Approach to extremity injury: Clinical sciences

Extremity injury is often caused by blunt trauma, including falls, crush injuries, and high-speed motor vehicle crashes. It can also result from penetrating trauma, such as gunshot or stab wounds.

While many of these injuries are treated nonoperatively, some can be life- or limb-threatening and are considered surgical emergencies.

When evaluating a patient with extremity injury, start with a primary survey by assessing their ABCDE.

First, secure the Airway by endotracheal intubation if necessary and keep the cervical spine immobilized with a c-collar.

Then comes Breathing, so ensure adequate ventilation and provide supplemental oxygen.

Next is Circulation, so obtain two large bore IVs, making sure to avoid placing the IV on the injured limb. If you’re unable to obtain IV access, obtain intraosseous access instead.

Continuously monitor patient’s vitals while starting appropriate resuscitative measures including crystalloid bolus and sometimes blood product transfusions.

Then, assess for Disability by evaluating the patient’s neurologic status using the Glasgow Coma Scale. Also, quickly check for spinal cord injury by asking your patient if they can feel or move all four extremities.

Finally, Expose the patient by removing all clothing and bandages to ensure no injuries are missed. After examining the patient, place a warm blanket over them to avoid hypothermia.

Okay, if your patient is unstable, move on to a secondary survey.

This includes history and a detailed head-to-toe physical exam to assess for life- or limb-threatening injuries.

Keep in mind, limb-threatening injuries that are left untreated can quickly become life-threatening by hemorrhagic shock or sepsis.

Here’s a clinical pearl! In trauma, the visible injury might not be the cause of instability, so always be sure to assess for internal injuries as well.

Alright, let’s dive into our first case, traumatic amputation or mangled extremity. History typically reveals high-force penetrating trauma like a stab or gunshot wound; industrial injury with an object such as heavy machinery; or a motor vehicle crash.

On physical exam, you’ll find a severed or mangled extremity, as well as ecchymoses and pallor. There may be absent distal pulses with sluggish capillary refill indicating inadequate blood flow to the distal limb. Some patients may also have soft tissue loss.

In this case, you are dealing with traumatic amputation or mangled extremity, which need emergent surgical intervention. Be sure to send for urinalysis and CMP because they have a high risk of rhabdomyolysis.

Next is arterial injury. This can result externally from penetrating trauma, or internally from a severe joint dislocation or long bone fracture.

Depending on the size of the injured artery and the amount of blood loss, the patient can be hypotensive and tachycardic. Distal pulses are typically absent on palpation, and there is a bruit on auscultation or a thrill over the injured vessel. If the skin is intact, you may notice an active pulsatile hemorrhage or a pulsatile expanding hematoma.

If these are your findings, that’s an arterial injury. These patients should go to the OR right away to gain control of the bleeding.

Here’s a high-yield fact! Certain fractures might be associated with specific arterial injuries. For example, a fracture of the lower third of the femur can cause a femoral artery injury.

A supracondylar fracture of the femur can lead to a popliteal artery injury, while a tibial fracture can injure the posterior tibial artery.

On the upper extremity, humeral fractures may cause brachial artery injuries, while a fracture-dislocation of the shoulder can cause an axillary artery injury.

While injuries to any of these arteries can cause limb-threatening ischemia of the affected extremity, pay close attention to femur fractures because they can cause life-threatening exsanguination.

Next up is compartment syndrome. History usually reveals crush injury, major fracture, or extensive burns.

On examination, you’ll find a swollen extremity that feels tense or “wood-like” and is extremely painful with passive stretching. The extremity might be pale with absent distal pulses, and neurologic exam can reveal paresthesia, motor deficits, or paralysis.

These findings support your diagnosis of compartment syndrome.

Management involves emergent fasciotomy to release the pressure within the muscle compartment and allow adequate blood flow to the rest of the limb.

If left untreated, worsening muscular edema and pressure will lead to limb ischemia and even necrosis. Okay, let’s move on to stable patients.

As before, your next step is to perform a secondary survey, which includes a focused history and physical exam, and obtain adjunctive tests like an x-ray.

Keep in mind that, unlike life- or limb-threatening conditions, isolated extremity injuries might not be obvious on initial examination.

Let’s start with vascular injuries. The mechanism of injury is similar as with unstable patients, but these are typically less severe. Most patients sustain a localized blunt or penetrating trauma to the limb.

Exam often reveals injury near major vasculature with diminished or absent distal pulses, and pallor of the affected extremity. You may observe external bleeding or hematoma. With this presentation, consider a vascular injury.

Next, order a CTA. If it reveals contrast extravasation or cutoff, that’s vascular injury.

Moving on to nerve injuries. History often reveals hyperextension stretch injuries, penetrating transection injuries, or crush injuries; with diminished sensation and motor function. Keep in mind, symptoms might start after an operation, indicating that the nerve damage occurred during surgery.

Exam reveals focal neurologic deficits like numbness, pain, paresthesia, sensory and motor deficits, and muscle weakness. If these are your findings, that’s a nerve injury.