O&T SC059: High Energy Open Injuries And Amputation Flashcards
High energy injuries
High energy:
- High velocity
- Mechanism of injury
Causes:
1. Missile
2. Traffic accidents
3. Crush
4. Blast
5. Fall from height
Clinical features:
1. Local
- Open fractures
- Severe soft tissue damage
- Contamination of wounds
- Severe bleeding
- Nerve + vessel injuries
- Severe pain
- Systemic
- Associated injuries
- Head
- Chest
- Abdomen
- Multiple fractures
- Multiple victims
Open fracture: Grading
***Gustilo and Anderson open fracture grading
Type 1:
- <1cm
- Clean
- Minimal soft tissue damage
- Minimal comminution
Type 2:
- >1cm
- Moderate dirt
- Moderate soft tissue damage
- Moderate comminution
Type 3A-C:
- >10cm
- Highly contaminated (e.g. soiling, farming, sea water —> gram -ve, anaerobes)
- Severe soft tissue damage
—> 3A: Severe with crushing
—> 3B: **Severe loss of cover + Poor bone coverage
—> 3C: **Vascular injuries require repair
- Severe bone injury
—> 3A: Soft tissue cover possible
—> 3 B/C: Require reconstructive surgery
3A: Infection uncommon, Amputation ~0%
3B: Infection rate increased, Amputation occasionally
3C: Infection rate increased, Amputation sometimes
Complications of High energy open fractures
- Infection
- Type 1: 1-2%
- Type 2: 2-4%
- Type 3a: 4-10%
- Type 3b: 10-25%
- Type 3c: up to 50%
Acute:
1. Skin loss
2. Compartment syndrome —> Scarring + Atrophy of muscles + nerves —> Severe loss of function, mobility, strength (Volkmann ischaemic contracture —> non-functional limb)
3. Neurovascular deficits
4. Missed associated injuries
5. Muscle loss
Chronic:
1. Exposed implants / bone
2. Malunion / Non-union
3. Joint arthritis
4. Amputation
Tissue prone to damage
Hard tissue
1. Bone
Soft tissue (more important than Bone)
1. Skin
2. Muscle
3. Tendons
4. Ligaments
5. Nerves
6. Vessels
Compartment syndrome (Surgical emergency)
Definition:
- Pressure in fascia compartment **>1/2 of DBP / **>40 mmHg (for a normal BP patient, if shocked —> need to check DBP as well)
- Increased pressure in confined space —> Neurovascular bundle compressed (veins + nerves first —> arterial very late) —> Tissue hypoxia
Clinical features:
1. **Pain out of proportion exacerbated by passive stretching of muscle / digits, unrelieved by analgesia
2. **Tense swelling, shiny skin
3. **Sensory deficit (Numbness due to compromised capillaries to sensory nerves) —> **Motor deficit (Paralysis)
4. ***Pulses normal (∵ Capillary pressure only ~30-40 (50% DBP) —> SBP is high ~120)
5. Other features: Blisters (∵ blood supply to skin blocked off)
6. Commonly post-traumatic
Diagnosis:
- Clinical (mainly)
- Pressure measurement
Causes:
1. High energy injury
- internal bleeding —> swell —> build up pressure —> blocked off capillary supply to **muscle + **nerve
2. Circumferential burn
Treatment:
1. Remove all tight dressing / plaster casts
2. Pain relief
3. ***Fasciotomy (only definitive treatment)
- cut open fascia in each compartment of limb
***Management of Open fractures (to prevent problems)
Save life —> Save limb —> Save function
- Advanced trauma life support (ATLS) protocol
- ABC
- Vitals
- IV fluid resuscitation
- O2 - ***Compression to control bleeding
- ***Irrigation of wound with normal saline —> Flush out contaminant
- Temporary **stabilisation with **splints / slab —> Immobilise fracture
- Examine for associated injuries
- ***Pain control
-
**Broad spectrum antibiotics (against Gram +ve (skin flora) / -ve organisms / anaerobes (depends on environment)) + **Anti-tetanus toxoid
- Prophylactic against future infection
- e.g. Augmentin, 1st gen Cephalosporin (Cefazolin) + Gentamicin +/- Metronidazole
***Surgery: Initial treatment vs Definitive treatment
Objective:
- Prevent infection
- Facilitate fracture healing
Initial: Emergency surgery
Soft tissue
1. Wound **Debridement + **Irrigation
- Removal of all contaminants + dead tissue
- Mechanical washing with normal saline / chlorhexidine
- Prevent wound infection
- Evaluation of degree of injury
- ***Repair major nerve / vessel / tendon damage
Bone
4. **Stabilisation
- Quick + avoid further damage to tissue
- **External fixation
- Pain control + prevent haematoma / dead space formation within wound to allow clotting
-
**Early soft tissue coverage / closure of open wound
- **Negative pressure wound dressing / **Suturing of soft tissue / **Skin flap / ***Skin graft coverage
- Prevent infection
- Meticulous soft tissue handling
- Suturing with minimal tension
Definitive: Elective surgery
- Few days - 2 weeks after initial injury
- When confirming ***no infection
- When soft tissue swelling improved
- Definitive fixation of fracture when soft tissue condition allows (Bone is last!!!)
