RADIOLOGIC EVALUATION

Thorough evaluation of lower extremity injuries should include anteroposterior and lateral radiographs of the injured area and the joint above and below. Penetrating injuries are best evaluated with entrance and exit site markers. Careful clinical evaluations can minimize needless overuse of angiography (and subsequently its complications and expense); however, if one or more pulses distal to a penetrating injury are absent, the patient needs angiography, computed tomographic arteriography (CTA), or immediate surgery. If pulses are present, ankle brachial indices (ABIs) should be obtained. If the dorsalis pedis and posterior tibialis ABI are 1.0 or greater, the patient can be safely observed for other injuries and discharged with follow-up ABIs taken at 1 week. If the dorsalis pedis or posterior tibialis ABI is less than 1.0 with clinical ischemia, emergency angiography, CTA, or surgery (if distal perfusion is clearly inadequate) should be done if duplex scanning is not available or wounds are extensive, such as shotgun injuries. If distal perfusion is clinically adequate with an ABI less than 1.0, duplex ultrasonography can be done electively. If it is negative or shows only a minor injury (small intimal defect or small pseudoaneurysm), the patient can be observed with follow-up ABIs obtained in 1 week. If duplex scanning reveals a major injury, such as a large intimal defect, large pseudoaneurysm, or intraluminal clot, angiography or exploration should be performed.

FRACTURES

It is now generally accepted that aggressive, appropriate early management of the trauma patient’s musculoskeletal injuries contributes substantially to overall care by reducing morbidity, mortality, and costs. Rehabilitation and ultimate function are also improved. This section is not a “how-to” discussion, but rather provides recommendations for immediate and knowledgeable collaboration with an experienced orthopedic traumatologist. Specific details of management for musculoskeletal injuries are treated only briefly (and thus arbitrarily) here. Several acceptable alternative treatments exist for many fractures. Differences of opinion are thus unavoidable.

Skeletal injuries cannot be managed safely in isolation. The treating physician must always think beyond the broken bone and assess associated soft tissue trauma, the status of the entire injured limb, and the whole patient. Other injuries, age and anticipated activity level, pre-existing musculoskeletal resources, and chances for meaningful participation in a rehabilitation program must also be considered. The choice of management for fractures and joint injuries may depend on whether an injury is isolated or is one of several problems in a patient with multiple injuries. Treatment is also affected by the resources available to the surgeon. In the absence of a well-equipped operating room, effective radiographic monitoring, and an experienced surgical team, modern techniques of internal fixation are likely to fail.

EARLY CARE OF MUSCULOSKELETAL INJURIES

Extremity injuries may be obvious or occult. Initial care of obvious injuries includes control of bleeding with pressure dressings, splinting unstable injuries in an acceptable position, and urgent identification and treatment of arterial occlusion.

Once resuscitation is proceeding satisfactorily, a thorough and systematic search must be made for more occult injuries. All skin surfaces, from digits to trunk, must be inspected for deformity, swelling, ecchymosis, and laceration. Skin abrasions are significant. If they are present in the region of a musculoskeletal injury, any needed operation must be done promptly or delayed until the abrasion heals. Palpate each bone and joint for swelling, deformity, and tenderness. Manually stress each bone to confirm stability. Move each joint to demonstrate normal passive range of motion and absence of abnormal motion (instability). When emergency surgery is a part of the resuscitation or early care of a trauma patient, examination of the extremities should always be completed before terminating the anesthetic. Confirm the presence of peripheral pulses. Obtain radiographs of all abnormal areas.

When the patient is conscious and able to cooperate, active voluntary motion of each joint must be assessed to check motor nerve and myotendinous integrity. Check sensation in the isolated sensory area of each major peripheral nerve. For critically ill patients who are unable to cooperate initially, completion of this evaluation may take several days. Such follow-through is mandatory to avoid missing injuries. Resuscitation of patients with multiple injuries necessarily places diagnosis and treatment of musculoskeletal conditions at a relatively low priority. Many injuries are not initially appreciated. Repeated examinations during the early recovery period are frequently rewarded by the discovery of additional injuries in time for effective treatment.

OPEN FRACTURES

COMPARTMENT SYNDROMES

Various injuries can cause progressive elevation of tissue pressure within the confines of “compartments” formed by the normal fascial envelopes around groups of skeletal muscles. Once compartment pressure is elevated sufficiently to obstruct microvascular perfusion, muscle and nerve ischemia leads to necrosis of the involved tissue. The pressure eventually recedes to normal levels, leaving behind dead muscle and nerve, the causes of Volkmann’s contracture.

The key to effective treatment is early diagnosis. This requires suspicion of compartment syndrome whenever an extremity sustains a crushing or severely contusing injury, with or without a fracture. Conscious patients with compartment syndrome develop pain and firm swelling of the entire involved compartment and soon lose function of the muscles and nerves that lie within it. Pulses and skin perfusion are often normal. Compartment syndromes may occur in open fractures, which do not necessarily provide an adequate surgical incisions made for debridement alone.

