Extremity trauma is a common, potentially life-threatening phenomenon. Injuries to the limbs include fractures and bleeding, which should be immobilized and controlled, respectively. Paramedics and EMRs/FRs should endeavour to resolve neurological or vascular compromise wherever possible.
Essentials
Bleeding from limbs can be life threatening. Control using direct pressure. Apply tourniquets as necessary.
If a limb is pulseless and severely angulated, it should be repositioned to allow for the restoration of pulses.
Fractures require stabilization with good splinting practices.
Additional Treatment Information
Altered sensation, loss of a pulse, or cold and dusky skin in a limb distal to a fracture or dislocation is an indicator of neurological or vascular compromise. This is a limb threatening injury and is time critical.
The general principles of reducing a fracture are:
Apply traction and gentle counter-traction in the line of the limb
If required, further manipulation should be done while the limb is still under traction
Splint the limb following reduction
Amputated limb portions should be rinsed with cool sterile saline prior to being wrapped in loose, saline-moistened sterile gauze. The limb can then be placed inside a plastic bag and kept in a cool, protected place while being conveyed with the patient. Do not immerse the amputated limb in water, keep the limb cool, and do not place directly on ice or use dry ice to cool.
The use of traction splints should be reserved for isolated, closed, mid-third femoral fractures. In major trauma cases, or with multiple injuries, splint the injured leg to the opposite leg (anatomical splinting) and use a clamshell to immobilize.
All patients with extremity trauma should be conveyed to the closest appropriate trauma receiving hospital as per local trauma destination guidelines or clinical pathway.
General Information
Fractures are a condition in which there is a break in the continuity of a bone. It may be caused by direct force or indirect impact. The aging process causes significant changes to the skeletal system; bones become less flexible, more brittle, and more susceptible to fractures. Additionally, pathological conditions such as tumours of the bone, periosteum, cartilage, or other diseases, can also increase the likelihood of fractures.
Fractures are characterized by deformity, swelling, pain, bruising, crepitus, and instability.
Fractures are categorized as:
Closed; surrounding skin remains intact
Open; disruption in the surrounding skin with or without protruding bone ends
Dislocations are a separation of two bones where they meet at a joint. In a complete displacement of a bone end from its normal joint position, the bone sits in an abnormal position. Risks associated with dislocations include trapping, compressing, or tearing of blood vessels and nerves. Dislocations are usually characterized by obvious deformity, pain, swelling, and immobility of the joint.
Paramedics and EMRs/FRs should exercise a high degree of suspicion with possible knee dislocations (as distinct from patellar dislocations): assume that a significant underlying arterial injury exists requiring careful management.