Extremity Trauma, Penetrating, Emergency Medicine

Basics

Description

Penetrating injury to extremity

Etiology

Stab or puncture
Gunshot
Laceration
Bite
High-pressure injection injury

Diagnosis

Signs and Symptoms

Entry and exit wound (if present), lacerations
High-muzzle-velocity gunshot wounds:
- Produce shock wave that results in significant tissue injury
- Often exit wound demonstrates more tissue damage than entrance wound.
Vascular injury:
- Arterial injury:
  - Decreased or absent distal pulse
  - Distal ischemic changes
  - Expanding hematoma
  - Bruit or thrill over injury
- Presence of distal pulse does not exclude proximal vascular injury.
Neurologic injury:
- Paresthesias
- Decreased or absent motor function
- Diminished sensation distal to injury
Musculoskeletal injury:
- Visible deformity
- Ligamentous laxity in joints adjacent to injury suggests tendon injury.
- Effusion in adjacent joint indicates fracture or ligamentous injury.
Compartment syndrome:
- Suggested by severe and constant pain over involved compartment
- Pain on active and passive extension or flexion of distal extremity
- Weakness, pain on palpation of compartment
- Hypesthesia of nerves in compartment
- Pulselessness and pallor are late findings.

History

Mechanism of injury
Age of wound
Circumstances of wounding:
- Assault
- Self-inflicted wound
- Domestic violence
Comorbid conditions:
- Immunosuppression or diabetes
- Valvular heart disease
- Asplenia
- Peripheral vascular disease

Physical Exam

Note location, length, depth, and shape of primary wound and exit wound, if present.
Vascular injury:
- Compare distal pulses by palpation and with Doppler study.
- Assess capillary refill:
  - Abnormal if >2 sec
- Ankle-brachial index (ABI):
  - Take BP in calf and arm (involved extremity).
  - Systolic pressure difference of >10 mm Hg suggests vascular injury.
- Expanding hematoma, bruit, or thrill over injury also indicates vascular injury.
Neurologic injury:
- Assess distal motor function and sensory function:
  - 2-point discrimination
  - Light touch
  - Proprioception
Musculoskeletal injury:
- Note associated crush, tendon, or ligamentous injury and bony deformity.
- Examine adjacent joints for range of motion.
- Assess for compartment syndrome.
Explore wound for foreign body (FB).

Essential Workup

Physical exam
Imaging if findings suggestive of bony injury or possible FB

Diagnosis Tests & Interpretation

Lab

Culture of acute wounds is not indicated.
Wounds with signs of infection may be cultured to guide antibiotic choice.

Imaging

Radiograph to evaluate for radiopaque FB or underlying fracture:
- Min. AP and lateral views
Radiolucent FBs may be located by US, fluoroscopy, or CT.

Diagnostic Procedures/Surgery
Arteriogram is indicated when vascular injury is suspected and immediate vascular surgery not required.

Differential Diagnosis

Any medical condition that presents with findings consistent with extremity trauma or a wound

Treatment

Pre-Hospital

Cautions:

Control hemorrhage with direct pressure over site.
Elevate extremity.
Evaluate neurovascular status.
Leave impaled objects in place and stabilize in current position.
Pain control

Initial Stabilization/Therapy

Manage airway and resuscitate as indicated.
Expose wound completely and remove constricting clothing or jewelry.
Control hemorrhage with direct pressure.
Blind clamping within wound and prolonged tourniquet use are not recommended.

Ed Treatment/Procedures

Pain control
Complete neurologic assessment before local anesthesia
Prolonged soaking of wounds, particularly with cytotoxic agents, is not recommended.
Remove any visible debris and d ©bride devitalized tissue.
Most important is copious high-pressure irrigation with saline.
Tetanus prophylaxis
Stab wounds and gunshot wounds should receive single dose of cefazolin in ED.
Immobilize extremity if there is suspicion of significant vascular injury, tendon injury, fracture, or joint violation.
Loss of pulse or distal ischemia requires emergent surgery:
- Do not delay surgical management for arteriogram.
Lacerations may be closed if they have been adequately cleaned, have minimal tissue loss, and are seen within 6-8 hr of injury:
- Delayed primary closure is an alternative for older or contaminated wounds.
Puncture or gunshot wounds should not be closed primarily.
Special considerations:
- Plantar puncture wounds:
  - Examine wound carefully under bright light.
  - Remove any foreign material.
  - Clean wound carefully.
- Coring wound is controversial and should be reserved for removal of devitalized tissue or imbedded debris:
  - Probing or high-pressure irrigation of puncture wound will only force particulate matter further into wound.
  - Prophylactic antibiotics are not recommended (unless patient is diabetic or immunocompromised or if the wound is highly contaminated or delayed in presentation).
- If not treated with aggressive debridement, can lead to osteomyelitis
- High-pressure injuries of hand:
  - Orthopedic evaluation in ED is essential because wounds that appear trivial on surface may have product track up tendon sheaths into more proximal aspects of hand.
  - Some paints and other products are radiopaque, and plain radiographs may demonstrate extent of spread.
- Soft tissue FBs:
  - Small inert FB in wound, including bullets, not easily retrievable and not in close proximity to joint, tendon, vessel, or nerve can be left in place with close follow-up.
  - FB in hands and feet should be referred to specialist as they often migrate and become or remain symptomatic.
  - Organic materials (thorns, wood, spines, clothing) should be removed as they are very reactive.

