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The European Trauma Course Manual

Edition 4.0
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10.
Extremity and soft tissue trauma
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
QIdentifying musculoskeletal injuries
QPrioritizing the treatment principles of extremity injuries in the primary and secondary survey
QAssessing common fractures and soft tissue injuries by the ‘Look - Feel - Move’ approach
QManagement of common fractures and soft tissue injuries in the resuscitation room
Introduction
Extremity trauma is very common in polytrauma
patients and may range from minor injuries to limb- or
life-threatening ones. Whatever the severity, proper
initial management is essential to prevent early mortality
as well as morbidity at a later stage. During the primary
survey, the aim is to identify and treat immediately
life-threatening problems with the secondary survey
detecting all limb-threatening injuries. It is now
recognized that patients with significant trauma
should also routinely undergo a tertiary survey, the aim
being to find all injuries not apparent during previous
examinations, often described as function-threatening
injuries. This is particularly important in those patients
on the ICU who may be sedated, ventilated and unable
to indicate the presence of minor injuries. In other
patients, it may take place when clinically stable or
after surgery. Whatever the circumstances, it should be
completed within 24 hours of first admission although
it may be several days before all injuries are identified.
Primary Survey
Patients with extremity trauma are assessed and
managed using the same system as described in
chapter 2. The focus in relation to extremity trauma
is to recognize and control catastrophic haemorrhage
that results from traumatic amputation, long bone
injuries and deep soft tissue lacerations which if
untreated can lead to exsanguination. While large
wounds and open fractures are readily apparent to the
trauma team, other extremity injuries such, as multiple
closed fractures, can cause significant occult bleeding
if a systematic assessment is not performed. Femoral
fracture can account for 1L-1.5L blood loss
Examples of when musculoskeletal injuries may be
identified during the primary survey are given in table
10.1. It is important to note however that though
fractures of the extremities (especially open fractures)
frequently look impressive they are rarely immediately
life-threatening unless associated with a vascular injury.
It is essential that the team avoids being distracted by
such injuries during the primary survey.
TABLE 10.1
Detection of musculoskeletal injuries in
the primary survey
Airway Complaints of pain
Circulation Blood loss associated with open fractures
Penetrating injuries involving major limb vessels
Multiple limb fractures
Large soft tissue injuries
Traumatic amputation
Disability Reduced limb movement
Exposure Fractures and dislocations
(deformity, angulation, wounds)
In the presence of life-threatening haemorrhage
associated with limb trauma the team leader should
direct the circulation team during the 5-second round
to immediately control the haemorrhage using a
stepwise process:
Qdirect pressure;
Qelevation of affected limb;
Qwound packing with novel pro-coagulant,
haemostatic dressings if available. Otherwise
gauze dressings are sufficient.
Qcorrect application of a tourniquet.
CHAPTER 10 EXTREMITY AND SOFT TISSUE TRAUMA | 131
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As a result of the military experience in both Iraq and
Afghanistan, appropriately applied tourniquets have
been shown to be life-saving for patients suffering
from both blast and ballistic injuries. Recent terrorist
atrocities have reinforced these lessons within a
civilian environment.
Ideally a tourniquet should be applied before the
onset of shock in the presence of catastrophic
haemorrhage to reduce morbidity associated with
their use. Once applied, the tourniquet is tightened
until haemorrhage ceases. The time of application
must be documented, included in the handover to
the trauma team. The time the tourniquet is applied
should be kept to a minimum but only be removed
when either the patient condition allows or when initial
surgery is commenced. Recent advances in tourniquet
technology have improved tourniquet safety and
lead to a decrease in complications including pain,
transient or permanent nerve damage, skin changes
(blistering, necrosis) and compartment syndrome.
Towards the end of the primary survey, additional
fracture treatment that is carried out includes
realignment and immobilization to decrease further
bleeding and reduce pain. This coincides with the
concept of “socially aligned” which does not need to
be anatomically or definitive. It also has the advantage
of reducing the risk of secondary trauma particularly
to neurovascular structures.
Secondary Survey
During the secondary survey, all patients
must be assessed for the presence of other
possible injuries on the basis of the history
and mechanism of injury.
By the end of the secondary survey all limb-threatening
trauma must be recognized and a management plan
be in place. Typical problems include:
Qmajor soft tissue injuries;
Qcompound fractures (delayed infection);
Qvascular limb injuries;
Qcompartment syndrome;
