General
The GMO evaluating an extremity with penetrating trauma must ascertain the presence
or absence of vascular, joint, or major nerve injury, open fracture, and compartment
syndrome. Minor superficial wounds of the soft tissues can be managed locally. All other
wounds should have a surgical evaluation. While rarely life threatening, they are often
limb-threatening and disabling.
Important historical factors to determine include mechanism of injury, environment,
predisposing factors (drug or alcohol use concomitant medical illnesses, previous injury),
and findings at the accident site along with initial treatment rendered.
Primary Survey
-
Evaluate the patient for the presence of a patent airway, adequate breathing, and intact
circulation (ABCs) per ATLS guidelines.
-
Immobilize the head and neck, and maintain the cervical spine in a neutral position.
Assume a cervical spine injury is present until proven otherwise by palpation and
radiological examination.
-
Disability: abbreviated neuro exam to include pupils and level of consciousness.
-
Exposure: fully undress the patient
-
Determine pre-hospital care already delivered
-
Mechanism of injury.
-
Pain - presence, absence, location.
-
Examine the extremities and the remainder of the patient for any other life threatening
injuries. Observe for immediate bleeding that needs to be controlled.
Secondary Survey
An "AMPLE" history per ATLS.
-
M
edications taken by the patient
-
E
nvironment and events related to patients injury(s)
Inspection - color, perfusion, deformities, swelling or discoloration, wounds or
amputations, and impaled foreign bodies.
Palpation - sensation, tenderness, crepitation (along with active and passive range of
motion in the absence of obvious fracture), pulse, capillary refill, and temperature
Signs and symptoms of vascular injury include hemorrhage, expanding hematoma,
diminished or absent pulses, bruit or thrill, diminished distal perfusion, decreased
sensation, or increasing pain.
Signs and symptoms of severe compartment syndrome include pain, pallor, paresthesia,
paralysis, pulselessness, and poikilothermia.
Ancillary Tests
-
AP and lateral roentgenograms confirm the diagnosis of fractures. Air in the joint space
may be seen. Radiographs are useful but not necessary if evacuation indicated by physical
exam. If obtained, transport these with the patient.
-
Doppler examination may assist in determining the presence or absence of non-palpable
pulses.
-
Ankle Brachial Index (ABI). Measure the doppler pressure in the leg and the arm. The
normal ratio is 1:1. If the ratio is <0.9 assume an arterial injury and transport
immediately.
Diagnosis
In penetrating extremity trauma, the presence of any of the above symptoms or signs on
exam indicates a major injury requiring surgical evaluation. Specific injuries include:
-
Open fractures and joints.
-
Impalements and embedded foreign bodies.
-
Vascular or nerve injury.
-
Development of compartment syndrome.
-
Major soft tissue loss or amputation.
Minor penetrating injuries are diagnosed by exclusion of all the above major criteria.
Treatment
-
Initial assessment and resuscitation using ATLS guidelines.
-
IV fluids should be started in patients with crush injuries.
-
Alkalinize the urine and use an osmotic diuretic to minimize renal tubular acidosis
(RTA) secondary to myoglobinuria.
-
Minor, superficial wounds may be debrided and dressed. Generally leave wounds open.
-
Major wounds - major soft tissue damage, bone or joint involvement, major nerve injury,
vascular injury, or development of compartment syndrome
Control hemorrhage by direct pressure: use a tourniquet only as a last resort to
control high-grade bleeding.
Dress wounds. Do not remove impaled, embedded foreign bodies.
Splint in position of function (a sling is adequate for most upper extremity injuries).
Administer tetanus prophylaxis, if not current
Evacuate to a facility with surgical capability, as a litter patient if appropriate.
Plan for emergent transport and definitive care within two hours.
Amputated parts may be wrapped in sterile, saline moistened dressings, and sent on ice
with the patient. Ice must not contact tissue directly.
Communicate with the accepting facility before transfer in all cases.
Surgical Consultation
Since all but minor injuries will require surgical consultation, few if any significant
injuries will be missed. All history, findings, and details of treatment should be
documented and accompany the casualty.
References
-
Emergency War Surgery, Second United States Revision of The Emergency War Surgery NATO
Handbook, Chapters XVI, XVIII, XIX, XX, and XXI, 1988. http://www.vnh.org/EWSurg/EWSTOC.html
-
Musculoskeletal Trauma, chapter 8, Advanced Trauma Life Support for Doctors, Student
Course Manual, American College of Surgeons Committee on Trauma, pp. 243-272, 1997.
Revised by CDR Lawrence H. Roberts, MC, USN, Trauma Training Coordinator for the
Navy, Department of General Surgery, Naval Medical Center San Diego, San Diego, CA (1999).