For a minimum of every 2 hours, patients with significant extremity injuries must be monitored for inordinate pain and for loss of sensation or motor function distal to the area of injury. Release of any constricting bandage or cast is the essential first step in treatment of a suspected compartment syndrome to permit examination and to avoid external compression of the involved compartment. This may reduce pressure sufficiently to restore tissue perfusion and prevent necrosis. If the patient is unconscious, or has an associated nerve injury that prevents clinical assessment, compartment pressures are measured with a commercially available tissue pressure measuring device (e.g., Stryker STIC or a slit-wick catheter made from polyethylene tubing with the terminal end slit about 1 mm longitudinally in several places). The device is filled with sterile saline solution and connected to a strain gauge, as used for monitoring intra-arterial pressure. The catheter is then introduced through a large-bore needle into the compartment in question. A satisfactory measurement system elicits a prompt response to manual pressure on the compartment, and pressure will fall to a reproducible level soon after such external compression is released. It is important to measure the pressure in each compartment of the involved area. For the leg, this means anterior, lateral, deep posterior, and superficial posterior spaces. In the forearm, both flexor and extensor groups should be assessed at several sites. The pressure is typically highest close to the fracture.

If neuromuscular findings are normal, a patient with elevated compartment pressure may be monitored clinically or by repeated pressure measurements. If sensation of contractility is impaired or not accessible and compartmental pressure is within 30–40 mm Hg of mean arterial pressure, fasciotomy is required. All involved compartments must be released. For the leg, we use two incisions. One is lateral with identification and preservation of the superficial peroneal nerve, and is used for release of anterior and lateral compartments. The second is immediately posterior to the medial, tibial shaft for the deep and superficial posterior compartments. Skin incisions 8–10 cm long, with proximal and distal “blind” fasciotomies, may permit adequate decompression but are often insufficient in severely injured limbs. Such limbs are best treated with incisions that extend nearly the entire length of the compartment. The skin is left open for delayed closure by suture or split-thickness graft. If an associated fracture is present, fixing it at the time of fasciotomy simplifies wound management. Either external or internal skeletal fixation may be used, depending on the fracture configuration and the degree of additional soft tissue dissection required.

Forearm compartment syndromes may involve anterior (flexor) or posterior (extensor) muscles and may require releasing the intrinsic fascia of each involved muscle. An extensive surgical approach is required, such as McConnell’s combined exposure of the median and ulnar nerves, as described by Henry in Extensile Exposure.¹

For any open wound of the lower extremity that is to be treated open, vacuum-assisted wound closure (VAWC) is becoming a routine technique in mitral management of these wounds. After the wound is cleansed and irrigated, polyurethane foam is cut to fit the wound, and a Silastic sheet is placed over the polyurethane. An incision is made in the middle of the Silastic sheet, an adaptor fitted over this incision, and continuous suction is begun at 100–125 mm Hg. The dressing can be changed on the ward or in the OR if closing the wound is also planned. This is possible when the edema decreases and distention of the circumferential diameter of the extremity lessens. This is usually associated with a diuresis of the patient. Using this technique, it is often possible to eventually close the wound primarily. If the defect is too large after multiple dressing changes, a split-thickness graft is indicated.

Quantitative biopsies comprise another technique that may help the surgeon in determining when a wound can be closed. These biopsies help differentiate wound colonization or contamination from bacterial invasion of the wound bed. With a VAWC, there is also a salutary effect in keeping the wound dry, and typically there is less invasive bacterial into the wound.

Compartment syndromes that are recognized after necrosis is far advanced are probably best left closed rather than treated with fasciotomy because of the significant risk for infection and the lack of benefit from decompressing dead tissue.

DEGLOVING INJURIES

Treatment of degloving injuries requires careful assessment of the extent of the devitalized tissue, the layers of tissue in the flap, and the direction of the avulsion (whether proximally or distally based) and a thorough understanding of the blood supply to the affected tissues.

Degloved skin that remains attached to a pedicle will try to live as a flap and obtain its nutrients from the pedicle rather than the underlying bed. Thorough understanding of the muscular and fascial perforators to the skin will help to predict which flaps can be preserved. Extensive avulsions of the skin with narrow or distal pedicles with or without superficial subcutaneous tissue and without damage to the deeper tissues are best addressed by completely dividing the pedicle, defatting the skin, and replacing the avulsed skin as a full-thickness skin graft.

If the wound is too contaminated or too swollen, the avulsed tissue should be cleansed with pulsatile lavage, left with little or no tension, and addressed at a second exploration. Intraoperative fluorescein examination is a reliable predictor of tissue survival. If arterial in-flow is adequate, the soft tissues can be debrided and closed; tension should be minimal during closure.

