The document discusses the assessment and management of extremity trauma and compartment syndrome in the emergency room. It describes a case of a 25-year-old male who was in a motorcycle accident and presented with pain in his left leg, right shoulder, and bleeding from his right foot. The document then outlines various types of extremity injuries commonly seen in the ER, including fractures, dislocations, open wounds, and compartment syndrome. It provides guidance on history taking, clinical examination, imaging, and immobilization techniques for different types of fractures, emphasizing the importance of managing ABCs first if life-threatening injuries are present.

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

11. FRACTURES

12. TYPES OF FRACTURE
1) OPEN FRACTURE- FRACTURE IN
WHICH PIECE OF BROKEN BONE
PROTRUDING THROUGH OVERLYING
SKIN.
2) CLOSED FRACTURE- FRACTURE IN
WHICH THERE IS NO BREAK IN
CONTINUITY OF OVERLYING SKIN.

13. ASSESSMENT-
• SWELLING
• TENDERNESS
• SURROUNDING NEUROVASCULAR INJURIES MAY BE PRESENT- SO CKECK
FOR DISTAL PULSES, MOTOR AND SENSORY FUNCTION.
• RANGE OF MOVEMENT
• BONY DEFORMITY
• BONY CREPTS
NOTE-
 LIFE THREATENING HEMORRHAGE- SEEN IN FEMUR FRACTURE AND PELVIS FRACTURE
 FRACTURE MAY OR MAY NOT BE ASSOCIATED WITH JOINT DISLOCATION
 CONTAMINATION- IMP COMPLICATION NOT TO IGNORED IN CASE OF OPEN FRACTURE

14. MANAGEMENT-
• IN CASE OF CLOSED FRACTURE-
ABC/CAB
IMMOBILIZE
ANALGESIC
XRAY-
WE MUST DO SPECIFIC VIEW FOR DIFFERENT PART.
XRAY MUST COVER ONE JOINT ABOVE AND ONE JOINT BELOW THE FRACTURE
SEGMENT
TEMPORARY STABALISATION BY GIVING SPLINT, SLAB OR BINDERS.
THEN SHIFT THE PATIENT TO WARD FOR DEFINITIVE MANAGEMENT.

15. MANAGEMENT CONT.. -
• IN CASE OF OPEN FRACTURE-
• THROUGH IRRIGATION TO BE DONE USING ANTI SEPTIC SOLUTION AND NORMAL
SALINE.
• IMMOBILIZE INJURED PART AND DRESSING OF OPEN WOUND.
• XRAY
• TEMPORARY STABALIZATION USING SPLINT, SLAB OR BINDER.
THEN SHIFT THE PATIENT TO WARD FOR DEFINITIVE MANAGEMENT.

16. CLAVICLE FRACTURE
• MECH OF INJURY- FALL ON
OUTSTRETCHED HAND
• XRAY- XRAY OF SHOULDER AP
• MIDSHAFT CLAVICLE FRACTURE-
FIGURE OF 8 BANDAGE/CLAVICULAR
BRACE WITH ARM POUCH SLING.
• LATERAL SHAFT CLAVICLE
FRACTURE- SHOULDER IMMOBILISER.

18. HUMERUS FRACTURE-
XRAY OF SHOULDER AP/
AXIAL/ SCAPULAR Y VIEW
XRAY OF HUMERUS AP/LAT

19. EARLY IMMOBILISATION- SHOULDER
IMMOBILISER, ARM SLING POUCH, U SLAB.

20. FRACTURE AROUND ELBOW-
XRAY OR ELBOW AP/LAT

21. IMMOBILIZATION-
ABOVE ELBOW SLAB,
ARM POUCH SLING
ABOVE ELBOW SLAB-
EXTEND FROM MIDDLE OF UPPER ARM TO DISTAL PALMAR CREASE
ELBOW AT 90*
FOREARM IN MID PRONE
WRIST USUALY IN NEUTRAL POSITION

22. RADIUS AND ULNA FRACTURE-
XRAY OF FOREARM AP/LAT

23. IMMOBILIZATION-
ABOVE ELBOW SLAB,
ARM POUCH SLING
ABOVE ELBOW SLAB-
EXTEND FROM MIDDLE OF UPPER ARM TO DISTAL PALMAR CREASE
ELBOW AT 90*
FOREARM IN MID PRONE
WRIST USUALY IN NEUTRAL POSITION

