Orthopedic Trauma

In the multiply-injured patient, orthopedic trauma rarely represents a risk to life. The exceptions are pelvic and femur fractures, which can bleed sufficiently to cause shock. The orthopedic injury may, however, present a threat to limb, and must be stabilized promptly.

During the secondary survey, find and stabilize orthopedic injuries. The physician may already be aware of the presence of limb-threatening injury, either by seeing it or by finding absent pulses in a pale, crooked limb while assessing circulation. However, unless obvious hemorrhage is found in an injured limb, stabilization of orthopedic injury waits until completion of the primary survey.

Palpate every inch of every limb. The examiner checks radial pulses, pedal pulses, capillary refill, and temperature differences. Note swelling or discoloration.

Eventually, every area with evidence of injury should be x-rayed. Because x-ray technicians cannot assign priorities to the x-rays, the physician should specify which x-rays are to be completed first. For the patient with urgent problems, certain extremity x-rays may need to be deferred. Because consulting physicians are human and forget (and lawyers are lawyers and never forget) the record should clearly state which x-rays must be obtained later and why the x-rays were deferred.

No x-ray should interrupt the primary survey or the stabilization measures that may be required during the primary survey. No extremity x-ray should take precedence over procedures or x-rays related to head, neck, chest, abdomen, or pelvis - as life-threatening problems may reside in those areas.

Stabilization of Orthopedic Injuries

Any fracture should be immobilized when found. Your documentation of "no neurovascular deficit" will serve only to hang you if the patient moves (or is moved by the anesthesiologist) in a way that creates a neurovascular problem in the injured extremity. Any suspected fractures that are not yet x-rayed should be splinted if the patient leaves the emergency department.

On finding a vascular problem (weaker pulse, delayed capillary refill, numbness) in a dislocated or fractured extremity, the treating physician must act to reduce the injury himself, unless an orthopedist is immediately at hand. If perfect reduction is not easily accomplished, splint the injury in as near to anatomic position as possible.

Traction splinting of femur fractures serves to reduce and stabilize them, and may decrease hemorrhage. Air-splints, or anti-shock trousers in the lower extremity, may be used to tamponade severe bleeding from fractures. Pelvic fractures may be "splinted," and hemorrhage decreased, by the application of anti-shock trousers.

Copyright 1996 Mad Scientist Software Citation: Argyle, B., Trauma One! Computer Program Manual. Mad Scientist Software, Alpine UT, 1996.