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

2. 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.

3. 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).

4. 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.

5. 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

6. 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.

7. 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.

8. 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.

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

10. 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.

11. 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.

12. Bibliography
The incidence of pelvic fractures with traumatic lower…
American Academy of Orthopedic Surgeons…
Extremity, Junctional, and Pelvic Trauma…
FileDownloadpublic.aspx?docid=ebea7e70-ab1c-45ba-b ea79a1d45
SSG Justin Jackson
FM-20