emergency treatment of extremity trauma

1. TREATMENT OF EXTREMITY
TRAUMA AND
COMPARTMENT SYNDROME
IN ER
DR. PRATIK AGARWAL

2. CASE SCENARIO
 25YRS/MALE
 A/H/O RTA DUE TO DASH BY 4
WHEELER WHEN HE WAS
DRIVING 2 WHEELER 2 HRS
BACK.
 C/O PAIN IN LEFT LEG, RIGHT
SHOULDER AND BLEEDING
FROM RIGHT FOOT SICNE
THEN.
 NO H/O ANY OTHER INJURY
 NO H/O LOC, VOMITING,
CONVUSION, ENT BLEED,
EVENT OF AMNESIA.
 NO H/O ANY MEDICAL
COMORBIDITIES

3. TYPES OF INJURIES TO EXTREMITY
ENCOUNTERED IN EMERGENCY ROOM-
FRACTURES
DISLOCATIONS
OPEN WOUNDS
AMPUTATIONS
SPRAINS AND STRAINS
IMPALED OBJECTS
CRUSH INJURY AND CRUSH SYNDROME
COMPARTMENT SYNDROME

4. ASSESSMENT AND MANAGEMENT
• HISTORY-
MECHANISM OF INJURY- VERY IMPORTANT, CAN GIVE IDEA ABOUT TYPE OF INJURY
AND SEVERITY OF INJURY.
FALL ON OUT STRETCHED HAND CAN LEAD TO
CLAVICULAR FRACTURE
SUPRACONDYLAR FRACTURE
RADIUS AND ULNA SHAFT FRACTURE
DISTAL END RADIUS AND ULNA FRACTURE
SCAPHOID FRACTURE
WRIST SPRAIN
POSTERIOR SHOULDER DISLOCATION

5. FALL FROM HEIGHT
CALCANEUM FRACTURE
ANKLE SPRAIN
FEMUR FRACTURE, PELVIS FRACTURE
VERTEBRAE FRACTURE
ABDOMINAL OR THORACIC ORGAN INJURY,
RIB FRACTURE

6. OTHER MODE OF INJURY
DASH BOARD INJURY
• POSTERIOR
DISLOCATION OF HIP
• NECK OF FEMUR
FRACTURE
• IT FEMUR FRACTURE

7. CAN LEAD TO OPEN WOUNDS, FRACTURES,
AMPUTATIONS
INJURY BY SHARP OBJECT INJURY BY BLUNT OBJECT

8. • ASSESSMENT-
I. IDENTIFY IMMEDIATE LIFE THREAT (AIRWAY, BREATHING & CIRCULATION)
II. LOOK FOR ANY OBVIOUS FRACTURE (CREPITATION IS DEFINITIVE SIGN OF
FRACTURE)
III. ANY EXTERNAL BLEEDING
IV. ANY EXTERNAL WOUND- ABRASION, BRUISE, PENETRATION, LACERATION,
AVULSION
V. ANY OBVIOUS SWELLING
VI. TENDERNESS
VII. DEFORMITY
VIII. RANGE OF MOVEMENT OF ALL JOINTS
IX. MOTOR AND SENSORY FUNCTION
X. DISTAL PULSES

9. MANAGEMENT-
• 1ST THING WE WILL MANAGE IS AIRWAY, BREATHING AND
CIRCULATION (ABC).
• IF WE SUSPECT ANY HEMORRHAGE AND IF PATIENT IS
HEMODYNAMICALLY UNSTABLE WE WILL MANAGE FIRST CIRCULATION,
THEN AIRWAY AND FINALLY BREATHING (CAB).
• THEN OUR AIM WILL BE TO IMMOBILIZE INJURED PART BY USING
SPLINT, PADDING, ETC. THIS WILL DECREASE PAIN, DISABILITY AND
SERIOUS COMPLICATION.
• PAIN CONTROL WITH ANALGESIC.
• FINALLY WE MANAGE THE UNDERLYING INJURY

