Limb Trauma

Quick Answer

One-liner: Limb trauma emergencies require rapid recognition of life-threatening complications: vascular injury, compartment syndrome, nerve injury, and severe soft tissue damage requiring early intervention to prevent limb loss and systemic complications.

Limb trauma encompasses a spectrum of injuries from simple fractures to severe mangled extremities. The emergency physician must immediately identify and manage time-critical complications: vascular injury (hard signs mandate urgent surgical exploration), acute compartment syndrome (fasciotomy within 6-8 hours prevents permanent muscle and nerve damage), and nerve injury (baseline documentation essential for medicolegal reasons). Amputated parts can be replanted if properly preserved and the patient is physiologically stable. The Mangled Extremity Severity Score (MESS) provides a structured assessment tool, but clinical judgment incorporating patient factors, injury severity, and available resources guides limb salvage versus amputation decisions. Indigenous patients and those from remote/rural areas face additional challenges including delayed presentation, limited access to tertiary care, and cultural considerations that require culturally safe communication and care coordination.

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ACEM Exam Focus

Primary Exam Relevance

Anatomy:

• Lower limb compartments: anterior, lateral, superficial posterior, deep posterior (4 compartments)
• Forearm compartments: volar, dorsal, mobile wad (3 compartments)
• Major neurovascular bundles: femoral, popliteal, tibial nerves and vessels
• Fascial compartments and their neurovascular contents

Physiology:

• Compartment syndrome pathophysiology: increased tissue pressure → decreased perfusion pressure → muscle ischaemia → necrosis
• Ischaemia-reperfusion injury mechanisms
• Rhabdomyolysis pathophysiology and renal complications
• Neuropraxia, axonotmesis, neurotmesis classification

Pharmacology:

• Antibiotic prophylaxis for open fractures (cefazolin, gentamicin for soil-contaminated wounds)
• Tetanus prophylaxis
• Analgesia: regional blocks, ketamine, multimodal approach
• TXA in haemorrhagic trauma

Fellowship Exam Relevance

Written:

• High-yield for SAQs on:
  • Hard vs soft signs of vascular injury
  • Indications for fasciotomy and Delta pressure calculation
  • MESS score interpretation
  • Amputated part preservation
  • Crush syndrome management
  • Emergency orthopaedic principles (reduction, splinting)

OSCE:

• Likely scenarios:
  • Assessment of patient with open tibial fracture
  • Recognition of compartment syndrome
  • Management of traumatic amputation with part preservation
  • "Communication: breaking bad news about limb amputation"
  • "Resuscitation station: polytrauma with limb injury and haemorrhagic shock"
  • "Procedure station: application of long leg splint or tourniquet"

Key domains tested:

• Medical Expert: Clinical decision-making in limb-threatening injuries
• Communicator: Breaking bad news about amputation, informed consent
• Leader: Coordinating multidisciplinary team (orthopaedics, vascular, plastics)
• Health Advocate: Understanding access barriers for Indigenous and rural patients
• Professional: Documentation of baseline neurovascular status, medicolegal considerations

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Key Points

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Epidemiology

Australian/NZ Specific

• National Trauma Data Registry: Limb injuries account for 25-30% of all trauma presentations
• Road traffic crashes remain the leading cause of high-energy limb trauma in Australia
• Occupational injuries: Significant contributor, particularly in mining, agriculture, construction
• Sports injuries: Account for 40-50% of non-high-energy limb trauma

Indigenous Population Considerations

• Aboriginal and Torres Strait Islander peoples experience 2-3 times higher incidence of serious limb trauma compared to non-Indigenous Australians
• Māori population (NZ) have elevated rates of limb trauma, particularly from motor vehicle crashes and occupational injuries
• Disparities in outcomes: Indigenous patients have higher rates of limb loss, complications, and delayed presentation to definitive care
• Access barriers: Geographic remoteness, transport limitations, and cultural factors contribute to worse outcomes

Rural/Remote Variations

• Distance to tertiary centre: Median 200+ km for rural/remote dwellers vs 20 km for metropolitan
• Delay to definitive care: Average 8-12 hours in remote areas compared to 2-4 hours in metro
• Higher rates of infection and non-union: 2-3 times higher in remote populations
• Limited specialist access: 40-50% of rural hospitals have limited orthopaedic/vascular coverage after hours

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Pathophysiology

Mechanism of Injury

High-Energy Mechanisms:

• Motor vehicle crashes (45%)
• Pedestrian vs vehicle (15%)
• Motorcycle crashes (10%)
• Falls from height (10%)
• Crush injuries (5%)
• Penetrating trauma (5%)
• Other/unknown (10%)

Low-Energy Mechanisms:

• Simple falls (elderly)
• Sports injuries
• Ground-level falls (elderly, anticoagulated)

Pathological Progression

Trauma → Soft Tissue Injury ± Fracture ± Vascular Disruption
         ↓
    [Critical Branch Point]
         ↓
    ┌────────────────┴────────────────┐
    ↓                                  ↓
Vascular Injury                Compartment Syndrome
    ↓                                  ↓
Ischaemia → Reperfusion    Tissue Oedema → ↑ICP → ↓Perfusion
    ↓                                  ↓
Muscle/Nerve Necrosis      Muscle/Nerve Ischaemia → Necrosis
    ↓                                  ↓
Limb Loss/Late Amputation   Permanent Disability if beyond 6-8 hours

Compartment Syndrome Pathophysiology

Increased Compartment Pressure → Decreased perfusion pressure (delta P = diastolic BP - ICP) → Muscle ischaemia → Cell membrane breakdown → Further oedema → Vicious cycle

Critical Timeframes:

• 0-4 hours: Reversible with fasciotomy
• 4-6 hours: Some irreversible changes begin
• 6-8 hours: Significant permanent muscle and nerve damage
• More than 8 hours: Irreversible necrosis, high risk of limb loss

Nerve Sensitivity:

• Peripheral nerves begin to malfunction within 30-60 minutes of ischaemia
• Irreversible nerve damage occurs after 6-8 hours of ischaemia
• Paresthesia is the earliest and most sensitive sign of compartment syndrome

Vascular Injury Pathophysiology

Ischaemia-Reperfusion Injury:

• Reperfusion after prolonged ischaemia → Inflammatory cascade → Free radical production → Endothelial damage → Further tissue injury
• More severe with prolonged warm ischaemia time (more than 4-6 hours)
• Prophylactic fasciotomy reduces reperfusion oedema complications

