Massive, Open, Long Bone Fractures

The blood loss from any long bone fractures may be significant; open fractures bleed more than closed ones because there is no tamponade effect from surrounding tissues. As a general rule, an open fracture causes twice the blood loss of a corresponding closed fracture. Thus a single, open, femoral shaft fracture may result in 40% loss of circulating blood volume. This in itself is life-threatening.

After airway and breathing have been assessed and treated, two relatively large-bore cannulae should be inserted and fluid boluses should be commenced according to the child’s overall circulatory state (see Chapter 13). Exsanguinating haemorrhage should be controlled both by the application of pressure at the fracture site, and by correct splinting of the limb; in certain cases the use of tourniquets may be indicated.

Emergency orthopaedic opinion should be sought. Angiography may be necessary to examine whether any major vessel rupture has occurred, and if such an injury is considered likely then a vascular surgical opinion should be obtained immediately.

17.4 SECONDARY SURVEY AND LOOKING FOR KEY FEATURES OF EXTREMITY TRAUMA

In a conscious child, inspection is usually the most productive part of the examination. Causing pain or eliciting crepitus in an injured extremity will only increase anxiety, ultimately making the child more difficult to manage.

The extremities should be inspected for discolouration, bruising, swelling, deformity, lacerations and evidence of open fractures.

Next, gentle palpation should be undertaken to establish any areas of tenderness. Limb temperature and capillary refill should be assessed, and pulses sought – a Doppler flow probe should be used if necessary.

Finally, the active range of motion should be assessed if the child is cooperative. If there is an obvious fracture or dislocation, or the child refuses to move a limb actively, passive movement should be avoided.

Limb-Threatening Injury

The viability of a limb may be threatened by vascular injury, compartment syndrome or by open fractures. These situations are discussed below.

Vascular Injury

Assessment of the vascular status of the extremity is a vital step in evaluating an injury. Vascular damage may be caused by traction (resulting in intimal damage or complete disruption) or by penetrating injuries caused by either a missile or the end of a fractured bone. Brisk bleeding from an open wound or a rapidly expanding mass is indicative of active bleeding. Complete tears are less likely to bleed for a prolonged period due to contraction of the vessel. It should be remembered that nerves usually pass in close proximity to vessels and are likely to have been damaged along with the vessel.

The presence of a pulse, either clinically or on Doppler examination, does not rule out a vascular injury. A diminished pulse should not be attributed to spasm.

The signs of vascular injury are shown in the box below.

If these signs are present, urgent investigation and emergency treatment should be commenced. The fracture should be aligned and splints checked to ensure that they are not restrictive. If no improvement occurs a vascular surgeon should be consulted and angiography considered. Vascular damage may not always be immediately apparent, so constant reassessment is essential.

Compartment Syndrome

If the interstitial pressure within a fascial compartment rises above capillary pressure, then local muscle ischaemia occurs. If this is unrecognised, it eventually results in Volkmann’s ischaemic contracture. Compartment syndrome usually develops over a period of hours and is most often associated with crush injuries. It may, however, occur following simple fractures and also as a result of misplaced intraosseous infusions. The classic signs are shown in the box below.

Distal pulses only disappear when the intracompartmental pressure rises above arterial pressure; by this time irreversible changes have usually occurred in the muscle bed. Initial treatment consists of releasing constricting bandages and splints. If this is ineffective then urgent surgical fasciotomy should be performed.

Open Fractures

Open wounds are classified according to the degree of soft tissue damage, the amount of contamination and the presence or absence of associated neurovascular damage. Initial treatment includes the removal of gross contamination and covering the wound with a sterile dressing. No attempt should be made to ligate bleeding points because associated nerves may be damaged as this is done. Bleeding should be controlled by direct pressure. Broad-spectrum antibiotics should be given, and tetanus immunisation status checked. Further management is surgical – debridement should be carried out within 6 hours by orthopaedic surgeons under operating theatre conditions. It may be useful to take a photograph of the wound to reduce the number of times the dressing is removed.

Other Injuries

Non-Accidental Injury

This must always be considered if the history is not consistent with the injury pattern. It is discussed in detail in Appendix C.

Fracture–Dislocation

It is difficult to distinguish fractures and fracture–dislocations on clinical grounds. Radiology is often helpful, but in very young children, where ossification centres have not yet formed, an ultrasound examination or magnetic resonance imaging (MRI) scan may be necessary. In an older child (when some of the ossification centres are present), a comparative radiograph of the normal side may be helpful before more invasive investigations are considered. These investigations should be performed in the definitive care phase, unless there are vascular or neurological complications. If suspected, early orthopaedic assistance must be sought.

Dislocations

Dislocations, other than of the elbow and hip, are rare in children but, as for adults, may produce neurovascular injury that can result in permanent impairment. All dislocations should therefore be reduced as soon as possible.

