Dr.AbdulWAHID M Salih

Ph.D. Surgery

LIMBS INJURY

WOUNDS OF LIMBS• 50-75% of all missile wounds and blast injuries

involve the limbs

Fractures• Should Be Stabilized To Avoid: 1. Further damage to surrounding tissue, 2. bleeding 3. pain.

IMMOBILIZATION of entire limb

INDICATIONS;1. All severe soft tissue wounds of extremities2. Fractures should initially be immobilized

METHODS OF IMMOBILIZATION

1. Sling 2. plaster back slabs.3. application of splints

The leg

• Splinted by binding it To the good leg

Thomas splint

• Immobilize compound fractures of the femur and fractures around the knee joint

METHODS OF IMMOBILIZATION

4. Plaster of paris (pop)5. Skin or skeletal traction

METHODS OF IMMOBILIZATION6. External fixation

Principles of cast application1. Slabs or cylinders that have been well split are the

only safe plasters to apply.2. Never put;

• Complete• Unsplit• Unpadded cylinder• Tight bandages

VASCULAR INJURIESpossible vascular injury ;• The Position Of The Missile Track, • The Presence Of A Subfascial Haematoma, • After Resuscitation, Distal Pulses Remain

Impalpable,

Management of arterial injury• Urgent surgical exposureas early as circumstances

allow, preferably within six hours of injury. • “LOOK AND SEE” is wiser than “wait and see”.• Every effort should be made to repair arterial damage• After major arterial ligation the incidence of limb gangrene is very high• Fractures should be treatedafter vascular surgery

Circulation can be impaired by1. Complete, unsplit, unpadded cylinder 2. Tight bandages applied to a limb 3. Swelling occurs in a limb within the first 24 – 48

hours after;Fracture,severe sprain, wound or operation;

Signs of compartment syndrome“7 P’s”:

1. severe pain at rest2. Pain with passive stretch3. Parasthesia (tingling and numbness)

4. Paresis (weakness) impaired movement

5. Pulses (diminished pulses in the affected limb)

6. Pallor (loss of normal color)

7. Persistent cold

• Pressure (tense)

A tonometer to directly measure pressure• indication for fasciotomy;

intracompartmental pressure >30 mmHg[10]

• <30 mmHg difference between intracompartmental pressure and diastolic blood pressure

Indications for fasciotomy

1. wounds directly involving the calf;2. concomitant major venous injuries;3. clinical compartment compression syndrome in

the immediate postoperative period;4. when the ischaemic state has existed for longer

than 4-6 hours before arterial surgery;5. any major arterial injury to the limbs.

The anterior and lateral fascial compartments

• A single longitudinal incision 15 cm in length

• Placed halfway down the leg,

• 2 cm anterior to the shaft of the fibula.• Dividing the anterior and lateral compartments,

The two posterior compartments• Single Longitudinal Incision 15 Cm In Length In The

Distal Part Of The Leg• 2 Cm Posterior To The Palpable Posteromedial Edge Of The Tibia.

FasciotomyThe deep fascia must be incised along the length

of the skin incisionallows wide and deep retractionleft open to allow post-operative oedematous and

congested tissue to swell without tensionexposes the depths of the wound

Fasciotomy• The wounds should be left open for delayed closure.

Complications• Muscle and nerve cell death• deformity, paralysis, permanent

muscle contraction (Volkmann's contracture),

• systemic infection (sepsis) • and renal failure.)• amputation

TENDON, NERVE

• No attempt should be made at primary;• Tendon or nerve repair, In Grossly contaminated wounds.

Major Artery

An injury to a major artery to the limb:• must be either repaired • or replaced by a saphenous vein graft immediately

INJURIES OF PERIPHERAL NERVES

• May be injured alone • more commonly, in association with vascular

damage or long bone fractures.

Nerve repair• In multiple injuries, nerve

repair is of the lowest priority. • Nerve repairs are performed

when wounds are healthy and clean, which is generally at least 6 weeks after injury.

• Repair can safely be deferred for 3 months but contractures must not be permitted to develop.

General indications for Amputation

1. severe damage:2. no chance of recovery of function of any part3. mangled, grossly contaminated wounds4. overwhelming infection5. established gangrene;6. continued infection associated with severe nerve and bone Injury7. secondary haemorrhage, uncontrollable by other measures8. multiple injuries,

GAS GANGRENEThe risk: 1. Foreign bodies in wounds such as clothing,

soil, metal or wood, 2. Prolonged application of tourniquets or tight

plasters3. Fascial compartment compression syndromes4. Delayed treatment

GAS GANGRENE• The incubation period ; less than three days• the sudden appearance of pain in the region of the wound.• oedematous • drainage of thin serous or

serosanguinous exudate • The pulse rate rises markedly • but the temperature is rarely more than 38° C. • clinically deteriorates• within several hours becomes anxious and frightened

• hypotensive and may vomit in severe cases.

GAS GANGRENEImmediate surgical intervention is essential