The Diagnosis and Management of Musculoskeletal Trauma

Airway. The
most common cause of preventable death in accidents is airway
obstruction, so the trauma leader must immediately check that the
patient’s airway is adequate and patent. Any obstruction (e.g.,
vomitus, tongue, blood, dentures) must be removed and the airway
secured by a jaw thrust maneuver or tracheal intubation.

Breathing.
After airway obstruction has been ruled out or controlled (i.e.,
intubation), the patient’s ventilation should be assessed. The major
life-threatening problems are tension pneumothorax, massive hemothorax,
and flail chest. Again, this aspect of the physical exam requires the
examiner to inspect, touch, and auscultate the patient as this is
typically done before roentgenographic diagnosis is available.

Circulation.
After breathing has been addressed, cardiovascular status must be
immediately evaluated and supported. Prompt determination of vital
signs is essential. Control of external bleeding
is accomplished by direct pressure and bandage. Simple elevation of the
lower extremities helps prevent venous bleeding from the limbs and
increases cardiac venous return and preload. The classic Trendelenburg
(head down) position is not used for more than a few minutes because it
can interfere with respiratory exchange. In the critically injured or
hemodynamically labile patient, venous blood samples should be taken
for type and cross matching.

Until cross-matched blood is available, rapidly infuse 1 to 2 L of isotonic Ringer lactate or normal saline solution. If blood loss is minimal,
then blood pressure should return to normal and remain that way with
only a maintenance intravenous amount of balanced saline solution.

In general, hypotension in a trauma patient should not
be assumed to come from a long bone fracture, and another source must
be sought. The following gross estimates of localized blood loss (units) from adult closed fractures can be useful in establishing baseline blood replacement requirements:

Neurologic mental status. The level of consciousness of the patient should first be noted. A brief “disability exam”
in an awake patient is a rapid, organized neurologic examination which
documents mental orientation, verbal response to questioning, and
response to stimuli. Furthermore, each extremity should be examined for
motor and sensory function as well; accurate documentation is crucial
since neurologic examinations can reveal progressive deficits. The
extremity neurologic exam can also be documented with the specific
physical exam of each extremity, but it is imperative that all four
extremities be included. It is good to develop a pattern of examination
and stick with that pattern each time for consistency.

In the unconscious patient, a Glasgow coma score is rapidly conducted based on pupil response to light, motor activity, and withdrawal to painful stimuli (Table 1-1).
This information is initially obtained by the medics who perform the
initial in-the-field evaluation. The Glasgow score therefore is used as
the measure of neurologic progress or deterioration. The medics
generally also note the position of the patient at the scene of the
accident, especially the head, and whether all limbs were actively
moving. It is frustrating to the orthopaedic or neurosurgeon to be
asked to evaluate a patient who has been sedated and chemically
paralyzed in the trauma room, particularly when the initial neurologic
exam was not properly documented. In general, the use of maximal monitoring and minimal medication is a useful trauma room principle which avoids such frustration by the examiner who relies on accurate neurologic exams.

Head and neck. Carefully palpate skull and facial bones and look for lacerations hidden in the hair. Cranial trauma should raise an immediate suspicion for cervical spine injury given the sudden and violent force it

takes to injure the face and cranium. Roentgenograms of facial bones
are difficult to interpret unless previous clinical examination
suggests the presence of trauma. The association between cervical spine and head injuries
must be emphasized. In a guided fashion with cervical immobility,
remove or loosen the C-collar to palpate the posterior cervical spine
looking for tenderness or spasm. In a conscious patient, any neck pain
or spasm is a cervical spine injury until proven otherwise. In the
unconscious patient, the neck must be protected with a hard C-collar
until bony injury is ruled out by cervical roentgenography and physical
exam. A benign physical exam by itself is unreliable if there are
distracting injuries or if the patient is intoxicated. If a cervical
spine injury is diagnosed, appropriate orthopaedic or neurosurgical
spine consultation should be obtained immediately, and the extremity
neurologic exam should be reported and documented.

