What is the appropriate management for a patient with a traumatic injury to the right leg after a fall from a stretcher?

Management of Traumatic Right Leg Injury After Fall from Stretcher

Immediately perform a focused clinical assessment for vascular injury, compartment syndrome, and fracture, followed by plain radiographs as the initial imaging study, with CT angiography if any signs of vascular compromise are present. 1

Immediate Clinical Assessment

Evaluate for Vascular Injury

• Assess for "hard signs" of vascular injury: externalized arterial bleeding, absent distal pulses, pallor, expanding hematoma, or palpable thrill/bruit 1
• Measure ankle-brachial index (ABI): An ABI <0.9 indicates potential vascular injury and requires immediate CT angiography 1
• Check for "soft signs": proximity of injury to major vascular axis, non-expanding hematoma, or isolated neurological deficit 1
• If hard signs are present or ABI <0.9, proceed directly to CT angiography without delay 1

Screen for Compartment Syndrome Risk

• Monitor every 30-60 minutes for the first 24 hours if the patient has fracture, crush injury, hemorrhagic injury, or hypotension 1
• Assess the "four P's": pain (especially with passive stretch), paresthesia, paresis, and pressure/tension in the compartment 1
• Critical pitfall: Pulselessness and pallor are late signs indicating irreversible damage—do not wait for these to appear 1
• Measure compartment pressure if clinical suspicion exists: pressure >30 mmHg or differential pressure (diastolic BP minus compartment pressure) <30 mmHg indicates compartment syndrome 1

Initial Imaging Strategy

Plain Radiographs First

• Obtain anteroposterior and lateral views of the affected leg as the initial imaging study 1
• Radiographs are the first-line modality for detecting fractures and should be performed before advanced imaging 1
• Include views of joints above and below the injury site 1

CT Angiography for Vascular Concerns

• Perform CT angiography immediately if any of the following are present: 1
  • Externalized arterial bleeding
  • Proximity to major vascular axis
  • Non-expanding hematoma
  • Isolated neurological deficit
  • ABI <0.9
• CT angiography has 96.2% sensitivity and 99.2% specificity for detecting vascular injuries in limb trauma 1
• CT angiography is superior to conventional arteriography due to faster access, lower cost, and similar accuracy 1

Hemorrhage Control

If Active Bleeding Present

• Apply direct compression first as the initial hemostasis technique 1
• Apply tourniquet if: 1
  • Direct compression is ineffective
  • Amputation is present
  • Foreign body in hemorrhagic wound
  • No radial pulse (hemodynamic instability)
  • Multiple simultaneous actions required
• Re-evaluate tourniquet effectiveness and location as soon as possible to minimize ischemic time and area 1
• Critical pitfall: Iterative tourniquet releases aggravate local muscle injury and systemic rhabdomyolysis—avoid repeated releases 1

Fracture Management Timing

If Hemodynamically Stable Without Severe Associated Injuries

• Perform early definitive osteosynthesis within 24 hours for diaphyseal fractures (femoral or tibial shaft) to reduce local and systemic complications 1
• Early fixation reduces risk of ARDS and fat embolism syndrome 1

If Hemodynamically Unstable or Multiple Severe Injuries

• Perform damage control orthopedics (DCO) with temporary stabilization using external fixator or skeletal traction 1
• Delay definitive osteosynthesis until clinical stabilization achieved 1
• This approach reduces perioperative blood loss, coagulopathy, and fat embolism syndrome in unstable patients 1

Additional Monitoring

Rhabdomyolysis Screening

• Measure plasma creatine phosphokinase (CPK), myoglobin, and potassium if crush injury or prolonged compression occurred 1
• CPK >5 times normal (>1000 IU/L) indicates rhabdomyolysis 1
• Initiate aggressive fluid resuscitation (3-6L/day for moderate rhabdomyolysis, >6L for severe with CPK >15,000 IU/L) 1
• Monitor urine output and maintain urine pH >6.5 1

Venous Thromboembolism Prophylaxis

• Initiate low molecular weight heparin (LMWH) within 6-36 hours after hemorrhage control and hemostasis achieved 1
• Earlier initiation (within 36 hours) is safe even with solid organ injury or stable traumatic brain injury 1
• For isolated lower limb trauma without ongoing bleeding, initiate within 6 hours post-trauma or surgery 1

Critical Pitfalls to Avoid

• Do not rely on pulse presence alone to rule out vascular injury—use ABI and assess for soft signs 1
• Do not wait for pulselessness or pallor to diagnose compartment syndrome—these are late, irreversible signs 1
• Do not perform early definitive fixation in hemodynamically unstable patients—use DCO approach instead 1
• Do not delay CT angiography if vascular injury is suspected—sensitivity is 96.2% and it guides immediate surgical planning 1