Tag Archives: extremity

Extremity

Posterior Hip Dislocation

Leave a comment

Although posterior hip dislocation is an uncommon injury, the consequences of delayed recognition or treatment can be dire. The majority are caused by head-on car crashes, and 90% of these are posterior dislocations. The femoral head is forced across the back wall of the acetabulum, either by the knee striking the dash, or by forces moving up the leg when the knee is locked. This occurs most commonly on the right side when the driver is standing on the brake pedal, desperately trying to stop.

On exam, the patient presents with the hip flexed, internally rotated and somewhat adducted. Range of motion is limited, and increasing resistance is felt when you try to move it out of position. An AP pelvic X-ray will show the femoral head out of the socket, but it may take a lateral or Judet view to tell if it is posterior vs anterior.

These injuries need to be reduced as soon as possible to decrease the chance of avascular necrosis of the femoral head. Procedural sedation is required for all reductions, since it makes the patient much more comfortable and reduces muscle tone. The ED cart needs to be able to handle both the patient’s weight and your own. I also recommend a spotter on each side of the cart.

Standing on the cart near the patient’s feet, begin to apply traction to the femur and slowly flex the hip to about 90 degrees. Then gently adduct the thigh to help jump the femoral head over the acetabular rim. You will feel a satisfying clunk as the head drops into place. Straighten the leg and keep it adducted. If you are unsuccessful after two tries, there is probably a bony fragment keeping the head out of the socket. See an instructional video on this in my next post.

Regardless of success, consult your orthopedic surgeon for further instructions. And be sure to thoroughly evaluate the rest of the patient. It takes a lot of energy to cause this injury, and it is flowing through the rest of the patient, breaking other things as well.

Extremity

ABI vs API For Vascular Trauma

Leave a comment

In general, the first maneuver in evaluating for possible vascular injury in an extremity is the good old physical exam. Is there a pulse or isn’t there? You can then subdivide that into: is the pulse weaker than normal. The problem is, what is “normal?” In most cases, we just compare it to another pulse somewhere and make a subjective judgment.

But we love to be more objective about things. Over the years, two simple, noninvasive techniques for evaluating pulses have been developed. The first is the ankle brachial index (ABI) , which was first described in 1930 and was used for diagnosis of peripheral vascular disease in 1950. It is performed by dividing the systolic pressure at the ankle of the affected extremity by the systolic pressure of one of the brachial arteries in the arms.

The new(er) kid on the block is the arterial pressure index (API), first described in 1991. This value is calculated by dividing the systolic pressure in the affected extremity by the systolic pressure in the contralateral uninjured extremity.

Many trauma professionals use the ABI when evaluating for potential vascular trauma. The typical threshold for pursuing further evaluation is 0.9, and several papers have been published on this topic. The API has also been critically evaluated, and the same threshold is used.

However, I believe that the API is more relevant and accurate than ABI. Why? Patients with atherosclerotic disease typically manifest it in their lower extremities. This serves to falsely elevate the ABI to a value greater than 1.0. It becomes more difficult to get down to that critical value of 0.9 that might indicate a vascular injury. Thus, the ABI may not detect a true injury, especially one in the lower extremities.

The API, on the other hand, relies on the fact that the amount of atherosclerotic disease is usually symmetric between the two lower extremities or the two upper extremities. Thus, the value will not be falsely elevated and will more accurately reflect the presence or absence of a vascular injury.

Bottom line: I recommend that you use the API when evaluating extremity vascular injury. Calculate the ratio by dividing the systolic pressure in the injured extremity with the pressure in the contralateral uninjured extremity (if there is one). A value < 0.9 indicates the need for angiographic evaluation, usually by CT scan.

And here’s a nice algorithm for managing peripheral vascular trauma from Life in the Fastlane:

Reference: Can Doppler Pressure Measurement Replace “Exclusion” Arteriography in the Diagnosis of Occult Extremity Arterial Trauma? Ann Surg 214(6):737-741, 1991.

General

Penetrating Injuries to the Extremities

Leave a comment

Simple penetrating injuries to the arms and legs are often over-treated with invasive testing and admission for observation. Frequently, these injuries can be rapidly evaluated and disposed of using physical examination skills alone.

Stabs and low velocity gunshots (no rifles or shotguns, please) should be thoroughly examined. This includes an examination of the entire, unclothed body. If this is not carried out, there is a risk that additional penetrating injuries may be missed.