Thorax and abdomen.
Though the thorax and abdomen are largely the domain of the general
surgeon, the examiner must inspect, palpate, and auscultate the abdomen
and thorax to determine possible underlying injury. Hemothorax and pneumothorax
often cause preventable death. Therefore, the chest should be examined
carefully and the examination repeated frequently. Furthermore, this
assessment helps the orthopaedist place musculoskeletal injuries in the
broader context of the patient. Abdominal injury
is also a common cause of preventable death. The imprint of clothes or
a contusion of the abdominal wall from the seat belt suggests
intraabdominal injury. Airbags have altered patterns of injury in
frontal collision (8). Appropriate diagnostic
studies should follow the suspicion of injury, and in many centers the
spiral “whole body” CT scan of the chest, abdomen, and pelvis has
supplanted selective CT scans, ultrasounds, and peritoneal lavage.

Pelvis. Low
back pain, pubic tenderness, or pain with compression of the iliac
crest can indicate a pelvic ring injury. Sequential anterior to
posterior compression over the iliac wings can help to discriminate
gross pelvic motion. Pelvic fractures may cause severe internal
bleeding, and as stated earlier, a patient can easily lose four or more
units of blood after a displaced pelvic fracture.

A rectal examination must be done in all patients with a spine or pelvic injury, both to check for bleeding as well as loss of sphincter tone indicative of neurologic injury. Furthermore, a high-riding prostate also indicates major urologic disruption common to high-energy pelvic fractures in men. An inspection of the penile meatus for hemorrhage should also be performed, and such a finding is further indication of a genitourinary system disruption. Bloody urine or the inability to void raises the suspicion of a urethral injury, so a retrograde urethrogram should be considered before a catheter is inserted (9).
In male patients, blood at the penile meatus or a “high-riding”
prostate seen on rectal examination is a clear indication for obtaining
a retrograde urethrogram before bladder catheterization. If the
catheter does not pass easily, then it should not be forced and the
urologist should be consulted. If a bladder injury is suspected, then
it is essential to insert an indwelling catheter unless the patient is
voiding clear urine.

A bimanual pelvic examination is appropriate in female patients to rule out open fractures which can penetrate the vaginal vault. Perineal inspection
for integument lacerations should be conducted and in the setting of
displaced pelvic fractures should be assumed to represent an open
pelvic fracture.

Back and spine. Carefully log roll the patient and palpate the entire spine
to detect tenderness or defects of the interspinous ligaments. It is
very important that a log roll be conducted properly with three
assistants controlling simultaneous rotation of the entire body. A
fourth assistant should be controlling the cervical spine (while in a
hard collar) with gentle traction. An increase in the interspinous
distance accompanied by local swelling may signify injury.
Occasionally, ecchymosis or kyphosis can be recognized, and their
presence or absence should be documented.

Upper and lower extremity examination. When gross deformity and crepitation
are present, further examination of the fracture site is not necessary.
Otherwise, all four limbs should be palpated thoroughly and each joint
placed through a passive range of motion. Look specifically for point
tenderness. Any obvious fractures or deformities are splinted, and any open wounds are covered
with sterile dressings. Dressings over open wounds, particularly over
fractures, should not be taken down multiple times by multiple
examiners. Such repeated exposures will only increase the rate of
infection with each exposure to the contaminated environment (10).
A more detailed description of fracture wound management is given later
in this chapter. Every diagnosed fracture should have properly centered
x-rays of the joint above and below. Carefully evaluate the circulation
of the limb distal to any fracture and record the presence of all
wounds after applying a sterile dressing.

Hemodynamically unstable patient with a pelvic fracture.
This is the one injury in which circulation can be compromised to the
extent that a life is immediately at risk and in which an orthopaedic
intervention can save such a life. The pelvic ring can be disrupted in
high-energy accidents (or low-energy falls in osteoporotic patients)
and most always is disrupted in at least two points around the ring.
The saying, “it is impossible to break a ring at a single point” nearly
always applies to the pelvis. Therefore, the examiner should look for a
lesion posteriorly in the sacrum or sacroiliac joint and anteriorly in
the pelvic ramii or pubic symphisis.

