Isolated extremity trauma

The focus of an isolated extremity trauma in an otherwise healthy patient should be on the assessment of the severity of the injury. Good communication with the prehospital care team and collection of all available information about the mechanism of injury is of highest priority [5]. The type of injury to be expected varies, depending on whether the patient sustained a car or a skiing accident, a gunshot wound, or, as a pedestrian, was hit by a car. The mechanism of injury provides important clues as to the location (eg, fracture of the proximal third of the tibia in a pedestrian struck by a car) and the potential severity of the lesions. The rescue team transporting the patient to the emergency department should further supply information about the initial condition of the patient as well as the time interval since the accident.

In patients with closed and benign-appearing soft tissues, the condition and real extent of the injury must be assessed carefully (chapter 5.1). In alert patients, the clinical evaluation with respect to pain, perfusion, and peripheral movement, eg, the ability to flex and extend the toes, most often is sufficient in order to detect or exclude compartment syndrome. In case of doubt, the additional measurement of compartment pressure can be helpful, especially if the measurements are repeated during the clinical course or performed on an unconscious patient (chapter 5.1, 11.1).

In open injuries, a primary inspection must be performed in the trauma bay. However, everybody involved must respect the local guidelines regarding sterility (ie, face masks as well as sterile gloves, cloth, bandages, and instruments). The size of the wound and the involvement of bone, muscles and/or neurovascular structures must be assessed, recorded, and adequately documented during the primary survey. Thereafter, a sterile wound dressing is mandatory, which should not be removed again until further treatment in the operating room is initiated. Inspection and evaluation of the structures peripheral to the injury is the next step.

Pallor of the skin and/or unequal palpation of the peripheral pulses when compared to the uninjured side are suspicious signs of vascular compromise. This condition mandates immediate assessment of the peripheral circulation, which means checking temperature, capillary refill, making use of Doppler sonography or angiography in order to confirm any vascular lesion, as well as to determine its extent and location. Furthermore, asymmetrical pulses after reduction of an articulation (eg, knee dislocation) as well as bluish discoloration and swelling of the extremity, which may indicate impaired venous drainage, are conditions that warrant a vascular study. If not already involved, the vascular or plastic surgeon needs to be informed and included in the decision-making process.

X-rays of the injured area are mandatory and can be obtained during the initial evaluation. Exceptionally, one x-ray plane may give sufficient information in case of total or subtotal amputations for primary diagnostics, whereas CT scans are sometimes necessary to adequately evaluate comminuted fractures with involvement of a joint. Beside the bone structures, special attention should be given to shadows and foreign bodies within the soft tissue, while the extent of the injury may often be judged on plain x-rays indicating the severity of the injury.

The information obtained at this point of the evaluation is sufficient to begin the multidisciplinary planning process, which will determine the time and nature of treatment.

Polytrauma

The basic approach to the evaluation of extremity injuries in a polytrauma patient is the same when compared to isolated injuries of the extremity, including the soft tissues. The soft-tissue injury should be incorporated into the polytrauma algorithm, and assessed and managed according to the priorities set by the overall patient condition. Soft-tissue trauma due to high-velocity/severe deceleration events are often associated with abdominal or cerebral injuries, which necessitate immediate surgical intervention after clinical and radiological diagnostics and stabilization of the vital parameters. An organized trauma team with well-defined roles and protocols for every single member of the trauma team or the emergency department staff will allow efficient assessment and rapid treatment of critically-injured patients, leading to a reduction in the rate of morbidity and mortality. In busy trauma centers, individual team members have preassigned roles and the initial resuscitation and evaluation proceeds automatically, with little direction from the team leader. It is important to have a person assigned to record vital signs and interventions as they occur, who does not have to participate directly in the starting of intravenous medication or any other tasks.

Together, the anesthesiologist, the intensivist and all consulting specialists who will be involved according to the type of injury, will follow the polytrauma algorithm for primary evaluation as defined by the advanced trauma life support (ATLS) criteria [5]. Initially, the goal is to resuscitate and stabilize the patient, which requires that primary evaluation and decision making must be fast and precise. This includes a check and record of all vital signs, such as airway and circulation. Problems are addressed as they are identified. Simultaneously, the primary clinical survey from head to toe is directed to find obvious instabilities that might include the pelvic ring, fractures of the long bones, and injuries of the soft tissues. Initial diagnostics such as x-ray (chest, pelvis, lateral cervical spine), blood tests including hematocrit, blood type and cross-match, and electrolytes, abdominal ultrasound or rapid-sequence CT scans are carried out in parallel in order to detect or exclude sources of major bleeding and potentially life-threatening injuries. The degree of consciousness is documented using the Glasgow coma scale (GCS), if the patient has not yet been intubated.

At this point, obvious diagnoses are summarized and recorded, while treatment priorities are set. With a successfully resuscitated and stabilized patient, further diagnostic steps may now be performed as clinically indicated. Severe soft-tissue injuries need to be included in the decision-making process as well.