Lower Extremity Trauma, 1st Edition
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Lower extremity
Trauma
Edited by
Milton B. Armstrong
University of Miami
Miami, Florida, U.S.A.
DK3501_C000a.indd 3 10/09/2006 2:38:59 PM
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To my sons Christopher and Bryan;
to my parents, James and Cornelia Armstrong, for their guidance, love,
and support;
to Annette, Jauqua, and Khara for all of their love;
to my immediate family, for their encouragement of all my efforts.
Preface
Increasingly, urban trauma is becoming a major health care issue. Large emer-
gency departments are inundated with patients with multiple injuries, requiring
state-of-the-art care. Most of these complex injuries involve trauma to the extrem-
ities, often due to motor vehicle accidents. In a study by MacKenzie et al. (1), it
was shown that lower extremity injuries accounted for about 40% of the charges
for motor vehicle trauma treatment in a given year.
This book is designed to be a guide for the evaluation and management by
physicians, nurses, students, and support personnel involved in the care of severely
injured patients. I am very pleased to have an outstanding group of contributors from
the University of Miami/Jackson Memorial Hospital Medical Center. University of
Miami/Jackson Memorial Hospital serves as the primary Level 1 trauma referral
center for South Florida. With such a tremendous volume of trauma patients, Univer-
sity of Miami/Jackson Memorial Hospital and its staff manages some of the most
complicated lower extremity trauma problems on a daily basis.
University of Miami/Jackson Memorial Hospital employs a comprehensive
system that allows for the coordination of care amongst multiple surgical ser-
vices. These services include trauma/critical care, orthopedic trauma, vascular,
and plastic surgery—all areas thoroughly covered within this text.
Milton B. Armstrong
REFERENCE
1. MacKenzie EJ, Cushing BM, Jurkovich GJ, et al. Physical impairment and functional
outcomes six months after severe lower extremity fractures. J Trauma 1993; 34(4):
528–539.
v
Acknowledgments
I am deeply indebted to my current and former University of Miami residents and
fellows, my colleagues in the University of Miami Division of Plastic Surgery,
the University of Miami Department of Surgery, and contributing authors from
around the country.
vii
Contents
Preface . . . . v
Acknowledgments . . . . vii
Contributors . . . . xi
1. Basic Principles of Trauma Care . . . . . . . . . . . . . . . . . . . . . . 1
Yoram Klein, Igor Jeroukhimov, Stephen M. Cohn,
and Mark Cockburn
2. Lower Extremity Surgical Anatomy . . . . . . . . . . . . . . . . . . . . 17
Kerry Latham, Marcelo Lacayo Baez, Milton B. Armstrong,
and Efrain Arias
3. Orthopedic Treatment of the Traumatized
Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Steven P. Kalandiak
4. Vascular Trauma of the Lower Extremity . . . . . . . . . . . . . . . 93
Fahim A. Habib, Pranay Ramdev, and Darwin Eton
5. Skin, Fasciocutaneous, and Muscle Flap Anatomy . . . . . . . . 113
Flaps: Classification, Form, and Function
Sabrina Lahiri and Rajeev Venugopal
6. Soft-Tissue Repair for Proximal
and Middle Third Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Joshua Kreithen, Kerri Woodberry, and Seung-Jun O
ix
x Contents
7. Microsurgical Repair of Complex
Soft-Tissue Defects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Jonathan Fisher, Rajeev Venugopal, and Milton B. Armstrong
8. Management of Lower Extremity Burn Injuries . . . . . . . . . . 161
Malachy E. Asuku and Robert L. McCauley
9. Wound Healing and Tissue Engineering . . . . . . . . . . . . . . . . . 189
Physiology of Wound Healing
Zubin J. Panthaki and Anire Okpaku
Index . . . . 201
Contributors
Milton B. Armstrong Division of Plastic Surgery, Miller School of Medicine,
University of Miami, Miami, Florida, U.S.A.
Efrain Arias Florida State University College of Medicine, Tallahassee,
Florida, U.S.A.
Malachy E. Asuku Department of Plastic and Reconstructive Surgery,
Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
Marcelo Lacayo Baez Universidad Autonoma de Guadalajara, Guadalajara,
Mexico
Mark Cockburn Department of Surgery, Morristown Memorial Hospital,
Morristown, New Jersey, U.S.A.