Epiphyseal Injuries

Fractures involving the epiphysis may be displaced or non-displaced. An orthopaedic surgeon should manage them.

17.5 EMERGENCY TREATMENT OF EXTREMITY TRAUMA

Life-threatening problems identified during the primary survey in the multiply injured child are managed first. Only then should attention be turned to the extremity injury. The specific management of complications such as vascular injury, compartment syndrome, traumatic amputation and open wounds have been discussed earlier in this chapter.

Alignment

Severely angulated fractures should be aligned. Gentle traction should be applied to the limb to facilitate alignment, particularly when immobilising long bone fractures. Splints should extend one joint above and below the fracture site. Perfusion of the extremity, including pulses, skin colour, temperature and neurological status, must be assessed before and after the fracture is aligned. Radiographs, including arteriograms, should not be obtained until the extremity is splinted.

When aligning a fracture, analgesia is usually necessary. Nitrous oxide or intravenous opioids should be used. Analgesia and further pain management is discussed in Appendix F. In femoral fractures, femoral nerve block is very effective – techniques are discussed in Chapter 22.

Immobilisation

Fractures (or suspected fractures) should be immobilised to control pain and prevent further injury. Splintage is an effective way of controlling pain, and subsequent doses of analgesia may be reduced. If pain increases after immobilisation, then an ischaemic injury and/or compartment syndrome must be excluded. Emergency splinting techniques for various injured extremities are described below.

Upper Limb

• Hand.  This should be splinted in the position of function with the wrist slightly dorsiflexed and the fingers slightly flexed at all joints. This is best achieved by gently immobilising the hand over a large roll of gauze.
  
• Forearm and wrist.  They should be splinted flat on padded pillows, or a dorsal above-elbow plaster back slab should be applied.
  
• Elbow.  The elbow should be immobilised in a flexed position to a maximum of 80° of flexion from full extension with a sling and an above-elbow plaster back slab.
  
• Arm.  The arm should be immobilised by a sling, which can be augmented with splints for unstable fractures. Circumferential bandages should be avoided, as they may be a cause of constriction, particularly when swelling occurs.
  
• Shoulder.  This is immobilised by a sling.

Lower Limb

• Femur.  Femoral fractures should be treated in traction splints or skin traction with a Thomas splint. Ipsilateral femoral and tibial fractures can be immobilised in the same splint. Excess traction may cause perineal injury and neurovascular problems, and should be avoided.
  
• Tibia and ankle.  Tibial and ankle fractures should be aligned and immobilised in padded box splints or an above/below-knee back slab depending on the position of the fracture. Foot perfusion should be assessed before and after application of the splint.

17.6 EXTREMITY TRAUMA: SUMMARY

• Extremity trauma is rarely life-threatening per se, unless exsanguinating haemorrhage ensues. Multiple fractures can cause significant blood loss.
  
• The first priority is assessment of the airway, breathing and circulation.
  
• Full assessment of the extremities takes place during the secondary survey. Limb-threatening injuries should be identified at this stage and further investigation and management begun. Other injuries should be treated by splintage.

17.7 SPINAL TRAUMA: INTRODUCTION

Spinal injuries are rare in children – which does not mean that they are unimportant. For any mechanism of injury capable of causing cervical spine damage (or in cases with an uncertain history), the cervical spine is presumed to be at risk. A high index of suspicion, correct management and prompt referral are necessary in order to prevent exacerbation of underlying cord injury. Every severely injured child should be treated as though he or she has spinal injury until adequate examination and investigation exclude it.

Immobilisation

If the child is unconscious, uncooperative or has had a significant mechanism of injury that makes it possible for there to be a spinal injury, the head and neck should be stabilised initially by manual immobilisation. A hard collar should be fitted and applied to all cooperative patients.

Some situations are particularly difficult. An injured child may be uncooperative for many reasons including fear, pain or hypoxia. Manual immobilisation should be maintained and the contributing factors addressed. Too rigid immobilisation of the head in such cases may increase leverage on the neck as the child struggles. The infant or baby who is too small for a hard collar should have manual immobilisation supported throughout.

Once a child has been immobilised, a member of staff must remain with the child at all times for reassurance, and to ensure that there is minimal movement and that the airway remains patent. Immobilisation of the cervical spine can be very frightening and disorientating to a child and thus must be carried out supportively and sensitively with careful explanation appropriate to the child’s age and cognitive level throughout the procedure.

Children being transported between institutions may require additional immobilisation. This may involve head blocks or a vacuum mattress, and where possible axial loading must be avoided. Spinal boards should only be used in the short term. Children who arrive in hospital on a spinal board must be removed from it as quickly as possible.

Stay updated, free articles. Join our Telegram channel

Join