Qneurological injuries;
Qjoint dislocations.
The majority of soft tissue injuries and fractures do not
fall into these categories. Nevertheless they still need
to be carefully assessed because they are:
Qa significant part of the Emergency Department
workload;
Qa frequent cause of prolonged and sometimes
significant morbidity;
Qa relatively common source of litigation.
132 | EUROPEAN TRAUMA COURSE
Soft tissue and bony injuries may lead to important
functional, cosmetic issues and long term psychiatric
problems, including persistent pain, numbness, joint
stiffness, weakness and deformity. Depending on
their location they may compromise hand function
or walking, and therefore produce difficulties with
mobility, rehabilitation, work and recreation.
Assessment of extremity injuries during the
secondary survey
History
Further details of the mechanism of the accident
must be obtained, including the time since injury.
For all patients vital information can be obtained
from the pre-hospital personnel (which may include
photographs from the accident scene and allow for
assessment of the damage to any vehicles, “reading
the wreckage”). Examples where the history is
important include:
QA limb run over by the wheel of a vehicle has
a risk of degloving injuries. This can result in a
limb threatening injury due to internal shearing
forces.
QThe position of the patient at the time of injury
may give clues as to where to look for injuries,
particularly after penetrating trauma.
QThe cause of the injury: lacerations associated
with contamination, e.g. wounds sustained
with a garden implement or gross aquatic
contamination.
The confirmation of corraborative information using
the AMPLE history as this will influence possible
treatment options to minimise risks to the patient:
Qsteroid usage;
Qdiabetes mellitus;
Qsmoking;
Qperipheral vascular disease;
Qmalnutrition;
Quse of immunosuppressant drugs.
Clinical examination
It is easy to miss both soft tissue and bony injuries,
particularly if the patient has a reduced level of
consciousness. These can be minimised by ensuring
the patient is appropriately exposed to facilitate a full
clinical examination of their musculoskeletal system
and performed in the following systematic fashion:
QLOOK: compare with the other side looking
for swelling, deformity and wounds. The key is
symmetry.
QFEEL: for tenderness, crepitus, swelling, skin
temperature, peripheral pulses, sensation and
compare with the uninjured side.
QMOVE: both actively and passively and compare sides.
Care should be taken however to reduce any pain
caused by clinical examination to a minimum. Many
patients with limb injuries will require x-rays but these
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and other investigations are NEVER a substitute for
adequate clinical examination.
Soft tissue trauma can be limb-threatening (table 10.2)
and may occur in isolation. It is important not to miss
these in patients with multiple injuries involving the
torso or head.
TABLE 10.2
Limb-threatening soft tissue injuries
Q Vascular injury at, or proximal to, the elbow or knee
Q Major joint dislocation, especially the knee
Q Crush injury
Q Compartment syndrome
Q Open fracture
Q Fracture with neurovascular injury
Wound Management
Assessment of soft tissue injuries requires an adequate
understanding of the anatomy of the injured area. In all
cases of penetrating trauma, clinical assessment must
be made of all structures underlying the area of the
wound. When making the assessment of the damage,
consider the patient’s posture at the time of injury.
If it is not possible to exclude underlying
damage the patient should be referred for a
specialist opinion and a formal exploration of
the wound.
Details of the wound should be quantified and
documented. This includes:
Qsite and dimensions of the wound and depth if this
is apparent;
Qthe state of the wound edges, e.g. ragged or
contused;
Qpresence of any obvious contamination;
Qpresence of devitalised tissue.
In the presence of high energy trauma, all wounds
should be considered as significant and may require
formal exploration. Foreign bodies do not always
need to be removed unless they are intra-articular,
near neuro-vascular structures or causing significant
symptoms.
Nerves
Assessment of sensation early after injury may be very
difficult. Patients may report the presence of sensation
even when subsequent exploration shows the relevant
nerve has been divided. Assess simple touch and
two-point discrimination using an appropriate blunt
device, e.g. a contoured paperclip. Compare sensation
with the opposite side, rather than ask if sensation is
present or normal. The area of abnormal sensation
should be mapped out and recorded. Motor function
can be assessed more precisely but again requires
anatomical knowledge. Motor power is recorded using
the Medical Research Council scale (chapter 9). If the
history, clinical symptoms and clinical findings suggest
the presence of a nerve injury, the patient must be
referred for exploration and if necessary nerve repair.
This should be undertaken in the operating room.
Vessels
Assessment of vascular damage should include
examination of skin pallor, capillary refill time, skin
temperature, skin turgor and peripheral pulses. The
latter may be undertaken by palpation; however if
there is any doubt a Doppler device can be used to
