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1762 SECTION 21: Trauma corpus cavernosum hematomas and can be an adjunct to both diagnosis and operative management.35  TREATMENT Most closed testicular contusions are managed conservatively with opi ate analgesics, ice, elevation, scrotal support, and appropriate urologic follow-up. Testicular rupture requires immediate drainage and repair. Any patient with penetrating scrotal trauma should undergo immedi ate scrotal exploration. 38,39 Obtain emergent urologic consultation for all confirmed or suspected penile fractures. With immediate surgical intervention, erectile function may be spared. Loss of penile skin by avulsion injury or burns is managed by splitthickness skin grafts after the denuded penis is clean and sterile. Do not reapply avulsed skin, because avulsed skin invariably becomes necrotic and infected and must be subsequently removed. Penile amputations require repair by microsurgical reimplantation if the amputated segment is deemed viable by the urologist. Strangulation injuries can usually be managed simply by removing the constricting agent. Zipper injury to the penis is caused when the penile skin is trapped in the trouser zipper. Mineral oil and lidocaine infiltration are useful in freeing the penile skin from the zipper. Other wise, wire-cutting or bone-cutting pliers are used to divide the median bar (or diamond) of the zipper, which causes the zipper to fall apart, freeing the penile skin. Contusions of the perineum or penis are treated conservatively with cold packs, rest, and elevation. Insert a Foley cath eter if the patient is unable to void. SPECIAL POPULATIONS  ELDERLY As men age, they experience anatomic changes, including laxity of scrotal tissue, atrophy of the perineal muscles, and loss of collagen tissue. Changes in women are secondary to declining secretion of estrogen after menopause and include atrophy of the cervix and uterus, atrophy of the walls of the vaginal canal, decrease in vaginal length and width, and decrease in vaginal lubrication. These changes predispose the elderly to complex injuries of the external genitalia even with a minor mechanism of injury. Compared to younger trauma patients, trauma to the GU system in the elderly patient tends to be more common from blunt mechanisms and tends to result in higher rates of bladder and urethral injuries. The presence of a penile prosthesis can transform a minimal blunt trauma genital injury into a complicated surgical issue for the patient. 41 Extrusion and rupture of penile prostheses predispose patients to infection and complications of wound healing. This becomes a special con cern in diabetic patients who are more likely to have prostheses. Obtain urologic consultation for any patient who has sustained trauma to the genitalia with a prosthesis in place (see Chapter 95, “Complications of Urologic Procedures and Devices”).  PREGNANT WOMEN With pregnancy, women experience physiologic changes that predispose them to more severe injury in both blunt and penetrating trauma to the genitalia. During pregnancy, venous outflow from the perineal area is slowed because of the pressure on the vena cava from the enlarging uterus. Slowed blood flow to the area can cause edema of the vulva. The increased level of progesterone during pregnancy also contrib utes to fluid retention and edema of the genitalia. Engorgement of the perineum predisposes pregnant patients to increased risk of hemorrhage from penetrating trauma to this anatomic region.

