Transcript Document

MANAGEMENT
OF LIMB
INJURIES
Dr K. Bougoulias
20/7/2015
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Objectives
 ATLS
 Scoring system
 Soft tissue trauma
 Joint injuries
 Fracture management
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Advanced Trauma Life
Support
 Primary and secondary surveys
 Primary ABCDE
 Identify life threatening injuries
 Identify limb threatening injuries
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Scoring systems
 Limb ischaemia:
1/ pulse reduced/ absent- perfusion normal
2/ Pulseless, parasthesia,diminished
capillary refill
3/ Cool, paralyzed,insensate numb
Score is doubled for ischaemia > 6h
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Amputation
Ischaemia time more than 6 h,
non- reconstructable defect,
limp salvage attempt would threaten
patients life
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Soft tissue Trauma
 Vascular trauma
Early evaluation
Distal pulses
Arterial disruption caused by: penetrating
trauma, dislocations, blunt trauma
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Frykman’s signs of arterial
damage
 Hard signs: pulselessness, massive
bleeding at injury, rapidly expanding
haematoma, pulsatile haematoma
 Soft signs: history of arterial bleeding at
scene, proximity of wound to the artery
in question, non- pulsatile haematoma
over an artery,
 One hard or two and more soft signs
suggest severe arterial injury
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Arterial repair
 One artery is enough for the limb
 Repair should be coordinated with
skeletal stability – fasciotomies distally
 Surgical emergency
 Definitive evaluation requires angiogram
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Compartment syndrome
 End capillary perfusion less than
intracompartmental pressure
 Pressure greater than 30mmHg (lower
threshold in hypotensive patients20mmHg
 Pulselessnes, pallor, excruciate pain,
paresthesia, paralysis
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Muscle viability
 Color
 Consistency
 Contractility
 Capacity to bleed
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Nerve injury
 Neuropraxia (nerve contusion)
 Axonotemesis (partial destruction of
axon & myelin sheaths, epineurium
intact)
 Neurotmesis (complete disruption)
Seddon, 1943
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Nerve injury
 After repair, return rate 1mm/day in
adults and 3-5mm/day in children
 Prognosis better <30y of age
distal than proximal
sharp lacerations
early repair (time limit
18 months)
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Joint Injuries
 Dislocations
Documentation of neurovascular status
before reduction
Always attempt a closed reduction
Open reduction if necessary
Documentation neurovascular status again
Splinting, bringing ex fix, traction
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Fracture management
 FRACTURE: a break in the continuity of
bony structure or….
 Open: bone exposed to the air
Local sterile irrigation, sterile cover
dressing, iv antibiotics, tetanus cover,
surgical debridement, skeletal
stabilization, soft tissue cover
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Classification of open fractures
 Gustilo & Anderson, 1984
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Classification of closed fractures
with soft tissue damage
 Tscherne et al, 1982
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Fracture management
 Closed fractures
 Reduce- immobilize- rehabilitate
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THANK YOU
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