Approach to skin and soft tissue injury: Clinical sciences

Skin and soft tissue injury refers to damage to the skin and its underlying structures such as fat, fascia, muscles, tendons, and ligaments. The majority of these injuries are caused by blunt or penetrating trauma, but they can also result from burns or infections.

Generally, skin and soft tissue injuries are categorized as either open or closed, ranging from superficial minor injuries to severe polytrauma involving the bone. In severe cases, these injuries can even be limb or life-threatening, so timely diagnosis is very important.

Alright, your first step in evaluating a patient presenting with skin and soft tissue injury is to perform the ABCDE assessment to determine if they are stable or unstable. If the patient is unstable, start acute management by stabilizing the airway, breathing, and circulation. Next, establish IV access and start IV fluid resuscitation. Additionally, continuously monitor the patient's vital signs.

Here’s an important clinical pearl to keep in mind! Make sure to avoid the injured extremity when obtaining IV access and placing a blood pressure cuff or arterial line.

Now that these important steps are done, you can move on to obtaining a focused history and physical exam as well as labs including CBC, CMP, arterial blood gas, and a urinalysis. Your initial assessment should be focused on identifying any life-threatening injuries and signs of impending hemodynamic collapse. Unstable patients typically present with a history of severe traumatic injury, burns or rapidly progressing infection.

On the physical exam, you might find altered mental status, tachycardia, and hypotension which are all signs of instability. Additionally, you might see obvious skin or soft tissue injury with surrounding edema, erythema, and even an eschar.

For open injuries, subcutaneous fat, muscle, or bone might be exposed. On the flip side, with closed injuries like crush injuries, you can expect to see tense skin and soft tissue with severe edema and erythema along with reduced distal pulses and sensory motor deficits. As for severe burns, you might see deeply scalded soft tissue with blisters containing clear fluid or blood. Lastly, if there is an underlying infection, you can expect to see purulent drainage and even crepitus.

Now, lab results typically reflect the severity of the injury and show leukocytosis, electrolyte abnormalities, metabolic acidosis, and even myoglobinuria. Based on your findings, you can make your clinical diagnosis of life or limb-threatening injuries which include mangled extremity, compartment syndrome, severe burns, and necrotizing soft tissue infection, or NSTI. Keep in mind that many of these injuries require emergent surgical intervention.

Now that unstable patients are taken care of, let's talk about stable ones. Your first step in assessing a stable patient with a skin and soft tissue injury is to perform a focused history and physical exam.