Injuries to the extremities

Bleeding from the extremities is best controlled by direct pressure or intermittent application of a tourniquet. Prolonged use of a tourniquet can aggravate ischemia, nerve injury, and tissue death, and should be avoided if at all possible. Arterial injuries can be primarily repaired, resected and grafted, ligated, or bypassed, depending on the condition of the patient and the nature of the wound. Low-velocity injuries require minimal debridement and resection; primary anastomosis is frequently possible. High-velocity injuries result in much longer segments of intimal damage and grafting is usually needed. Options for bypass include autologous vein (e.g. saphenous) or prosthetic material; the latter has the disadvantage of decreased patency as well as increased risk of infection ( Fig 2). All arterial repairs should be covered. If the graft fails, or if temporary ligation is required because of the patient's overall condition, a bypass may be performed in a more controlled setting if there is the possibility of salvaging an ischemic limb. Postoperatively, patients should receive antiplatelet medication. When ligation is necessary, amputation rates depend on the site of injury and the available collateral supply. Limb loss occurs in 80 per cent of cases when both the superficial and deep femoral arteries are ligated, while ligation of the femoral artery alone results in limb loss rates of 25 to 50 per cent. If major venous injury requires ligation, a significant proportion of patients will experience limb swelling and edema which may progress to compartment syndrome. Management may include elevation, possible fasciotomy, and consideration of anticoagulation therapy ( Shackfoid.,..§D,d,.B,!£h 199,1).

Fig. 2 (a) Emergency department arteriogram of a patient who sustained a gunshot wound that traversed the right and left thighs. The bullet is seen lying laterally in the left thigh and the study demonstrates an injury to the superficial femoral artery. (b) Operative findings demonstrating a transected superficial femoral vein and contused superficial femoral artery. (c) The vein has been ligated and the artery has been grafted with Gortex after debridement.

High-velocity gunshot wounds or blast injuries resulting in complex orthopedic and arterial injuries are technically more challenging, and an attempt should be made to keep the ischemic time below 6 to 8 h. Approaches include stabilizing with external fixation devices followed by vascular repair, using a shunt during bone stabilization, and vascular repair followed by bone fixation.

Simple extremity swelling may be managed conservatively with elevation and ice packs. Compartment syndrome requires complete fasciotomy. A 'four-compartment' fasciotomy, using two incisions or one incision with fibulectomy, is required in the leg below the knee. The muscle should be viable and bulge freely after the fasciotomy. The wound is closed electively (primary and/or skin grafting).

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