Penetrating nontorso trauma: the extremities

Stopping extremity hemorrhage: More than just a tourniquet

Major extremity hemorrhage is a surgical emergency, and the physical examination is essential to help dictate appropriate clinical decision making. Hard signs that require immediate surgical intervention include ongoing bleeding, expanding hematoma, ischemic limb, as well as partial/complete amputation. Packing, compression, balloon tamponade, and tourniquets are very helpful to temporize major hemorrhage. Mangled extremities are very challenging to manage and require a multidisciplinary approach. Temporary vascular shunts are excellent tools for vascular/orthopedic damage control and for temporary stabilization prior to transport for definitive care.

Impalement injuries of the shoulder: a case report with literature review

The management of penetrating skeletal extremity trauma is a clinical challenge even for experienced surgeons. While the treatment of associated vascular injuries should be prioritized, there is still a lack of evidence regarding the management of foreign bodies in case of bone fractures or neurological injuries. Here we present a case of impalement of the right proximal humerus with a construction steel rod. The 54-year-old man was successfully treated without vascular, neurological, and thoracic sequelae. A review of the current literature about the most appropriate extrication sequences and soft tissue reconstruction following massive foreign body injuries was carried out.

Treating fractures in upper limb gunshot injuries: The Cape Town experience

BACKGROUND

Upper extremity gunshot fractures are generally treated conservatively or surgically using open reduction and internal fixation (ORIF), intramedullary nails (IM) or external fixators. However, there is no gold standard for the management of these complex, multi-fragmentary upper extremity fractures. The aim was to describe and identify the injury patterns, management, complications and associated risk factors for upper extremity gunshot fractures.

PATIENT AND METHODS

Data of patients with upper extremity gunshot injuries that presented to a Level I Trauma Unit in Cape Town, South Africa was collected prospectively over a ten-month period from June 2014 to April 2015. Clinical notes and radiographs were reviewed retrospectively.

RESULTS

Fifty-one of 90 patients (56.7%) with ballistic injuries had fractures, 30% had neurovascular injuries and 75% had additional injuries to other anatomical structures including head, neck, spine, chest, abdomen, pelvis and urogenital tract. Most fractures were diaphyseal, multi-fragmentary and extra-articular. Fractures were treated conservatively in more than half of the cases. Median fracture length was 5.5 centimetres. A longer fracture zone was statistically associated with surgical treatment. When surgically treated, open reduction and internal fixation was most often performed. Median hospital stay was six days. Infection and injury severity prolonged hospital stay.

DISCUSSION

In contrast to studies from the USA and Europe, most fractures in this study were managed conservatively. High quality prospective controlled trials are required to evaluate radiographic and clinical outcomes of treatment methods for upper extremity gunshot injuries.

LEVEL OF EVIDENCE

IV, case series.

Damage control surgery

PURPOSE OF REVIEW

Damage control surgery (DCS) has become a lifesaving maneuver for critically injured patients when utilized in appropriate scenarios. Despite this reality, indications for initiating DCS remain debated.

RECENT FINDINGS

Despite discussion surrounding the appropriate indications for DCS, this series of fundamental principles includes a rapidly abbreviated operative intervention aimed at arresting ongoing hemorrhage and containing gastrointestinal contamination in a patient approaching physiologic exhaustion, which includes both vascular and nonvascular damage control techniques, in addition to management of the open abdomen. Patients are then returned to the operating theater for definitive reconstruction once their physiology has been stabilized within the ICU.

SUMMARY

DCS is lifesaving when applied in appropriate clinical scenarios involving critically injured patients. Overuse of this technique can lead to increased patient morbidity and cost however.