When a pelvic fracture is
recognized on the anteroposterior x-ray view obtained with the initial
trauma series, two more radiographs should be obtained: a pelvic inlet
and pelvic outlet view. These are orthogonal views of the pelvis
which help to critically evaluate all the pelvic bony landmarks as well
as displacement of fractures. If there is significant displacement
(more than 5 mm) at any one pelvic fracture line, a pelvic CT scan
should be obtained. Many orthopaedists will prefer a CT scan with even
lesser displacements to more critically evaluate the injury or
preoperatively plan. If a fracture line enters the acetabulum, then Judet x-ray views should be obtained.
These are 45-degree angled x-ray views from the right and left side of
the patient centered on the pelvis, once again giving the examiner
orthogonal views to critically assess the

bony landmarks of each acetabulum. Note that it is wasteful to obtain “five views of the pelvis” for every pelvic fracture
as the Judet views are not needed unless the acetabulum is involved.
Likewise, it is not necessary to get five views of an acetabular
fracture, omitting the inlet and outlet pelvic x-rays when the
posterior pelvic ring (sacrum or sacroiliac joint) is not involved.

The pelvis is like a cylinder or sphere of bone that
contains many critical soft tissue structures and organs such as the
bladder, the iliac vessels, prostate or vaginal vault, and the rectum.
All these organs are at risk, but the worrisome life-threatening
hemorrhage is what must be diagnosed promptly and addressed. Bleeding
typically continues until tamponade can occur and clotting factors take
control. It is highly recommended to tie a sheet
around the pelvis of a patient who is hemodynamically unstable until
the anteroposterior radiograph of the pelvis rules in or out a
displaced pelvic fracture. The sheet must be tied very snug, and
it is recommended to be applied at the level of the greater trochanters
for maximal effectiveness in closing down the volume of the broken and
separated sphere, thus leading to earlier tamponade of bleeding vessels
(11). There is little to lose if the patient
does not have such an injury, and the sheet is simply removed.
Commercially available pelvic slings, now with pressure calibration,
are becoming commonplace in trauma units for such a purpose. There is
essentially no role for the trauma room application of an external
fixator as this maneuver has been simplified by the more effective use
of a pelvic sling.

Extremity arterial injury.
Probably the next most emergent condition which an orthopaedist faces
is the extremity that is at risk for limb loss. This can occur due to a
torn or lacerated artery or compartment syndrome. Arterial injury can
be caused by blunt or penetrating trauma. There are four “hard signs” of arterial injury which warrant immediate vascular exploration, and time should not be wasted ordering and performing a diagnostic arteriogram (12).
The rationale is that a vascular surgeon knows the proximity of the
injury based on the wound or the x-ray that demonstrates the pathology.
There is no sense in using precious minutes finding out what is already
known when irreversible ischemic damage to nerve and muscle tissue
occurs after 4 hours of warm ischemia time. A warm ischemia time
interval of less than 6 hours is the generally accepted time interval
within which arterial continuity must be restored in order to avoid
loss of limb (13).

The only time an arteriogram would be warranted in such
an acute circumstance is when there is multilevel injury (multiple
fractures or shotgun wound) in which the vascular surgeon cannot be
sure what level the arterial damage has occurred.

The more difficult diagnostic problem occurs in the
majority of patients who present with more subtle clues to vascular
injury. Such “soft signs” might include a history of severe hemorrhage
at the accident scene, subjectively decreased pulses, a deficit of an
anatomically related nerve, or a nonpulsatile hematoma. Other soft
signs include the orthopaedic injury patterns that have been associated with a high incidence of arterial damage:

The best screening exam for an arterial injury should be
quick, non-invasive, portable, and cost effective, as well as reliable.
Determination of the

arterial
pressure index (API) requires the use of a Doppler machine and a blood
pressure cuff. It has been investigated as a screening tool for
clinically significant arterial compromise (14).
The API has also been referred to in the literature as the ABI (Ankle
Brachial Index) or AAI (Ankle Arm Index), and the terms are
interchangeable. To conduct an API examination, a blood pressure cuff
is placed just above the ankle or wrist in the injured limb so that a
systolic pressure can be determined with a Doppler probe at the
respective posterior tibial artery or radial artery. The dorsalis pedis
or ulnar arteries may logically be used as well, as long as the blood
pressure cuff is placed distal to the injury. The same measurement is
determined on an uninjured upper or lower extremity limb (Fig. 1-1). The
API is simply the calculation of the systolic pressure of the injured
limb divided by the systolic pressure of the uninjured limb:

Since pulses have been reported to be palpable distal to major arterial lesions, including complete arterial disruption (15,16,17),
and perception of a pulse is subjective and impossible to quantify,
physical exam alone or the detection of a palpable pulse is not
appropriate for diagnosis.

