A, B, C (Airway, Breathing and Circulation) take precedence over limb injuries but polytrauma patients benefit from aggressive treatment of Limb or Pelvic Trauma.
- Time of the injury.
- Mechanism of injury.
- Associated medical conditions.
- Pre-injury status.
- Previous treatment if any.
- Remove all the clothing including jewelry.
- Inspect entire affected limb including hands and feet for deformity and asymmetry as compared to the opposite side.
- Nature of wound e.g. incised, lacerated or gunshot.
- Palpate all the limbs, noting tenderness, crepitus, deformity or instability.
- Assess range of motion at all joints.
- Assess vascular status by checking pulses, temperature, colour and comparing these to the opposite side.
- Remember normal pulses do not rule out the compartment syndrome.
- Check the neurovascular status closely and frequently to avoid compartment syndrome.
- Signs to watch for are;
- Pain, out of proportion to the injury & with passive movements.
- Measure elevated compartment pressure in high-risk patients and in unconscious patients with limb trauma.
In Unconscious Patients, Rule Out Spinal and Pelvic Injury.
- Request for the X-Rays of the affected area to assess limb fracture or dislocation by including two views, 90 degree to each other, with joints above and below the injured area.
- All the trauma patients and unconscious patients must have screening chest, pelvis and lateral cervical spine radiographs.
- Isolated soft tissue injuries such as ligament sprain and muscle strain are treated with rest, ice, compression bandage and injury elevation (RICE THERAPY), with or without immobilization.
- Provide adequate analgesia (e.g. diclofenac sodium 75 mg I/M stat)
- Assess the wounds if any.
- Irrigate grossly contaminated wounds with normal saline.
- Administer tetanus prophylaxis and antibiotics in open injuries.
- Apply sterile dressings on wounds and debride all the necrotic tissue.
- Reduce fractures and dislocations (using gentle traction) under I/V analgesia (Injection Nalbufin 10 mg + Inj. Marzine I/V stat) by trained personnel (Senior Resident) and splint the extremity.
- Do post-reduction X-Rays.
- Repair vascular injuries if identified.
- Repair tendons / nerves if needed.
- Joints such as shoulder, elbow and small joints of fingers and toes that are dislocated without neurovascular compromise or fracture can be reduced in the Emergency Room.
Complications: Avascular Necrosis and Neurovascular Complications
- Post reduction angiography is indicated after all knee dislocations.
- In gunshot injuries, the high-energy injuries require operative debridement but low-energy injuries may not need operative treatment.
- If the wound is near a joint then aspirate for haemarthosis (under aseptic measures) distend the joint capsule with sterile saline.
- Look for extravasation from wound to exclude communication.