Severed or Constricted Limbs or Digits
By Amy H. Kaji, MD, PhD, Associate Professor, Department of Emergency Medicine, Harbor-UCLA Medical Center
Body parts such as fingers and toes can become severed (amputated). Also, tissue may die because blood flow has been cut off by rings or other constricting devices. Rings cut off blood flow when parts of the body near the ring swell, often as the result of an injury or simply because of constriction by the ring.
Severed body parts, if properly preserved, can sometimes be reattached in the hospital. To prolong tissue life, the severed part should be put in sterile gauze or a damp paper towel or washcloth and then placed inside a sealed, dry plastic bag. The bag should then be put in another bag or container with ice. Dry ice should not be used. The severed part should not be placed directly in water.
An injured finger will probably swell. Thus, if a ring is on an injured finger, it should be removed as soon as possible, before swelling develops. Similarly, any other object that encircles a body part, such as a finger or toe or an arm or a leg, must be removed before the body part swells. Sustained, gentle traction can be used to remove rings. Soap and water may reduce friction, easing removal. Otherwise, prompt medical care is needed.
Overview of Fractures, Dislocations, and Sprains
By Danielle Campagne, MD, Assistant Clinical Professor, Department of Emergency Medicine, University of San Francisco - Fresno
Bones may break (called fractures), bones in joints may become separated from each other (called dislocations), and tears may occur in ligaments (called sprains), muscles (called strains), and tendons (called a tendon rupture).
· Most injuries to bone, muscles, and the tissues that connect them result from injuries or overuse.
· The injured part hurts (especially when it is used), is usually swollen, and may be bruised or look distorted, bent, or out of place.
· Other injuries, such as blood vessel and nerve damage, compartment syndrome, infections, and long-lasting joint problems, may also be present or develop.
· Doctors can sometimes diagnose these problems based on symptoms, the circumstances causing the injury, and results of a physical examination, but sometimes x-rays or other imaging tests are needed.
· Most injuries heal well and result in few problems, but how long they take to heal varies, depending on many factors, such as the person's age, the type and severity of the injury, and other disorders present.
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· Treatment depends on the type and severity of the injury and may include pain relievers, PRICE (protection, rest, ice, compression, and elevation), maneuvers or procedures to move the injured parts back into their normal position (reduction), immobilization of the injured part (for example, with a cast or splint), and sometimes surgery.
Bones, muscles, and the tissues that connect them (ligaments, tendons, and other connective tissue, called soft tissues) make up the musculoskeletal system. They give the body its form, make it stable, and enable it to move.
Tissues of the musculoskeletal system can be damaged in various ways:
· Bones can be cracked or broken (fractured). Usually, the surrounding tissues are also injured.
· The bones in joints may become completely separated from each other (called dislocation) or only partly out of position (called subluxation).
· Ligaments (which attach bone to bone) can be torn (sprained).
· Muscles can be torn (strained).
· Tendons (which attach muscle to bone) can be torn (ruptured).
Fractures, dislocations, sprains, and strains (called musculoskeletal injuries) vary greatly in severity and in the treatment needed. For example, fractures can range from a small, easily missed crack in a foot bone to a massive, life-threatening break in the pelvis. Fractures can break the skin (called open fractures) or not (called closed fractures).
Sprains and strains can be mild, moderate, or severe. Ligaments, muscles, and tendons may be completely or partially torn. If a tendon is completely torn, the affected body part usually cannot move. If only part of the tendon is torn, movement is unaffected, but the tendon may continue to tear and may later tear completely, particularly if people put substantial pressure on the affected part.
3D Model: Connective Tissue System
An injury that breaks a bone may also seriously damage other tissues, including the skin, nerves, blood vessels, muscles, and organs. These injuries can complicate treatment of the fracture and/or cause temporary or permanent problems.
Most often, the limbs are injured, but any body part, such as the head (see Head Injuries), face (see Facial Injuries), eyes (see Overview of Eye Injuries), ribs (see Chest Injuries), or spine (see Compression Fractures of the Spine), can be.