As it is impossible to spell out every clinical scenario
that may be associated with an arterial injury, it should be reiterated
that every case bears

individual
judgment, and given the absent morbidity of the API examination, a
conservative approach to testing and documentation is the most prudent
course. The clinician should approach the patient who has a high-risk
vascular injury with a clear diagnostic algorithm (Fig. 1-2).
Besides the patient with one of the four hard signs of vascular
arterial injury who warrants immediate surgical exploration, a
patient’s API should dictate the next step. If the API is greater than
0.9, then the patient may be followed clinically without any further
workup. If the API is less than 0.9, then they should proceed to the
next diagnostic step of either an arteriogram or duplex ultrasound, the
results of which will dictate the final plan of action.

Compartment syndrome.
Compartment syndrome is a condition in which there is increased
pressure within a closed soft tissue space, with the capacity to cause
damage or necrosis to such tissues. Therefore, it should be recognized
that the condition can occur in any muscular compartment of the body,
though it is most commonly encountered in the leg. It is perhaps the
most common orthopaedic emergency and often difficult to diagnose. In
the awake and alert patient, symptoms include

Mangled extremity and traumatic amputations.
Another clinical entity that should warrant great concern for limb
viability is the so-called mangled extremity. The mangled extremity is
not clearly defined, and there is no objective criteria on which
clinicians agree on definition. Suffice it to say that it represents
the end of an injury spectrum that involves a magnitude of trauma which
destroys soft tissue to the extent that limb survival is in question.

The principles of open fracture management as discussed
in the next section should be heeded, and the algorithm for a vascular
workup should be followed expeditiously as described in the former
section (III.A).
Most importantly, several services should come to bear in assessment,
workup, and coordination of care including trauma surgery, orthopaedic
surgery, plastic surgery, and, if necessary, vascular surgery.
Communication around treatment considerations and timing should be
open, clear, and decisive. In the same way, the patient and loved ones
should be included in the communication in order to understand the
gravity of the injury and that amputation is a real and sometimes
optimal solution (20).

An accurate neurovascular exam should be performed and documented. If an adult patient has a severed tibial nerve, then amputation should be executed,
though absent tibial nerve sensation does not necessarily mean that
neurodiscontinuity has occurred. A patient with a mangled extremity
should be managed at a Level I Trauma Center where the appropriate
expertise and experience is available.

There are several prognostic factors that influence
outcome and therefore should be weighed in the consideration for limb
salvage versus amputation. A number of scoring systems have been
developed to account for these variables, but none has proved reliable
in predicting limb viability. A simple and popular grading system is
the MESS (Mangled Extremity Severity Score), which helps to guide the
clinician. The MESS yields a score to the variables of injury energy, limb ischemia, shock or hypotension, and age (Table 1-2) (21). A score of more than seven was found to be predictive of the need for amputation. This scale is merely a guide.

Early management includes skeletal stabilization versus
amputation, wide and aggressive debridement of all devitalized tissue,
abundant irrigation, reestablishing vascular continuity, and
reoperations every couple of days for wound management until definitive
coverage can be executed by a microvascular team if necessary. An
antibiotic bead pouch or perhaps a vacuum-assisted closure system for
open wounds are helpful in the interim between cases.

For the complete traumatic
amputation of a finger or entire extremity, the team approach should
also be used to assess the possibility of a replantation. The proximal stump is first dressed with Ringer’s

lactate soaked dressing and pressure is applied. A tourniquet is to be avoided. The amputated
part is wrapped in a Ringer’s lactate moistened sterile sponge and
placed in a plastic bag. It should be cooled by placing it in a
container with ice, which delays autolysis and thus allows time for transport to a center with a replantation team. The part must not be frozen or placed in direct contact with ice.
If the travel distance by car is less than 2 hours, then this form of
transport can be used. If not, arrangements should be made for air
evacuation. Make no promises to the patient regarding whether replantation can be attempted or what the outcome will be. Absolute
indications for attempts at replantation include thumb amputations and
pediatric amputations, and border digits are a relative indication. Prognosis
is improved when an extremity has been amputated in a sharp cutting
mechanism as opposed to a crushing or traction mechanism.

