Clinical Pathways
Clinical Pathways
Bony Injury
Bony Injury

Bony Injury

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Action

  • Perform local wound care
  • Administer tetanus vaccine (Class I)
  • Stabilize, splint
  • Consider antibiotics (Class I)
  • Consult with orthopedic

Decision

Is there concern for compartment syndrome?

Yes

  • Arrange for operative management
  • Transfer to trauma center, if necessary
  • Consider fasciotomy if transfer will be delayed

(Class I)

No

  • No additional imaging needed
  • Perform local wound care
  • Consider antibiotics (Class III)
  • Consider tetanus vaccine (Class I)

Background

Compartment Syndrome

Extremity wounds, especially lower extremity wounds, should be re-evaluated frequently due to the risk for compartment syndrome. The lower leg has 4 compartments: anterior, lateral, superficial posterior, and deep posterior. The anterior compartment is the most commonly affected. (See Figure 8.) The forearm has 3 compartments: flexor, mobile wad, and extensor. (See Figure 9.) The upper leg and upper arm are less likely to develop compartment syndrome. Common symptoms of compartment syndrome are severe pain refractory to analgesics, pain on passive stretching of muscles in the affected compartment, numbness, and weakness. Measurement of compartment pressures can aid in the diagnosis of compartment syndrome but is not required. Normal compartment pressure is <10 mm Hg. The delta pressure (the difference between the diastolic blood pressure and the intracompartmental blood pressure) can be diagnostic for compartment syndrome if it is <30 mm Hg. These pressures can be measured using different commercial devices, one being a Stryker® kit. However, if the patient has obvious clinical signs of compartment syndrome, measuring the pressure is not needed for a diagnosis. Treatment of compartment syndrome is emergent operative management. If transfer to another hospital is needed for this, fasciotomy in the ED should be considered.

Soft-Tissue Injuries

Simple GSWs to the extremity with no bony or vascular injury can be washed out at bedside, loosely approximated with sutures (only if gaping), tetanus vaccine updated if necessary, and followed up in the outpatient setting. There is no consensus on whether prophylactic antibiotics should be used, but the risk for infection is lower when there are no fractures. Retained bullets do not need to be removed unless they are causing discomfort, there is concern for compression of neurovasculature, or if it communicates with synovial fluid.

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