For gunshots, look at the wounds and the estimated trajectory to try to demonstrate that the object stayed clear of neurovascular structures. This exam is imprecise, and must be accompanied by a full neurovascular exam and evaluation of the bones and joints. If there is any doubt regarding bony involvement, plain radiographs with entry markers should be performed. Any abnormal findings will require more in-depth evaluation and inpatient admission.

If the exam is negative but the trajectory is “in proximity” to a major vessel, an arterial pressure index (API) should be measured. This test involves the calculation of the ratio of the systolic pressure in the injured extremity to the contralateral uninjured extremity. It should not be confused with the ankle brachial index (ABI) which compares the systolic pressure in the ipsilateral uninjured arm  or leg.

The magic ratio is 0.9. If the API is less than this, there is some likelihood that a vascular injury is present. If the API is higher, there is virtually no chance of injury.

The final test that must be performed before discharge is a function test. If the injured extremity is too painful to use or walk on, the patient may need to be admitted for pain management and therapy. Patients managed in this way can avoid arteriography, CT angiography or admission and save thousands of dollars in hospital charges.

Reference: Journal Am Coll Surgeons 2009;209:740-5.

General

Using CT To Diagnose Extremity Vascular Injury

Leave a comment

The traditional gold standard for diagnosis of vascular injury to the extremities has been a good physical exam plus conventional catheter angiography. However, using angiography always adds a layer of complexity and risk to patient care. The interventional team may not be immediately available after hours, there is typically a road trip within the hospital to deliver the patient for the study, and overall it is quite expensive.

With the advancements we have seen in CT angio techniques and scanner technology, some centers have been using computed tomography to evaluate for vascular injury. A few small retrospective studies have been done, but this month a larger prospective study was published.

Over a 20 month period, 635 patients with extremity trauma and a suspicion for vascular injury were entered into the study. A structured physical exam was performed, and any patient with “hard signs” of vascular injury were taken to the OR. 527 patients had no signs of vascular injury and were observed and released. The remaining 73 (most had soft signs of vascular injury) underwent CT angiography of the extremity.

The sensitivity and specificity of this test were 82% and 92%, respectively. Positive and negative results were nearly perfectly predictive. However, approximately 10% were inconclusive, usually due to bullet artifact or reformatting errors. These patients either underwent confirmatory conventional angiography or operation.

Bottom line: Angiography using multi-detector CT scanners is an excellent tool for evaluating potential extremity vascular trauma from penetrating trauma. The technology is available around the clock without a wait, and usually does not involve lengthy trips through the hospital. A good physical exam is imperative so patients with hard signs of injury can go straight to the OR. Equivocal studies must be evaluated further by conventional angio or an operation.

Reference: Prospective multidetector computed tomography for extremity vascular trauma. J Trauma 70:808-815, 2011.

General

Penetrating Injuries to the Extremities

Leave a comment

Simple penetrating injuries to the arms and legs are often over-treated with invasive testing and admission for observation. Frequently, these injuries can be rapidly evaluated and disposed of using physical examination skills alone.

Stabs and low velocity gunshots (no rifles or shotguns, please) should be thoroughly examined. This includes an examination of the entire, unclothed body. If this is not carried out, there is a risk that additional penetrating injuries may be missed.

For gunshots, look at the wounds and the estimated trajectory to try to demonstrate that the object stayed clear of neurovascular structures. This exam is imprecise, and must be accompanied by a full neurovascular exam and evaluation of the bones and joints. If there is any doubt regarding bony involvement, plain radiographs with entry markers should be performed. Any abnormal findings will require more in-depth evaluation and inpatient admission.

If the exam is negative but the trajectory is “in proximity” to a major vessel, an arterial pressure index (API) should be measured. This test involves the calculation of the ratio of the systolic pressure in the injured extremity to the contralateral uninjured extremity. It should not be confused with the ankle brachial index (ABI) which compares the systolic pressure in the ipsilateral uninjured arm  or leg.

The magic ratio is 0.9. If the API is less than this, there is some likelihood that a vascular injury is present. If the API is higher, there is virtually no chance of injury.

The final test that must be performed before discharge is a function test. If the injured extremity is too painful to use or walk on, the patient may need to be admitted for pain management and therapy. Patients managed in this way can avoid arteriography, CT angiography or admission and save thousands of dollars in hospital charges.

Reference: Journal Am Coll Surgeons 2009;209:740-5.