locate the pulse, estimate pressures and compare
with the normal side. Remember, vascular injuries
may be present even in the presence of distal pulses
and muscle is increasingly vulnerable with ischemia
exceeding 120 minutes. Therefore, if suspected, re-
assessment is crucial.
If an injury to a major limb artery is suspected, urgent
vascular opinion is necessary. With direct vascular
trauma in penetrating injuries the need for referral
is usually obvious, however following blunt trauma
the clinician must maintain a high index of suspicion
and seek expert opinion if there is any doubt. The
aim is to minimise warm ischaemic time to reduce
tissue damage, ideally to less than five hours. These
patients are likely to require angiography, pre- or
intraoperatively.
Tendons
Tendon injuries occur frequently in lacerations
to the limbs, in particular the wrist and hand. An
understanding of the anatomy is vital along with
a systematic way of examining each body area.
Simple inspection of wounds is often misleading, as
the tendon ends may retract out of sight. If there is
any suspicion of tendon injury, referral for a formal
exploration is required.
Analgesia after extremity trauma
Analgesia should be provided at the earliest
opportunity following an injury and may already
have been given by pre-hospital personnel. Non-
pharmacological interventions include elevation
of the injured limb, immobilization using plaster
backslab in a neutral position. There is no indication
for the application of a full cast in trauma patients
due to the significant risk of swelling and subsequent
compartment syndrome. Additionally oral or IV
analgesics are a standard of care, while peripheral
nerve blocks may be indicated in specific injuries
(chapter 2). In major trauma the oral, subcuteanous
and intra-muscular routes should be avoided due to
poor efficacy.
CHAPTER 10 EXTREMITY AND SOFT TISSUE TRAUMA | 133
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Management of injuries
No matter what the cause of extensive wounds, the
principles of management remain the same and are
summarised in table 10.3.
TABLE 10.3
Principles of wound management
Q Arrest of external haemorrhage
Q Adequate analgesia
Q Photograph
Q Removal of gross contamination
Q Reduction of any extruding bone, particularly if risk of skin necrosis
Q Application of a sterile “Betadine” soaked dressing, covered
with transparent, self-adhesive dressing (e.g. Opsite)
Q Realignment of the limb (angulation, rotation and length)
Q Splintage of the limb, without compression if possible
Q Antibiotic therapy
Q Anti-tetanus protection
Q Early referral for specialist opinion (if not already a part of the
resuscitation team)
Simple wound closure
All simple lacerations, particularly if superficial
(affecting only the skin and subcutaneous fat), may
be treated under local anaesthesia in the resuscitation
room. Prior to closure the wound must be thoroughly
cleaned, washed out and inspected to ensure there
is no deeper extension. Any contamination that is
obviously present would mean that the would should
be explored formally in theatre and closure is often a
delayed procedure.
Tissues which are severely contused or significantly
contaminated, should be left open at the initial
exploration and be reviewed at 48-72 hours. If clean
at that time the wound can be closed, (a technique
called ‘delayed primary closure’) giving results very
similar to those of primary closure. Wounds that
cannot be closed at 72-96hrs often contain retained
dirt. Closure of wounds should only be undertaken
when complications are minimised (ICRC surgical
guidelines).
All traumatic wounds that cannot be closed
with simple methods should be referred to the
surgical speciality that can provide advanced
wound management.
It is essential to maintain adequate records. If
wounds or lacerations are present, a diagram and
description or photograph should be included in the
documentation.
Extensive wounds
If a wound cannot be closed, and it is not suitable
to be left to heal by second intention (e.g. extensive
area, cosmetically important, risk of contracture),
134 | EUROPEAN TRAUMA COURSE
the patient should be referred to the plastic or
reconstructive surgery service at the time of initial
presentation. Management options include split skin
grafts, full thickness skin grafts, rotation flaps (skin or
myofascial) or free flaps.
Specialised wounds
Gun shot wounds
All gun shot wounds require special consideration
because of the associated pathophysiology, the
features of which are summarised in table 10.4. Tissue
destruction occurs as a result of the direct path of the
bullet producing a permanent cavity. In injury due to
high-energy transfer, temporary cavitation also occurs
in which a large cavity, (30-40 times the volume of the
permanent one) is created. This results in extensive
soft tissue damage over a much wider area and as the
cavity collapses, debris is sucked into the wound. The
principles of treatment are as illustrated above, taking
into consideration the specific features of this type of
injury.
TABLE 10.4
Specific characteristics of gun shot wounds
Q Kinetic energy of the missile
Q Presenting area of the missile
Q The missile’s tendency to deform and fragment
Q The tissue density
Q Tissue mechanical characteristics
Q Cavitation (permanent and temporary)
Q Wound contamination
Blast injuries
