Severe extremity injury in the adult patient
- Jeremy W Cannon, MD, FACS
Jeremy W Cannon, MD, FACS
- Associate Professor of Surgery
- Perelman School of Medicine at the University of Pennsylvania
- Todd E Rasmussen, MD, FACS, COL, USAF, MC
Todd E Rasmussen, MD, FACS, COL, USAF, MC
- Harris B Shumacker, Jr. Professor of Surgery
- Associate Dean for Research
- F. Edward Hebért School of Medicine
- Uniformed Services University of the Health Sciences
- Bethesda, MD
- Attending Vascular Surgeon
- Walter Reed National Military Medical Center
- Bethesda, MD
- Section Editors
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Trauma to the extremities represents one of the most common injury patterns seen in emergency medical and surgical practice. As extremity injuries are evaluated, each of four functional components (nerves, vessels, bones, and soft tissues) must be considered individually and together. If three of these four elements are injured, the patient has a “mangled extremity” [1,2]. Achieving the best outcome in patients with severe extremity injuries requires a multidisciplinary approach with oversight by the general or trauma surgeon and commitment from other specialists including orthopedic, vascular, and plastic surgeons, as well as rehabilitation specialists. In most instances, limb salvage can be attempted even if the patient has a mangled extremity. However, at times, the injury to the extremity is so severe that primary amputation at the initial operation is required to save the patient’s life.
The initial management of severe extremity injury will be reviewed here. The management of minor extremity injuries, including isolated fracture management, is discussed elsewhere. (See "General principles of fracture management: Bone healing and fracture description" and "General principles of fracture management: Early and late complications" and "General principles of acute fracture management" and "General principles of definitive fracture management".)
The etiology of extremity injuries ranges widely from falls and motor vehicle collisions to blast and fragmentation injuries. The nature and severity of extremity injuries differs between the military and civilian setting. Military extremity injuries are primarily due to penetrating or combined mechanisms, which are associated with high rates of open fracture and vascular injury . In contrast, most severe extremity injuries in civilians are due to blunt trauma, but about 12 percent of civilian extremity injures occur as a result of penetrating or combined mechanisms.
Civilian — Civilian extremity injuries occur most often due to falls (representing 50 to 60 percent of lower extremity injuries and 30 percent of upper extremity injuries), industrial or work-related accidents (up to 20 percent of upper extremity injuries), and motor vehicle crashes . Most upper extremity injuries occur as a result of using machinery or tools.
In civilians with nonfatal trauma, upper and lower extremity injuries are the most common reason for hospitalization, with more than one-third of those hospitalized having serious or limb-threatening injuries [4-6]. In a systematic review of 3187 lower extremity injuries requiring vascular repairs, the overall secondary amputation rate was 10 percent .
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- EXTREMITY ANATOMY
- INITIAL EVALUATION AND MANAGEMENT
- Control of hemorrhage
- Extremity radiography
- Tetanus prophylaxis
- Special situations
- - Traumatic amputation
- - Extremity electrical injury
- EXTREMITY EVALUATION
- Peripheral nerve assessment
- Vascular assessment
- - Hard signs of arterial injury
- - Injured extremity index
- - Arteriography
- Soft tissue and bone assessment
- INJURY SEVERITY SCORING
- Open fracture grading
- Predicting limb loss
- - Clinical predictors
- - Scoring systems
- MANAGEMENT APPROACH
- Hemodynamically unstable
- Hemodynamically stable with vascular injury
- Hemodynamically stable without vascular injury
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS