Chapter 184 - Extremity trauma

Question 1

Incidence of extremity trauma vs all vascular injuries

Answer 1

0.5-1% of all injuries 20-50% of all vascular injuries

Question 2

Mortality after vascular trauma in extremities

Answer 2

Blunt 2-5% Total 2.8% (78% penetrating)

Question 3

Amputation rate after extremity trauma

Answer 3

7-30% (higher with blunt

Question 4

Most common areas of extremity vascular trauma in UE and LE

Answer 4

UE: forearm LE: popliteal (blunt); SFA (penetrating)

Question 5

Associated injuries with extremity vascular injuries (fracture, venous, nerve, soft tissue)

Answer 5

Fracture: 80-100% blunt; 15-40% penetrating Venous: 15-35% Nerve: LE 10%; UE 40-50% Soft tissue: LE 30%; UE 40-70%

Question 6

Hard signs of extremity arterial injury

Answer 6

1) Absent distal pulse 2) Palpable thrill or audible bruit 3) actively expanding hematoma 4) Active pulsatile bleeding

Question 7

Soft signs of extremity arterial injury

Answer 7

1) Diminished distal pulse 2) History of significant hemorrhage 3) Neurologic deficit 4) Proximity of wound to named vessel

Question 8

Physical exam for extremity arterial injury: PPV and NPV

Answer 8

PPV 100% NPV 99%

Question 9

Injury extremity index calculation and SEN/SPE

Answer 9

Distal / proximal Sensitivity 82-86%; specificity 40%

Question 10

In extremity injury, what if only soft signs and doppler index is normal

Answer 10

no further investigation needed

Question 11

CTA for extremity vascular injury SEN/SPE

Answer 11

Sensitivity 95% Specificity 90%

Question 12

Non-operative management in extremity vascular injury

Answer 12

1) success in > 70% 2) for injuries distal to axillary and femoral

Question 13

Dogma of harvesting conduit vein from non-injured limb

Answer 13

No evidence

Question 14

Key points to open repair in extremity vascular injury

Answer 14

1) longitudinal incision 2) tournequet 3) endoballoons 4) localized heparin 5) venous conduit preparation

Question 15

Temporary shunts uses in extremity injury

Answer 15

1) good in larger arteries and veins 2) poor in small forearm and tibial vessels

Question 16

Venous repair types

Answer 16

1) end-to-end 2) lateral venorrhaphy 3) patch 4) interpositional graft 5) ligation

Question 17

Ligation of injured vein key points

Answer 17

1) increase DVT but no change in PE rate 2) If cannot tollerate additional OR time for repair then ligate

Question 18

Management of venous injury to avoid edema

Answer 18

1) elevation 2) compression

Question 19

Axillary artery injury

Answer 19

1) mostly penetrating 2) all segments have similar rate 3) 1/3 have plexus injury 4) 2/3 have pulse deficit 5) open repair with interpositional graft given difficulty near thoracic outlet

Question 20

Brachial artery injury

Answer 20

1) 3/4 have pulse deficit 2) associated with # and dislocation 3) end-to-end or interpositional

Question 21

Radial/ulnar artery injury

Answer 21

1) 80% have pulse deficit 2) soft tissue trauma associated 3) Doppler based Allen test is key 4) end-to-end

Question 22

Doppler based allen test for radial/ulnar injuries

Answer 22

1) if patent palmar –> ligate 2) if not patent –> repair 3) if both injured –> repair ulnar

Question 23

Femoral artery injury

Answer 23

1) 90% pulse deficit 2) CTA needed to see PFA 3) PFA can be ligated in unstable patients with its branches embolized IR

Question 24

Popliteal artery injury

Answer 24

1) 100% diminished pulses 2) Type IV tibial plateau fractures associated with popliteal injury 3) medial approach to repair and avoid dissecting behind knee 4) highest amputation of all injuries 5) interpositional graft needed

Question 25

Risk factors fo amputation following popliteal artery injury

Answer 25

1) severe soft tissue injury 2) deep tissue infection 3) pre-operative ischemia 4) no systemic anticoagulation use 5) not primarily repaired 6) no pedal pulses within 24 hours

Question 26

Tibial artery injury

Answer 26

1) pulse deficit 2) high impact injuries 3) single tibial –> leave alone 4) repair at least 1 tibial vessel

Question 27

Compartment syndrome

Answer 27

1) 40% LE injury get fasciotomies 2) fasciotomy associated with LE #, dislocation, venous and nerve injury and multiple arteries 3) fasciotomy associated with UE # and multiple arteries 4) 20% brachial artery injury get compartment syndrome

Question 28

Mangled extremity severity score (MESS) cut off for primary amputation

Answer 28

7 or higher

Question 29

Intraarterial drug injection treatment

Answer 29

1) systemic anticoagulation with heparin 2) Dexamethasone 4 mg IV q6h 3) Dextran 40 IV at 20ml/hr 4) pain control 5) elevation 6) physio

Question 30

Frostbite

Answer 30

1) tpa if < 24 hr and shown not to due to vasospasm 2) 0.5-1.0 mg/hr TPA total via all ports 3) heparin 500 U/hr via each port/sheath

Question 31

Mangled extremity severity score

Answer 31

Question 32

Schatzker classification of tibial plateau fractures

Answer 32