008
AO Courses Jakarta 2008
management
of open fx. Erfurt algorithm

• remove wound dressing only in OR

• foto documentation
• debridement
• fracture fixation (FixEx)
• leave the wound open or
• temporary wound coverage by
 skin substitute or
 vacuum therapy
Mechanisms of Vascular Injury in
the Extremities
Gunshot wound – 54%
Stab wound – 15%
Shotgun wound – 12%
Blunt trauma – 15%
Iatrogenic – 3%
Presentation of Vascular Injury
First priority is
hemorrhage
control followed by
appropriate
diagnostic work-up
Presentation of Vascular Injury
Dislocations and
displaced or
angulated fractures:
realigned
immediately if
vascularity is
compromised
Evaluation for Vascular Injury
Physical Examination
Doppler Flowmeter
Duplex Ultrasonography
Arteriogram
Local wound exploration should not be
done in an uncontrolled setting
Close coordination with a general or
vascular surgeon recommended
Physical Examination
Hard Signs
Absent or diminished distal pulses
Active hemorrhage
Large, expanding or pulsatile hematoma
Bruit or thrill
Distal ischemia (pain, pallor, paralysis,
paresthesias, coolness)
Physical Examination
Soft Signs

Small, stable hematoma

Injury to anatomically related nerve
Unexplained hypotension
History of hemorrhage no longer present
Proximity of injury to major vessel
Doppler Examination
Non-invasive adjunct to physical examination
Small, hand-held (non-directional) Doppler
flowmeter provides for subjective interpretation of
audible signal
Useful as modality for determining the Ankle-
Brachial Index (ABI)
Arteriography
Gold standard for evaluation of peripheral
vascular injuries
Formal arteriograms done in radiology may cause
critical delays in diagnosis or intervention
Single-shot arteriograms done in the emergency
room or operating room should be considered in
cases where arteriography is indicated.
Indications for Arteriography :
Multiple potential sites of injury (shotgun wounds)
Missile track parallels vessel over long distance
Blunt trauma with signs of vascular trauma
Chronic vascular disease
Extensive bone or soft tissue injury
Thoracic outlet wounds
Evaluation of equivocal results from non-invasive
tests
Proximity (gsw, knife wound) (controversial)
ABI < .9
Compartment Syndrome
Definition
Elevated tissue pressure within a closed
fascial space
Reduces tissue perfusion
Results in cell death
Pathogenesis
Too much inflow (edema, hemorrhage)

Decreased outflow (venous obstruction, tight

dressing/cast)
Compartment Syndrome
Historical Review

Late complications of ischemic contracture

Volkmann, 1881
 Ischemia of forearm

venous stasis leading

to irreversible contracture
Ellis, 1958; Seddon, 1966
 Lower extremity

Retrospective reviews
Advised the early recognition of the syndrome and
fasciotomies of the affected limbs
Compartment Syndrome
Tissue Survival

Muscle
 3-4 hours - reversible changes
6 hours - variable damage
8 hours - irreversible changes
Nerve
2 hours - looses nerve conduction
4 hours - neuropraxia
8 hours - irreversible changes
Compartment Syndrome
Etiology

Fractures-closed and open Exertional states

Blunt trauma GSW
Temp vascular IV/A-lines
occlusion Hemophiliac/coag
Cast/dressing Intraosseous IV(infant)
Closure of fascial Snake bite
defects Arterial injury
Burns/electrical
Compartment Syndrome
Diagnosis
Pain out of proportion
Palpably tense compartment
Pain with passive stretch
Paresthesia/hypoesthesia
Paralysis
Pulselessness/pallor
Compartment Syndrome
Differential diagnosis

Arterial occlusion

Peripheral nerve injury

Muscle rupture
Compartment Syndrome
Emergent Treatment
Remove cast or dressing
Place at level of heart
(DO NOT ELEVATE to optimize
perfusion)
Alert OR and Anesthesia
Bedside procedure
Medical treatment
 Compartment Syndrome
Surgical Treatment
Fasciotomy - prophylactic release of
pressure before permanent damage
occurs. Will not reverse injury from
trauma.
Fracture care – rigid
stabilization
Ex-fix
IM Nail