Dr.AbdulWAHID M Salih Ph.D. Surgery

1. LIMBS INJURY Dr.AbdulWAHID M Salih Ph.D. Surgery

2. WOUNDS OF LIMBS • 50-75% of all missile wounds and blast injuries involve the limbs

3. Fractures • Should Be Stabilized To Avoid: • Further damage to surrounding tissue, • bleeding • pain.

4. IMMOBILIZATION of entire limb INDICATIONS; • All severe soft tissue wounds of extremities • Fractures should initially be immobilized

5. METHODS OF IMMOBILIZATION • Sling • plaster back slabs. • application of splints

6. The leg • Splinted by binding it To the good leg

7. Thomas splint • Immobilize compound fractures of the femur and fractures around the knee joint

8. METHODS OF IMMOBILIZATION 4. Plaster of paris (pop) 5. Skin or skeletal traction

9. METHODS OF IMMOBILIZATION 6. External fixation

10. Principles of cast application • Slabs or cylinders that have been well splitare the only safe plasters to apply. • Never put; • Complete • Unsplit • Unpadded cylinder • Tight bandages

11. VASCULAR INJURIES possible vascular injury ; • The Position Of The Missile Track, • The Presence Of A SubfascialHaematoma, • After Resuscitation, Distal Pulses Remain Impalpable,

12. Management of arterial injury • Urgent surgical exposureas early as circumstances allow, preferably within six hours of injury. • “LOOK AND SEE” is wiser than “wait and see”. • Every effort should be made to repair arterial damage • After major arterial ligation the incidence of limb gangrene is very high • Fractures should be treated after vascular surgery

13. Circulation can be impaired by • Complete, unsplit, unpadded cylinder • Tight bandages applied to a limb  • Swelling occurs in a limb within the first 24 – 48 hours after; Fracture, severe sprain, wound or operation;

16. Signs of compartment syndrome “7 P’s”: • severe pain at rest • Pain with passive stretch • Parasthesia(tingling and numbness) • Paresis (weakness) impaired movement • Pulses (diminished pulses in the affected limb) • Pallor (loss of normal color) • Persistent cold • Pressure (tense)

17. A tonometer to directly measure pressure • indication for fasciotomy; intracompartmental pressure >30 mmHg[10] • <30 mmHg difference between intracompartmental pressure and diastolic blood pressure

18. Indications for fasciotomy • wounds directly involving the calf; • concomitant major venous injuries; • clinical compartment compression syndrome in the immediate postoperative period; • when the ischaemic state has existed for longer than 4-6 hours before arterial surgery; • any major arterial injury to the limbs.

19. The anterior and lateral fascial compartments • A single longitudinal incision 15 cm in length • Placed halfway down the leg, • 2 cm anterior to the shaft of the fibula. • Dividing the anterior and lateral compartments,

20. The two posterior compartments • Single Longitudinal Incision 15 Cm In Length In The Distal Part Of The Leg • 2 Cm Posterior To The Palpable Posteromedial Edge Of The Tibia.

23. Fasciotomy The deep fascia must be incised along the length of the skin incision allows wide and deep retraction left open to allow post-operative oedematous and congested tissue to swell without tension exposes the depths of the wound

24. Fasciotomy • The wounds should be left open for delayed closure.

25. Complications • Muscle and nerve cell death • deformity, paralysis, permanent muscle contraction (Volkmann's contracture), • systemic infection (sepsis) • and renal failure.) • amputation

27. TENDON, NERVE • No attempt should be made at primary; • Tendon or nerve repair, In Grossly contaminated wounds.

28. Major Artery An injury to a major artery to the limb: • must be either repaired • or replaced by a saphenous vein graft immediately

29. INJURIES OF PERIPHERAL NERVES • May be injured alone • more commonly, in association with vascular damage or long bone fractures.

30. Nerve repair • In multiple injuries, nerve repair is of the lowest priority. • Nerve repairs are performed when wounds are healthy and clean, which is generally at least 6 weeks after injury. • Repair can safely be deferred for 3 months but contractures must not be permitted to develop.

31. General indications for Amputation • severe damage: • no chance of recovery of function of any part • mangled, grossly contaminated wounds • overwhelming infection • established gangrene; • continued infection associated with severe nerve and bone Injury • secondary haemorrhage, uncontrollable by other measures 8. multiple injuries,

33. GAS GANGRENE The risk: • Foreign bodies in wounds such as clothing, soil, metal or wood, • Prolonged application of tourniquets or tight plasters • Fascialcompartment compression syndromes • Delayed treatment

34. GAS GANGRENE • The incubation period ; less than three days • the sudden appearance of pain in the region of the wound. • oedematous • drainage of thin serous or serosanguinousexudate • The pulse rate rises markedly • but the temperature is rarely more than 38° C. • clinically deteriorates • within several hours becomes anxious and frightened • hypotensive and may vomit in severe cases.

35. GAS GANGRENE Immediate surgical intervention is essential