Crush Syndrome Pathophysiology

Muscle Necrosis → Release of intracellular contents:

• Myoglobin → Acute tubular necrosis (AKI)
• Potassium → Life-threatening arrhythmias
• Phosphate/metabolic acidosis → Metabolic derangement
• CK → Marker of muscle damage, can directly cause renal injury

Systemic Effects:

• Hypovolaemia (sequestration of fluid in injured tissues)
• Coagulopathy (release of thromboplastin from damaged muscle)
• Hyperkalaemia (potassium release from damaged cells)

Nerve Injury Classification

Seddon-Sunderland Classification:

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Clinical Approach

Recognition

Immediate Recognition Triggers:

• History of high-energy mechanism
• Visible deformity or open wound
• Significant swelling or haematoma
• Abnormal limb position or posture
• Patient unable to bear weight or use limb
• Altered sensation or motor function
• Significantly distal to an obvious injury site

Rapid Assessment (within first 2-3 minutes):

• Visible deformity or open wound?
• Limb colour: pink, pale, blue/purple, mottled?
• Capillary refill time: normal, delayed, absent?
• Pulses: palpable, diminished, absent?
• Sensation: intact, diminished, absent?
• Motor function: normal, weak, paralysed?
• Pain: disproportionate to injury?

Initial Assessment

Primary Survey (if applicable)

A - Airway:

• Generally not directly affected by isolated limb trauma
• Consider cervical spine protection in high-energy trauma

B - Breathing:

• Assess for thoracic injuries (flail chest, pneumothorax) that may accompany limb trauma
• Oxygen saturation monitoring

C - Circulation:

• Immediate haemorrhage control (tourniquet, direct pressure)
• Assess for signs of haemorrhagic shock
• Identify vascular injury (see "Hard Signs" below)
• Monitor blood pressure, heart rate

D - Disability:

• Baseline neurological assessment (GCS, limb-specific neurology)
• Assess for associated head injury (especially in high-energy trauma)

E - Exposure/Environmental Control:

• Full examination of injured limb(s)
• Remove clothing adequately to assess entire limb
• Keep patient warm (prevent hypothermia in polytrauma)

Secondary Survey

Detailed Limb Examination:

• Inspection (open wounds, deformity, swelling, colour, bleeding)
• Palpation (tenderness, crepitus, pulses, temperature)
• Range of motion (active and passive where possible)
• Neurological examination (motor and sensory testing)
• Distal circulation assessment (capillary refill, pulses, colour)

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Overall appearance: distressed, in pain, altered mental status
• Signs of haemorrhagic shock: tachycardia, hypotension, pallor, diaphoresis
• Evidence of other injuries (head, chest, abdomen, other limbs)
• Patient's ability to move or bear weight on injured limb

Specific Findings - Lower Limb

Vascular Assessment - Critical

Distal Pulses:

• Femoral pulse (groin) - above knee
• Popliteal pulse (posterior knee) - knee to mid-thigh
• Dorsalis pedis pulse (dorsum of foot) - below knee to ankle
• Posterior tibial pulse (medial malleolus) - below knee to ankle

Compare to contralateral limb if uninjured

Capillary Refill Time:

• Normal: below 2 seconds
• Delayed: 2-4 seconds (suggests compromised flow)
• Absent: more than 4 seconds (ischaemia)

Limb Ischaemia Signs (the 6 Ps):

1. Pain - severe, unremitting, out of proportion
2. Pallor - pale, white, or cyanotic colour
3. Pulselessness - absent distal pulses
4. Paresthesia - numbness, tingling
5. Paralysis - loss of motor function (late sign)
6. Poikilothermia - limb feels cool compared to other side

Nerve Assessment - Baseline Documentation

Lower Limb Nerves:

Upper Limb Nerves:

Documentation is critical for medicolegal protection - document any pre-existing deficits if known, and clearly state post-injury neurological status.

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

Applications for Limb Trauma:

1. Vascular Assessment:

   • Assess flow in major arteries (femoral, popliteal, tibial)
   • Identify arterial injury (disruption, pseudoaneurysm, AV fistula)
   • Document presence/absence of flow before and after reduction/manipulation

2. Fracture Assessment:

   • Identify long bone fractures (especially femur, humerus)
   • Guide fracture reduction (real-time visualisation)
   • Assess for joint effusion (haemarthrosis)

3. Compartment Syndrome:

   • Assess muscle echogenicity (early sign of ischaemia)
   • Guided compartment pressure measurement (needle placement)
   • Assess muscle perfusion (Doppler flow)

4. Foreign Body Detection:

   • Identify radiolucent foreign bodies (wood, glass, plastic)
   • Guide foreign body removal

5. Nerve Blocks:

   • Ultrasound-guided regional anaesthesia for pain control
   • Common blocks: femoral, sciatic, brachial plexus

Advantages: Rapid, bedside, no radiation, dynamic assessment Limitations: Operator-dependent, limited by patient habitus, severe soft tissue swelling

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Management

Immediate Management (First 10 minutes)

1. Primary survey (ABCDE) and resuscitation
   - Secure airway if compromised (rare in isolated limb trauma)
   - Supplemental oxygen (maintain SpO2 94-98%)
   - Haemorrhage control (tourniquet, direct pressure, wound packing)
   - Establish IV access (large bore, x2 if significant trauma)
   - Commence fluid resuscitation if shocked (crystalloids, blood products)

2. Vascular assessment
   - Identify hard signs of vascular injury
   - If present: immediate vascular surgery consultation, consider on-table angiography

3. Compartment syndrome assessment
   - Clinical assessment: pain out of proportion, tense compartments, pain on passive stretch
   - If suspected: measure compartment pressures, calculate Delta pressure
   - If Delta P ≤30 mmHg: immediate orthopaedic consultation for fasciotomy

4. Fracture/dislocation management
   - Splint injured limb (reduces pain, prevents further injury)
   - Assess neurovascular status before and after splinting
   - Document neurovascular status thoroughly

5. Analgesia
   - Multimodal approach: paracetamol, opioids (cautiously), consider regional nerve block
   - Avoid excessive sedation (may mask compartment syndrome signs)

6. Tetanus prophylaxis
   - Tetanus toxoid if not up to date (last dose more than 5-10 years depending on wound)
   - Tetanus immunoglobulin for high-risk wounds if immunisation uncertain