Stephen M. Cohn Divisions of Trauma and Surgical Critical Care, Miller
School of Medicine, University of Miami, Miami, Florida, U.S.A.
Darwin Eton Miller School of Medicine, University of Miami, Miami,
Florida, U.S.A.
Jonathan Fisher Division of Plastic Surgery, Miller School of Medicine,
University of Miami, Miami, Florida, U.S.A.
Fahim A. Habib Division of Trauma and Surgical Critical Care, DeWitt
Daughtry Department of Surgery, Miller School of Medicine, University of
Miami, Miami, Florida, U.S.A.
xi
xii Contributors
Igor Jeroukhimov Divisions of Trauma and Surgical Critical Care, Miller
School of Medicine, University of Miami, Miami, Florida, U.S.A.
Steven P. Kalandiak Department of Orthopedics and Rehabilitation, Miller
School of Medicine, University of Miami, Miami, Florida, U.S.A.
Yoram Klein Divisions of Trauma and Surgical Critical Care, Miller School of
Medicine, University of Miami, Miami, Florida, U.S.A.
Joshua Kreithen Division of Plastic Surgery, University of Florida School of
Medicine, Gainesville, Florida, U.S.A.
Sabrina Lahiri Division of Plastic Surgery, Miller School of Medicine,
University of Miami, Miami, Florida, U.S.A.
Kerry Latham Division of Plastic Surgery, Miller School of Medicine, Univer-
sity of Miami, Miami, Florida, U.S.A.
Robert L. McCauley Department of Plastic and Reconstructive Surgery,
Shriners Burns Hospital, Surgery and Pediatrics, University of Texas Medical
Branch, Galveston, Texas, U.S.A.
Seung-Jun O Division of Plastic Surgery, Medical University of South Carolina,
Charleston, South Carolina, U.S.A.
Anire Okpaku Department of Surgery, Jackson Memorial Hospital, Miller
School of Medicine, University of Miami, Miami, Florida, U.S.A.
Zubin J. Panthaki Departments of Clinical Surgery, Clinical Orthopedics,
and Rehabilitation, Division of Plastic and Hand Surgery, DeWitt Daughtry
Family Department of Surgery, Miller School of Medicine, University of Miami,
Miami, Florida, U.S.A.
Pranay Ramdev Division of Vascular Surgery, DeWitt Daughtry Department of
Surgery, Miller School of Medicine, University of Miami, Miami, Florida, U.S.A.
Rajeev Venugopal Department of Surgery, University of the West Indies,
Jamaica, West Indies
Kerri Woodberry Division of Plastic Surgery, Saint Louis University School of
Medicine, St. Louis, Missouri, U.S.A.
1
Basic Principles of Trauma Care
Yoram Klein, Igor Jeroukhimov,
and Stephen M. Cohn
Divisions of Trauma and Surgical Critical Care, Miller School of Medicine,
University of Miami, Miami, Florida, U.S.A.
Mark Cockburn
Department of Surgery, Morristown Memorial
Hospital, Morristown, New Jersey, U.S.A.
OVERVIEW
In the United States, trauma constitutes the third major cause of death of all ages
and the leading cause of death among persons less than 44 years old (1). Currently,
more than 400 people die of injuries in the United States every day (2) and about
50% of these deaths occur prior to hospital arrival. The major causes of trauma-
related death are devastating injury of the central nervous system (CNS) (50%)
and uncontrolled hemorrhage (35%) (3). Thirty-seven million people are treated
for injuries in emergency departments each year, accounting for 37% of all emer-
gency department visits of which 2.6 million require hospitalization. The total cost
associated with injuries is estimated to be more than $250 billion per year.
Satisfactory outcomes for injured patients are strongly influenced by the
initial care delivered following admission to the hospital emergency department
(4). Approximately 60% of all trauma-related hospital deaths occur during the
first hour. Inadequate assessment and resuscitation contributes to a preventable
death rate of about 35% (5).
1
2 Klein et al.
A schematic approach for the treatment of severely injured patients consists
of triage, primary survey, resuscitation, secondary survey, monitoring and evalua-
tion, and transfer to definitive care (6).
