Management of Limb Injuries

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Priorities

A, B, C (Airway, Breathing and Circulation) take precedence over limb injuries but polytrauma patients benefit from aggressive treatment of Limb or Pelvic Trauma.

History

Ask About;

  1. Time of the injury.
  2. Mechanism of injury.
  3. Age.
  4. Associated medical conditions.
  5. Pre-injury status.
  6. Previous treatment if any.

Physical Examination

  1. Remove all the clothing including jewelry.
  2. Inspect entire affected limb including hands and feet for deformity and asymmetry as compared to the opposite side.
  3. Nature of wound e.g. incised, lacerated or gunshot.
  4. Palpate all the limbs, noting tenderness, crepitus, deformity or instability.
  5. Assess range of motion at all joints.
  6. Assess vascular status by checking pulses, temperature, colour and comparing these to the opposite side.
  7. Remember normal pulses do not rule out the compartment syndrome.
  8. Check the neurovascular status closely and frequently to avoid compartment syndrome.
  9. Signs to watch for are;
  10. Pain, out of proportion to the injury & with passive movements.
  11. Paraesthesia.
  12. Paralysis.
  13. Measure elevated compartment pressure in high-risk patients and in unconscious patients with limb trauma.

In Unconscious Patients, Rule Out Spinal and Pelvic Injury.

Radiological Examination

  1. Request for the X-Rays of the affected area to assess limb fracture or dislocation by including two views, 90 degree to each other, with joints above and below the injured area.
  2. All the trauma patients and unconscious patients must have screening chest, pelvis and lateral cervical spine radiographs.

Treatment

  1. Isolated soft tissue injuries such as ligament sprain and muscle strain are treated with rest, ice, compression bandage and injury elevation (RICE THERAPY), with or without immobilization.
  2. Provide adequate analgesia (e.g. diclofenac sodium 75 mg I/M stat)
  3. Assess the wounds if any.
  4. Irrigate grossly contaminated wounds with normal saline.
  5. Administer tetanus prophylaxis and antibiotics in open injuries.
  6. Apply sterile dressings on wounds and debride all the necrotic tissue.
  7. Reduce fractures and dislocations (using gentle traction) under I/V analgesia (Injection Nalbufin 10 mg + Inj. Marzine I/V stat) by trained personnel (Senior Resident) and splint the extremity.
  8. Do post-reduction X-Rays.
  9. Repair vascular injuries if identified.
  10. Repair tendons / nerves if needed.
  11. Joints such as shoulder, elbow and small joints of fingers and toes that are dislocated without neurovascular compromise or fracture can be reduced in the Emergency Room.

Complications:  Avascular Necrosis and Neurovascular Complications

  1. Post reduction angiography is indicated after all knee dislocations.
  2. In gunshot injuries, the high-energy injuries require operative debridement but low-energy injuries may not need operative treatment.
  3. If the wound is near a joint then aspirate for haemarthosis (under aseptic measures) distend the joint capsule with sterile saline.
  4. Look for extravasation from wound to exclude communication.