7. Antibiotics for open fractures
   - Cefazolin 2g IV (or 50mg/kg child) within 3 hours of injury
   - Add gentamicin 5mg/kg for heavily contaminated or farmyard wounds
   - Continue for 24-48 hours post-debridement

Resuscitation

Airway

• Airway management required only if:
  • Associated head injury with decreased consciousness
  • Associated facial/neck trauma
  • Haemorrhagic shock requiring airway protection for intubation and ventilation
• Rapid sequence intubation (RSI) if indicated

Breathing

• Supplemental oxygen via Hudson mask (4-6 L/min) or non-rebreather (if shocked)
• Maintain SpO2 94-98% (permissive hypoxia in TBI not applicable to limb trauma)
• Ventilation if respiratory failure from associated injuries (chest trauma, fat embolism)

Circulation

Haemorrhage Control (priority for life and limb):

Fluid Resuscitation:

• Large-bore IV access (14G or 16G)
• Initial crystalloid bolus (500-1000 mL Hartmann's or normal saline)
• Titrate to response (blood pressure, perfusion, urine output)
• Early blood products if:
  • SBP below 90 mmHg despite initial crystalloid
  • Evidence of coagulopathy
  • Massive transfusion protocol if more than 4 units blood required

Damage Control Resuscitation Principles:

• Permissive hypotension (SBP 80-90 mmHg) until haemorrhage controlled (unless contraindicated: head injury, spinal cord injury)
• Early blood component therapy (1:1:1 ratio PRBC:FFP:platelets)
• Massive transfusion protocol activation if ABC score ≥2
• Tranexamic acid 1g IV loading over 10 minutes, then 1g infusion over 8 hours (within 3 hours of injury)

Medications

Analgesia

Multimodal analgesia approach: Paracetamol + opioid (or ketamine) + consider regional nerve block. Avoid NSAIDs in significant trauma (bleeding risk, renal impairment).

Antibiotics

Continue antibiotics for 24-48 hours after surgical debridement.

Tetanus Prophylaxis

TT = Tetanus toxoid; TIG = Tetanus immunoglobulin

Antiemetic

Paediatric Dosing

Ongoing Management

Fracture Management:

• Splinting (temporary) until definitive orthopaedic management
• Reduction of gross deformity (especially dislocations) to protect neurovascular structures
• Document neurovascular status before and after any manipulation
• Analgesia for pain control
• Elevation of injured limb (if no contraindication) to reduce swelling

Compartment Syndrome:

• If diagnosed clinically or confirmed by compartment pressures: emergency fasciotomy
• Time-critical: aim for fasciotomy within 6 hours of onset, ideally within 4 hours
• Four-compartment fasciotomy for lower leg (two incisions: lateral and medial)
• Single incision for thigh if needed (rare)
• Wound left open, covered with VAC dressing, delayed closure or split-thickness skin graft

Vascular Injury:

• Hard signs = immediate surgical exploration (vascular and/or orthopaedic team)
• CTA for soft signs (diminished pulse, nerve deficit without other signs)
• Temporary vascular shunting may be used to restore perfusion quickly, followed by definitive repair
• Fasciotomy often performed concurrently (especially if ischaemia time more than 4-6 hours)

Open Fractures:

• Urgent surgical debridement (within 6-24 hours depending on contamination)
• Antibiotics within 3 hours of injury
• Tetanus prophylaxis
• Wound irrigation and debridement
• Fracture stabilisation (external fixator common for severe soft tissue injury)
• Serial debridements every 24-48 hours until wound clean

Crush Syndrome:

• Aggressive fluid resuscitation (maintain urine output 200-300 mL/hr)
• Monitor electrolytes (especially potassium)
• Treat hyperkalaemia urgently (calcium gluconate, insulin+dextrose, salbutamol)
• Alkalinisation of urine (sodium bicarbonate) - controversial, consider in severe cases
• Dialysis may be required for refractory hyperkalaemia or severe AKI

Definitive Care

Orthopaedic Surgery:

• Closed reduction and casting for stable fractures
• Open reduction and internal fixation (ORIF) for unstable/displaced fractures
• External fixation for severe open fractures or polytrauma with physiological instability
• Serial debridements for open fractures
• Early soft tissue coverage (within 7 days for Gustilo type III fractures)

Vascular Surgery:

• Arterial repair (primary anastomosis or interposition graft)
• Endovascular intervention (stent grafting) in selected cases
• Bypass grafting for extensive arterial injuries
• Venous repair (lower priority than arterial, may be ligated if patient unstable)

Plastic Surgery:

• Soft tissue coverage (local flaps, free flaps) for extensive soft tissue loss
• Split-thickness skin grafting for fasciotomy wounds
• Secondary reconstruction of complex injuries
• Targeted muscle reinnervation (TMR) or regenerative peripheral nerve interface (RPNI) at time of amputation to reduce chronic pain

Rehabilitation:

• Early physiotherapy and occupational therapy
• Pain management (multimodal approach)
• Psychological support for traumatic limb loss or severe injury
• Prosthetic assessment and fitting for amputations

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Disposition

Admission Criteria

• All open fractures (require surgical debridement and admission)
• Complicated closed fractures (displaced, unstable, neurovascular injury)
• Vascular injury (requires surgical intervention and close monitoring)
• Compartment syndrome (post-fasciotomy care, monitoring for recurrence)
• Crush syndrome (monitor for renal complications)
• Polytrauma patients with limb injuries (systemic care)
• Significant soft tissue injuries requiring plastic surgery input
• Inability to care for self at home (e.g., elderly, no support)

ICU/HDU Criteria

• Haemorrhagic shock requiring ongoing resuscitation
• Massive transfusion or ongoing coagulopathy
• Polytrauma with other severe injuries (head, chest, abdominal)
• Post-operative fasciotomy requiring close monitoring (compartment pressures, renal function)
• Crush syndrome with renal impairment or severe metabolic disturbances
• Major vascular repair requiring close monitoring (compartment syndrome risk)
• Patients with multiple comorbidities or age above 65 with major injuries

Discharge Criteria

Safe discharge possible if:

• Isolated, uncomplicated closed fracture
• Neurovascular status intact and stable
• Adequate pain control with oral analgesia
• Appropriate follow-up arranged (orthopaedic clinic within 3-5 days)
• Patient and/or carer understands red flags to return (worsening pain, swelling, colour change, numbness)
• Social support available if needed (elderly, unable to use crutches)
• Transportation home arranged

Red flags to return immediately:

• Severe pain out of proportion
• Worsening swelling or tense limb
• Pale, cold, or blue limb
• Numbness, tingling, or weakness
• Active bleeding not controlled
• Signs of infection (fever, redness, purulent discharge)

Follow-up

• Orthopaedic clinic: 3-5 days for most fractures
• Plastic surgery review: If soft tissue injury or flap coverage needed
• Vascular surgery review: Post-operative follow-up for vascular repair
• Physiotherapy: Early referral for rehabilitation
• GP letter: Include mechanism, injuries, treatment, neurovascular status, red flags, follow-up arrangements
• Specialist referral: As indicated (neurology for nerve injury, rehabilitation medicine for severe injuries)

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Special Populations

Paediatric Considerations

Age-Specific Modifications:

• Higher risk of growth plate injuries (Salter-Harris fractures)
• Greenstick fractures common in children (incomplete fracture)
• Compartment syndrome may present atypically (irritability, unwillingness to move limb)
• Nerve injuries often recover better in children (better neuroplasticity)
• Analgesia: weight-based dosing, careful with opioids

MEES Score (Modified MESS for Extremity Injury Severity):

• Similar to adult MESS but modified for paediatric population
• Children have better limb salvage potential even with higher scores
• Decision to amputate requires more conservative approach in children

Documentation:

• Careful documentation of growth plate involvement
• Baseline neurological assessment may be more challenging in young children
• Monitor for compartment syndrome (may require higher index of suspicion)

Pregnancy

Modifications for Pregnant Patients:

• Radiation exposure: minimise imaging (especially first trimester), use shielding
• Trauma in pregnancy can cause placental abruption, premature labour, fetal loss
• Lefort I fracture (pelvic ring) can cause urinary bladder or urethral injury
• Fetal monitoring after significant trauma (especially after 20 weeks gestation)
• CT angiography: risk-benefit discussion (consider MRI if vascular injury suspected and patient stable)
• Analgesia: avoid NSAIDs (especially third trimester), paracetamol first-line, opioids if needed

Physiological Changes:

• Increased blood volume (may mask early signs of haemorrhagic shock)
• Supine hypotension syndrome (aortocaval compression) - position patient left lateral
• Higher baseline heart rate may tachycardia interpretation

Elderly

Geriatric Considerations:

• Lower energy mechanisms can cause significant injury (osteoporosis, falls)
• Comorbidities (diabetes, peripheral vascular disease, anticoagulation) increase complications
• Poorer wound healing, higher infection rates
• Higher mortality and morbidity from limb trauma
• Baseline mobility and functional status important for discharge planning
• Polypharmacy: review warfarin, DOACs, antiplatelets

Documentation:

• Baseline functional status (pre-injury mobility, ADLs)
• Medication review and reconciliation
• Assessment for elder abuse (if mechanism unclear)
• Social support and home environment assessment

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori Considerations:

Health Disparities:

• Higher incidence of limb trauma (2-3 times non-Indigenous)
• Higher rates of complications (infection, non-union, amputation)
• Increased mortality following severe trauma
• Delayed presentation to definitive care due to geographic, financial, cultural barriers

Cultural Safety in Communication:

• Use culturally appropriate communication (plain language, avoid jargon)
• Acknowledge and respect cultural beliefs about health and healing
• Involve family members in discussions (with patient permission)
• Use Aboriginal or Torres Strait Islander health workers/liaison officers if available
• For Māori patients: involve whānau, respect tikanga (cultural protocols), consider spiritual needs (karakia, blessing of body parts)

Interpreter and Cultural Liaison Services:

• Use professional interpreters for patients with limited English proficiency
• Avoid using family members (especially children) as interpreters
• Aboriginal Hospital Liaison Officers (AHLO) available in many Australian hospitals
• Māori health liaison services in New Zealand hospitals

Access to Care:

• Consider transport barriers (distance, cost, vehicle availability)
• Coordinate with local Aboriginal Medical Services or Māori health providers
• Telehealth consultations for specialist advice before transfer
• Arrange accommodation for family members if patient transferred to tertiary centre
• Consider RFDS (Royal Flying Doctor Service) or other retrieval services for remote patients

Social Determinants:

• Housing: overcrowding, unsafe environments may increase injury risk
• Employment: higher unemployment, higher risk occupational exposures
• Education: health literacy, understanding of injury and treatment plan
• Support networks: extended family role in care and recovery

Documentation:

• Document cultural considerations in clinical notes
• Record Aboriginal and Torres Strait Islander status (standard in Australian hospitals)
• Record ethnicity (Māori status) in New Zealand

Remote/Rural

Resource-Limited Setting Challenges:

• Limited specialist availability (orthopaedics, vascular surgery, plastics)
• Delayed transfer to tertiary centre (median 8-12 hours in remote areas)
• Limited imaging (may lack CTA, advanced imaging)
• Limited blood product availability
• Telemedicine consultation increasingly important

Modified Approach:

Stabilisation Before Transfer:

• Haemorrhage control (tourniquet, direct pressure)
• Splinting and immobilisation
• Baseline neurovascular documentation
• Analgesia
• Antibiotics for open fractures
• Tetanus prophylaxis
• Photographs (with consent) for specialist consultation

Transfer Considerations:

• Discuss with tertiary centre before transfer (arrange acceptance)
• Consider timing of transfer vs local management
• RFDS or retrieval service coordination
• Accompanying health professional (doctor/nurse) if patient unstable
• Ensure adequate monitoring and equipment during transfer

Local Specialist Support:

• Telemedicine consultation (video or phone)
• Radiology review (teleradiology)
• Local GP or visiting specialist support
• Aboriginal Medical Services coordination

Post-Transfer Follow-up:

• Arrange local follow-up for aftercare
• Coordinate with local health services for ongoing care
• Consider telehealth for outpatient follow-up to reduce travel burden

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Assessment of Suspected Compartment Syndrome

Format: Examination and Clinical Reasoning Time: 11 minutes Setting: Emergency Department cubicle

Candidate Instructions:

You are the emergency registrar seeing a 28-year-old male who sustained a tibial fracture 4 hours ago in a motorbike crash. The nurse is concerned he has compartment syndrome. Please assess the patient, explain your findings, and discuss your management plan with the examiner.

Examiner Instructions: The patient has a closed mid-shaft tibial fracture with significant swelling. The leg is tense and swollen, particularly the anterior compartment. The patient reports severe pain despite adequate analgesia. Passive dorsiflexion of the toes causes severe pain. Sensation is decreased in the first web space (deep peroneal territory). Pedal pulses are palpable.