Femoral neck fracture in the nonelderly.
A femoral neck fracture in a young patient is considered an emergency
because the blood supply to the femoral head is threatened. The lateral epiphyseal artery branch off the medial circumflex artery is the dominant blood supply to the femoral head (the artery of the ligamentum teres supplies 10%). There is an associated risk of avascular necrosis
(AVN) of the femoral head after a femoral neck fracture, which can lead
to femoral head collapse, which is a catastrophic complication in a
young active patient in whom a hip replacement or a hip fusion is a
dreaded salvage option.

The risk of AVN exists even in nondisplaced fractures;
therefore all such femoral neck fractures (in a hip which needs to be
saved) are regarded as emergent. For the displaced variety, an open
reduction is indicated to establish anatomic alignment followed by
internal fixation, classically with three large

cannulated
screws. In the nondisplaced variety, percutaneous fixation may be
appropriate, but the hip capsule should still be surgically
decompressed.

The possible mechanisms for arterial insufficiency include (22)

Hip dislocation.
For the same reason as for the femoral neck fracture, a dislocated hip
is an emergent condition as prognosis and the rate of AVN are directly
related to the amount of time dislocated (24,25).
One or two attempts at a closed reduction in the emergency room is
indicated, but, if unsuccessful, a trip to the operating room for
complete anesthesia and muscular relaxation usually suffices.

Threatened soft tissues.
Anytime a fracture or dislocated bone is tenting the skin, and the
injury cannot be reduced, the patient should go to the operating room
emergently so that a closed reduction with pharmacologic paralysis can
be attempted. If that fails, an open reduction should be performed.
This scenario commonly occurs with ankle and subtalar fractures or
dislocations, wrist fractures, and even fractures and dislocations
around the knee. Leaving any joint dislocated does not make sense when considering the tissues at risk (even if it is not compromising skin), venous obstruction, and pain.

Open joints. Open joint injuries are also at risk for septic complications. The surgeon should assume that lacerations over a joint extend into the joint until the contrary is proven in the operating room.
Air in the joint noted on roentgenography is a sign that a laceration
extends into the joint. It is a reasonable idea to inject the joint
with saline or a methylene blue-enhanced saline to check for
communication with the suspected laceration. A healthy volume of fluid
under pressure must be used to enhance sensitivity of this test—(for
the knee, no >50 mL). This method is not 100% sensitive and should
be used with judgment. An operative joint lavage, either open or
arthroscopic technique, should be performed if an open joint is
suspected. Certainly, if there are foreign bodies in the joint, such as
missile fragments from gunshot wounds, these must be evacuated. A
course of 48 hours of

gram-positive
and gram-negative coverage with parenteral antibiotics (as with a
Gustilo type IIIA fracture) is a reasonable and prudent adjunct to
surgery.

Talus fractures.
A fracture of the talus is considered a relative operative emergency
due to its vulnerable blood supply. Though underpowered, and
inconclusive, a recent study seems to suggest that time to operative
fixation does not matter, while talar neck comminution and open
fractures do correlate with poorer outcomes and a higher rate of AVN (36).
Since the talus is at risk for AVN, collapse, and subsequent arthrosis,
and since it is a weight-bearing joint, most orthopaedic
traumatologists prefer to operate on this fracture urgently for the
same reasons described for the femoral neck fracture in a young
patient. Certainly the displaced variety of talus fracture, in which
soft tissue tenting occurs, is an emergency due to the eventuality of
full-thickness skin necrosis, which can lead to catastrophic
complications.

Long bone fractures in the face of multisystem trauma.
Patients who present with a femur fracture and other injuries to
critical organs such as the lung, brain, or abdomen, or who have
extended periods of hypotension, are at risk for complications such as
acute respiratory distress syndrome, fat embolism syndrome, extended
internsive care unit (ICU) stays, and pneumonia. It is generally well
accepted that early stabilization of femur
fractures helps to decrease such complications and will allow for
earlier mobility and thus less consequent problems from extended
recumbent time periods on a ventilator in the ICU. Patients with femur fractures and head injury should generally have the femur fracture stabilized (37).
It is important that fluid management be well controlled by anesthesia
in such a setting. Aggressive stabilization for femur and pelvic
fractures has a favorable effect on pulmonary function following blunt
trauma (38). In general, fixation of femur fractures with an interlocking nail is indicated in the multiply injured patient (37,39,40). Evidence supports femur fixation within 24 hours of injury in the polytrauma patient (41,42,43).

