Wilderness and Rescue Medicine 8th Edition

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Section IV: Trauma

Tenting or trapping of the skin by clavicle fragments can cause problems with ischemia. Prolonged deformity can result in skin breakdown if not corrected. In rare cases, a clavicle fracture will be compli- cated by tenting or trapping of the skin by fracture fragments causing skin ischemia. While this is not a critical system problem it will result in infarction and skin breakdown if not corrected. Usually the problem can be relieved by the patient changing position, moving the arm, or the rescuer pressing the fragments into better position. If the ischemia cannot be relieved, early surgical intervention is ideal. In the absence of a serious respiratory or circulatory problem, there is no emergency and the patient remains ambulatory and otherwise functional. Compartment Syndrome Swelling due to bleeding or edema inside a muscle compartment can increase intra-compartment pressure to the point that perfusion is impaired. The mechanism is usually blunt trauma or collat- eral damage from a fracture. It is also possible to see compartment syndrome develop from repeti- tive motion injury. Ischemia develops, with necro- sis of muscle and nerve tissue as the anticipated problem. Typical symptoms include severe pain out of proportion to the apparent injury, distal numbness, and pain on passive stretching of the affected muscle group.

This fasciotomy was performed to relieve pressure and restore perfusion to muscle tissue affected by compartment syndrome. This is not a field pro- cedure. It is shown here to better illustrate the problem. With the right training and equipment, it is possible to measure intracompartmental pres- sures and this is sometimes performed in the hospital. However, it is more often the same signs and symptoms seen in the field that motivates an urgent trip to the operating room; pain out of proportion, pain on passive motion, and distal numbness. The compartment is decompressed (fasciotomy) to relieve the pressure and allow blood to flow into the injured muscle. Compartment syndrome can develop hours to days after the initial injury. Field treatment includes anti-inflammatory medication, rest, ele- vation, and cooling of the extremity. Emergency evacuation is indicated if immediate improvement is not noted. A field fasciotomy would be a high- risk procedure, and become a significant wound management challenge. Open Fracture In an open fracture , the site is exposed to the outside environment through a wound in the skin. This opening can be produced from inside by sharp bone ends, or from outside by the same object that caused the fracture (such as a bullet). Unfortunately, this adds serious infection to the anticipated problem list.