-
**Internal fixation
- Removal of external fixator
- **Plating / ***Intramedullary nailing - ***Repeat debridement (2nd look surgery ~2-3 days later) —> examine wound again under surgery
External fixation
- Stabilise bone ***without further soft tissue damage
- Temporary (Convert to internal fixation Iater) / Definitive
- ***Wait for soft tissue condition to improve
Complications:
- Pin tract infection (if placed too long)
Negative pressure wound therapy
- Sealed system
- Suction removal of exudates
- Reduced edema
- Improve rate of granulation (vascular —> allow skin graft later)
Amputation
Scoring system to decide Salvage vs Amputation:
**Mangled Extremity Severity Score (MESS) —> **>=8 need amputation
1. **Skeletal / Soft tissue injury
2. **Shock
3. **Limb Ischaemia
4. **Age (less tolerant to ischaemia, toxic materials flow back to circulation when restored flow to ischaemic limb)
(5. ***Nerve injury)
Current try not to amputate unless ***obviously non-salvageable:
1. Muscle ischaemia >6 hours
2. Patients in extremis (age / general medical condition)
3. Better as an elective decision with in-depth discussion involving Patient, Family, 2 Doctors
Indications (Damage too much / Poor baseline health):
1. Peripheral vascular disease (e.g. Gangrene)
2. Trauma
3. Infections (e.g. Necrotising fasciitis)
4. Burns
5. Malignant tumours
6. Neurological conditions
7. Congenital deformities
3 “D”s:
1. Dead limb (gangrene)
2. Dying / Deadly / Dangerous
3. Damn nuisance (e.g. non-functional painful limb)
Open amputation:
1st stage:
- Remove least needed in acute situations
- Open drainage of contamination to prevent infection
2nd stage:
- Stump revision + Early closure (within a few days)
Types:
- Open (i.e. 2 stage) vs Closed (1 stage)
Upper limb:
- MESS score not really apply —> Try to avoid amputation at all cost —> ∵ Very debilitating to patient
NB: Amputation is more costly to the patient (lifetime cost: money wise) (esp. when young)
Choosing the level of Amputation
Choice:
1. Try to preserve as much as possible
2. If pulse not felt at a level —> amputate at the level above it (e.g. popliteal pulse not felt —> above knee amputation)
Too long (i.e. level too low):
- Compromised soft tissue coverage —> Difficult to close wound
- Inadequate removal of disease
- Increasing rate of wound problems (esp. in vascular disease)
Too short:
- Inadequate stump for prosthesis fitting
- Impaired function
- Increasing energy expenditure
Levels:
1. Ankle disarticulation (Syme)
2. Trans-tibial (Below knee)
3. Knee disarticulation (Through knee)
4. Trans-femoral (Above knee)
5. Hip disarticulation (Through hip)
6. Trans-pelvic / Hemipelvectomy (Hind-quarter)
Challenges of an amputee
Psychosocial:
1. Feeling incomplete as a person
2. Social stigmata
3. Costs of prosthesis
Local:
1. **Increased energy expenditure
2. Stump problems
3. **Neuropathic pain
Systemic:
1. Recurrent medical problems
2. Challenges to rehabilitate
3. ***Functional impairment: disability, handicap
Prosthesis fitting
Before:
1. Stump care
2. Edema reduction (otherwise prosthesis will be fitted based on swollen leg)
- Pressure stockings
- Casting
3. Pain control
- Phantom pain
- Neuroma
4. Mobility training
- Wheelchair, Walking aid
- Bed transfer (transfer from bed to wheelchair)
Post-amputation Training
- Strengthening
- ROM exercise
- Prevent ***flexion contracture of hips (without weight of limb —> hip flexions tend to flex hip upwards —> contracture)
- ***Balance activities (∵ without weight of limb to balance —> difficult to sit up from lying position)
- Fitting of prosthesis
- Cardiorespiratory training
- ADL training
Amputation stump (Traumatic) neuroma
Not a true tumour: Result of nerve regeneration (Wallerian degeneration of cut off part —> Severed axon of proximal part will sprout —> Stump neuroma (sensitive lump of nerve fibres))
Treatment:
1. Desensitisation
2. Antiepileptics
3. GABA receptor inhibitor
4. Opioids (less effective)
5. Surgical excision + Re-burying of stump (Bury it very deeply)