Diminished venous return is a common cause for the ultimate death of tissue in degloving injuries. Pharmacologic manipulation with an antithromboxane treatment, such as Dermaid Aloe cream applied topically every 4 hours and 81 mg aspirin daily, coupled with the liberal use of leech therapy, has improved tissue survival with both delayed and immediate wound closures. Leeches are applied every 4 hours initially, and should remain on the wound until the cyanosis from venous congestion is relieved. Large flaps may require two leeches initially. Leeches can be stored on site with minimal tending or obtained within hours by calling a supplier (e.g., Leeches U.S.A., 1-800-645-3569). As venous recanalization occurs, the frequency of leech application can be reduced and is usually unnecessary after 3 days.

MANGLED EXTREMITIES: DELAYED AMPUTATION

In a perfect world, it should be possible for a general or orthopedic surgeon to assess a patient with a mangled extremity and to make a perfect decision as to whether to do prompt amputation or to attempt reconstruction. Unfortunately, the literature does not help such surgeons in making these decisions, and most of the literature that addresses the mangled extremity focuses on the lower extremity. These fractures have been classified as 3C and are invariably open. Some have vascular injuries, and some do not. Some are insensate, and some are not.

Many scoring systems have been developed to predict those patients who should undergo immediate amputation and those who should have reconstruction. Our own bias is reflected by Bonanni et al.,¹³ who state that predictive scoring is an exercise in futility. In their study, they could not show reliable sensitivity or specificity using the MESI, PSI, MESS, or the LSI. Surgical judgment based on experience is still the gold standard.

In a recent study by Bosse et al.,¹⁷ of 569 patients with severe leg injuries who underwent reconstruction or amputation, the sickness impact profile (SIP) showed no difference in outcomes between these two groups. Their study did show that there was a poorer score for the SIP if the patient was rehospitalized or had a major complication, lower educational level, nonwhite ethnicity/race, poverty, lack of private health insurance, poor social support network, low selfefficiency, smoking, and involvement in disability-compensation litigation. Interestingly, patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation. Return to work in the two groups was similar. The fact that the groups are similar reflects good decisions made by the surgeons.

Few other areas in trauma care are as controversial as whether amputations for mangled extremities should be done early or delayed. The most common reasons for delayed amputation are loss of wound cover in un-united fractures, infection in a nonunion fracture, an insensate limb, recurrent ulcerwations, a dystrophic limb, sympathetic dystrophy, and phantom pain, to name a few. Some surgeons have argued that functional recovery is faster and less costly following amputation than with multiple procedures for salvage and reconstruction. In addition to the study by Bosse et al.¹⁷ mentioned previously, Pozo et al.¹⁸ studied 35 patients who had amputation following the failure of treatment for severe lower limb trauma. Seven of the amputations were for ischemia within 1 month of the injury; 13 were between 1 month and 1 year for infection, complicating loss of limb cover or un-united fractures; and 15 occurred later than 1 year postinjury mainly for infected nonunion. The latter group had an average of 12 operations and 50 months of treatments, including 8 months in hospital. Factors that contributed to salvage failure were vascular injuries, nerve damage, bone damage, muscle damage, skin cover, and sepsis. Overall, these authors concluded that if lower limb reconstruction is attempted, it should be assessed very early on by two specialists, one in trauma surgery and the other in orthopedic or plastic surgery, as to whether failure is inevitable. Obviously, this requires experience, and persistent attempts at salvage can be extremely difficult.

Another study that might influence surgeons on whether to salvage comes from Case Western Reserve.¹⁶ Thirty-four patients were followed, of whom 16 had a successful limb salvage procedure, and 18 had an immediate below knee amputation (BKA). The patients who had a successful limb salvage procedure took significantly more time to achieve full weight bearing, were less willing or able to work, and had higher hospital charges than the patients who had been managed with an early BKA. Furthermore, patients who had limb salvage considered themselves severely disabled, and they had more problems than the amputation group with the performance of occupational and recreational activities. These quality-of-life evaluations, however, must be put into the perspective that Bosse and MacKenzie¹⁷ have already outlined.

In a final study for consideration, Roessler and colleagues¹⁹ reviewed 80 patients for a 4-year period and asked the question of when to amputate. They concluded that neurologic, bone, and tissue status influenced the decision regarding immediate amputation, but had little to do with delayed loss of limb or life. Somewhat surprisingly, they found that the circulation as determined by the presence or absence of a palpable or Doppler-detected pulse was critical. They concluded that in cases in which salvage is attempted, amputation should be performed at 24 hours if the patient’s condition, including a markedly positive fluid balance, indicates systemic compromise. They also made the observation that in the absence of a distal pulse on presentation, the eventual amputation rate is high.