Extremities may be injured by blast injuries. Such
trauma is typically associated with penetrating
injuries due to shrapnel, which can act as high or
low velocity projectiles. As well as penetration, the
blast may lead to a closed injury arising from the
shock wave. This in itself results in injuries to vascular
structures in soft tissues causing gross swelling and
ischemia. Consequently, exploration may be required
to decompress fascial compartments (fasciotomies)
and assess the viability of tissue. Primary closure in
such injuries is contraindicated. These are complicated
wounds and should be dealt with by the relevant
experienced specialities.
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Assessment of fractures
History
The energy sufficient to break a bone varies between
patients. Older patients with osteoporosis suffer
fractures with minimal trauma (fragility fractures),
while young patients can withstand high-energy
forces with no skeletal damage. Such mechanisms
may be direct (e.g. assault with a blunt weapon) or
indirect (e.g. twisting injury to planted foot causing
a tibial fracture). Generally, a fall over a distance
greater than body height is described as a high-
energy transfer injury. A further factor determining
the degree of damage is the direction of the force.
A fall onto the tip of the shoulder is likely to be
associated with a fractured clavicle, while a fall on to
the outstretched hand may lead wrist fractures.
Examination
The classical signs and symptoms of a fracture are:
Qpain;
Qdeformity;
Qswelling;
Qtenderness;
Qcrepitus;
Qloss of function.
Fractures are painful. In the upper limb they result in
restricted use and in the lower limb weight bearing is
impaired. Some fractures, e.g. femoral shaft fractures,
may be associated with significant blood loss,
requiring appropriate resuscitation and stabilisation of
the fracture during the primary survey. Gross fracture
displacement can compromise surrounding soft
tissues including skin and neurovascular structures.
For this reason, following the primary survey and
provision of analgesia, the fracture should be realigned
by manual in-line traction to restore congruity with
the uninjured limb without awaiting radiographs
of the injury. Only when the diagnosis is uncertain,
e.g. in fractures near joints (which can be difficult to
differentiate from fracture- dislocations), should x-rays
be undertaken prior to limb realignment. However
when the diagnosis is certain, e.g. fracture-dislocation
of the ankle, reduction should preceed x-rays.
Fracture realignment achieves reduction of:
Qpain;
Qblood loss;
Qpressure on the soft tissues;
Qrisk of neurovascular compromise;
Qrisk of fat emboli.
Before obtaining x-rays, temporary splintage or support
should be applied. In the upper limb the use of a sling
may be sufficient or it may be necessary to use a plaster
back slab, box or vacuum splint. In the lower limb a back
slab, box splint, vacuum splint or traction splint may be
appropriate depending on the site of injury. Such simple
measures will help minimise pain from the fracture and
during any movement, while the x-ray is taken.
Imaging
Plain radiographs are the first line of imaging in
musculoskeletal trauma. To be acceptable and
adequate these should:
Qbe clearly labelled and identified including the
side (left or right);
Qbe bi-planar (usually antero-posterior and lateral);
Qdemonstrate the joint above and the joint below
any bony injury. However, in the poly-traumatised
patient, CT is often more timely and efficient.
If there is time then simple AP radiographs can
help to identify significant boney abnormality at
little risk to patient.
The exception to above is a fracture at the extreme end
of a bone, e.g. a distal radial or malleolar fracture where
it is acceptable to obtain radiographs of the affected
part only. However it is essential that an adequate
examination of the whole affected bone is undertaken
to determine any tenderness or other features that
suggests damage. In doing this the clinician should be
mindful of common fracture patterns such as:
Qinjury of the medial malleollus and/or diastasis
of the distal tibio-fibular joint that may be
associated with fracture of the proximal fibula
(e.g. Maisoneuve fracture);
Qfracture of the mid-radius that can be associated
with a dislocation of the distal radio-ulna joint
(e.g. Galeazzi fracture).
Interpretation of radiographs
Increasingly, radiographs are digitalised and made
available for viewing electronically. These images
should be viewed on a screen with appropriate
resolution. Hard copy films should always be examined
on a light box. Fractures are identified by:
Qa break in the cortex of the bone on one or more
of the views;
Qangulation of bone, especially in children;
Qa radiolucent line (in the case of a distracted fracture)
or a radiodense line (in an impacted fracture) across
part or all of the bone at the injury site;
Qsoft tissue swelling adjacent to the suspected site
of the fracture;
Qsoft tissue evidence of fractures (e.g. the fat pad
sign in radial head fractures or a lipohaemarthrosis
in intra-articular knee injuries).
Once a fracture is spotted on the x-ray and correlated
to clinical symptoms there are a number of important
features which need to be noted:
QLocation: is it in the diaphysis, metaphysis or
epiphysis? This predicts the healing potential and
