Limb and extremity trauma

The limb and the extremity trauma encompasses the fractures, dislocations, vascular and the nerve injuries, the compartment syndrome and the crush injury, and it is the most common form of the trauma that the emergency physician manages. Though rarely immediately life-threatening, the limb injury is the common source of the long-term disability and the limb loss if it is not managed promptly and correctly. The Fellowship candidate must know the Gustilo classification of the open fracture, the hard and the soft signs of the vascular injury, the clinical diagnosis of the compartment syndrome, and the principles of the open-fracture management.[2][3]

The open fracture: the Gustilo classification

The open fracture — the fracture with a wound communicating between the bone and the external environment — is classified by the Gustilo-Anderson system, which predicts the infection risk and guides the management.[2] Grade I: the wound under 1 centimetre, the low-energy, the clean puncture. Grade II: the wound over 1 centimetre, the moderate soft-tissue damage, no flap needed. Grade III: the severe soft-tissue damage, the high-energy, further subdivided: Grade IIIA the adequate soft-tissue coverage, Grade IIIB the flap needed for the coverage, Grade IIIC the vascular injury requiring the repair. The Grade III has the high rate of the infection and the amputation, and the Grade IIIC has the highest amputation rate of all.

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1. [1]Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma (fifth edition). Critical Care, 2023.PMID 36859355
2. [2]Galvagno SM Jr, Nahmias JT, Young DA Advanced Trauma Life Support(®) Update 2019: Management and Applications for Adults and Special Populations. Anesthesiology clinics, 2019.PMID 30711226
3. [3]Halvorson JJ, Anz A, Langfitt M, et al. Vascular injury associated with extremity trauma: initial diagnosis and management. The Journal of the American Academy of Orthopaedic Surgeons, 2011.PMID 21807917
4. [4]Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. Journal of Trauma, 1984.PMID 6471139
5. [5]Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. Journal of Bone and Joint Surgery (Am), 1976.PMID 773941
6. [6]FLOW Investigators, Bhandari M, Jeray KJ, et al. A trial of wound irrigation in the initial management of open fracture wounds. New England Journal of Medicine, 2015.PMID 26448371
7. [7]Better OS. The crush syndrome revisited (1940-1990). Nephron, 1990.PMID 2194135
8. [8]Bywaters EGL, Beall D. Crush injuries with impairment of renal function. 1941. Journal of the American Society of Nephrology, 1998.PMID 9527411