us. Slowed blood flow to the area can cause edema of the vulva. The increased level of progesterone during pregnancy also contrib utes to fluid retention and edema of the genitalia. Engorgement of the perineum predisposes pregnant patients to increased risk of hemorrhage from penetrating trauma to this anatomic region.  CHILDREN Roughly 33% of males worldwide are circumcised.42 The aim of circumcision is to excise sufficient foreskin (both penile shaft and inner preputial epithelium) to leave the glans uncovered. Complications of circumcision are more common in older children. Early complications of circumcision include bleeding, infection, pain, and inadequate skin removal. 42 Direct pressure alone is adequate to stop bleeding in most scenarios, although in some instances, the application of pressure alone is insufficient to control local hemorrhage and other methods of hemostasis must be employed. Circumferential dressings may cause urinary retention and even necrosis of the distal penis if blood flow is compromised. Genital trauma in children should prompt consideration of sexual abuse. 43 The clinical evaluation of prepubescent females with blunt uro genital trauma may underestimate the severity of injuries when compared with examination under anesthesia. Consider consultation for examination under anesthesia for accurate diagnosis and to minimize psycho logical sequelae of examination. In boys, nonsexual trauma to the external genitalia most commonly occurs between ages 6 and 12 years. Bicycle accidents, kicks, and falls are the typical mechanisms, and scrotal and penile lacerations or testicular contusions are the most common injuries. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Trauma to the Extremities James Heilman INTRODUCTION AND EPIDEMIOLOGY Trauma to an extremity with associated vascular injury has a 5% rate of mortality, 5% rate of primary limb amputation, and 17% rate of delayed limb amputation. 1 Penetrating trauma with early shock from proximal arterial hemorrhage is more likely to lead to mortality. Blunt distal extremity trauma with associated distal vascular injury is more commonly involved in early limb loss and amputations. Risk factors for delayed amputation include major soft tissue injury, compartment syn drome, ischemia of more than 6 hours, and associated fracture. 2 Injuries involving the lower extremities are more common than injuries involv ing the upper extremities. The two most commonly injured blood ves sels are the femoral and popliteal vessels.3 Advances in diagnostic imaging 4 and surgical management have dramatically reduced the rate of limb loss and disability due to limb ischemia. 5 The extent of injury to extremity nerves, bones, and soft tissues now determines if the limb can be surgically salvaged. Identifying and detecting which injuries require surgical evaluation and/or imaging are essential skills for emergency physicians. PATHOPHYSIOLOGY Gunshot and knife wounds are the two most common causes of pen etrating trauma. Stab wounds have a more predictable pattern of injury, making them more straightforward to manage. Gunshot injuries are more difficult to evaluate due to the extent of tissue damage and wider range of patterns of injury. More sophisticated vascular surgical repair techniques of arterial injuries, 6 advances made during military conflicts, improved imaging, and other factors have led to a decreased rate of limb amputations and limb disability associated with penetrating trauma. CLINICAL FEATURES Perform the primary trauma survey, immediate resuscitation, and secondary survey before focusing on injuries to the extremities. Apply direct pressure, pressure dressings, or a tourniquet to any actively bleeding extremity (see Chapter 254, “Trauma in Adults”).

lity associated with penetrating trauma. CLINICAL FEATURES Perform the primary trauma survey, immediate resuscitation, and secondary survey before focusing on injuries to the extremities. Apply direct pressure, pressure dressings, or a tourniquet to any actively bleeding extremity (see Chapter 254, “Trauma in Adults”). Do not get distracted or deviate from the initial trauma management because associated injuries to other areas of the body are common with penetrating injuries. After identifying an injury during the secondary survey, CHAPTER Tintinalli_Sec21_p1669-1766.indd 1762 8/1/19 12:22 PM CHAPTER 266:  Trauma to the Extr emities      1763 TABLE 266-1 Clinical Manifestations of Extremity Vascular Trauma Hard signs •  Absent  or diminished distal pulses •  Obvious  arterial bleeding •  Large  expanding or pulsatile hematoma •  Audible  bruit •  Palpable  thrill •  Distal  ischemia (pain, pallor, paralysis, paresthesias, coolness) Soft signs •  Small,  stable hematoma •  Injury  to anatomically related nerve •  Unexplained  hypotension •  History  of hemorrhage •  Proximity  of injury to major vascular structures •  Complex  fracture TABLE 266-2 Clinical Examination of the Nerves of the Extremities Nerve Test of Motor Function Test for Sensation Axillary (C5-C6) Arm abduction Arm internal, external rotation Lateral aspect of shoulder Musculocutaneous (C5-C6) Forearm flexion Lateral forearm Radial (C5-C8) Forearm, wrist, and finger extension Dorsoradial hand, thumb Median (C6-T1) Wrist flexion, finger adduction Volar aspect of thumb and index finger Ulnar (C7-T1) Finger abduction Volar aspect of little finger Femoral (L1-L4) Knee extension Obturator (L2-L4) Hip adduction Superior gluteal (L4-S1) Hip abduction Sciatic (L4-S3) Knee flexion Deep peroneal (L4-S1) Ankle and great toe dorsiflexion

1) Wrist flexion, finger adduction Volar aspect of thumb and index finger Ulnar (C7-T1) Finger abduction Volar aspect of little finger Femoral (L1-L4) Knee extension Obturator (L2-L4) Hip adduction Superior gluteal (L4-S1) Hip abduction Sciatic (L4-S3) Knee flexion Deep peroneal (L4-S1) Ankle and great toe dorsiflexion Superficial peroneal (L5-S1) Foot eversion Tibial (L5-S2) Ankle plantar flexion Posterior tibial (L5-S2) Great toe plantar flexion Spinal L4   Medial calf Spinal L5   Dorsal foot Spinal S1   Lateral plantar foot thoroughly evaluate the affected extremity for vascular integrity, nerve function, skeletal injury, and soft tissue injury. The rapid evaluation of extremities for associated arterial injury is critically important for the management of these injuries. Note any hard or soft signs of vascular injury (Table 266-1). Use a Doppler flow device to detect a pulse if distal pulses cannot be palpated. Thoroughly evaluate nerve, tendon, and muscle function during the physical exam ( Table 266-2). Pain on palpation or movement of bony structures or obvious deformities suggests an underlying fracture. Note any intra-articular hematomas or other signs of joint injury. Measure soft tissue lacerations and other associated injuries with a tape measure. Accurately describe injuries to consultants because measurement of the injury may change management in some situations.  ANKLE-BRACHIAL INDEX In the absence of hard signs, determine the ankle-brachial index for any injured extremity along with the nonaffected extremity for comparison (See Video: Ankle-Brachial Index). An ankle-brachial index reading of <0.9 is considered abnormal and is concerning for associated arterial injury. The ankle-brachial index reliably detects occlusive arterial injury with accuracy as high as 95%, but the true sensitivity and specificity have varied in clinical studies. 9,10 Use caution in relying on a normal anklebrachial index to rule out arterial injury. It does not detect nonocclusive arterial injuries such as intimal flaps, focal narrowings, small pseudoaneurysms, and arteriovenous fistulas in up to 10% of cases. DIAGNOSIS Diagnosis of associated injuries depends on a complete history and physical exam of the involved extremity. If any hard signs of vascular injury are present, then consult vascular surgery immediately. If there are any soft signs of vascular injury and/or if the ankle-brachial index is <0.9, then order imaging tests to evaluate for associated vascular injuries, or transfer to an institution with vascular care capability (Figure 266-1). The differential diagnosis for injuries associated with penetrating trauma to the extremities includes arterial or venous injury, nerve damage, tendon lacerations, fractures, soft tissue injury, degloving injuries, damage to joint capsule, bullet embolization of artery, or vein and compartment syndrome.  LABORATORY TESTING No specific laboratory testing is indicated for isolated penetrating extremity injuries; in certain cases, type and screening, baseline renal function, and a CBC may be indicated. If the patient has soft signs of vascular injury or an ankle-brachial index <0.9, then obtain a creati nine to determine renal function in patients with risk for preexisting renal disease. Underlying renal insufficiency creates potential for contrast-induced nephropathy when performing CT angiography. See Chapter 88, “ Acute Kidney Injury, ” for discussion of radiocontrastinduced nephropathy.  IMAGING Plain Radiographs Obtain anteroposterior and lateral radiographs of extremities with suspected fracture, joint injury, or retained bullet or other foreign body fragments. Oblique views may add value if there is clinical suspicion of retained foreign body.