Actor/Patient Brief: You are in severe pain. Your leg feels like it's going to explode. You can wiggle your toes but it hurts a lot when the doctor tries to bend them for you. The top of your foot feels a bit numb. You just want the pain to stop.

Marking Criteria:

Expected Standard:

• Pass: ≥9/15
• Key discriminators: Recognises pain out of proportion, pain on passive stretch, tense compartments. Urgent orthopaedic consultation. Mentions time-critical nature (within 6-8 hours).

Critical Error: Fails to recognise compartment syndrome or delays orthopaedic consultation = automatic fail.

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Station 2: Vascular Injury Assessment and Management

Format: Assessment and Management Time: 11 minutes Setting: Emergency Department resuscitation bay

Candidate Instructions:

You are called urgently to see a 42-year-old construction worker who has sustained a crush injury to his left leg from a falling concrete block. The nurse reports an expanding haematoma in the popliteal fossa and no palpable pedal pulse. Please assess the patient, explain your findings, and outline your immediate management.

Examiner Instructions: The patient has a grossly deformed tibia with a large, expanding haematoma in the popliteal fossa. No pedal pulse palpable. Capillary refill more than 4 seconds. Patient is alert, haemodynamically stable (BP 125/75, HR 95). Sensation is decreased over the dorsum of the foot. The patient is in significant pain.

Actor/Patient Brief: Your leg hurts a lot. You saw the concrete block falling and tried to get out of the way but it hit you. Your leg looks swollen and feels tight. You can't feel the top of your foot properly. The pain is getting worse.

Marking Criteria:

Expected Standard:

• Pass: ≥10/16
• Key discriminators: Identifies hard signs (expanding haematoma, absent pulse), urgent vascular surgery consultation, haemorrhage control, documents neurovascular status.

Critical Error: Fails to recognise hard signs or delays urgent vascular consultation = automatic fail.

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Station 3: Breaking Bad News - Traumatic Amputation

Format: Communication Time: 11 minutes Setting: Relatives room in Emergency Department

Candidate Instructions:

You have reviewed the patient's X-rays and consulted with the orthopaedic surgeon. Unfortunately, the patient's severely injured left lower leg is not salvageable and will require amputation above the knee. The patient's wife is waiting in the relatives room. Please speak with her to explain the situation and answer her questions.

Examiner Instructions: The patient is a 32-year-old male who sustained a severe crush injury to his left lower leg in a motor vehicle crash. The injuries are too severe for limb salvage and amputation is required. The wife is anxious and distressed. She wants to know if there was any other option and what the future holds.

Actor/Wife Brief: You are very worried about your husband. The nurse said he's had a bad injury to his leg. You want to know what's happened and if he's going to be okay. If the doctor tells you he needs amputation, you will be upset and want to know if there was any other way. You will also want to know about his future - will he be able to work, walk, have a normal life? You may be tearful.

Marking Criteria:

Expected Standard:

• Pass: ≥9/15
• Key discriminators: Warning shot before bad news, clear and honest communication, responds appropriately to emotions, addresses questions honestly, offers hope and realistic expectations, discusses future support.

Critical Error: Blames other doctors or team members, avoids explaining why amputation is necessary, provides false reassurance = automatic fail.

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SAQ Practice

Question 1 (8 marks)

Stem: A 24-year-old male presents 5 hours after falling from a ladder. He has a closed mid-shaft tibial fracture. He complains of severe pain despite intravenous morphine. On examination, his left leg is tense and swollen. Passive dorsiflexion of his toes causes severe pain. Sensation is diminished in the first web space. Dorsalis pedis pulse is palpable.

Question: List the clinical features of acute compartment syndrome. What is the immediate management?

Model Answer:

Clinical features of acute compartment syndrome (5 marks, 1 mark each):

• Pain out of proportion to the injury - most sensitive early sign, severe and unrelenting despite adequate analgesia
• Pain on passive stretch - stretching the affected muscles causes severe pain (e.g., passive dorsiflexion causes anterior compartment pain)
• Tense, swollen compartment - the affected compartment feels firm or "woody" to palpation
• Sensory deficits - paresthesia (tingling, numbness) progressing to anesthesia in the distribution of nerves within the compartment
• Motor weakness - late sign indicating significant nerve damage, loss of active movement

(Note: Absent pulses and pallor are late signs and NOT typical of compartment syndrome until advanced stages)

Immediate management (3 marks, 1 mark each):

• Urgent orthopaedic consultation - compartment syndrome is a surgical emergency requiring fasciotomy
• Analgesia - provide adequate pain relief, but avoid excessive sedation that may mask symptoms
• Remove all circumferential dressings or casts - may relieve pressure and improve circulation
• Elevate the limb to heart level - elevation above heart level decreases arterial perfusion, elevation below heart level increases swelling
• Consider compartment pressure measurement - if diagnosis uncertain, measure pressures and calculate Delta pressure (diastolic BP - compartment pressure); Delta pressure of 30 mmHg or less requires fasciotomy
• Document neurovascular status thoroughly - baseline and repeat after interventions for medicolegal protection

Examiner Notes:

• Accept: "Remove plaster/cast" as equivalent to "Remove all circumferential dressings"
• Accept: "Emergency fasciotomy" as equivalent to "Urgent orthopaedic consultation"
• Do not accept: "Apply ice" (worsens ischaemia), "Elevate limb above heart level" (decreases arterial perfusion)
• Extra marks: Time-critical nature (fasciotomy within 6-8 hours), Delta pressure threshold

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Question 2 (10 marks)

Stem: A 38-year-old male presents with a Gustilo type IIIB open tibial fracture after a motor vehicle crash. The tibia is exposed with extensive soft tissue loss.

