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TRAUMATIC EXTREMITY INJURIES 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 limb salvaging in cases of extreme trauma and the potential of patients to have a good quality of life when amputation is a necessary resolution to injury. Without rapid and appropriate interventions, extremity trauma has a high incidence of morbidity. All clinicians have a vital role in the initial treatment, ongoing management, and support of patients with extremity trauma, a role that has a significant impact on each patient’s recovery and rehabilitation. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning 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 clinicians and emergency treatment teams be knowledgeable to provide patients with safe and appropriate assessment and care of an extremity injury. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Course Purpose This course will provide advanced learning for clinicians interested in the management of the trauma patient with an extremity injury. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. The most common types of closed injuries include: a. Contusion b. Hematoma c. Crush d. All of the above 2. Which following type of fracture poses the greatest risk of nonunion: a. Wrist (carpus) fractures b. Femur fractures c. Facial fractures d. Spinal fractures 3. Life threatening extremity injuries include: a. Pelvic disruption with massive hemorrhage b. Severe arterial hemorrhage irrespective of mechanism c. Multiple long bone fractures (blood loss into the compartments) d. All of the above 4. True or False. Patients who do not present with any of the hard or soft signs for vascular injury may still have damage that is not yet apparent. a. True b. False 5. Type IIIA fracture classification involves: a. Severe tissue injury with open bone exposed b. Fracture to upper and/or lower extremity limbs c. Low contamination with infection rate less than 2 % d. None of the above nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 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 improving the chance to salvage an extremity. This approach typically requires the involvement of a variety of clinicians, such as trauma surgeons, orthopedic, vascular and plastic surgeons, and rehabilitation specialists among some others. The focus will be on salvaging the limb while repairing the initial damage.2 Without rapid and appropriate intervention, extremity trauma has a high incidence of morbidity. 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. Types Of Extremity Injuries 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. In civilian nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 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. 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 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 the patient’s potential to have good quality of life when amputation is a necessary resolution to injury. 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 most common types of open injuries include those involving abrasions and lacerations, avulsions, punctures, traumatic amputation and crush.4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 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 contusion, hematoma and crush injury.4 Blunt Versus Penetrating 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.4 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. In many instances, the blunt injuries will occur internally and will not be noticeable without the use of diagnostic imaging. Additionally, many blunt injuries will produce few outward symptoms. However, while blunt injuries are not easily detected, they can have severe consequences.5,6 If not detected, a blunt injury can cause death in a patient within a short period of time.
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