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Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

ABSTRACT

Advances in modern medicine have improved both physicians’ abilities to salvage limbs in cases of extreme trauma and patients’ potential to have a good quality of life when amputation is a necessary resolution to injury. However, without rapid and appropriate intervention, extremity trauma has a high incidence of morbidity. Nurses and all members of the health team play a vital role in the initial treatment and ongoing management and support of patients with extremity trauma, a role that has a significant impact on each patient’s recovery and rehabilitation.

Continuing Nursing Education Course Director & Planners

William A. Cook, PhD,
 Director

Doug Lawrence, MS, Nurse Webmaster Course Planner

Susan DePasquale, CGRN, MSN, Nurse Lead Nurse Planner

Accreditation Statement

is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Credit Designation

This educational activity is credited for 6 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Course Author & Planner Disclosure Policy Statements

It is the policy of to ensure objectivity, transparency, and best practice in clinical education for all nursing educational activities. All authors and course planners participating in the planning or implementation of an educational activity are expected to disclose to course participants any relevant conflict of interest that may arise.

Statement of Need

The treatment of individuals with an extremity injury requires that all members of the health team be familiar with all four components of injury and associated risks. The mechanisms of injury to an extremity are important clues as to the immediate and ongoing evaluation and treatment plan. Immobilization and stabilization and the immediate interventions of pain management, as well as evaluation of potentially serious and masked injuries, require that nurses and associates be knowledgeable to provide patients with safe and appropriate assessment and care of an extremity injury.

Course Purpose

This course will provide advanced learning for nurses interested in the management of the trauma patient with an extremity injury.

Learning Objectives

1. Differentiate between simple and complex extremity trauma.

2. Describe the symptoms of osseous extremity trauma.

3. Identify the signs of vascular extremity trauma.

4. List the symptoms of nerve trauma to extremities.

5. Explain the treatment priority for patients with extremity trauma.

6. Identify the treatment goal for patients with extremity trauma.

7. List common risks involved in the treatment of extremity trauma.

8. Describe the role of general surgeons/specialists in treating extremity trauma.

9. Identify the factors that prognosticate limb salvage.

10. Describe risk factors for amputation.

Target Audience

Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Medical Assistants

Course Author & Director Disclosures

Jassin M. Jouria, MD has no disclosures

William S. Cook, PhD has no disclosures

Doug Lawrence, MS has no disclosures

Susan DePasquale, CGRN, MSN has no disclosures

Acknowledgement of Commercial Support:

There is no commercial support for this course.

Activity Review Information:

This course has been peer reviewed by Susan DePasquale, CGRN, MSN. Review Date: November 3, 2013.

Release Date: November 15, 2013 Termination Date: November 15, 2016

INTRODUCTION

Extremity trauma is one of the most common forms of trauma treated in emergency departments throughout the United States. Extremity trauma can be simple or complex, as it may cause injuries in only one of the components of the extremity or all of the four components. The four components of the extremity are the nerves, vessels, bones, and soft tissue. The most severe cases of extremity trauma will involve more than one of the components of the extremity and will be difficult to manage and repair. When a patient experiences injury in three of the four components, he or she has a mangled injury and is at an increased risk of losing the limb (1).

Treatment for extremity injuries, especially those that are severe, requires a multifaceted approach that addresses the immediate needs of the patient while preventing long term damage and salvaging the extremity. This approach typically requires the involvement of a variety of providers, including but not limited to trauma surgeons, orthopedic, vascular and plastic surgeons, and rehabilitation specialists. The focus will be on salvaging the limb while repairing the initial damage (2).

In some instances, the damage will be too severe to salvage the extremity. When this occurs, the patient will require an amputation of the extremity. In other instances, the extremity will be amputated as part of the initial injury, and will require treatment and repair to clean up the damaged area (3). While limb salvage is the primary goal, it must not take precedence over the health and safety of the patient. If the injured limb poses a risk to the patient’s survival, it must be amputated as soon as possible.

Extremity injuries are common in both military and civilian trauma situations and can be caused by a number of different mechanisms. In military situations, most extremity injuries are the result of penetrating trauma. They are often the result of explosive devices and landmines (4). In civilian trauma, the majority of extremity injuries are caused by blunt trauma. They are often the result of motor vehicle accidents and industrial accidents. However, when penetrating injuries occur in the civilian population, they are typically the result of gunshot wounds and stabbings (5).