The primary survey is performed to identify immediately the life-threatening
injuries:
1. Airway control with cervical spine protection,
2. Breathing and ventilation,
3. Circulation with hemorrhage control,
4. Disability: neurologic status, and
5. Exposure/environment control.
The primary survey and resuscitation are performed simultaneously. The
secondary survey consists of obtaining a complete history and a “head-to-toe”
examination following the primary survey. Frequent reevaluation is performed to
recognize and treat any deterioration in the patient’s condition.
The modern concept of initial trauma care focuses on the physiological
derangements following severe trauma, rather than the specific injuries
sustained by the patient. A thorough understanding of the basic management
principles of the multi-injured trauma patient is therefore essential for success-
ful treatment of the patient with severe lower extremity trauma. In contrast,
certain lower extremity injuries are specifically associated with dangerous
systemic effects. Every physician who takes care of trauma patients should be
acquainted with these injuries and their management.
AIRWAY MANAGEMENT IN THE TRAUMA SETTING
The first priority in the treatment of trauma patients is to establish airway patency,
because obstructed upper airway will cause almost immediate hypoxia and respira-
tory acidosis. Posterior displacement of the tongue due to loss of muscle tone in
comatose patients, and obstructive particles such as tissue debris, vomitus, or foreign
bodies are the most common causes for upper airway obstruction in trauma patients.
Cervical spine injuries occur in 1.5% to 3% of blunt trauma victims, of which
25% to 75% are unstable (7–9). Patients with clinically significant head trauma may
have a greater risk of cervical spine injury (4.9% vs. 1.1% without head injury), and
the incidence increases to 7.8% in trauma victims with a Glasgow coma score (GCS)
less than 8 (10). These facts make the presence of unstable cervical spine fracture
relatively common in trauma patients that require airway control. Until cervical
spine instability is ruled out, neck immobilization should be maintained at all times.
During airway management, neck manipulation is common. Minimizing unneces-
sary neck movement is best achieved with a minimum of two persons, because one
of them is committed exclusively to maintaining in-line neck immobilization (11).
Overt signs of airway obstruction may be complete with apnea, marked
cyanosis, or stridor. More subtle signs such as labored ventilation, hoarseness, or
use of accessory muscles of ventilation may suggest incomplete or milder airway
Basic Principles of Trauma Care 3
obstruction. Finally, severe oromaxillofacial injury or burn are situations associated
with pending airway obstruction, and securing the airway in these circumstances
should be performed prior to clinical signs of obstruction.
After evacuating the airway of foreign bodies, tissue debris, or vomited
material, a jaw thrust or chin lift maneuver, followed by the insertion of a short
oropharyngeal airway tube may quickly alleviate obstruction due to tissue laxity
or posterior displacement of the tongue. These techniques are temporary airway
control maneuvers. If airway obstruction is not resolved using this simple tech-
nique, definitive airway control should be achieved promptly by endotracheal
intubation or a surgical airway procedure.
Indications for Intubation
Intubation is reserved for those patients who continue to show signs of inade-
quate respiration after basic interventions or those in whom these interventions
alone are not likely to sustain appropriate respiration (12).
Absolute Indications for Intubation:
1. Airway obstruction unrelieved with basic interventions,
2. Apnea or near apnea,
3. Respiratory distress, and
4. Severe neurologic deficit or decreased consciousness (i.e., focal deficit
or GCS rating less than 9) due to head trauma or any other cause.
Urgent Indications for Intubation:
1. Penetrating neck injury (with any signs of airway compromise or
expanding hematoma),
2. Persistent or refractory hypotension, especially due to active hemorrhage,
3. Chest wall injury with respiratory dysfunction, and
4. Moderate altered mentation, especially after head trauma, including
both combative and mildly obtunded patients.
Relative Indications for Nonemergent Intubation:
1. Oromaxillofacial injury,
2. Impending respiratory failure,
3. Need for diagnostic or therapeutic procedures [e.g., computed tomog-
raphy (CT) or angiography] in patients with risk for deterioration or
those unable to remain motionless during the examination, and
4. Potential respiratory failure after sedative-analgesic use.
Direct Orotracheal Intubation
All victims of blunt trauma undergoing urgent intubation should be regarded as
having a cervical spine injury until proven otherwise. Preoxygenation should be
performed in trauma patients prior to intubation. Oral endotracheal intubation