24. FRACTURE AROUND WRIST-
XRAY OF WRIST AP/LAT

25. FRACTURE AROUND
WRIST JOINT
DISTAL END RADIUS
AND ULNA
FRACTURE
ABOVE ELBOW SLAB
FROM MIDDLE OF
UPPER ARM TO
DISTAL PALMAR
CREASE
ISOLATED DISTAL
END RADIUS
FRACTURE
BELOW ELBOW SLAB
FROM 5CM DISTAL
TO OLECRANON
PROCESS TO DISTAL
PALMAR CREASE
CARPAL BONE
FRACTURE
BELOW ELBOW SLAB
COCK UP SLAB
SCAPHOID
FRACTURE
THUMB SPICA SPLINT
OR SLAB
BELOW ELBOW SLAB
COVERING THUMB
ALSO

27. FRACTURE IN HAND-
XRAY OF HAND AP/OBLIQUE

30. FRACTURE AROUND HIP JOINT-
XRAY OF PBH AP
NOTE-
• HEMODYNAMIC STATUS
OF THE PATEINT MUST BE
CHECKED CAREFULLY
• HEMORRHARGE IS VERY
SERIOUS COMPLICATION
SEEN IN PELVIC
FRACTURE.
• TO STOP BLEEDING
PELVIC BINDER IS USED.

32. XRAY PBH AP
XRAY FEMUR AP/LAT

33. THOMAS SPLINT

34. FEMUR SHAFT FRACTURE-
NOTE-
• MID SHAFT FEMUR FRACTURE CAN LEAD TO
FAT EMBOLISM.
• TO PREVENT FAT EMBOLISM IV FLUID TO BE
GIVEN ALONG WITH OXYGEN.
• XRAY OF FEMUR AP/LAT.
• IMMOBILIZATION- THOMAS SPLINT

35. FRACTURE AROUND KNEE JOINT-
XRAY OF KNEE AP/ LAT

36. XRAY OF KNEE AP/ LAT/ SKYLINE VIEW

37. ABOVE KNEE SLAB
EXTEND FROM MIDDLE OF THE THIGH TO BASE OF TOES
KNEE IN 5-20* FLEXION
ANKLE IN NEUTRAL POSITION

38. SHAFT TIBIA AND FIBULA FRACTURE
• XRAY OF LEG AP/ LAT
• IMMOBILIZATION- ABOVE
KNEE SLAB

39. FRACTURE AROUND ANKLE OR FOOT-
XRAY OF ANKLE AP/ LAT/ MORTISE VIEW

40. XRAY OF FOOT BP/OBLIQUEXRAY OF CALCANEUM- CALCANEUM VIEW

41. BELOW KNEE SLAB
 EXTEND FROM TIBIAL TUBEROSITY
TO THE BASE OF THE TOE
 ANKLE IN NEUTRAL POSITION

42. HOW TO PREPARE SLAB

49. THINGS TO REMEMBER WHILE APPLYING SLAB
• FOR UPPER LIMB 12-14 LAYERS OF POP IS ENOUGH.
• FOR LOWER LIMB 16-20 LAYERS OF POP IS ENOUGH.
• AFTER APPLYING POP ALWAYS CHECK FOR DISTAL MOVEMENT TO
PREVENT MOST COMMON COMPLICATION, COMPARTMENT
SYNDROME.
• ALWAYS GIVE SLING FOR UPPER LIMB AND PILLOW FOR LOWER LIMB
TO PREVENT INCREASE OF SWELLING OF DISTAL PART WHICH WILL
AGAIN LEAD TO COMPARTMENT SYNDROME.

50. HOW TO APPLY THOMAS SPLINT

51. IMPORTANT THINGS TO RECOLLECT
• EXTREMITY TRAUMA HAVE MORE DRAMATIC APPEARANCE AND MAY BE DISABLING,
BUT DO NOT BE DISTRACTED BY THOSE INJURIES, ABC SHOULD BE MANAGED FIRST IF
ANY THREAT PRESENT THEN EXTREMITY TRAUMA.
• EVERYWHERE WE DO X-RAY AP & LAT VIEW EXCEPT-
 HAND- AP/ OBLIQUE
 FOOT- AP/ OBLIQUE
 SHOULDER- AP/ AXIAL/ SCAPULAR Y VIEW
 PATELLA- AP/ LAT/ SKYLINE VIEW
• X-RAY MUST BE DONE FOR ONE JOINT ABOVE AND BELOW THE 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.

52. THANK YOU