Extremity trauma can range in severity and may be life threatening for the patient. However, advances in modern medicine have improved both physicians’ abilities to salvage limbs in cases of extreme trauma and patients’ potential to have a good quality of life when amputation is a necessary resolution to injury. Unfortunately, without rapid and appropriate intervention, extremity trauma has a high incidence of morbidity. Nurses and all members of the health team play a vital role in the initial treatment and ongoing management and support of patients with extremity trauma, a role that has a significant impact on each patient’s recovery and rehabilitation.

Open versus closed injuries

Open injuries

On open injury is any injury that involves a break in the skin. In all open injuries, the tissue underneath the skin is exposed. Open injuries can range in severity and some may appear as a small break in the skin, while others may be deep and wide. There are different types of open injuries, which are caused by various factors. The following are the most common types of open injuries (6):

• Abrasions & lacerations

• Avulsions

• Punctures

• Traumatic amputation

• Crush

Closed Injuries

A closed injury is any injury that occurs underneath the skin, with no open path from the outside to the injured area. Closed injuries are often the result of blunt trauma and will range in severity depending on a number of factors including the cause of the injury, the strength of impact, and the area that is injured. Most closed injuries are not easy to detect and often require diagnostic imaging for confirmation. The most common types of closed injuries include the following (7):

• Contusion

• Hematoma

• Crush injury

Blunt versus penetrating injuries

Blunt injuries

Blunt injuries occur as the result of blunt force trauma and can range in severity depending on the mechanism used and the strength of impact. Blunt force trauma is defined as a severe traumatic episode caused to the body or head with the sudden introduction of a blunt instrument used with great force (8).

Blunt force trauma can occur as the result of any type of object striking a part of the body with significant force and can cause a range of injuries. However, while blunt force trauma is often significant, many patients will not show signs of blunt injuries (9). In many instances, the blunt injuries will occur internally and will not be noticeable without the use of diagnostic imaging (10). Additionally, many blunt injuries will produce few outward symptoms. However, while blunt injuries are not easily detected, they can have severe consequences. If not detected, a blunt injury can cause death in a patient within a short period of time (5).

While some blunt injuries may not be apparent upon initial examination, there are some blunt injuries that produce distinct signs. The following table provides descriptions of the most common signs of blunt injuries (6):

|Sign |Description |

|Bruising |Bruising is often a good indicator that there are broken blood |

| |vessels beneath the surface of the skin. Although there may be some |

| |bruising this cannot always be a definite indicator as to how much |

| |damage has been sustained deeper within the body. |

|Abrasions |Cuts, grazing of the skin or friction burns, which can be caused by |

| |the victim being beaten, dragged or kicked. These wounds can |

| |sometimes indicate that an individual hit against something or was |

| |hit with something. In instances of assault, it can be used to |

| |measure how much of a struggle a victim put up against his or her |

| |attacker. |

|Lacerations |This is the tearing of tissue underneath the skin. An individual may |

| |have sustained a severe bump against a stationary object and |

| |underneath the skin (subcutaneous) there may be severe damage caused |

| |to tissue and organs. Visual examinations do not always show this. |

Penetrating Injuries

Although the majority of trauma injuries will be caused by blunt trauma, a number of patients will experience penetrating trauma and subsequent penetrating injuries. Penetrating injuries can range in severity depending on the object involved and the site of injury. Penetrating trauma occurs when an object pierces the patient’s skin. After the object pierces the skin, it enters the body and causes damage to the internal structures (11). With penetrating trauma, any of the internal regions can be damaged, including the bones, tendons, ligaments, nerves and blood vessels (5).

Penetrating injuries are especially common in the extremities and occur in both civilian and military trauma situations. In most instances, penetrating injuries are not life threatening. However, vascular injuries do pose a risk of death if untreated, and nerve and tendon injuries can cause long-term damage and disabilities to the patient. Penetrating injuries can occur as the result of any object piercing the skin. However the majority of penetrating injuries are the result of stabbings and gunshots, which are discussed further below (12).