is important for planning what sort of fixation to
use, if any.
QPattern: is the fracture transverse, oblique or
spiral? This indicates the stability of the fracture
to axial loading after splinting/reduction and may
determine whether operative treatment is required.
Q Involvement of a joint surface: if so, is there
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displacement of the subchondral bone (and
hence articular cartilage)? Is the fracture actually a
fracture-dislocation or fracture-subluxation?
Q Involvement of a growth plate in children. If the
fracture line actually crosses it, this is associated
with risk of growth disturbance.
QSegmental fracture (more than one fracture in the
same long bone) increases the risk of compartment
syndrome, vascular injury, non-union.
Further information may be required to determine
fracture configuration, particularly in complex joint
fractures. This is usually obtained following specialist
opinion. Although additional plain x-rays may be
helpful, CT scanning is often required to elucidate more
details and allow planning of operative treatment.
Sometimes it is not possible to identify a fracture on
an initial radiographs. If careful clinical examination
indicates the presence of signs of fracture (bony
tenderness and swelling), there are a number of
management options:
Qdecide that it is clinically insignificant (undisplaced
fracture in an unimportant site, e.g. 5th toe);
Qsplint the limb and repeat the radiographs usually
after a week or two. If the fracture is not visible
on the original radiograph, it may become visible
due to bone resorption at the fracture line (e.g.
scaphoid fractures);
QC T scan;
QMRI scan.
Initial management of fractures
The principles of initial fracture immobilization are
summarised in table 10.5. The majority should be
immobilised in the first instance as this will reduce
pain and then appropriate referrals can be made. In
open fractures it is important to resist the temptation
to repeatedly inspect the wound. This should not
occur again until the patient is in the operating room
for wound exploration, debridement and lavage.
Management of open fractures should comply with
national guidelines and clinicians should refer to their
local hospital protocols.
TABLE 10.5
Treatment of skeletal injuries
Site of fracture: Preliminary stabilisation:
Clavicle, humeral neck Sling
Humeral shaft U slab, collar and cuff
Forearm Full arm back slab
Distal radius, metacarpus Short arm back slab
Femoral shaft Traction splint
Around the knee, tibia Full leg back slab
Ankle, foot Short leg back slab
136 | EUROPEAN TRAUMA COURSE
Early complications after a fracture
Impairment of circulation to the limb beyond the fracture
It is vital to check for the presence of pulses distal to
the fracture, while keeping in mind the possibility
that, even with palpable pulses, arterial damage
may have occurred. Pulses may be present initially
and then disappear, for instance with intimal flap
tears of the arterial wall. The only adequate guard
against ischaemia due to arterial injuries is repeated
examination of temperature, sensation and pulses of
limbs (table 10.6). If a vascular injury has occurred, an
emergency vascular surgical assessment is needed.
TABLE 10.6
Signs of vascular impairment
Q Pain
Q Pallor
Q Perishing cold
Q Pulselessness
Q Paraesthesia
Q Paralysis
Compartment syndrome
Compartment syndrome most commonly follows
blunt trauma to the leg resulting in a closed tibial
fracture. However it also occurs after injuries to
the forearm, foot, buttock or any other muscle
compartment. Progressive swelling within the fascial
compartments results in ischaemia of muscles and
nerves. The classical features are:
Qprogressive pain;
Qpain of inappropriate severity to the background
injury;
Qextreme tenderness over the affected muscle
group;
Qpain with passive movements/stretching of the
affected muscle group.
Beware, this condition can occur even when there
are open fractures. This is because limbs have several
compartments (e.g. the lower leg has four) and it
is possible that some of the compartments remain
unopened even though there are overlying skin wounds.
If unrecognized, the late features include
paraesthesiae, pulselessness and eventually necrosis
of muscle and nerves. The diagnosis may not be
apparent in unconscious patients, where based on
the history and clinical findings (e.g. marked limb
swelling), the clinician should have a low incidence for
suspecting an acute compartment syndrome and seek
urgent orthopaedic opinion for surgical management.
The common sites of compartment syndrome are
summarised in table 10.7.
Remember: severe pain after a fracture,
persisting after immobilization is due
to compartment syndrome until proven
otherwise.
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TABLE 10.7
Common sites of compartment syndrome Summary
Soft tissue injuries and fractures are frequently
Q Lower leg Q Foot
challenging, potentially disabling and occasionally
Q Forearm Q Thigh
Q Hand Q Buttock
life-threatening. Careful assessment of the anatomical
extent of these injuries, and appropriate treatment is
essential and can make an enormous difference to
Causes of compartment syndrome: the initial symptoms and the degree of long-term
Qfractures; disability experienced by patients after trauma.
Qcrush injury;