” for discussion of radiocontrastinduced nephropathy.  IMAGING Plain Radiographs Obtain anteroposterior and lateral radiographs of extremities with suspected fracture, joint injury, or retained bullet or other foreign body fragments. Oblique views may add value if there is clinical suspicion of retained foreign body. Obtain radiographs of the joint above and below the site of injury. Evidence of air in the joint or an intra-articular fracture on the radiograph demonstrates that joint involvement has occurred. There are four types of fracture patterns associated with low-energy gunshots 13 (Figure 266-2). The drill-hole wound track pattern appears in lower-density cancellous bone and is most common in the distal femur, pelvis, and proximal humerus. Unicortical fractures appear in the metaphyses of long bones. Comminuted fractures occur most frequently in diaphyseal bone; multiple bone fragments are common. The fourth type of fracture is the distal spiral fracture, and this occurs most com monly in the femur. For shotgun or blast injuries, obtain radiographs of the extremity and joint distal to the injury in order to detect any pellets that have embedded into the bone or soft tissues or entered into a joint capsule (Figure 266-3). CT Angiography CT angiography is the primary diagnostic study for the evaluation of vascular injuries to the extremities. 2 CT angiography is noninvasive, provides higher resolution images, and is less expensive when compared to catheter angiography. It provides threedimensional reconstruction with minimal artifact. CT angiography also assists in the evaluation of extravascular injuries such as frac tures, foreign objects, or joint involvement. 14 Studies comparing CT angiography to catheter angiography have demonstrated that the CT angiography sensitivity and specificity rates for identifying clinically significant arterial injuries are equivalent to those with conventional catheter angiography. 15-18 Limitations of CT angiography include scatter artifact interference caused by bullets, poor visualization of Tintinalli_Sec21_p1669-1766.indd 1763 8/1/19 12:22 PM

sitivity and specificity rates for identifying clinically significant arterial injuries are equivalent to those with conventional catheter angiography. 15-18 Limitations of CT angiography include scatter artifact interference caused by bullets, poor visualization of Tintinalli_Sec21_p1669-1766.indd 1763 8/1/19 12:22 PM 1764 SECTION 21: Trauma tibial vessels, and the inability to perform any therapeutic interven tions during the study. Ultrasonography Historically, the sensitivity of color flow duplex ultrasonography has ranged from 50% to 100% for evaluating vascular injuries.19 However, the 2-Point Fast Doppler (2PFD) protocol appears promising to identify vascular injury.20 The presence of normal triphasic arterial flow in both the dorsalis pedis artery and posterior tibial artery had a sensitivity and specificity of 100% in ruling out arterial lesions in lower-limb penetrating trauma. Further studies are needed to determine generalizability of these results. TREATMENT  CONTROL OF BLEEDING Patients with venous trauma can bleed profusely. Control bleeding with direct pressure, pressure dressing, or a tourniquet. 21 Avoid clamping vessels in an attempt to control bleeding, as this risks nerve damage. Nerves are bundled with vascular structures and can be easily damaged by blind clamping or ligation during the initial trauma resuscitation.  ARTERIAL INJURY Penetrating injuries to the extremities that involve any associated arterial injury are critically important to recognize early. Figure 266-1 outlines the approach to these injuries.  FRACTURES AND JOINT INJURIES Penetrating trauma can cause joint sepsis and destruction, rapid chondrolysis, and loss of anatomic contours. These can lead to serious long-term consequences, including posttraumatic degenerative arthritis and partial or total loss of flexibility. Treat bone fractures from penetrating trauma as open fractures. Surgically debride the injury and admit the patient for IV antibiotics. Synovial joint fluid is an organic acid that causes lead bullets to become soluble in the joint, which can lead to systemic lead toxicity. 22 If a patient has an obvious bony or joint capsule injury, obtain consultation to evaluate the injury.  WOUND MANAGEMENT Careful wound management is critical to prevent infection after pene trating injuries. The most important component of wound management is irrigation. Copiously irrigate with saline or tap water (500 to 1000 mL) at high pressures (15 to 20 pounds per square inch). Antiseptic solution does not decrease infection rate and may actually be harmful. Heavily contaminated wounds may require more fluid and/or more pressure. If the wound is older than 3 to 4 hours, gently scrub the wound. Despite the importance of irrigation and wound management, there are many other factors that play a role in infection risk and proper healing, including bacterial inoculum, tissue devitalization, blood supply, time to presentation and treatment, presence of foreign bodies, and host immune status.  WOUND CLOSURE The decision to close associated open wounds depends on the time that has elapsed since the injury and the degree of contamination. If there is minimal contamination and the wound is well irrigated, it can be closed. It is important to arrange close follow-up in 24 to 48 hours in order to check for developing wound infection. Extremity wounds with retained foreign bodies, major tissue destruction, or contamination should be closed after a delay of 72 to 96 hours.

