ADDITIONAL ORTHOPAEDIC INJURIES IN MULTIPLE TRAUMA246 Surgical Emergencies
Limb injury
The management of limb injuries in the multi-trauma patient does not take
precedence over head, thoracic, abdominal or pelvic injuries, even though they
may appear more dramatic and attract instant attention.
Limb injuries are covered in detail in Section IX, Orthopaedic Emergencies.DIAGNOSIS1 Look for obvious deformity, swelling, tenderness, abnormal movement or
crepitus (if the patient is unconscious).
2 Check the distal pulses, particularly in a supracondylar humeral fracture or
a dislocated knee.
3 Remember that closed fractures bleed extensively with little external evidence,
and open fractures bleed even more. See Table 8.7 for the amounts of concealed
blood loss expected wit h pelv ic and limb injuries in multiple trauma.4 Note any neurological deficit, e.g. sciatic nerve damage in posterior hip
dislocation, or radial nerve damage in humeral shaft fracture.MANAGEMENT1 Restore any deformity to a normal anatomical alignment. This will reduce
the risk of neurovascular compromise and maintain skin integrity, reducing
long-term complications. Examples include:
(i) Posteriorly dislocated hip, to prevent sciatic nerve damage.
(ii) Dislocated knee, to maintain vascular circulation to the distal
extremity.
(iii) Dislocated ankle, to prevent ischaemic pressure necrosis of the
skin overlying the malleolus (see p. 312).
2 Give increments of morphine 2.5–5 mg i.v. for pain with an antiemetic such
as metoclopramide 10 mg i.v.
3 Cover compound fractures with a saline-soaked sterile dressing. Give
f lucloxacillin 2 g i.v. or cefuroxime 1.5 g i.v. and tetanus prophylaxis.
4 Immobilize the fracture using a plaster of Paris backslab, or a specially
designed splint such as the Donway™ traction splint for femoral shaft
fractures.Table 8.7 Expected concealed blood loss from orthopaedic injuries in
multiple trauma
Site of closed fracture Predicted blood loss
Pelvic ring Up to 6 units or more
Femoral shaft 2–4 units
Tibial shaft 1–3 units