10. FRACTURE
• HISTORY- MECHANISM OF INJURY
• ASSESSMENT- ABC  EXAMINATION  DRESSING AND IMMOBILIZE  X-RAY
• X-RAY- FOR EVERY PART OF THE BODY WE DO X-RAY AP & LAT VIEW EXCEPT-
 HAND- AP/ OBLIQUE VIEW
 FOOT- AP/ OBLIQUE VIEW
 SHOULDER- AP/ AXIAL/ SCAPULAR Y VIEW
 PATELLA- AP/ LAT/ SKYLINE VIEW
• MANAGEMENT- STABALIZATION OF FRACTURE SEGMENT
 IMMOBILIZATION MUST BE DONE FOR ONE JOINT ABOVE AND BELOW THE FRACTURE
FRAGMENT.
 ALWAYS CHECK FOR DISTAL PULSE, MOTOR FUNCTION AND SENSORY SENSATION
BEFORE AFTER APPLYING SPLINT.
 ANY OPEN FRACTURE MUST NOT BE SUTURED IN EMERGENCY ROOM.

11. STAGES OF HAEMORRHAGIC
SHOCK

12. DISLOCATIONS
 DISTORTION OF NORMAL JOINT ANATOMY.
 EXTREMELY PAINFUL.
 MOST COMMON DISLOCATION SEEN IS
SHOULDER DISLOCATION.
 RARE DISLOCATION IS ANKLE DISLOCATION.
 CAN CAUSE NEUROVASCULAR
COMPROMISE, SO WE MUST ALWAYS ASSESS
FOR PULSES, MOTOR FUNCTION AND
SENSATION.
 DISLOCATION MAY OR MAY NOT BE
ASSOCIATED WITH FRACTURE.

13. SHOULDER
DISLOCATION
• TYPES-
 ANTERIOR DISLOCATION (96%)
 POSTERIOR DISLOCATION (4%)
• XRAY- OF SHOULDER AP/
AXIAL/ SCAPULAR Y VIEW.
• CAUSES-
 ROTATOR CUFF TEAR
 STRETCHING OR TEARING OF
CAPSULE
 BANKART LESION
 HILL SACHS LESION
CORACOID PROCESS
ACROMIAN
PROCESS
LATERAL BORDER OF SCAPULA

14. CLINICAL PICTURE OF SHOULDER
DISLOCATIONANTERIOR SHOULDER
DISLOCATION
POSTERIOR SHOULDER
DISLOCATION
UPPER LIMB IN EXTENTION
AND EXTERNAL ROTATION
UPPER LIMB IN EXTENSION
AND INTERNAL ROTATION

15. MANAGEMENT OF SHOULDER DISLOCATION
• ASSESS ABC
• SWELLING
• TENDERNESS
• RANGE OF MOVEMENT
• NEUROVASCULAR COMPLICATION- AXILLARY NERVE COMMONLY INJURED IN
ANTERIOR DISLOCATION
• BONY DEFORMITY AND CREPTS
• XRAY
• RELOCATION OF SHOULDER JOINT
• SHOULDER IMMOBILISER

16. RELOCATION OF
SHOULDER JOINT
• PREPARATION-
 INJ MYORIL 8MG IM STAT
 INJ DYNAPAR 2ML IM STAT
 INJ PAN 40 MG IV STAT
 INJ EMSET 4 MG IV STAT
• MODIFIED HIPPOCRATIC
TECHNIQUE-TRACTION –
COUNTERTRACTION WITH
EXTERNAL ROTATION .
• POST RELOCATION, XRAY TO
CONFIRM RELOCATION AND NO
FRACTURE AT TIME OF
RELOCATION.
• SHOULDER IMMOBILISER

17. ELBOW
DISLOCATION
• INCIDENCE-6-8 CASES/
1LAKHS POPULATION/ YEAR.
• PURE DISLOCATION IS PURELY
LIAGMENTOUS.
• GENERALLY ASSOCIATED
FRACTURES, BRACHIAL ARTERY
INJURY & DISRUPTION OF
MEDIAL COLLATERAL
LIGAMENT.
• XRAY OF ELBOW AP/LAT
• IMMOBILIZE THE ELBOW JOINT
BY USING ARM POUCH SLING.
• REFER TO ORTHOPAEDICS

