EM · Limb & extremity trauma
Limb and extremity trauma
The limb trauma from the open fracture and the Gustilo classification, the vascular injury and the hard signs, the compartment syndrome, the neurovascular examination, the dislocation reduction, the open-fracture management with the antibiotics and the washout, and the crush injury with the rhabdomyolysis.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- The hard signs of the vascular injury (the pulsatile bleeding, the expanding haematoma, the absent pulse) mandate the immediate surgical or the endovascular intervention
- The compartment syndrome is diagnosed clinically by the pain out of proportion and the pain on the passive stretch — the fasciotomy is not delayed for the pressure measurement
- The open fracture is washed out within 6 hours and given the empirical antibiotics and the tetanus prophylaxis
- The knee dislocation has the high rate of the popliteal artery injury — the CT angiogram or the angiography is indicated even if the pulse is initially present
- The Gustilo Grade III open fracture has the high rate of the infection and the amputation
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.
References8ShowHide
- [1]Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care, 2023.PMID 36859355
- [2]Galvagno SM Jr, Nahmias JT, Young DA Advanced Trauma Life Support(®) Update 2019: Management and Applications for Adults and Special Populations. Anesthesiol Clin, 2019.PMID 30711226
- [3]Halvorson JJ, Anz A, Langfitt M, et al. Vascular injury associated with extremity trauma: initial diagnosis and management. J Am Acad Orthop Surg, 2011.PMID 21807917
- [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. J Trauma, 1984.PMID 6471139
- [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. J Bone Joint Surg Am, 1976.PMID 773941
- [6]FLOW Investigators, Bhandari M, Jeray KJ, et al. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med, 2015.PMID 26448371
- [7]Better OS. The crush syndrome revisited (1940-1990). Nephron, 1990.PMID 2194135
- [8]Bywaters EGL, Beall D. Crush injuries with impairment of renal function. 1941. J Am Soc Nephrol, 1998.PMID 9527411