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Causes
Trauma is the most common cause of injuries to musculoskeletal tissues. Traumaincludes
· Direct force, as occurs in falls or motor vehicle accidents
· Repeated wear and tear, as occurs during daily activities or results from vibration or jerking movements
· Overuse, as may occur when athletes overtrain
How severe an injury is depends partly on how strong the force is. For example, a fall on level ground usually causes minor fractures, but a fall from a tall building can cause severe fractures that involve several bones.
Some injuries occur while playing certain sports (see Sports Injuries).
Some disorders, such as certain infections, bone tumors (which may be cancerous or not), and osteoporosis (see Osteoporosis), can weaken bone. People with one of these disorders are more likely to break a bone, even when only slight force is involved. Such fractures are called pathologic fractures.
Symptoms
The most obvious symptom of musculoskeletal injuries is
· Pain
The injured part hurts, especially when people try to put weight on it or use it. The area around the injury is tender to the touch. Othersymptomsinclude
· Swelling
· A part that looks distorted, bent, or out of place
· Bruisingordiscoloration
· Inability to use the injured part normally
· Possibly loss of feeling (numbness or abnormal sensations)
The injured part (such as an arm, a leg, a hand, a finger, or a toe) often cannot be moved normally because movement is painful and/or a structure (bone, muscle, tendon, or ligament) is torn, broken, or out of place. When muscles around the injured area try to hold a broken bone in place or compensate for other injuries, muscle spasms may occur, causing additional pain.
Bruises appear when bleeding occurs under the skin. The blood may come from blood vessels in a broken bone or in the surrounding tissues. At first, the bruise is purplish black, then slowly turns green and yellow as the blood is broken down and reabsorbed back into the body. The blood can move quite a distance from the fracture, causing a large bruise or a bruise some distance from the injury. It can take a few weeks for blood to be reabsorbed. The blood can cause temporary pain and stiffness in the surrounding structures. For example, shoulder fractures can bruise the entire arm and cause pain in the elbow and wrist. A bruise on the forehead can cause a bruise to later appear under the eyes.
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Because moving the injured part is so painful, some people are unwilling or unable to move it. If people (such as young children or older people) cannot speak, refusal to move a body part may be the only sign of a fracture or other injury. However, some fractures do not keep people from moving the injured part. Being able to move an injured part does not mean that there is no fracture.
Complications
Musculoskeletal injuries can be accompanied by or lead to other problems (complications). However, serious complications are unusual. The risk of serious complications is increased if the skin is torn or if blood vessels or nerves are damaged. Dislocated joints, unless they are realigned quickly, are more likely to damage blood vessels and nerves than are fractures.
Some complications (such as blood vessel and nerve damage, compartment syndrome, fat embolism, and infections) occur during the first hours or days after the injury. Others (such as problems with joints and healing) develop over time.
Blood vessel damage
Many fractures and other musculoskeletal injuries cause noticeable bleeding around the injury. Rarely, bleeding within the body (internal bleeding) or from an open wound (external bleeding) is massive enough to cause a life-threatening drop in blood pressure (shock—see Shock). For example, shock may result when fractures of the thighbone (femur) cause severe internal bleeding or when fractures of the pelvis cause massive internal bleeding. If a person is taking a drug to prevent blood clots from forming (an anticoagulant), relatively minor injuries can cause substantial bleeding.
A dislocated hip or knee can disrupt blood flow to the leg. Thus, the tissues in the leg may not get enough blood (called ischemia) and may die (called necrosis). If enough tissue dies, part of the leg may have to be amputated. Certain elbow injuries can disrupt blood flow to the forearm, causing similar problems. A disrupted blood supply may not cause any symptoms until several hours after the injury.
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Nerve damage
Sometimes nerves are stretched, bruised, or crushed when a bone is fractured or a joint is dislocated. A direct blow can bruise or crush a nerve. Crushing causes more damage than bruising. These injuries usually heal on their own over weeks to months to years, depending on the severity of the injury. Some nerve injuries never heal completely.
Rarely, nerves are torn, sometimes by sharp bone fragments. Nerves are more likely to be torn when the skin is torn. Torn nerves do not heal on their own and may have to be repaired surgically.