Timing and titration of orthopaedic procedures, however,
is very important and requires significant judgment. Damage control
orthopaedics is a recently espoused philosophy which favors femur
stabilization with an external fixator rather than an intramedullary
nail in order to prevent the “second hit” or second physiologic insult
which occurs from intramedullary reaming and manipulation (44).
It is thought that the intramedullary nailing should be delayed further
stabilization, if a patient is physiologically challenged from multiple
injuries; however, early (less than 24 hours) femur stabilization with
an external fixator is still prudent.

Up to 30 degrees of angulation in the plane of joint motion is acceptable in metaphyseal fractures in young children. The younger the patient, the greater
the angulation acceptable. The closer the fracture is to the dominant
growth plate, the more angular deformity, and so the greater the
capacity to remodel. The dominant growth plate is

If a fracture deformity is obvious on inspection, it should be reduced.

Fractured femurs in the 3- to 8-year-old group can be allowed to have 1.0 to 1.5 cm of overlap due to the potential for overgrowth.

Children do not experience stiffness of otherwise normal joints.

Class 1. A
fracture through the zone of provisional calcification without fracture
of bone tissue. Such an injury does not involve a germinal layer unless
associated with severe trauma either from the initial injury or from
attempted reductions. Growth disturbances are rare but do occur.

Class 2. An
epiphyseal plate fracture with an associated fracture through the bony
metaphysis. Growth disturbance (physeal arrest) is also rare in this
category of injury.

Class 3. An
epiphyseal plate fracture associated with fractures through the
epiphysis. These fractures involve the articular surface.
Histologically, there is a fracture through the germinal layers.
Accurate reduction is essential to prevent subsequent growth
disturbance, but even so, alterations in growth are unpredictable. If
the articular surface has more than 1 mm of “step off,” then open
reduction is indicated.

Class 4. A
fracture through the epiphysis, epiphyseal plate, and metaphysis. Such
an injury almost invariably results in significant growth disturbance
unless it is anatomically reduced. Open reduction and internal fixation
is indicated if there is any displacement.

Class 5. This
is an impact or “smash” injury that destroys all or part of the
epiphyseal plate and results in growth arrest. Close monitoring for
remaining growth is essential. Surgical resection of the bone bridge
and fat interposition are necessary if growth arrest results.

Always obtain an opposite limb (joint) x-ray to aid interpretation of a physeal injury, particularly in the injured elbow.

Diagnosis (48)

Treatment.
Direct treatment toward immobilization, with the disrupted tissue ends
approximated. In some settings, this requires removal of devitalized
tissue and repair by the sites and type of suture that will not cause
further devitalization. When possible, sutures are placed in the
surrounding fascia and not in the muscle itself.

Tendons are relatively avascular
structures and do not handle infection well. At sites where they course
along long synovial tunnels, blood supply is via the long axis of the tendon or vincula. Trauma or sheath infections can jeopardize nutrition of the tendon.

As a general principle,
a lacerated or ruptured tendon should be repaired primarily with a
nonreactive material and a suture technique to ensure continued
approximation of the tendon ends. Even with prophylactic antibiotics,
primary repair of tendons in wounds more than 12 hours old carries
considerable risk. A nonreactive synthetic suture or braided wire is
the suture of choice. If the tendon is expected to glide subsequently,
then handling the tendon with sponges and forceps is avoided because
this causes further trauma and may be associated with dense adhesions.

Any involved tendon sheath
should be opened in a longitudinal fashion so that the tendon is
unroofed for the entire excursion of a repaired laceration site to

Only those with special training in hand surgery should repair digital flexor tendons in the hand.

