IMMEDIATE MANAGEMENT OF LIFE-THREATENING INJURIES
Patients with orthopedic injuries and musculoskeletal disorders constitute a large portion of patients presenting to the emergency department (ED). All trauma patients should be managed initially in the same manner, with similar guiding principles of trauma care regardless of their underlying injuries. Orthopedic injuries may be gruesome, but they should not draw attention away from more critical elements of initial patient assessment and treatment. The emergency physician must assess the patient and manage injuries based on the immediate threat to survival, evaluating each trauma patient with the primary survey, which consists of assessing the airway, breathing, circulation, disability, and exposure (ABCDEs) (Table 28–1).
++ Table Graphic Jump Location Table 28–1.Potential blood loss from closed fractures. ||Download (.pdf) Table 28–1. Potential blood loss from closed fractures.
|Site ||Amount (L) |
|Pelvis ||1–5+ |
|Femur ||1–4 |
|Spine ||1–2 |
|Leg ||0.5–1 |
|Arm ||0.5–0.75 |
Once the primary survey has been addressed, proceed to the secondary survey, which should be a thorough, but rapid physical examination from head to toe to assess for all remaining injuries. With cervical spine precautions in place, logroll the patient, assess the posterior scalp, and examine the entire spine for tenderness or step-off deformities. Perform a digital rectal examination to evaluate for sphincter tone, gross blood, or abnormal prostate position. When evaluating the pelvis for stability, apply gentle anteroposterior and lateral compression. Visualize and go through range of motion of all joints and document all lacerations, abrasions, and contusions. Physical examination of orthopedic injuries includes inspection for deformity, color change, palpation for tenderness, range of motion, and assessment of neurovascular status. At this time, consider reduction of certain orthopedic emergencies such as a dislocated hip, knee, or any fracture or dislocation in which vascular compromise is present (Figure 28–1). Delayed reduction may lead to avascular necrosis, or other complications; therefore, if possible, reduce fractures and dislocations with neurovascular compromise before transferring the patient.
Technique of manual traction to align an angulated fracture and correct deformity.
ESSENTIALS OF DIAGNOSIS
Sharp, guillotine injuries are best candidates for reimplantation.
Keep amputated part clean, moisten by wrapping in saline-soaked gauze, put in plastic bag and put on ice.
Do not allow the amputated part to freeze.
Cooling will help increase viability of amputated part up to 12–24 hours.
Patients incurring traumatic amputations should be considered for reimplantation surgery. Young healthy patients with sharp, guillotine injuries without crushing or avulsion damage are the best candidates for successful reimplantation. However, it is best to consider all patients as potential candidates, care for the amputated part, and make appropriate consultations or arrange for transfer.