Management of extremity injury

Injuries to the extremities are the primary cause of injury-related disability in many countries. These disabilities can be greatly reduced if promptly recognized and corrected. Functional disabilities due to neglected or late treatment of these injuries continue to constitute a major burden on the developing world.The ability of individuals to return to work may be compromised and they may thus become a burden on their families and communities.

The recognition of major limb injuries and associated neurovascular compromise (including compartment syndrome) are essential at all health care levels. The skills and resources required to immobilize limb injuries are considered essential at all levels, including the basic level, as appropriate immobilization can reduce or stop haemorrhage, provide pain relief, correct deformities and ensure safe transport. In unstable injuries, particularly those involving the cervical and thoracolumbar spine, immobilization may also limit secondary neurological damage, as discussed in section 5.9 (Management of spinal injury).

It is recognized that there will be great variation in types of immobilization devices used across various countries. There will be indigenous material and designs for devices and various types of splints used to immobilize the injured extremity. Any improvisation that is inexpensive and based on scientific principles should be encouraged. Individual countries may seek professional expertise as they standardize their immobilization devices to ensure patient safety. Quite often, such devices are used as a part of definitive treatment in many conditions. All health workers are expected to have the skills to provide suitable immobilization to the injured patient, as transportation may be necessary for definitive care. It is essential that necessary immobilization devices for major extremity injuries, including hand injuries, be made available at the basic level.

Spine boards (see section 5.9 for further details), which can be produced at low cost, are considered to be desirable equipment at the basic level but will be essential at higher levels of care. Immobilization technique and resources for wrapping pelvic fractures are deemed essential even at the basic level of care as this can be performed with a piece of cloth and may save many lives by minimizing blood loss in unstable fractures of the pelvis. Similarly, splinting fractures of the femoral shaft will be helpful in reducing blood loss and providing pain relief, particularly in settings where transportation times are long.

A spectrum of procedures is required for definitive management of fractures, both those presenting acutely and those with delayed presentation. These include closed manipulation and casting, skeletal traction, external fixation (and its functional equivalent, pins and plaster), internal fixation, and irrigation and debride-ment (toileting) of complex extremity wounds, including open fractures. All of these are essential at tertiary hospitals, which in general have orthopaedic surgeons. All of these are essential at specialist hospitals. Depending on the country or area involved and its resources, specialist hospitals may have orthopaedic surgeons. If they do, all of the above are pertinent. If they do not, general surgeons with appropriate training and experience may be required to perform the above-mentioned procedures, especially in circumstances where capabilities for referral to tertiary facilities are limited. The increased infection potential with more aggressive procedures, such as internal fixation, must be kept in mind. Hence, in addition to the physical presence of the implants and equipment, and to the skills necessary to conduct the procedures, a sufficiently sterile operating theatre environment is essential whenever internal fixation itself is considered essential.

In some rural, low-income circumstances, the above spectrum of capabilities might be possibly required for GP-level hospitals. This would include some procedures carried out for definitive care. It might also include procedures such as irrigation and debridement of open fractures in circumstances where transfer to higher levels is possible but often delayed for several days.

A variety of other procedures need to be considered in the armamentarium of care of extremity injuries. These include management of injured hands, tendon lacerations and compartment syndrome. They also include an understanding of the indications for amputation and the capabilities to perform this safely.The same considerations of capabilities for care by orthopaedic surgeons, general surgeons and GPs pertain.

In all cases in which practitioners are routinely called upon to provide a level of care that is above and beyond what they would ordinarily be considered to be trained for, their training should be maximized as part of planning for essential trauma care. This would include training in medical school and postgraduate programmes, as well as continuing education. It would include training for GPs and general surgeons in the above-mentioned spectrum of skills. In the case of general surgeons, it might also include training in the higher-level orthopaedic care, such as internal fixation.

As with other topics considered in previous sections, the availability of a service implies the skills needed to provide it effectively and safely, as well as the needed equipment. The relevant equipment must not only be physically present, but also promptly available to all who urgently need it, without regard to ability to pay, and worn-out or broken equipment must be repaired or replaced. As regards such physical resources, the care of injured extremities entails diagnostic (e.g. radiographic) equipment, implants and operative equipment, the latter of which will not be dealt with further in these guidelines.

X-ray facilities are generally designated essential for the diagnosis, treatment and successful outcome of skeletal injuries. It is essential that such facilities be available at appropriate levels in the system, particularly where orthopaedic surgical expertise is available. It is desirable to have X-ray facilities at a lower level (e.g. GP-level hospital or even basic facilities) to facilitate primary diagnosis and decisions regarding transfer of the patient. Portable X-rays assist in the management of patients in traction and during operative procedures. Capabilities for portable X-rays should be essential at the tertiary care level and are desirable at lower-level hospitals. C-arm image intensifier (fluoroscopy) is considered an integral part of the orthopaedic armamentarium in many settings these days as it offers accuracy, reduces operative time, decreases radiation exposure, allows closed procedures and hence saves blood loss and reduces infection rate (37, 38). It is considered a desirable resource in facilities with a trained orthopaedic surgeon. Cost constraints prevent this from being deemed essential. However, it is important to note the image intensifiers manufactured in India cost approximately $15000, which is considerably less than comparable units manufactured in high-income countries. Better resourced environments and especially highvolume facilities may want to convert this particular item of equipment to essential in their own plans.

It is noted that in countries with poor access to resources, non-operative treatment is often offered for fractures, despite the fact that operative repair would result in a better functional outcome. The reasons for this include the unavailability of implants, equipment and imaging capability, lack of surgical training, lack of a good operative environment or simply inability on the part of the patient to pay for such treatment. It is hoped that the benefits of early mobility through stabilization of fractures will eventually be passed on to every injured patient in whom internal/external fixation would be helpful to prevent disability.

The range of implants and equipment used for external and internal fixation varies greatly between countries and between hospitals in the same country. The choice of implants will depend primarily on the training and capability of the surgeons, and on the availability of implants and other resources. No attempt has been made to list the hardware required for fixation of fractures, but it is expected that a country will be able to standardize its own requirements (implants and equipment sets) with local professional expertise. Inexpensive metal implants are used in many countries, with varying degrees of success. Countries may

TABLE 8 Extremity injury

Facility level

Resources

Basic

GP

Specialist

Tertiary

Recognition of neurovascular compromise; disability-prone injuries

E

E

E

E

Basic immobilization (sling, splint)

E

E

E

E

Spine board

D

E

E

E

Wrapping of pelvic fractures for haemorrhage control

E

E

E

E

Skin traction

I

PR

E

E

Closed reduction

PR

PR

E

E

Skeletal traction

I

PR

E

E

Operative wound management

I

PR

E

E

External fixation (or its functional equivalent: pins & plaster)

I

PR

E

E

Internal fixation

I

I

E

E

Tendon repair

I

PR

E

E

Hand injury: assessment and basic splinting

E

E

E

E

Hands: debride, fix

I

PR

E

E

Measurement of compartment pressures

I

D

D

E

Fasciotomy for compartment syndrome

I

PR

D

E

Amputation

I

PR

E

E

X-ray

D

D

E

E

Portable X-ray

I

D

D

E

Image intensification

I

I

D

D

Proper management of immobilized patient to prevent complications

D

E

E

E

address the quality assurance of metal implants through appropriate mechanisms, in due course.

Complications such as pressure sores may arise from prolonged immobilization. Hence, proper management of immobilized patients (e.g. log rolling, frequent turning and early removal of spine boards) is essential at all hospital levels.

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