From the Guidelines
The approach to a 28-year-old man presenting with right leg pain following a traumatic explosion should be focused on immediate haemorrhage control and assessment of severity using the Vittel criteria, which include features such as long bone fractures, proximal amputation, and specific limb injuries like degloving or crushing 1.
Initial Assessment and Management
- The patient's haemodynamic status should be evaluated, including blood pressure, heart rate, and presence of radial pulse, to determine the severity of the injury and guide management decisions.
- Direct manual compression with a pressure dressing may be sufficient for small, simple haemorrhagic wounds, but in cases of severe limb trauma, a tourniquet may be necessary to control bleeding, especially if there is active haemorrhage, amputation, or foreign body in the wound 1.
- The effectiveness, usefulness, and location of the tourniquet should be re-evaluated as soon as possible to limit morbidity and minimize the risk of compartment syndrome.
Risk Factors for Compartment Syndrome
- Patients with severe limb trauma are at risk of developing compartment syndrome, especially if they have fracture, crush injury, haemorrhagic injury, or hypotension 1.
- Clinical signs of compartment syndrome, such as pain, tension, paraesthesia, paresis, and increased compartmental pressure, should be monitored repetitively during the first 24 hours.
Treatment of Compartment Syndrome
- Early fasciotomy is the treatment of choice for established compartment syndrome, involving a wide incision of the skin, subcutaneous tissue, and fascia.
- Volume resuscitation is crucial in patients with severe rhabdomyolysis to prevent acute kidney injury, with volumes greater than 6L potentially required in severe cases 1. By following these guidelines, healthcare providers can provide optimal care for patients with severe limb trauma, reducing the risk of morbidity and mortality.
From the Research
Approach to a 28-year-old man presenting with right leg pain following a traumatic explosion
- The first step in evaluating a patient with leg pain is to determine the etiology of the pain, which can be achieved through a complete history and physical examination 2
- A comprehensive evaluation is necessary to establish a relationship with the patient and to explore various treatment options 2
- The diagnosis of leg pain is often based on patient history and clinical examination, and a good knowledge of anatomy and different etiologic entities is essential to guide diagnostic and therapeutic strategies 3
- All tissues of the lower leg can cause pain, and a systematic approach to evaluating the different types of tissue, including spine, neural plexus, peripheral nerves, muscles, and vasculature, is necessary 4
- In cases of traumatic injury, additional imaging studies, such as X-rays and computerized tomography scans, may be necessary to determine the extent of the injury and to guide treatment decisions 5
Diagnostic Considerations
- A comprehensive physical examination is imperative to confirm a diagnosis and should include an inquiry regarding the location and onset of the patient's pain and tenderness 6
- Diagnostic studies, such as radiographs, bone scans, magnetic resonance imaging, magnetic resonance angiography, compartmental pressure measurements, and arteriograms, may be necessary to confirm a diagnosis 6
Treatment Considerations
- Treatment options for leg pain will depend on the underlying cause of the pain and may include nonsurgical management, such as pain management and physical therapy, or surgical intervention, such as repair of damaged tissues or relief of compression 3, 6
- In cases where surgical intervention is not necessary, a conservative approach based on close clinical observation and pain management may be employed 5