18. HIP DISLOCATION
• TYPES-
 POSTERIOR (MC)
 ANTERIOR
 CENTRAL (RARE)
• MECHANISM OF INJURY-
 HIGH ENERGY TRAUMA
 MOTOR VEHICLE ACCIDENT
 FALL FROM HEIGHT
• 50% PATIENT SUSTAIN
CONCOMITANT FRACTURES.
• SCAITIC NERVE INJURY OCCURS
IN 10-20 % OF POSTERIOR
DISLOCATIONS

19. CLINICAL PICTURE
FLEXION, INTERNAL
ROTATION & ADDUCTION
FLEXION, EXTERNAL
ROTATION & ABDUCTION
POSTERIOR DISLOCATION ANTERIOR DISLOCATION

20. X-RAY PHB AP VIEW
POSTERIOR DISLOCATION ANTERIOR DISLOCATION

21. KNEE
DISLOCATION
• RARE TYPE OF
DISLOCATION BUT MAY BE
LIFE THREATENING AND
SHOULD BE TREATED AS
ORTHOPAEDIC EMERGENCY.
• X-RAY AP & LAT VIEW.
• BECAUSE OF HIGH
INCIDENCE OF
NEUROVASCULAR
COMPROMISE IMMEDIATE
REDUCTION IS
RECOMMENDED BEFORE
RADIOGRAPHIC
EVALUATION.

22. PATELLA
DISLOCATION
• MORE COMMON IN
WOMEN.
• TYPES-
 LATERAL DISLOCATION
(MC)
 MEDIAL DISLOCATION
 INTRAARTICULAR
DISLOCATION
 SUPERIOR DISLOCATION
• CLINICALLY-
 INABILITY TO FLEX KNEE
 DISPLACED PATELLA ON
PALPATION

23. • Q ANGLE-
INCREASED Q
ANGLE
PREDISPOSES TO
PATELLA
DISLOCATION.
• X-RAYS OF KNEE AP
& LATERAL VIEW.
• XRAY OF BOTH
PATELLA SKYLINE
VIEW.

25. OPEN WOUND
 INJURY INVOLVING EXTERNAL OR INTERNAL
BREAK IN BODY TISSUE, USUALLY INVOLVING
SKIN.
 CAUSED BY SHARP OBJECT, BLUNT OBJECT, FALL
ON ANY OBJECT.
 TYPES-
a) INCISION
b) LACERATION
c) ABRASION
d) PUNTURE
e) PENETRATING
f) AVULSION

26. IMPORTANT THING TO REMEMBER IN OPEN WOUND
• ASSESS AIRWAY BREATHING AND CIRCULATION OF THE PATIENT.
• ASSESS FOR ANY UNDERLYING INJURY-
i. ANY MAJOR VESSEL CUT,
ii. NERVE INJURY,
iii. MUSCLE OR ANY TENDON CUT
• CONTAMINATION- THOROUGH IRRIGATION IS TO BE DONE USING
ASEPTIC SOLUTION AND NORMAL SALINE.
• ASSOCIATED WITH FRACTURE OR NOT, SO X-RAY TO BE DONE.
• IF FRACTURE NOT PRESENT- THOROUGH IRRIGATION AND THEN SUTURE
THE WOUND
• IF FRACTURE PRESENT-SUTURING NOT TO BE DONE, ONLY DRESSING TO
BE DONE AFTER IRRIGATION AND IMMOBILIZE THE FRACTURE FRAGMENT
.

27. STEPS OF IRRIGATION-
AFTER EXPOSING THE WOUND, CLEAN WITH
NORMAL SALINE
CLEAN THE WOUND WITH BETADINE SOLUTION
POUR WOUND HYDROGEN PEROXIDE
LASTLY POUR NORMAL SALINE TO WASH OUT
ALL CONTAMINATION & FOREIGN BODY

28. HOW TO DO SUTURING-
AFTER
PROPER
HAND WASH
WEAR STERILE
GLOVES
PAINTING
•USING BETADINE
SOLUTION
DPRAING
•USING STERILE
DRAPE
INFILTRATE
LOCAL
ANAESTHETIC
•2% LIGNOCAINE
SUTURE THE
WOUND
•ETHILON 3-0 IN
UPPER LIMB
•ETHILON 2-0 IN
LOWER LIMB
SEPTIC
DRESSING
DONE

