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MANAGEMENT OF LIMB INJURIES

MANAGEMENT OF LIMB INJURIES. Dr K. Bougoulias. Objectives. ATLS Scoring system Soft tissue trauma Joint injuries Fracture management. Advanced Trauma Life Support. Primary and secondary surveys Primary ABCDE Identify life threatening injuries Identify limb threatening injuries.

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MANAGEMENT OF LIMB INJURIES

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  1. MANAGEMENT OF LIMB INJURIES Dr K. Bougoulias

  2. Objectives • ATLS • Scoring system • Soft tissue trauma • Joint injuries • Fracture management

  3. Advanced Trauma Life Support • Primary and secondary surveys • Primary ABCDE • Identify life threatening injuries • Identify limb threatening injuries

  4. Scoring systems • Limb ischaemia: 1/ pulse reduced/ absent- perfusion normal 2/ Pulseless, parasthesia,diminished capillary refill 3/ Cool, paralyzed,insensate numb Score is doubled for ischaemia > 6h

  5. Amputation Ischaemia time more than 6 h, non- reconstructable defect, limp salvage attempt would threaten patients life

  6. Soft tissue Trauma • Vascular trauma Early evaluation Distal pulses Arterial disruption caused by: penetrating trauma, dislocations, blunt trauma

  7. Frykman’s signs of arterial damage • Hard signs: pulselessness, massive bleeding at injury, rapidly expanding haematoma, pulsatile haematoma • Soft signs: history of arterial bleeding at scene, proximity of wound to the artery in question, non- pulsatile haematoma over an artery, • One hard or two and more soft signs suggest severe arterial injury

  8. Arterial repair • One artery is enough for the limb • Repair should be coordinated with skeletal stability – fasciotomies distally • Surgical emergency • Definitive evaluation requires angiogram

  9. Compartment syndrome • End capillary perfusion less than intracompartmental pressure • Pressure greater than 30mmHg (lower threshold in hypotensive patients- 20mmHg • Pulselessnes, pallor, excruciate pain, paresthesia, paralysis

  10. Muscle viability • Color • Consistency • Contractility • Capacity to bleed

  11. Nerve injury • Neuropraxia (nerve contusion) • Axonotemesis (partial destruction of axon & myelin sheaths, epineurium intact) • Neurotmesis (complete disruption) Seddon, 1943

  12. Nerve injury • After repair, return rate 1mm/day in adults and 3-5mm/day in children • Prognosis better <30y of age distal than proximal sharp lacerations early repair (time limit 18 months)

  13. Joint Injuries • Dislocations Documentation of neurovascular status before reduction Always attempt a closed reduction Open reduction if necessary Documentation neurovascular status again Splinting, bringing ex fix, traction

  14. Fracture management • FRACTURE: a break in the continuity of bony structure or…. • Open: bone exposed to the air Local sterile irrigation, sterile cover dressing, iv antibiotics, tetanus cover, surgical debridement, skeletal stabilization, soft tissue cover

  15. Classification of open fractures • Gustilo & Anderson, 1984

  16. Classification of closed fractures with soft tissue damage • Tscherne et al, 1982

  17. Fracture management • Closed fractures • Reduce- immobilize- rehabilitate

  18. THANK YOU

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