Qreperfusion injury (post correction of any Having worked through this chapter you are now
displacement causing vascular impairment); ready to apply the following knowledge in the
Qpharmacological, e.g. anticoagulants; extremity trauma workshop:
Qinjection (e.g. misplaced intraosseous needle). Qidentifying musculoskeletal injuries;

Qprioritizing the treatment principles of

Patients with acute compartment syndrome require extremity injuries during the primary and
immediate surgical decompression. secondary survey;
Qassessing common fractures and soft tissue

Dislocations injuries by the ‘Look-Feel-Move’ approach;

A dislocation is an injury to a joint which results in the Qmanagement of common fractures and soft

two joint surfaces no longer being in contact. A partial tissue injuries in the resuscitation room.
dislocation (subluxation) may also occur. These are
often difficult to distinguish from periarticular fractures These cognitive abilities will be integrated with
and it is important to obtain adequate imaging. the practical skills during the course workshops.
However, if there is gross deformity, neurovascular
compromise or a problem with overlying skin, it is
appropriate to reduce the deformity prior to obtaining Further information
x-rays. Experience will help, as there are a limited
number of characteristic deformities with dislocations. Q AO Foundation Trauma:


https://aotrauma.aofoundation.org
Dislocations are painful and are an orthopaedic Q BOAST 4 The Management of severe open lower

emergency. They are often dealt with in the emergency limb fractures (BOA & BAPRAS consenscus 2009)
department. In any dislocation, the neurovascular Q BOAST 10 Diagnosis and management of

status of the dislocated limb should be documented compartment syndrome of the limbs (BOA &
pre & post manipulation. A typical dislocation is BAPRAS 2016)
anterior dislocation of the shoulder. It usually follows Q Key Clinical Topics in Trauma 2016 Porter, Greaves

a fall on to the outstretched hand. This is frequently & Burke

recurrent, occurs in young patients and is associated
with a typical deformity of the shoulder (empty
glenoid). Neurovascular injuries occasionally occur
but are uncommon. Reduction has to be performed
by a doctor with experience in joint reduction. Gleno-
humeral (shoulder) dislocations are usually anterior.
Hip dislocations are usually posterior.
Other common joints that dislocate are:
QPatello-femoral