29. AMPUTATIONS
 OPEN INJURY CAUSED BY CUTTING OR
TEARING AWAY OF LIMB, BODY PART OR
ORGAN.
 TYPES- PARTIAL OR COMPLETE.
 BLEEDING IS MOST IMP COMPLICATION.
 AMPUTATED PART MUST NOT BE
NEGLECTED. IT MUST BE RINSED OFF,
WRAPPED IN NORMAL SALINE SOAKED
STERILE GAUZE AND PLACED IN PLASTIC
BAG. NEVER IMMERSE IN WATER OR
SALINE OR USE ICE DIRECTLY
 PATIENT SHOULD BE DIRECTLY
TRANSPORTED TO FACILITY THAT HAS
ABILITY TO PERFORM REPLANTATION

30. Normal Saline
Soaked Gauze
Piece
TRANSPORTATION OF AMPUTATED PART

31. SPRAINS AND STRAINS
• SPRAINS- STRETCHING OR TEARING OF LIGAMENTS OF A JOINT,
DUE TO TWISTING OF JOINT. CANNOT BE DIFFERENTIATED
FRACTURE.
• STRAINS- STRETCHING OR TEARING OF MUSCLE OR
MUSCULOTENDINOUS UNIT. CAN BE DIFFERENTIATED FROM
FRACTURE.
• IT CAUSES PAIN AND SWELLING.
• IN BOTH CASE SPLINTING SHOULD BE DONE
• ICE APPLICATION FOR SWELLING

32. IMPALED OBJECT

33. IMPALED OBJECT
• INJURY IN WHICH AN OBJECT IS EMBEDDED IN BODY
TISSUE.
• SECURE THE OBJECT IN PLACE.
• REMOVING OBJECT CAN CAUSE SEVERE HEMORRHAGE.
• SO BULKY PADDING TO BE DONE TO KEEP THE OBJECT IN
PLACE AND THEN TRANSPORT.

34. CRUSH INJURY & CRUSH SYNDROME
CRUSH INJURY TO EXTREMETIES
COMPROMISE CIRCULATION, DECREASES PERFUSION
ANAEROBIC METABOLISM LEADS TO LACTIC ACIDOSIS,
CELL DAMAGE LEAKING POTASSIUM AND MYOGLOBIN
WHEN CIRCULATION IS RESTORED
TOXIC PRODUCTS CARRIED TO WHOLE BODY AND ORGAN
SYSTEM
CRUSH
SYNDROME

35. CRUSH SYNDROME
 DECREASED HEART PUMPING ACTIVITY.
 LACTIC ACID, HYPERKALEMIA, AND MYOGLOBIN
FILTERED THROUGH KIDNEY LEADING TO ACUTE
RENAL FAILURE.
 EXTREMETIES CAN TOLERATE UP TO 4HRS OF
ISCHEMIA BEFORE CELL DEATH OCCUR.
 MANAGEMENT-
i. PRIMARY SURVEY
ii. FLUID RESUSCITATION TO MAINTAIN URINE
OUTPUT AT 0.5 TO 1 ML/KG BODY WEIGHT PER
HOUR.
iii. ALKALINIZATION OF URINE BY IV SODIUM
BICARBONATE TO INCREASE EXCRETION OF
MYOGLOBIN.

37. COMPARTMENT SYNDROME
CONDITION IN WHICH INCREASED TISSUE PRESSURE IN MUSCLE COMPARTMENT
RESULT IN DECREASED BLOOD FLOW, LEADING TO TISSUE HYPOXIA AND POSSIBLE
MUSCLE, NERVE AND VESSEL IMPAIRMENT, AND WHICH CAN BE PERMANENT IF
THE CELL DIE.