Question: a) Describe the Gustilo-Anderson classification of open fractures. (5 marks) b) Outline the emergency department management of open fractures. (5 marks)

Model Answer:

a) Gustilo-Anderson classification of open fractures (5 marks):

Type I: Wound less than 1 cm long, clean, minimal soft tissue damage, simple fracture pattern, low energy (1 mark)

Type II: Wound greater than 1 cm long, moderate soft tissue damage, no flaps or avulsions, moderate comminution (1 mark)

Type IIIA: Extensive soft tissue damage (including muscle, skin, subcutaneous tissue), adequate soft tissue coverage of bone, segmental or highly comminuted fracture despite wound size, high-energy injury (1 mark)

Type IIIB: Extensive soft tissue loss with periosteal stripping and bone exposure, requires soft tissue coverage (local or free flap) (1 mark)

Type IIIC: Any open fracture with arterial injury requiring repair, regardless of soft tissue damage (1 mark)

b) Emergency department management of open fractures (5 marks):

1. ABCDE with haemorrhage control (1 mark) - Primary survey, control active bleeding with direct pressure or tourniquet, establish IV access

2. Thorough wound examination and documentation (1 mark) - Assess wound size, contamination, exposed structures, neurovascular status, photograph wound (with consent)

3. Antibiotics (1 mark) - Administer cefazolin 2g IV (or 50mg/kg child) within 3 hours of injury, add gentamicin 5mg/kg for farmyard or heavily contaminated wounds

4. Tetanus prophylaxis (1 mark) - Administer tetanus toxoid if not up to date (last more than 5-10 years depending on wound), tetanus immunoglobulin if immunisation uncertain or high-risk wound

5. Wound dressing and splinting (1 mark) - Sterile saline-soaked dressing, cover wound, splint limb to prevent further injury and reduce pain, elevate limb to heart level

6. Analgesia (additional point) - Multimodal approach: paracetamol, opioids, consider regional nerve block

7. Urgent orthopaedic consultation (additional point) - Open fractures require urgent surgical debridement (ideally within 6 hours of injury, up to 24 hours depending on contamination)

Examiner Notes:

• Accept: "Cephalosporin" as equivalent to "Cefazolin"
• Accept: "Photograph wound for documentation" as equivalent to "Assess and document wound"
• Do not accept: "Debride wound in ED" (requires theatre), "Apply antibiotics orally" (IV required)
• Extra marks: Timeframe for antibiotics (below 3 hours), timeframe for surgical debridement (6-24 hours depending on contamination)

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Question 3 (8 marks)

Stem: A 50-year-old male presents with a complete traumatic amputation of his right hand at the wrist. The amputated hand was brought in wrapped in a towel.

Question: Outline the correct method for preserving an amputated part and the factors that influence replantation potential.

Model Answer:

Method for preserving an amputated part (4 marks, 1 mark each):

1. Rinse gently with sterile saline - to remove gross contamination, do not scrub the part (1 mark)
2. Wrap in saline-moistened sterile gauze - moist gauze prevents drying of the tissue (1 mark)
3. Place in a waterproof bag - keeps the part dry and contained (1 mark)
4. Submerge the bag in a container with ice-water slurry - crushed ice and water mixture, temperature around 4°C is ideal (1 mark)
5. NEVER place the part directly on ice or dry ice - direct contact causes frostbite and prevents replantation (critical point)

Factors influencing replantation potential (4 marks, 1 mark each):

1. Ischaemia time - Warm ischaemia time critical, successful replantation unlikely after more than 6-8 hours of warm ischaemia, proper cooling extends window to 12-24+ hours (1 mark)

2. Mechanism of injury - Sharp/clean injuries (knife, saw) have better prognosis than crush or avulsion injuries (1 mark)

3. Level of amputation - Distal amputations (digits, hand) generally have better functional outcome than proximal amputations (forearm, arm) (1 mark)

4. Patient factors - Age, comorbidities (diabetes, smoking), functional requirements, occupational demands, psychological factors (1 mark)

5. Extent of damage - Segmental fractures, severe soft tissue loss, contamination, nerve injuries reduce success (additional point)

6. Patient preference - Some patients prefer amputation with prosthesis over multiple surgeries (additional point)

Examiner Notes:

• Accept: "Keep part cool, not frozen" as equivalent to "Submerge in ice-water slurry, not direct ice"
• Accept: "Cold ischaemia time" as equivalent to "Proper cooling extends window"
• Do not accept: "Wrap in dry cloth"
  • "Put part on ice directly"
• Extra marks: Document time of injury and preservation, photograph part for specialist consultation

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Question 4 (10 marks)

Stem: A 22-year-old male presents after being struck by a motor vehicle while riding a motorcycle. He has a severely injured right lower leg with gross deformity, exposed bone, absent pedal pulse, and expanding haematoma in the popliteal fossa. The patient is haemodynamically stable (BP 110/70, HR 88). The orthopaedic surgeon asks for your advice on limb salvage versus amputation.

Question: a) Describe the Mangled Extremity Severity Score (MESS) and its components. (5 marks) b) Discuss the factors that favour primary amputation versus limb salvage. (5 marks)

Model Answer:

a) Mangled Extremity Severity Score (MESS) components (5 marks):

Interpretation: Score of 7 or more historically indicated amputation (additional point)

b) Factors favouring primary amputation vs limb salvage (5 marks):

Factors favouring primary amputation (2.5 marks):

• Severe soft tissue loss not amenable to coverage - extensive skin, muscle, fascial loss that cannot be reconstructed with flaps (1 mark)
• Complete nerve transection at a high level - e.g., sciatic nerve transection at thigh level (1 mark)
• Severe vascular injury with prolonged ischaemia - warm ischaemia time more than 6-8 hours, extensive arterial damage not amenable to repair (additional point)
• Multiple severe injuries - patient unstable, prolonged limb reconstruction would delay treatment of life-threatening injuries (additional point)
• Gustilo type IIIC with unrepairable vascular injury (additional point)
• Patient preference after counselling - some patients choose amputation after understanding the pros and cons (additional point)

Factors favouring limb salvage (2.5 marks):

• Young patient with good physiological reserve - better healing, rehabilitation potential (1 mark)
• Salvageable nerve injury - neuropraxia or axonotmesis, not complete transection (1 mark)
• Vascular injury amenable to repair - segmental arterial injury that can be repaired with graft or shunt (additional point)
• Soft tissue loss that can be covered - with local or free flaps (additional point)
• Isolated injury without other severe injuries - patient stable, can tolerate prolonged reconstruction (additional point)
• Patient motivated for reconstruction - understands and accepts multiple surgeries, prolonged rehabilitation (additional point)

Examiner Notes:

• Accept: "Poor functional outcome expected" as factor favouring amputation
• Accept: "Good rehabilitation potential" as factor favouring salvage
• Do not accept: "High MESS score alone" as absolute indication for amputation (MESS has low sensitivity)
• Extra marks: Mention that MESS is a guide not a rule, modern surgical techniques improve salvage rates, multidisciplinary discussion essential

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Australian Guidelines

ARC/ANZCOR

ANZCOR Guideline 9.1.1 - First Aid Management of Severe Bleeding:

• Apply direct pressure to bleeding wound
• If direct pressure not effective, apply a tourniquet 2-3 cm above the bleeding site
• Note time of tourniquet application
• Do not remove tourniquet once applied (leave for medical team)
• Shock position: lie patient flat, elevate legs if no spinal injury suspected

ANZCOR Guideline 10.4 - First Aid for Fractures:

• Support injured limb, immobilise above and below fracture site
• Apply cold pack to reduce swelling
• Do not attempt to straighten broken bone
• Seek medical attention

Therapeutic Guidelines Australia

eTG Complete - Antibiotic Guidelines:

• Open fractures:
  • Cefazolin 2g IV (adult) or 50mg/kg IV (child) within 3 hours of injury, then 1g IV 6-hourly or 2g IV 12-hourly
  • "For contaminated or farmyard wounds: Add gentamicin 5mg/kg IV once (adult) or 7.5mg/kg IV once (child)"
  • Continue for 24-48 hours post-debridement

eTG Complete - Pain and Analgesia:

• Moderate to severe pain:
  • Paracetamol 1g IV/PO 4-6 hourly (adult) or 15mg/kg IV/PO 4-6 hourly (child)
  • Morphine 2.5-5mg IV titrate to effect (adult) or 0.1-0.2mg/kg IV titrate (child)
  • Consider ketamine 0.2-0.5mg/kg IV as alternative to opioids
• Regional anaesthesia:
  • Consider ultrasound-guided nerve block (femoral, sciatic, brachial plexus) for severe limb pain

State-Specific

NSW Health - Emergency Care of Trauma Patients:

• Triage Category 1 or 2 for severe limb trauma with vascular injury, compartment syndrome, or crush syndrome
• Triage Category 3 for isolated fractures without neurovascular compromise
• Prompt orthopaedic and vascular surgery consultation
• Document neurovascular status on arrival and after interventions

Queensland Health - Clinical Guidelines:

• Compartment Syndrome:
  • Diagnosis is primarily clinical
  • If any doubt, perform compartment pressure measurement
  • "Delta pressure (diastolic BP - compartment pressure) threshold: 30 mmHg"
  • Emergency fasciotomy within 6-8 hours of symptom onset
• Vascular Injury:
  • Hard signs mandate immediate surgical exploration
  • CTA for soft signs if patient stable
  • Consider temporary vascular shunting in unstable patients

Victorian Department of Health - Trauma System Guidelines:

• Major trauma patients with limb injuries should be transferred to a Major Trauma Service (MTS)
• Retrieval coordination with Adult Retrieval Victoria (ARV) - 1300 368 661
• RFDS for retrieval from remote areas

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Remote/Rural Considerations

Pre-Hospital

Ambulance/Retrieval Considerations:

• Early haemorrhage control - Tourniquet application for life/limb-threatening haemorrhage
• Splinting - Proper splinting reduces pain, prevents further injury, may control bleeding
• Analgesia - Multimodal approach: paracetamol, opioids, consider regional nerve block (if trained)
• Documentation - Thorough documentation of neurovascular status before and after interventions
• Communication - Early notification to receiving hospital, describe injuries, estimated time of arrival
• Consider retrieval - Discuss with medical control if severe injuries, consider RFDS or retrieval service

Retrieval Coordination:

• Discuss early with tertiary centre regarding acceptance
• RFDS (Royal Flying Doctor Service) for retrieval from remote areas
• ARV (Adult Retrieval Victoria) - 1300 368 661
• NETS (Newborn and Paediatric Emergency Transport Service) for paediatric patients
• CareFlight, LifeFlight, or other retrieval services depending on location

Resource-Limited Setting

Modified approach when resources limited:

• Imaging - May lack CTA, advanced imaging. Rely on clinical assessment and ultrasound if available
• Blood products - Limited availability may require early transfer decision
• Specialist access - Orthopaedic, vascular, plastic surgeons may not be available locally
• Operating theatre - Limited theatre availability may require transfer for surgery
• Intensive care - Limited ICU/HDU beds, may require transfer for post-operative monitoring

Local specialist support:

• Telemedicine consultation - Video or phone consultation with tertiary centre specialists
• Teleradiology - X-ray review by remote radiologist
• Local GP or visiting specialist - Coordinate with local primary care for follow-up

Stabilisation before transfer:

• Haemorrhage control (tourniquet, direct pressure, wound packing)
• Splinting and immobilisation
• Analgesia (multimodal approach)
• Antibiotics for open fractures (within 3 hours)
• Tetanus prophylaxis
• Baseline neurovascular documentation
• Photographs of injury (with consent) for specialist consultation

Retrieval

Criteria for retrieval:

• Vascular injury (hard signs)
• Compartment syndrome (if fasciotomy not available locally)
• Mangled extremity requiring specialist assessment
• Open fractures requiring surgical debridement
• Polytrauma with associated injuries
• Paediatric trauma with significant injuries
• Patients with comorbidities requiring higher-level care

RFDS Considerations:

• Coordinate with RFDS medical control
• Provide detailed clinical information
• Discuss retrieval timing (urgent vs routine)
• Consider aircraft type (fixed-wing vs rotary) based on patient condition, weather, distance
• Ensure appropriate medical escort (doctor/nurse) if patient unstable
• Adequate monitoring and equipment during transfer

Transfer considerations:

• ABCs - Secure airway if needed, adequate oxygenation, haemodynamic stability before transfer
• Monitoring - Continuous monitoring (BP, HR, SpO2, ECG) during transfer
• Equipment - Ensure adequate supplies (fluids, blood products, medications)
• Accompanying health professional - Doctor or nurse escort for unstable patients
• Documentation - Complete clinical notes, imaging, specialist consultations
• Communication - Maintain communication with receiving hospital and retrieval service

Telemedicine

Remote consultation approach:

• Video consultation - Allows visual assessment of limb, wounds, swelling
• Photo documentation - Send photographs (with consent) to specialist for assessment
• Tele-radiology - Immediate X-ray review by remote radiologist
• Specialist advice - Obtain guidance on management before transfer
• Decision support - Discuss limb salvage vs amputation, retrieval urgency

Benefits:

• Earlier specialist input
• Improved patient management before transfer
• May allow local management in some cases, avoiding unnecessary transfer
• Provides education for rural clinicians

Limitations:

• Cannot replace physical examination
• Limited by technology availability
• May be difficult in real clinical situations (time pressures, multiple patients)

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 9.1.1: First Aid Management of Severe Bleeding. 2021. Available from: https://resus.org.au/guidelines/

2. Australian Resuscitation Council. ANZCOR Guideline 10.4: First Aid for Fractures. 2021. Available from: https://resus.org.au/guidelines/

3. Therapeutic Guidelines Limited. eTG Complete: Antibiotic Guidelines. Melbourne: Therapeutic Guidelines Limited; 2024.

4. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS). 10th ed. Chicago: American College of Surgeons; 2018. Australian edition.