Qelbow

Qankle (usually associated with a fracture)

Qwrist

Qknee (high incidence of occult vascular injury

CHAPTER 10 EXTREMITY AND SOFT TISSUE TRAUMA | 137

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BRITISH ORTHOPAEDIC ASSOCIATION and

BRITISH ASSOCIATION OF PLASTIC, RECONSTRUCTIVE
AND AESTHETIC SURGEONS
STANDARD for TRAUMA – 2009

BOAST 4: THE MANAGEMENT OF SEVERE

OPEN LOWER LIMB FRACTURES
Background and Justification:
The British Orthopaedic Association and the British Association of Plastic, Reconstructive and Aesthetic
Surgeons have reviewed their 1997 guidance and now publish a review of all aspects of the acute man-
agement of these injuries using an evidence-based approach, leading to the “Standards for the
Management of Open Lower Limb Fractures,” which are free to download from www.boa.ac.uk and
www.bapras.org.uk. This BOAST is derived from these standards. Contrary to traditional teaching, best
outcomes are achieved by timely, specialist surgery rather than emergency surgery by less experienced
teams.

Included Patients:
All patients with high energy open fractures as manifest by the following injury patterns:
Fracture Pattern: - Multifragmentary (comminuted) tibial fracture with fibular fracture at same level
- Segmental fractures
- Fractures with bone loss, either from extrusion or after debridement
Soft tissue injury: - Swelling or skin loss, such that direct, tension-free wound closure is not possible
- Degloving
- Muscle injury that requires excision of devitalised muscle via wound extensions
- Injury to one or more major arteries of the leg
- Wound contamination with marine, agricultural or sewage material

Standards for Practice Audit:

1. Intravenous antibiotics are administered as soon as possible, ideally within 3 hours of injury: Co-amoxiclav
(1.2g) or Cefuroxime (1.5g) 8 hourly and are continued until wound debridement. Clindamycin 600mg, 6
hourly if penicillin allergy
2. The vascular and neurological status of the limb is assessed systematically and repeated at intervals, par-
ticularly after reduction of fractures or the application of splints
3. Vascular impairment requires immediate surgery and restoration of the circulation using shunts, ideally within
3-4 hours, with a maximum acceptable delay of 6 hours of warm ischaemia
4. Compartment syndrome also requires immediate surgery, with 4 compartment decompression via 2 incisions
(see overleaf)
5. Urgent surgery is also needed in some multiply injured patients with open fractures or if the wound is heav-
ily contaminated by marine, agricultural or sewage matter.
6. A combined plan for the management of both the soft tissues and bone is formulated by the plastic and
orthopaedic surgical teams and clearly documented
7. The wound is handled only to remove gross contamination and to allow photography, then covered in saline-
soaked gauze and an impermeable film to prevent desiccation
8. The limb, including the knee and ankle, is splinted
9. Centres that cannot provide combined plastic and orthopaedic surgical care for severe open tibial fractures
have protocols in place for the early transfer of the patient to an appropriate specialist centre
10. The primary surgical treatment (wound excision and fracture stabilisation) of severe open tibial fractures only
takes place in a non-specialist centre if the patient cannot be transferred safely
11. The wound, soft tissue and bone excision (debridement) is performed by senior plastic and orthopaedic sur-
geons working together on scheduled trauma operating lists within normal working hours and within 24 hours
of the injury unless there is marine, agricultural or sewage contamination. The 6 hour rule does not apply for
solitary open fractures. Co-amoxiclav (1.2g) and Gentamicin (1.5mg/kg) are administered at wound excision
and continued for 72 hours or definitive wound closure, which ever is sooner
12. If definitive skeletal and soft tissue reconstruction is not to be undertaken in a single stage, then vacuum
foam dressing or an antibiotic bead pouch is applied until definitive surgery.
13. Definitive skeletal stabilisation and wound cover are achieved within 72hours and should not exceed 7 days.
14. Vacuum foam dressings are not used for definitive wound management in open fractures.
15. The wound in open tibial fractures in children is treated in the same way as adults

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Evidence Base:
Derived from the 2009 BOA/BAPRAS Standards for the Management of Open Lower Limb Fractures.
This is based upon case series, case-controlled studies and reviews together with an evolved, multi-
national, professional consensus over 15 years.