Fat embolism
Fat embolism rarely occurs. It usually occurs when long bones (such as the thighbone) are fractured and release fat from the bone's interior (marrow). The fat may travel through the veins, lodge in the lungs, and block a blood vessel there. As a result, the body does not get enough oxygen, and people may become short of breath and have chest pain. Their breathing may become rapid and shallow, and their skin may become mottled or blue.
Compartment syndrome
Rarely, compartment syndrome (see Compartment Syndrome) develops. For example, it may develop when injured muscles swell a lot after an arm or a leg is broken. Because the swelling puts pressure on nearby blood vessels, blood flow to the injured limb is reduced or blocked. As a result, tissues in the limb may be damaged or die, and the limb may have to be amputated. Without treatment, the syndrome can be fatal. Compartment syndrome occurs most often in people who have fractures of both lower leg bones (tibia and fibula—see Leg Fractures) or a Lisfranc fracture (a type of foot fracture—see Foot Fractures).
Infections
If the skin is torn when a bone is broken, the wound may become infected, and the infection may spread to the bone (called osteomyelitis—see Osteomyelitis). This infection is very difficult to cure.
Joint problems
Fractures that extend into a joint usually damage the cartilage at the ends of bones in the joint (called joint surfaces). Normally, this smooth, tough, protective tissue enables joints to move smoothly. Damaged cartilage tends to scar, causing osteoarthritis (see Osteoarthritis (OA)), which makes joints stiff and limits their range of motion. The knee, elbow, and shoulder are particularly likely to become stiff after an injury, especially in older people.
Physical therapy is usually needed to prevent stiffness and help the joint move as normally as possible. Surgery is often needed to repair the damaged cartilage. After such surgery, the cartilage is less likely to scar, and if scarring occurs, it tends to be less severe.
Severe sprains can make a joint unstable. Appropriate treatment, often including a cast or splint, can help prevent permanent problems.
Problems with healing
Sometimes broken bones do not grow back together as expected. Theymay
· Not grow back together (called nonunion)
· Grow back together very slowly (called delayed union)
· Grow back in the wrong position (called malunion)
These problems are more likely to occur when
· The broken bones are not kept next to each other and are not kept from moving (immobilized).
· The blood supply is disrupted.
Certain disorders, such as diabetes and peripheral vascular disease, and certain drugs, such as corticosteroids, can delay or interfere with healing.
HowBonesHeal
| When most tissues, such as those of the skin, muscles, and internal organs, are significantly injured, they mend themselves by producing scar tissue to replace the injured tissue. The scar tissue often looks different from normal tissue or interferes with function in some way. In contrast, bone heals by producing actual bone tissue. When a bone heals itself after a fracture, the fracture often eventually becomes virtually undetectable. Even bones that have been shattered, when treated appropriately, can often be repaired and function normally. Fractures heal in three overlapping stages: inflammation, repair, and remodeling. Inflammatory stage: Healing begins immediately after the fracture. Cells of the immune system remove damaged tissue, bone fragments, and blood that leaked from broken blood vessels. The immune cells release substances that attract more immune cells, increase blood flow to the area, and cause more fluids to enter the damaged area. As a result, the area around the fracture becomes inflamed—red, swollen, and tender. The inflammatory process peaks in a couple of days, but it takes weeks to subside. This process causes most of the pain people feel soon after a fracture. Repair stage: This stage begins within days after the injury and lasts for weeks to months. New bone (called callus) is made to repair the fracture. At first, this new bone, called the external callus, does not contains any calcium (a mineral that gives bone its strength and density). This new bone is soft and rubbery. Thus, it can be damaged easily and may allow the healing bone to slip out of place (be displaced). Also, it cannot be seen on x-rays. Remodeling stage: Remodeling involves breaking bone down, rebuilding it, and restoring it to its former state (see Osteoporosis). This process lasts many months. Calcium is deposited in the callus, which then becomes much stiffer and stronger and easier to see on x-rays, and the normal shape and structure of the bone are restored. During this stage, people should gradually resume their normal activities and gradually increase the amount of stress they put on the injured part. |
Pulmonary embolism
Pulmonary embolism (see Pulmonary Embolism) is the most common fatal complication of serious fractures of the hip or pelvis. It occurs when a blood clot forms in a vein, breaks off (becoming an embolus), travels to a lung, and blocks an artery there. As a result, lung tissue may die, and the body may not get enough oxygen.