Stab Wounds:

Stab wounds are one of the most common causes of penetrating trauma. They have the potential to produce significant amounts of blood loss and can cause extensive damage to the surrounding areas. The severity of injury produced by stab wounds will differ depending on the site of injury, the depth of injury, and the type of knife used (13). In many instances, the stab wound will cause trauma through extensive blood loss at the site of the wound. However, in some instances, the stab wound will result in significant muscle, vascular and tissue damage in the extremities (12). Since the extent of the damage is not visible from the outside, the patient will undergo a thorough assessment, including radiologic imaging, to determine the extent of damage.

Gunshot Wounds:

There are approximately 500,000 gunshot wounds per year in the United States, and these wounds typically cause severe damage (14). The amount and severity of injury caused by firearms depends on a number of factors, such as (15):

• Type of weapon/bullet used

• Distance from weapon

• Location and trajectory/path of injury

• Permanent vs. temporary cavity

All firearm injuries are not the same. Injury and trauma level depends on the type of firearm used. Typically, firearm injuries are categorized as either low velocity injuries or high velocity injuries, and they are classified based on the type of firearm used and the projectile impact that is caused (16). Low velocity injuries are primarily caused by firearms with a muzzle velocity of less than 600 meter per second (m/s). Most low velocity firearm injuries are caused by handguns and are more prevalent than other types of injuries (14). High velocity injuries are caused by firearms with a muzzle velocity of more than 600 meter per second. Most high velocity injuries are caused by military weapons or high powered hunting rifles (16).

Damage is often dependent on the type of bullet used. Bullets that are encased with hard shells produce deeper penetration and more significant cavitation. Bullets with soft or hollow points typically deform or fragment and often ricochet inside the body (16). This can produce damage to more areas. The actual injuries are influenced by a number of factors, including the point of entry and the distance that the victim is from the weapon (39). Some guns, such as shotguns, contain small pellets that spread apart when they are released from the barrel. This produces a blast that spreads over a larger area and will often cause damage to numerous areas of the body rather than one specific point of entry (14). However, these produce less damage when fired from a greater distance (14).

TYPES OF INJURIES

There are a variety of injuries that occur in instances of extremity trauma. The types of injury that occur are broken into categories based upon the structure that they damage. In instances of extremity trauma, injuries occur in the following regions: soft tissue, blood vessels, nerves, and bones (17). In some instances, the patient will experience injuries in more than one region. When injury occurs in three or more regions, it is considered a mangled extremity and must be treated accordingly. In most instances, mangled extremities will require amputation. However, when injury occurs in less than three regions, the risk of amputation is reduced (18). In many instances, the damage can be repaired and the patient will be able to recover with limited disability or other long term effects (19).

Osseous or Soft Tissue

Soft tissue is one of the most common injuries in extremity trauma and can occur as the result of direct or indirect trauma to the region. Soft tissue injury, broadly defined, is any injury that occurs to a non-bony, non-organ area. However, in most instances, soft tissue injury is any injury that occurs in the muscles, ligaments, and joint capsules (6).

The most common forms of soft tissue trauma are abrasions, lacerations and burns. However, soft tissue injuries can take many other forms depending on the cause and location of the injury. The primary mechanisms of soft tissue injury are mechanical and thermal. Mechanical force includes the following (20):

• Shearing

• Tension

• Compression

Of these three, compression has the potential to produce the most significant damage to the tissue and can cause additional complications for damage repair and overall healing (21).

Thermal injuries are caused by the following mechanisms (6):

• Radiation

• Convection

• Conduction

• Electricity

• Excessive cold

In both types of injury, the mechanism of injury, the material that causes the injury, and the site of the injury will impact the degree of severity. In addition, the patient’s health status and other biological factors will impact the body’s response to the injuring agent (20).

Osseous tissue is the tissue present within bones, and it provides the primary composition of the bone itself. The two types of osseous tissue are spongy and compact, and the injury will differ depending on what type of osseous tissue is damaged (22). Spongy tissue is arranged loosely within the bone and provides space for the bone marrow. Compact osseous tissue is comprised of tightly packed minerals and can be found in the outer regions of the bones (23). Osseous injuries often occur in conjunction with fractures as the tissue is exposed to damage and often swells in response to the trauma. However, osseous damage can also occur in the absence of fractures. Osseous injury that is not related to fractures is especially common in instances of blunt trauma (9).

