EXTREMITY TRAUMA

• Instructor Name:

• Title:

• Unit:

OVERVIEW

• Relationship of extremity trauma to assessment of life-threatening injury

• Types of extremity injuries• Assessment & management

– General• Estimation of blood loss

• Splinting

– Specific injuries

FRACTURE PRIORITIES

• Fractures rarely life-threatening

• Perform BTLS Primary Survey to find life-threatening injuries– Do not be distracted by obvious but not life-

threatening extremity injuries– Be alert to major bleeding from extremity

injuries

TYPES OF FRACTURES

• Open– Bone ends protrude through the wound– High risk of infection

• Closed– No opening through the skin

• Fractures may– Damage adjacent nerves and vessels– Produce severe bleeding– Blood loss may be internal

DISLOCATIONS

• Joint deformity may be fracture or dislocation

• Can cause neurovascular compromise of distal extremity

• Always assess– Distal sensation– Distal motor function– Distal pulses and skin color

AMPUTATIONS

• Control bleeding by direct pressure– Tourniquets rarely needed

• Locate amputated part

• Do not place amputated part directly in ice or water– Place part in plastic bag– Place bag in ice-water mixture

SPRAINS & STRAINS

• Signs similar to fractures

• X-rays needed to distinguish from fractures

• Treat as if fractured

“If an extremity hurts, immobilize it”

OPEN WOUNDS

• Control bleeding with pressure– Tourniquets rarely

needed

• Check distal PMS– Pulse

– Motor

– Sensory

COURTESY ROY ALSON M.D.

Applying Tourniquet

IMPALED OBJECTS

• Stabilize in position found– Removal may cause uncontrollable

bleeding

• Exceptions– Object in cheek– Cannot control major bleeding with

object in place

COMPARTMENT SYNDROME

• Early– Pain

– Paresthesias

• Late– Pallor

– Pulselessness

– Paralysis

Pathophysiology

Signs and symptoms

SIGNS & SYMPTOMS OF EXTREMITY INJURY

• Pain

• Deformity

• Swelling

• Loss of movement

• CrepitusCOURTESY ROY ALSON,

M.D.

ASSESSMENT

• Scene Size-Up– Clues to specific injuries

• BTLS Primary Survey– Pelvic fractures or bilateral femur fractures are

Load & Go– Control major bleeding– History may suggest other injuries

BLOOD LOSS FROM FRACTURES

• Pelvis - 500cc for each break– May lacerate major vessels causing

major internal bleeding

• Femur - 1000cc

• Multiple fractures can produce life-threatening hemorrhage– May all be internal

DETAILED EXAMCHECK EXTREMITIES FOR

• Deformities

• Contusions

• Abrasions

• Penetrations

• Burns

• Tenderness

• Lacerations

• Swelling

ALSO CHECK FOR PMS

MANAGEMENT

• SPLINTING– Decreases pain– Prevents further

injury– Decreases blood

lossCOURTESY DAVID EFFRON, M.D.

GENERAL RULES OF SPLINTING

• Visualize injured part• Check and record PMS before and after

splinting• May apply gentle in-line traction• Cover open wounds with sterile

dressings• Pad the splint• Immobilize one joint above and below

the site of the injury

GENERAL RULES OF SPLINTING

• Do not push bone ends back under the skin

• May apply splints en route to the hospital

• If in doubt, splint • Never delay transport of critical

patient to perform splinting of minor fractures

MANAGEMENTLOAD & GO PATIENTS

• Spinal immobilization– Long backboard– C-collar– Head immobilizer

• Limit splinting until en route• Backboard acts as “whole body”

splint

MANAGEMENTSPECIFIC INJURIES

• CLAVICLE FRACTURES– Common injury

– Apply sling & swathe

SHOULDER INJURIES

• AC separation– Sling & swathe

• Shoulder dislocation– Use pillow with

sling & swathe

• Fracture– Use sling & swathe

ELBOW INJURY

• Fracture or dislocation may cause neurovascular injury

• Splint in position found

• Transport promptly

FOREARM/WRIST INJURY

• Rigid splint– Keep hand in

position of function

• Air splint– May be difficult

to reassess circulation

• Pillow

FEMUR FRACTURES

• High force injury• High potential for

shock• May use traction splint• PASG or air splint

may give adequate stabilization

COURTESY OF ROY ALSON M.D.

KNEE FRACTUREOR DISLOCATION

• Orthopedic emergency• Frequently causes

vascular injury• Dislocation associated

with high incidence of leg amputation

MANAGEMENT KNEE DISLOCATION

• Obvious dislocation without distal pulse– Apply gentle in-line traction

• If gentle traction does not restore the pulse– Splint in place

• Prompt transport

TIBIA-FIBULA FRACTURES

• Frequently open fractures• Significant hemorrhage

possible• Dress open wounds• Depending on level of

fracture– Upper - Rigid splint

– Lower - Air splint or pillowCOURTESY OF ROY ALSON M.D.

FOOT OR HANDINJURIES

• Common industrial injury• Often disabling• Rarely life-threatening• Splint foot with pillow• Splint hand in position of

function

SUMMARY

• Note mechanism of injury

• Remember priorities– ABCs first

• Be prepared for shock

• Record PMS

SUMMARY

• Critical patients– Do not waste time on minor splinting– Immobilize spine– Apply other splints en route

• Immobilize one joint above and below

• If in doubt, splint

QUESTIONS?