Having a hip fracture greatly increases the risk of pulmonary embolism because it involves
· Injury to the leg, where most of the clots that cause pulmonary embolism form
· Forced immobility (having to stay in bed) for hours or days, slowing blood flow and thus giving clots the opportunity to form
· Swelling around the fracture, which also slows blood flow in the veins
About one third of people who die after a hip fracture die of pulmonary embolism. Pulmonary embolism is much less common when the lower leg is broken and is very rare when the arm is broken.
Osteonecrosis
When blood flow to a bone is disrupted, part of the bone may die, resulting in osteonecrosis (see Osteonecrosis (ON)). Certain injuries (such as certain wrist fractures and a dislocated hip, particularly if it is not realigned quickly) are more likely to cause osteonecrosis.
Diagnosis
· A doctor'sevaluation
· X-raystoidentifyfractures
· Sometimes magnetic resonance imaging or computed tomography
If a musculoskeletal problem occurs suddenly, people must decide whether to go to an emergency department, call their doctor, or wait and see whether the problem (pain, swelling, or other symptoms) go away and lessen on their own.
People should be taken to an emergency department, often by ambulance, if any of the following apply:
· The problem is obviously serious (for example, if it resulted from a car crash or if people cannot use the affected body part).
· They suspect that they have a fracture (a possible exception is a toe or fingertip injury).
· They suspect they have a severe soft-tissue injury (such as a dislocation, torn tendon, or severe sprain or strain).
· Theyhaveseveralinjuries.
· They have symptoms of a complication—for example, if they lose sensation in the affected body part, they cannot move the affected part normally, the skin feels cool or turns blue, or the affected part is weak.
· They cannot put any weight on the affected body part.
· An injured joint feels unstable.
People should call a doctor when
· The injury causes pain or swelling, but they do not think the injured part is fractured or severely injured.
If none of the above apply and the injury seems minor, people can call the doctor or wait and see whether the problem goes away on its own.
If injuries result from a serious accident, the doctor's first priority is
· To check for severe injuries and complications, such as an open wound, nerve damage, significant blood loss, disrupted blood flow, and compartment syndrome (see Compartment Syndrome)
For example, doctors check for numbness, measure blood pressure (which is low in people who have lost a lot of blood), check pulses (which are absent or weak when blood flow is disrupted), and look for other signs of disrupted blood flow, such as skin that is pale and cool. If any of these injuries and complications are present, doctors treat them as needed, then continue with the evaluation.
Description of the injury
Doctors ask the person (or a witness) to describe what happened. Often, the person does not remember how an injury occurred or cannot describe it accurately. Knowing how the injury occurred can help doctors determine the type of injury. For example, if a person reports that a snap or pop occurred, the cause may be a fracture or an injury to a ligament or tendon. Also, doctors ask in which direction the joint was stressed during the injury. This information can help doctors determine which ligaments and/or bones are damaged.
Doctors also ask when the pain started. If it started immediately after the injury, the cause may be a fracture or a severe sprain. If the pain began hours to days later, the injury is usually minor. If the pain is more severe than expected for the injury or if the pain steadily worsens during the first hours after the injury, compartment syndrome may have developed or blood flow may be disrupted.
Physical examination
The physical examination includes the following (in order of priority):
· Checking for damage to blood vessels near the injured body part—for example, by checking pulse and skin temperature and color
· Checking for damage to nerves (for example, checking sensation) near the injured part
· Examining and moving the injured part
· Examining the joints above and below the injured part
Doctors gently feel the injured part to determine whether bones are in pieces or out of place and whether the area is tender. Doctors also check for swelling and bruising. They ask whether the person can use, put weight on, and move the injured part.
Doctors test the stability of a joint by gently moving it, but if a fracture is possible, x-rays are done first to determine whether moving the joint is safe. Doctors check for grating or crackling sounds (crepitus) when the injured part is moved. These sounds may indicate a fracture.