Diagnosis of
the extent of the ligamentous injury presents one of the major problems
in orthopaedics. Rupture may be suspected from the mechanism of injury
or from physical examination, which reveals tenderness over the
ligament. If the patient is seen shortly after injury, a gap may be
felt where the ligament is normally located. The injury might be fairly
painless, especially if the ligament is completely disrupted. Once
hemorrhage and swelling occur, this diagnostic possibility is
eliminated. Another diagnostic aid is a stress roentgenogram, but it
must be compared with the opposite and normal side. Such films should
be made when the pain is inhibited by regional or general anesthesia.
Arthroscopy or arthrography can provide pertinent information and a
diagnosis, but a skilled arthroscopist should first be consulted. An
MRI scan can be used to make the diagnosis.

Treatment of
a complete ligamentous rupture is in essence the treatment of a
dislocated joint after the dislocation has been reduced. In general,
preserving motion is most important, and early mobilization is the
treatment of choice. Ligaments are relatively avascular, so healing is
slow. The larger ligaments must be protected until the scar matures
(8–16 weeks).

There often is no clear answer when operative repair of ligaments is essential, but open repair is indicated in the following instances:

Nerve injuries are of three types: contusion or neurapraxia, crush or axonotmesis, and complete division or neurotmesis.
Blunt injuries and those associated with fractures tend to be either
neurapraxia or axonotmesis. For this reason, the fracture should be
treated in its usual manner and the nerve injury observed. If it is
neurapraxia, recovery will be complete within 6 to 12 weeks. If it is
an axonotmesis, recovery from the trauma site to the next muscle to be
innervated should be followed, keeping in mind that the expected
recovery rate is 1 mm/day or 1 in./month. If reinnervation does not
occur on time, exploration is indicated. When the distance from the
site of trauma to the next innervated muscle that can be assessed
causes a 6-month delay, early exploration is indicated. An
electromyogram shows reinnervation approximately 1 month before it can
be detected clinically, but one is dependent on the skill of the
electromyographer for interpretation (see App. F).
A traction injury is usually a mixed lesion with a large element of
neurotmesis of individual axons at various places along the nerve. A
nerve injury associated with sharp trauma is usually neurotmesis, and
surgical repair is indicated. The brachial plexus
presents a special diagnostic and treatment problem. Injuries from
lacerations, especially in children, should be repaired primarily. Most
brachial plexus injuries, however, are caused by traction and are
either an avulsion of the root from the cord or the typical tearing of
the axons at multiple levels along the nerve. MRI is essential for
differentiation. If the lesion is an avulsion injury, no recovery is
possible, and the patient should be started early on rehabilitation. If
the lesion is the typical traction injury, the patient should be
followed up to document recovery. If no recovery appears at the
appropriate time intervals, exploration and possible suture or nerve
graft should be considered.

As a general principle, secondary repair (3–6 weeks after injury) is preferable to primary repair for the following reasons:

There are many exceptions to the preference for secondary repair, such as suturing

Nerve surgery should not be performed at any time by a surgeon inexperienced in microscopic techniques.

Treatment of
large hematomas (large compared to the area of confinement) whether
subcutaneous or in muscle usually should consist of evacuation as an
elective procedure in the operating room. A hematoma is not absorbed
but undergoes organization, fibrosis, and scarring. Aspiration of a
clot is not possible, so a large hematoma is evacuated by open
drainage. Before considering this, the surgeon must be sure the
hematoma is not expanding or is the cause of shock. If it is, vascular
surgery consultation is mandatory to consider primary repair.

Prehospital care. Protection of the frostbitten part from mechanical trauma. Avoid rewarming until it can be done definitively.

Rewarming.
Hypothermia of the patient should be treated first. Stimulation of the
vagus or myocardium with Naso-gastric (NG) tubes, Swan-Ganz catheter,
or other methods should be avoided. If the patient is breathing,
intubation is not appropriate. The patient should be rewarmed in a
water bath with mild antibacterial soap at 40° to 42°C (104°–108°F). A
flushed appearance indicates reperfusion and the patient should be
removed from the bath.

Definitive care.
The goals of definitive care are to preserve viable tissue and prevent
infection. If possible, a burn center should be contacted for
initiation of thrombolytic therapy to salvage threatened tissue and
limbs. The injured limb should be elevated and protected from even mild
trauma. Lambs wool should be placed between the toes. Analgesics and
ibuprofen 4 mg/kg should be administered 3 times a day. Tetanus
prophylaxis is appropriate. Any source of nicotine should be strictly
prohibited.