38. PATHOPHYSIOLOGY OF COMPARTMENT SYNDROME
MUSCLE
ISCHEMIA
•NORMAL PRESSURE- 0-5 MM OF HG
•TRAUMA
VENOUS
OBSTRUCTION
•INCREASED CAPILLARY PERMEABILITY
•OEDEMA
ARTERIAL
OCCLUSION
•INTRAMUSCULAR PRESSURE >30 MM OF HG
•VENOUS, LYMPHATIC &ARTERIAL
COMPRESSION
CELL DEATH
• TOLERANCE OF TISSUE TO ISCHEMIA VARIES
TO TYPE OF TISSUE

39. CAUSES OF
COMPARTMENT
SYNDROME
1) FRACTURE
2) BLUNT TRAUMA
3) VASCULAR OCCLUSION
4) CAST OR DRESSING
5) CLOSURE OF FASCIAL
DEFECTS
6) BURN/ ELECTRICAL
7) ARTERIAL INJURY
8) SNAKE BITE ETC

40. DIAGNOSIS OF COMPARTMENT SYNDROME
• HISTORY
• FIVE P’S
• COMPARTMENT PRESSURE
• LABORATORY TEST- CPK, URINE
MYOGLOBIN
• PULSE OXIMETRY- IDENTIFY
HYPOPERFUSION, BUT NOT SENSITIVE
ENOUGH TO RULE OUT COMPARTMENT
SYNDROME.
FIVE P’S
EARLY SYMPTOMS
1. PAIN OUT OF PROPORTION
2. PARESTHESIA (TINGLING & NUMBNESS)
LATE SYMPTOMS
1) PALLOR
2) PULSELESSNESS
3) PARALYSIS
PAIN AND AGGRAVATION OF PAIN ON PASSIVE STRETCHING OF
MUSCLE IS MOST SENSITIVE CLINICAL FINDING OF
COMPARTMENT SYNDROME.

41. PRESSURE MONITORING TECHNIQUES
• WHITESIDES TECHNIQUE- INJECT SALINE INTO COMPARTMENT MAY AGGRAVATE
IMPENDING SYNDROME.
• SLIT CATHETER- REQUIRE POLYETHYLENE TUBING FILLED WITH AIR WITH NO AIR
BUBBLE, CONNECTED TO PRESSURE TRANSDUCER. MORE ACCURATE AND
CONTINOUSLY MONITOR HOWEVER END OF THE TUBING CAN BE BLOCKED BY
BLOOD CLOT.
• STRYKER SOLID STATE TRANSDUCER INTRACOMPARTMENTAL CATHETER (STIC)-
CAN MONITOR UPTO 16 HRS.
• NEAR INFRARED SPECTROSCOPY (NIRS)- ALLOWS TRACKING OF VARIATION IN
OXYGENATION OF MUSCLE TISSUE.
• LASER DOPPLER FLOWMETRY (LDF)- NON-INVASIVE, ESTIMATE BLOOD
PERFUSION IN MICROCIRCULATION

42. MANAGEMENT OF COMPARTMENT
WHEN PRESSURE 10-30 MM OF HG- IMPENDING ISCHEMIA-
REMOVE CAST OR PADDING CAUSING SYMPTOM
ICE APPLICATION
LIMB ELEVATION AT THE LEVEL OF HEART
TRACTION
OXYGEN SUPPLEMENTATION
WHEN PRESSURE >30 MM OF HG- ISCHEMIA
SURGICAL INTERVENTION REQUIRED- FASCIOTOMY

43. RECENT ADVANCES
POP SLAB DISPENSER-
• 6 LAYER OF POP IS BEING DISPENSED AT A TIME.
 FOR UPPER LIMB DOUBLE IT.
 FOR LOWER LIMB TRIPLE IT.
• LESS TIME CONSUMING
• HELP TO KEEP EMERGENCY ROOM CLEAN

44. DYNACAST PRELUDE-
• VERSATILE SPLINTING SYSTEM FOR
INDIVIDUAL PATIENT APPLICATION
• CLEAN MODERN ALTERNATIVE TO
PLASTER OF PARIS SLABBING
• STRONG AND LIGHT WITH NO PLASTER
MESS
• ALL-IN-ONE ROLL IS EASY AND QUICK

45. GYPSONA SPLINT DISPENSER

46. PREFORMED SPLINT

47. THANK YOU