Moving the affected joint can also help doctors determine the severity of an injury. For example, they can determine how severe a sprain (a torn ligament) is based on how far they can move the joint and how painful the movement is. When a ligament is partially torn, moving the joint is very painful. When a ligament is completely torn, moving the joint is less painful because the torn ligament is not being stretched as the joint is moved. A joint can usually be moved more freely when a ligament is torn than when it is not and can be moved more freely when a ligament is completely torn than when it is partially torn.
Because tendons connect muscles to bone, doctors can often determine the severity of a tendon injury by moving the muscle that the tendon is attached to. When a tendon is completely torn, moving the muscle attached to the tendon may not move the bone. For example, if the Achilles tendon (which attaches the calf muscles to the heel bone) is completely torn, the foot may not move. Partial tears may be hard to detect because the joint may seem to move normally.
Doctors also check the joint above and below the injured joint.
If pain or muscle spasms interfere with the examination, the person may be given a pain reliever and/or muscle relaxant by mouth or injection, or a local anesthetic may be injected into the injured area.
Doctors may check sensation in the skin—whether the person can feel normally—and ask whether the person has abnormal sensations, such as a pins-and-needles sensation or tingling. Abnormal sensations suggest that nerves have been damaged.
Doctors may check pulses and the color and temperature of the skin to determine whether an artery is damaged or compartment syndrome has developed.
Tests
Imaging tests used to diagnosis musculoskeletal injuries include
· X-rays
· Magneticresonanceimaging (MRI)
· Computedtomography (CT)
X-rays are the most important and usually the first and only test done to diagnose a fracture. X-rays are also useful for diagnosing dislocations. X-rays are not useful for detecting injuries to ligaments, tendons, or muscles because they show only bones (and the fluid that collects around an injured joint).
X-rays are usually taken from at least two angles to show how the fragments of bone are aligned. These routine x-rays may not show small fractures when the pieces of broken bone remains in place (that is, they do not separate into fragments). Such fractures are called occult (hidden) fractures. So sometimes additional x-rays are taken from different angles. Occasionally, doctors wait to take x-rays for a few days or even weeks because some occult fractures (such as rib fractures—see Rib Fractures—and stress fractures—see Stress Fractures of the Foot) become visible on x-rays only after the fracture begins to heal and calcium is deposited in the new bone.
If x-rays show a fracture in a bone that looks abnormal (for example, if areas of bone look unusually thin), the fracture probably occurred because a disease (such as osteoporosis) weakened the bone.
X-rays are not always needed, depending on which body part is affected and what doctors suspect. For example, if an injured body part (such as the toes, except the big toe) would be treated the same way regardless of whether it is a fractured, x-rays are usually not needed.
CT or MRI may be done when
· Results of the examination strongly suggest a fracture but x-rays do not show one.
· A specialist needs more detailed views of the fracture to determine the best way to treat it.
Sometimes doctors apply a splint and re-examine the person days later and, if symptoms are still bothersome, take another x-ray.
CT and MRI may also be done to provide more detail about fractures than routine x-rays can show. CT can show the fine details of a fractured joint surface and areas of a fracture that are covered by undamaged bone. CT and particularly MRI can show soft tissues, which are not usually visible on x-rays. MRI shows the tissues around the bone and thus helps detect injury to nearby tendons, ligaments, cartilage, and muscle. It can show changes caused by cancer. MRI also shows injury (swelling or bruising) within the bone and can thus detect small fractures before they appear on x-rays.
DidYouKnow...
| · X-rays show only bones and thus usually cannot help doctors identify injuries such as sprains, strains, and tendon injuries, even severe ones. |
Othertestsmayinclude
· Angiography (x-rays or CT scans taken after a dye is injected into arteries—see Angiography) to check for damaged blood vessels
· Nerve conduction studies to check for damaged nerves (see Tests for Brain, Spinal Cord, and Nerve Disorders : Electromyography and Nerve Conduction Studies)
Types of fractures
Imaging tests enable doctors to identify the type of fracture and describe it precisely.
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