Life Threatening Orthopedic Injuries Femur Fractures/Traumatic Lower Extremity Amputations with Concurrent Pelvic Fractures. SSG Justin Jackson FM-20

Blast Injuries and Orthopedic Emergencies “No one ever died from a broken bone” is a myth sometimes heard among circles of less-informed healthcare providers. Traumatic injuries are the leading cause of death for people under age 44. Each year, roughly 1 in 10 people will visit and emergency room to seek treatment for a traumatic injury. Orthopedic trauma is usually classified as a lower priority than airway and breathing. However, to universally think orthopedic trauma to be insignificant in nature is a serious mistake that may cost your patient their life.

Traumatic Amputations and Pelvic Fractures Amputation Pattern Incidence of pelvic Fx % Any lower limb amputation 22% Unilateral BKA 10% Bilateral BKA 30% Bilateral AKA 39% These values are a representation of a study performed from 15 Sep 2009 – 30 April 2010 from the Role III (ISAF) Hospital at Camp Bastion, Afghanistan, Helmond Province, RC-South. *77 consecutive patients with lower limb amputations due to blast injuries were identified (with the most common injury pattern seen being Bilateral AKA’s).

Traumatic Amputations and Pelvic Fractures Major pelvic ring disruption injuries are commonly subdivided by mechanism: (APC) antero-posterior compression; (LC) lateral compression; (VS) vertical shear; and (CMI) combined mechanical injury. APC fractures are associated with higher shock in the civilian population whereas the CMI is usually associated with blast injuries as seen in combat. Amputation from a blast injury results from the blast wave into the tissues, causing axial stress to the bone and thus fracture. These patients experience the additional trauma of being thrown and receive subsequent injuries upon landing.

Traumatic Amputations and Pelvic Fractures A civilian study done in 2007 found 33% fatality rate in pelvic ring fracture patients, all of which were related to pelvic hemorrhage. Pelvic Fractures are among the most dangerous orthopedic injuries as large vessels such as the iliac arteries as well as portions of the bowel, bladder, and reproductive organs pass through the pelvic ring, thus they can result in massive hemorrhage. Femur fractures alone can be responsible for approximately 1.5 liters of blood loss per leg. This alone is significant, but when concomitant with a pelvic fracture that may hold an additional 1.5 – 3 liters of the patients circulating blood volume this will become an immediate life threat. Antero-posterior compression fracture

Traumatic Amputations and Pelvic Fractures Pain is always almost present in pelvic fractures. With that stated the assessment of occult pelvic injury can be problematic, especially in the unconscious patient. Here you have to base your index of suspicion on the MOI. Even in conscious patient studies have shown that many MOI’s that produce pelvic fractures tend to have other distracting injuries that tend to make an individuals assessment less reliable. The presence of any of these signs and symptoms would indicate the potential of a fracture. Without x-ray, its difficult to differentiate fractures from other soft tissue injuries. Treat all injuries with signs and symptoms of a fracture as if they were, in fact, fractures.

Traumatic Amputations and Pelvic Fractures Shock associated with blood loss from pelvic or femur fractures should be identified when assessing circulation in the primary survey and not based solely on a secondary assessment of an extremity. Because of the force needed in the average patient to fracture the pelvis, spinal injuries often occur as well. Therefore, you should consider using a backboard to immobilize the patient after the application of a pelvic binder. This needs to be done in this order so major vessels are not compromised during the movement associated with placing the patient on a long spine board.

Applying a Pelvic Binder The style of binder you have available to use will determine the correct placement landmarks during your application. When using sheets to make an improvised pelvic splint, or when using the commercial sam splint pelvic binder, the proper landmarks are the greater trochanters. The intent is to apply enough equal pressure to close the pelvic ring, relieve pain, and make a smaller area for blood to drain into. When using a devise like a T-Pod splint the upper portion of the splint should encompass the iliac crests for proper placement as seen in the middle of the picture to the right.

Applying a Pelvic Binder Commercial Sam Splint Pelvic Binder applied over the greater trochanters Improvised pelvic binder using a bed sheet

Pre-Hospital Treatment Proper pre-hospital packaging should include immobilization of the lower extremities after the application of a pelvic binder. In some circumstances this may be difficult (ie. Blast injuries with amputations) but, anything you can do to secure the remainder of the extremities back to a close to neutral position is ideal by utilizing tape, kerlix, or ace bandages may help.

Traumatic Amputations and Pelvic Fractures The last thing to note, when picking up a patient from a facility with a suspicion of a pelvic fracture or when dropping a patient off at a facility with imaging capabilities, serial images need to be done. Initially with the pelvic binder still in place and then again after a brief removal of it. The purpose for this is many times with proper application of a pelvic binder fractures may go unseen even with experienced clinicians on the initial imaging.

Bibliography The incidence of pelvic fractures with traumatic lower… https://www.ncbi.nlm.nih.gov/pubmed/25335309 American Academy of Orthopedic Surgeons…http://www.aaos.org/AAOSNow/2007/MarApr/managing/managing10/?ssopc Extremity, Junctional, and Pelvic Trauma…http://www.cs.amedd.army.mil/ FileDownloadpublic.aspx?docid=ebea7e70-ab1c-45ba-b953-801ea79a1d45 SSG Justin Jackson FM-20