Medication

Tetanus prophylaxis: TDap 0.5 mL IM (TD only if >65 yr
Wounds >12 hr old, especially of hands and lower extremities, crush wounds with devitalized tissue, contaminated wounds

First Line

Cefazolin: 1 g IV/IM (peds: 20-40 mg/kg IV/IM single dose in ED)
Cephalexin: 500 mg PO (peds: 25-50 mg/kg/d) QID for 7 days or
- Amoxicillin/clavulanate: 875/125 mg PO (peds: 25 mg/kg/d) BID for 7 days
Erythromycin: 333 mg PO TID (peds: 40 mg/kg/d q6h for 7 days)
Contaminated wounds in patients with pre-existing valvular heart disease:
- Cefazolin: 1 g IV/IM, then cephalexin 500 mg PO QID for 7 days
Plantar through shoe at risk for Pseudomonas:
- Ciprofloxacin 500 mg BID for 7-10 days or
- Levofloxacin 500 mg QD for 7-10 days

Second Line
If penicillin allergic:

EES: 800 mg PO, then 400 mg PO q6h for 7 days or
Clindamycin: 300 mg PO q6-8h for 7 days

Follow-Up

Disposition

Admission Criteria

Emergent surgical consultation and admission are required for any penetrating wounds with potential for vascular compromise, associated compartment syndrome, and joint penetration.
High-muzzle-velocity penetrating gunshot wounds
Diabetic or immunocompromised patients with contaminated wounds

Discharge Criteria
Penetrating extremity injuries not requiring surgical intervention may be discharged after appropriate wound care with instructions to elevate extremity, keep wound clean, and to return for recheck in 24-48 hr or for any signs of infection.
Issues for Referral

Plantar puncture wounds: Close follow-up is necessary to assess for infection from unseen FB.
Delayed primary closure is alternative for older or contaminated wounds.
Wounds at high risk for infection should have close 1-2 day follow-up.

Followup Recommendations

Return to the ED for increasing pain, numbness, tingling, redness, swelling drainage, fevers or other changes in clinical presentation.

Pearls and Pitfalls

Presence of distal pulse does not exclude proximal vascular injury.
High-pressure injuries of hand may have wounds that appear trivial on surface but track up tendon sheaths into more proximal aspects of hand.
Plantar surface puncture wounds through shoes or socks have relatively high risk of retained foreign material - patients should be told of this possibility.
Post-puncture wound infections failing to respond to antibiotics should be suspected of having retained FB.

Additional Reading

Bekler H, Gokce A, Beyzadeoglu T, et al. The surgical treatment and outcomes of high-pressure injection injuries of the hand. J Hand Surg Eur Vol. 2007;32(4):394-399.
Belin R, Carrington S. Management of pedal puncture wounds. Clin Podiatr Med Surg. 2012;29(3):451-458.
Gonzalez RP, Scott W, Wright A, et al. Anatomic location of penetrating lower-extremity trauma predicts compartment syndrome development. Am J Surg. 2009;197(3):371-375.
Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: A review of the literature. J Orthop Trauma. 2006;20(7):503-511.
Manthey DE, Nicks BA. Penetrating trauma to the extremity. J Emerg Med. 2008;34(2):187-193.
Newton EJ, Love J. Acute complications of extremity trauma. Emerg Med Clin North Am. 2007;25(3):751-761.

Codes

ICD9

884.0 Multiple and unspecified open wound of upper limb, without mention of complication
894.0 Multiple and unspecified open wound of lower limb, without mention of complication
928.9 Crushing injury of unspecified site of lower limb
927.9 Crushing injury of unspecified site of upper limb
880.03 Open wound of upper arm, without mention of complication
881.00 Open wound of forearm, without mention of complication
890.0 Open wound of hip and thigh, without mention of complication
891.0 Open wound of knee, leg [except thigh], and ankle, without mention of complication

ICD10

S41.139A Puncture wound w/o foreign body of unsp upper arm, init
S81.839A Puncture wound w/o foreign body, unsp lower leg, init encntr
S87.80XA Crushing injury of unspecified lower leg, initial encounter
S47.9XXA Crushing injury of shoulder and upper arm, unsp arm, init
S51.839A Puncture wound w/o foreign body of unsp forearm, init encntr
S57.80XA Crushing injury of unspecified forearm, initial encounter
S71.139A Puncture wound without foreign body, unsp thigh, init encntr
S77.10XA Crushing injury of unspecified thigh, initial encounter

SNOMED

432618005 Penetrating wound of lower limb (disorder)
428860005 Penetrating wound of upper limb (disorder)
39595001 Crushing injury of lower limb (disorder)
9560007 Crushing injury of upper limb (disorder)
283357002 Laceration of lower limb (disorder)
283366003 Laceration of upper limb (disorder)
283459000 Stab wound of upper limb (disorder)
283480006 Stab wound of lower limb (disorder)
283545005 gunshot wound (disorder)
425322008 Stab wound (disorder)

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