Limitations:
There is inconclusive evidence to the best method of skeletal stabilisation.

Recommended incisions for fasciotomy and wound extensions. (a) Margins of subcutaneous bor-
der of tibia marked in green, fasciotomy incisions in blue and the perforators on the medial side arising
from the posterior tibial vessels in red. (b) line drawing depicting the location of the perforators. (c) mon-
tage of an arteriogram. The 10cm perforator on the medial side is usually the largest and most reliable
for distally-based fasciocutaneous flaps. In this patient, the anterior tibial artery had been disrupted fol-
lowing an open dislocation of the ankle; hence the poor flow evident in this vessel in the distal 1/3 of the
leg. The distances of the perforators from the tip of the medial malleolus are approximate and vary
between patients. It is essential to preserve the perforators and avoid incisions crossing the line between
them.

Cross-section through the leg showing incisions to decompress all four compartments

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Extremity and soft tissue trauma - Skills

How to apply a Thomas Splint
A Thomas splint can be applied as a temporary measure
prior to definitive fixation of a femoral fracture or for
transport of patients abroad (as seen in evacuation of
UK military patients from Iraq and Afghanistan)
Procedure
QInform patient about fitting of the splint and
QSelect the correct sized Thomas splint and take
all the equipment to the patient. If the splint is a
half ring construct, ensure that the medial side is
shorter than the lateral.
QAfter the analgesia has been given, ensure patient
is comfortable.
QApply skin traction taking care to protect the
malleoli and head of fibula with padding.
QApply the bandage snugly but do not make it too

traction tight.
QProvide adequate analgesia

QPrepare the equipment:

You will need the following:

1. Correct size splint
2. Skin traction kit
3. 2 crepe bandages
4. 3-5 calico-type slings
5. safety pins or bull dog clips
6. Gamgee dressing (length of cotton wool
enclosed in gauze to serve as cushion)
7. Tape
8. 2 wooden spatulas
9. Scissors
QMeasure the uninjured leg and make allowance

for present and anticipated swelling

Measure also the length of the leg from inner thigh to

the heel and add 20-30 cm

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QApply traction with one hand on the spreader bar

of the skin traction.
QThe selected splint is pushed up the leg. It should

reach the ischial tuberosity or perineum and it

should be possible to pass one finger beneath the
ring around its complete circumference.

Q A Gamgee dressing can be applied above the

slings as a protective cushion underneath the leg.
A cotton pad can also be applied below the knee to
flex it by about 10-15˚ and another cotton pad can
be applied along the head of the fibula to protect
the common peroneal nerve from pressure against
the outer rod of the splint.

QWhen fully pushed in, the splint must have 30 cms

projecting beyond the foot. There should also be
space enough between the inner ring and thigh
for one finger to go round.
QStrips of 6 inch Calico bandage can be used to

make slings

Q A Chinese windlass using 2 spatulas may be used

to take up the slack. The 2 spatulas are inserted
between the two chords and then rotated to
create further traction and tightening.

After care:
QOne of the slings should be placed directly under QCheck for tightness of the ring from swelling.

the fracture. QLook for any developing pressure sores.

QThe slings should be sagging and not tight. QCheck Achilles tendon and malleoli for pressure

areas.
QCheck for new weakness of ankle dorsiflexion

(common peroneal Nerve pressure) and repad as

necessary around fibula head.

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How to apply the Kendrick traction device.

Place upper thigh strap high into groin with the poles
on the outside of the leg. Measure pole against leg.
The bottom of the pole should extend 1 section below
the foot. The pole can be shortened or lengthened.
NB maintain inline traction of limb

Prior to attachment of the ankle strap, the yellow

Velcro strap can be placed just above the knee.

Apply the ankle strap with the padded bit behind the
ankle. Tighten using the green strap. The yellow strap
fits over the pole and traction applied with the red
strap. (a small amount of counter-traction needs to be
applied at this point)

Apply the other two Velcro straps: the red strap at

the top of the thigh, the green strap on the lower leg.
Manual traction is now released.

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