Symptoms of Osseous/Soft Tissue Injury

Patients may display a variety of symptoms relating to soft tissue/osseous injury. The specific symptoms the patient experiences will depend on the cause, location and severity of the injury. However, there are common symptoms that most patients will experience in conjunction with a soft tissue/osseous injury. The following is a list of the most common soft tissue/osseous injuries (23):

• Pain

• Swelling

• Discoloration

• Temperature change

• Numbness/tingling

• Loss of function

Depending on the cause and type of sift tissue injury, patients may require special treatment considerations. In some instances, the injury will require special care, while other injuries may only require standard wound care. The following fact sheet (24)

provides information on special considerations for treating and managing soft tissue injuries.

| |

|Closed Wounds |

|Suspect underlying fractures |

|Splint if fracture is suspected |

| |

|Open Wounds |

|Expose all wound sites |

|Clear wounds of loose foreign material |

|Apply dressings and bandages to all wounds |

|Control bleeding |

| |

|Incised Wounds or Lacerations |

|Edges of the wound may need to be drawn together prior to dressing the wound(s) |

| |

|Impaled Objects |

|Stabilize the object |

|If the object impedes transport then careful shortening (cut) of the object may be required (object impaled in chest) |

|Immobilize object securely during shortening effort |

|Do not remove object unless it interferes with CPR or causes a complete airway obstruction (e.g. object |

|Impaled in cheek) |

| |

|Avulsions |

|Clean the wound surface |

|Fold the skin flap back to its normal state |

|Control bleeding with direct pressure |

| |

|Gun Shot Wounds |

|If possible, identify the type of weapon and the caliber |

|Assess the patient carefully for entrance and exit wounds |

|Expose all wound sites |

|Treat injuries as per the appropriate Guideline |

|Clear wounds of loose foreign material |

|Apply dressings and bandages to all wounds |

|Control bleeding |

|Consider internal bleeding, fractures, and injuries to underlying organs and structures |

|Any additional surveys and treatment should be conducted |

|Be prepared to manage cardio respiratory distress or arrest |

Vascular Trauma

Vascular trauma is defined as any injuries that occur in the vascular regions, including veins, blood vessels, and arteries. Vascular injuries occur in both blunt and penetrating trauma, with the majority of injuries caused by penetrating trauma. Approximately 75 – 80% of vascular injuries are the result of penetrating trauma, and approximately 20 – 25% of vascular injuries occur as the result of blunt trauma (25). The severity of the injury will vary depending on the location of the trauma, as damage to minor blood vessels will be less traumatic than damage to major arteries. However, vascular trauma can have long term implications if not treated properly, even when the damage occurs in minor blood vessels (26).

Vascular trauma can be difficult to detect and identify in initial trauma evaluations, unless the damage is to a major artery or blood vessel. Some patients will display very few, or no, signs of vascular trauma, which can be problematic (27). Therefore, the treating provider will have to conduct a thorough examination to determine the presence of vascular injuries. The signs for vascular injuries are separated into two categories, which are used to determine the level and immediacy of required treatment. Hard signs indicate definite injury and require immediate attention, while soft signs indicate potential injury and require additional evaluation. The following is a list of the different hard and soft signs for vascular injury.

Hard Signs:

• External or pulsate hemorrhage

• Rapidly expanding or pulsatile hematoma

• Palpable thrill / audible bruit

• Ischemic limb (absent pulses, pallor, paraesthesia, pain, paralysis, poikilothermia)

Soft Signs:

• History of arterial bleeding at the scene / in transit, now ceased

• Proximity of penetrating wound / blunt injury to an artery

• Small non-pulsatile and non-expanding hematoma over an artery

• Neurologic deficit originating in a nerve adjacent to a named artery

• Reduced pulses

• Mechanism (posterior dislocation of knee, anterior dislocation of elbow)

• Ankle Brachial Index (ABI) or Arterial Pressure Index (API) 100 mm Hg |0 |

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