Extremity Trauma

Courtesy of Bonnie Meneely, EMT-P

Overview
Priority of extremity trauma

Major complications and treatment:

• Fractures • Neurovascular injuries
• Dislocations • Sprains and strains
• Amputations • Impaled objects
• Open wounds • Compartment syndrome

Estimated blood loss

• Pelvic and extremity fractures

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Overview
Major mechanisms, associated trauma,
potential complications, management:
• Pelvis • Clavicle/shoulder
• Femur • Elbow
• Hip • Forearm and wrist
• Knee • Hand or foot
• Tibia/fibula

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Extremity Trauma
Distorted or wounded extremities must
not distract from life-threatening injuries.
• Easy to identify
• Disabling but rarely immediately life-threatening

Potential danger:
• Hemorrhagic shock (very few)
• Neurovascular compromise
• Distal PMS

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Extremity Trauma
Extremity injuries
• Fractures
• Dislocations
• Amputations
• Open wounds
• Neurovascular injuries
• Impaled objects
• Compartment syndrome Courtesy of Roy Alson, MD

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Extremity Injuries
Fractures
• Open (compound)
• Communication to outside
• Danger of contamination
• Blood loss outside body
• Closed (simple)
• No communication to outside
• Danger of contamination
• Blood loss inside body

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Fractures
Hemorrhage with fracture
• Closed femur fracture
• Loss of 1 liter of blood
• Two closed femur fractures life-threatening

• Closed pelvic fracture

• Extensive bleeding into abdomen or retroperitoneal
• Usually fractures in several places
• 500 cc of blood loss for each fracture
• May lacerate bladder or large pelvic blood vessels

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Extremity Injuries
Dislocations
• Neurovascular compromise
• True emergency though not life-threatening
• Check PMS distal to major joint dislocations

Courtesy of Roy Alson, MD

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Dislocations
Management
• No neurovascular compromise
• Splint in position found
• Neurovascular compromise
• Apply only gentle traction in effort to straighten
• No more than 10 pounds of force
• Often best: pad and splint in most comfortable
position and rapid safe transport

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Extremity Injuries
Amputations
• Disabling and sometimes life-threatening
• Potential for massive hemorrhage
• Most often, bleeding controlled with ordinary pressure

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Amputations
Management
• Cover with damp sterile dressing, elastic wrap
• Uniform reasonable pressure across stump
• Tourniquet if bleeding absolutely not controlled
• Rarely needed
• Retrieve amputated part
• In plastic bag, inside ice water

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Extremity Injuries
Open wounds
• Remove contamination
• Gross: remove
• Smaller: irrigate with normal saline
• Sterile dressing and bandage
• Pressure dressing, if necessary
• Pressure point
• Tourniquet rare
• Hemostatic agent Courtesy of Roy Alson, MD

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Open Wounds

Obvious
exsanguinating hemorrhage—
only time can change order of
ABC to CAB.

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Extremity Injuries
Neurovascular injuries
• Nerves and major vessels
run beside each other in
flexor area of major joints

Distal PMS
• Assess pulse
• Assess motor function
• Assess sensory

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Extremity Injuries
Impaled objects
• Do not remove
• Airway obstruction exception

• Apply very bulky padding

• Transport object in place
• No unnecessary movement
• Motion magnified in tissues

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Extremity Injuries
Compartment syndrome
• Forearm and lower leg most common
• Swelling compresses nerves and vessels

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Compartment Syndrome
Early symptoms Late symptoms
• Pain • Pain
• Paresthesia • Pallor
• Pulselessness
• Paresthesia
• Paralysis

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ITLS Patient Assessment
Mechanism History Common Injury
Falls landing on feet Foot, lumbar spine
Sitting position Knee, hip
Fall onto wrist Wrist, elbow
Fall onto ankle Ankle, proximal fibula
Shoulder involved Shoulder, neck, chest
Pelvis involved Pelvis, shock

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Extremity Trauma
ITLS Primary and Secondary Surveys
• Major bleeding
• DCAP-BTLS
• Instability
• Crepitation
• Joint pain
• Joint movement
• Distal PMS

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Management
Splinting
• Prevent motion in broken bone ends
• Eliminate further damage
• Decrease pain

Load-and-go patients
• Temporary splinting with long backboard
• Additional splinting during transport

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Splinting
Rules
• Adequately visualize
• Distal PMS before and after splinting
• Treat neurovascular compromise
• Cover open wounds with sterile dressing
• Immobilize one joint above and below
• Apply on side away from open wound
• Pad splint well
• Do not attempt to push bone ends under skin

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Extremity Trauma

If in doubt, splint possible injury.

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Types of Splints

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Extremity Trauma
Spine

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Extremity Trauma
Pelvis

Courtesy of Sam Splints

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Extremity Trauma
Femur

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Extremity Trauma
Hip

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Extremity Trauma
Knee

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Extremity Trauma
Tibula/fibula

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Extremity Trauma
Clavicle

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Extremity Trauma
Shoulder

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Extremity Trauma
Elbow

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Extremity Trauma
Forearm and wrist

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Extremity Trauma
Hand or foot

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Summary
ITLS Primary Survey has priority.
• Extremity trauma not usually life-threatening
• Pelvic, femur fractures can be life-threatening

Proper splinting decreases further injury.

Dislocations of elbows, hips, knees:
• Careful splinting and rapid reduction
to prevent severe disability to extremity

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Discussion

© Craig Jackson/In the Dark Photography

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