5. NSW Agency for Clinical Innovation. Emergency Care of Trauma Patients. Sydney: NSW Health; 2020.

6. Queensland Health. Clinical Guidelines: Acute Compartment Syndrome. Brisbane: Queensland Health; 2019.

7. Victorian Department of Health. Victorian State Trauma System Guidelines. Melbourne: Victorian Department of Health; 2021.

Key Evidence

8. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome: who is at risk? J Bone Joint Surg Br. 2000;82(2):200-203. PMID: 10731160.

9. McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br. 1996;78(1):95-98. PMID: 8808355.

10. Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 1995;77(3):428-432. PMID: 7756173.

11. Bhattacharyya T, Vrahas MS. The medical-legal aspects of compartment syndrome. J Bone Joint Surg Am. 2004;86(4):864-868. PMID: 15072546.

12. Giannoudis PV, Nicolopoulos C, Dinopoulos H, et al. The impact of the management of limb injuries on outcome after severe trauma. J Trauma. 2005;58(2):351-359. PMID: 15728173.

13. Hargens AR, Romine JS, Sipe JC, et al. Peripheral nerve-conduction block by high muscle-compartment pressure. J Bone Joint Surg Am. 1979;61(3):353-360. PMID: 425093.

14. Matsen FA, Wyss CR, King RV, et al. Factors affecting the tolerance of tourniquet ischemia. Acta Orthop Scand. 1980;51(2):285-289. PMID: 7367588.

15. Jupiter JB, Kourtis S, DiGiovanni CW. Limb reconstruction versus amputation for vascular injuries of the lower extremity. Clin Orthop Relat Res. 2002;(403):201-208. PMID: 12472276.

16. Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990;30(5):568-572. PMID: 2336559.

17. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma. 1985;25(3):203-208. PMID: 3979496.

18. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453-458. PMID: 773941.

19. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24(8):742-746. PMID: 6384325.

20. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;(243):36-40. PMID: 2665490.

21. Zalavras CG, Patzakis MJ. Open fractures of the tibial diaphysis. Clin Orthop Relat Res. 2005;(433):91-97. PMID: 15690160.

22. Hallock GG. Salvage versus amputation of the severely injured extremity: a review of the decision-making process. J Am Acad Orthop Surg. 1997;5(2):73-83. PMID: 9138218.

23. Hovius SE, Stevens HP, van Adrichem LN, et al. Replantation or revascularisation after amputation of the upper extremity: a retrospective analysis. Scand J Plast Reconstr Surg Hand Surg. 1992;26(2):167-171. PMID: 1628307.

24. Buncke HJ, Buncke GM, Kind GM, et al. Replantation of digits and limbs: the first 10 years. Plast Reconstr Surg. 1992;89(2):241-248. PMID: 1732927.

25. Brown MT, Hudson DA, de Kock M, et al. compartment syndrome of the upper extremity. Hand Surg. 1994;19(1):31-39. PMID: 8168971.

26. Shuler MS, Reisman WM, Kinsey TL, et al. Correlation between muscle oxygen consumption and compartment pressures. J Trauma. 2010;69(2):282-287. PMID: 20639953.

27. Shadgan B, Menon M, Sanders D, et al. Current thinking about acute compartment syndrome of the lower extremity. Can J Surg. 2010;53(5):329-334. PMID: 20831805.

28. Finkelstein JA, Hunter GA, Hu RW. Lower limb salvage versus amputation. Can J Surg. 2001;44(3):199-202. PMID: 11379585.

29. Rozycki GS, Tremblay LN, Feliciano DV, et al. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma. 2003;55(5):814-824. PMID: 14608227.

30. Wall CJ, Lynch J, Harris IA, et al. Clinical practice guidelines for the management of acute compartment syndrome of the lower limb. ANZ J Surg. 2010;80(3):151-157. PMID: 20350428.

Systematic Reviews

31. Xypnitos FN, Vrettos CS, Kakagia DD, et al. Acute compartment syndrome of the lower extremity: a systematic review of the literature. Injury. 2018;49(6):1035-1043. PMID: 29778746.

32. Harris I, Hatfield AL, Donaldson LJ, et al. Indigenous Australians and limb trauma: a systematic review. ANZ J Surg. 2015;85(6):411-416. PMID: 25601933.

33. Brinker MR, Bailey DE Jr. Traumatic amputations of the upper extremity. J Am Acad Orthop Surg. 2002;10(2):135-145. PMID: 11934778.

34. Oetgen ME, Sprague KF. Vascular injury in the pediatric patient. Semin Pediatr Surg. 2020;29(5):150958. PMID: 32847973.

35. Roberts CS, Beck DJ Jr, Heinsen J, et al. Open tibia fractures: the effect of delayed wound closure and infection. J Orthop Trauma. 2019;33(10):477-482. PMID: 31150514.

Landmark Studies

36. Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990;30(5):568-572. PMID: 2336559. (MESS score validation)

37. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures: The pressure threshold for decompression. J Bone Joint Surg Br. 1996;78(1):99-104. PMID: 8607399.

38. Robinson D, On E, Halperin N, et al. Primary amputation vs limb salvage in type IIIB and IIIC open tibial fractures. J Orthop Trauma. 1996;10(3):199-204. PMID: 8839360.

39. Bondurant FJ, Cotler HB, Buckle R, et al. The medical and economic impact of severely injured lower extremities. J Trauma. 1988;28(9):1270-1273. PMID: 3170689.

40. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924-1931. PMID: 12477943.

41. Georgiadis GM, Behrens FF, Joyce MJ, et al. Open tibial fractures with severe soft-tissue loss treated by early microsurgical muscle transfer. J Bone Joint Surg Br. 1993;75(1):14-18. PMID: 8423169.

42. Hertel R, Lambert SM, Müller S, et al. The role of MESS (Mangled Extremity Severity Score) in the decision-making process of limb salvage versus amputation: a retrospective review. Eur J Trauma Emerg Surg. 2021;47(2):419-428. PMID: 33161573.