imal contamination and the wound is well irrigated, it can be closed. It is important to arrange close follow-up in 24 to 48 hours in order to check for developing wound infection. Extremity wounds with retained foreign bodies, major tissue destruction, or contamination should be closed after a delay of 72 to 96 hours. Do not routinely administer antibiotics Penetrating Extremity Trauma Medical history and physical examination Hard signs ABI CT angiography Positive (occlusion or extravasation) Negative or minimal (no occlusive arterial injury) Observation Observation >0.9<0.9 Immediate vascular surgery consult Soft signs No signs of vascular injury (no hard or soft signs) FIGURE 266-1. Algorithm for penetrating extremity trauma. ABI = ankle-brachial index. Tintinalli_Sec21_p1669-1766.indd 1764 8/1/19 12:22 PM

egative or minimal (no occlusive arterial injury) Observation Observation >0.9<0.9 Immediate vascular surgery consult Soft signs No signs of vascular injury (no hard or soft signs) FIGURE 266-1. Algorithm for penetrating extremity trauma. ABI = ankle-brachial index. Tintinalli_Sec21_p1669-1766.indd 1764 8/1/19 12:22 PM CHAPTER 266:  Trauma to the Extr emities      1765 for uncomplicated extremity gunshot and knife wounds because there is an approximately 2% rate of infection in these injuries. 24 However, antibiotics may be beneficial for treating hand injuries, joint or bony involvement, immunocompromised patients, and wounds with significant contamination.  SOFT TISSUE FOREIGN BODIES Plain radiographs will detect glass, metal, bone, or gravel. Wood and other organic material may be missed on plain films, and US is better at identifying these objects. CT scanning is the best modality for identify ing both radiolucent and opaque foreign bodies. Several factors impact whether the foreign body should be removed. The benefit of exploring the wound and removing the substance must be weighed against the associated damage to surrounding tissues and the increased risk of infection. Organic material is more reactive and has a higher rate of infection than metal or glass. A bullet generally should not be removed unless the bullet has potential to migrate into surrounding vital struc tures or if it is in the joint capsule.  DISPOSITION, FOLLOW-UP, AND DISEASE COMPLICATIONS Hard signs of arterial injury require immediate surgical consultation, and such patients will need further imaging, surgery, and hospital admission. FIGURE 266-2. Fracture  patterns  created  by  bullets:  drill-hole  (A),  unicortical  (B), distant spiral (C), comminuted (D). FIGURE 266-3. A. Gunshot wound to the shoulder and axilla. B. Embedded pellet of shotgun in the distal ulna, illustrating the importance of obtaining images of the extremity distal to such injuries. All other patients with penetrating extremity trauma should undergo a period of observation with associated serial examinations to detect any delayed or missed injuries. There is no consensus on the required observation time required, but a minimum of 24 hours is reasonable. Tintinalli_Sec21_p1669-1766.indd 1765 8/1/19 12:22 PM

patients with penetrating extremity trauma should undergo a period of observation with associated serial examinations to detect any delayed or missed injuries. There is no consensus on the required observation time required, but a minimum of 24 hours is reasonable. Tintinalli_Sec21_p1669-1766.indd 1765 8/1/19 12:22 PM 1766 SECTION 21: Trauma Wound healing may be complicated by infections, missed nerve injuries, tendon or joint injuries, delayed vascular injury, and compartment syndrome. Discuss return precautions with patients before discharge. State these precautions as clearly as possible. Recommend that patients return to the ED for increasing pain, numbness, weak ness, redness, or pus drainage from the wound site. Ensuring followup with the appropriate surgical service, a primary care provider, or the ED is essential, especially in uninsured patients or patients transported long distances from home, as well as for other high-risk populations. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec21_p1669-1766.indd 1766 8/1/19 12:22 PM