Musculoskeletal Trauma:
When bones break there is damage to the structural continuity itself, the blood vessels that both enter and surround the the bone, and the various soft tissues in that area. The sharp ends of bone fragments cause damage during the initial fracture, and this damage can be exacerbated by moving the fractured extremities. This is why we are taught to immobilize injuries in the position found, unless there is neurovascular compromise noted distal to the fracture site. There are numerous fracture patterns that can occur in trauma, and the presentation varies depending on the mechanism of injury and the direction of force applied to the body. In general, fractures can be divided into either Closed or Open categories.
Closed fractures: In a closed fracture, the affected bone(s) are contained in their anatomical location. While the ends of the bone may be displaced from their original position, the fracture is not exposed to the outside environment. The major risks are bleeding, and neurovascular compromise.
Open (compound) fractures: These are fractures that involve the protrusion of the fractured bone end through the tissues. This results in bone and underlying tissues being exposed to the outside environment. Just as with closed fractures, we need to be concerned about bleeding and impaired neurovascular function, however we now have the added complication of potential contamination of the wounds themselves.
Common fracture types include:
Because head, thoracic and spinal trauma have been covered already, I will focus on extremity trauma, with emphasis on pelvic and femur fractures.
Pelvic fractures:
The pelvis is composed of the Iliac bones and the Sacrum. The Iliac bones are connected anteriorly at the symphysis pubis. The pelvis serves as the articulating point for the hip joint, and the pelvic bowl forms the base of the abdominal cavity, housing organs including the bladder, distal colon, and reproductive organs. The abdominal aorta branches into the right and left femoral arteries here, and the major venous vessels travel through as well. Damage to the pelvic bone presents several risks including:
Tearing of the major blood vessels
Impingement of nerves
Tearing of pelvic muscles
Perforation or compression of pelvic organs, and subsequent systemic effects.
The most significant concern in trauma is massive hemorrhage into the pelvic cavity. If a pelvic fracture causes bleeding, the patient can lose approximately 2500cc of blood into the pelvic cavity itself. This is more than sufficiently fatal.
We recognize an unstable pelvis both through assessment of the MOI, and physical assessment. During the rapid trauma survey we palpate the pelvis (some places teach that this is to be done in 3 planes, some only medially; I am a fan of the latter). Placing both hands on the iliac crests and applying medial force should identify an unstable pelvis. Typically what we are looking for is inward movement of those crests, or a “Spongey” feeling. If Identified, a sheet wrap or commercial pelvic binder can be applied to splint the fracture in place. In the event of a pelvic fracture, we need to watch very closely for evidence of shock, and decompensation. In trauma we want to start 2 large bore IV and provide isotonic fluid to maintain a MAP of 65mmHg, or an SBP of 90mmHg. We want to be conservative with fluids because IV fluids do not actually fix the problem, and too much can make things worse.
Femur fractures:
The femur is the largest bone in the human body, and significant force is required to cause a fracture. That being said, individuals with bone disorders, parathyroid disorders, and the elderly, are all at greater risk for these injuries. The femur can fracture at any point along its structure, however the most common sites are the midshaft and the proximal end (Hip). Proximal/Hip fractures typically present with pain on palpation, and shortening and external rotation of the leg. Midshaft femur fractures usually present with displacement of the fractured ends, which leads to obvious shortening and deformity of the thigh. Femur fractures may also be open/compound, and present infection risk. If we are dealign with a hip fracture we really want to stabilize the affected leg, checking circulation, sensation, and movement distally before and after splinting. Several options exist to splint the hip, but the most effective is use of a scoop (break-away) stretcher, or backboard. Place the patient on the board, and place a pillow between the knees. Secure the injured leg to the uninjured one with triangular bandages or crevats. In the case of a midshaft femur fracture, we have the option to use a traction splint, which allows us to realign the displaced ends of the femur and provides significant pain reduction. As with the pelvis there is a risk of massive hemorrhage with femur fractures. The cavity around a fractured femur can hold as much as 1500cc of blood per leg. Caution and hemodynamic management should be the same as that of the pelvis.
Tibial-fibial fractures:
Fractures to the lower leg may also be open or closed. In general these are not life threatening, but may be quite painful. If there is neurovascular compromise, gentle traction may be applied to attempt to restore perfusion. Rigid splints, and malleable splints are typically effective in stabilizing these.
Upper extremity fractures:
Fractures of the humerus, radius, and ulna can all be managed much the same as those of the lower extremities. Sling and swath, or use of malleable or rigid splints is effective.
Overall, our concern with managing any fracture should focus on:
Restoring neurovascular function
Stabilization to prevent further injury
Managing potential blood loss
Assessment for shock
Providing analgesia and BLS interventions such as cold packs
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