Primary survey and resuscitation, secondary survey and definitive care

Within the primary survey, life-threatening injuries are identified and treated. Where musculoskeletal injuries threaten life, it is usually as a circulation problem. There is a need to recognise hypovolaemia, a rapid inspection to identify sites of major bleeding and then measures to stop the bleeding. Beyond the initial resuscitation phase, renal failure can result from traumatic rhabdomyolysis caused by crush injuries; fat embolism is an uncommon, but lethal, complication of long-bone fractures.

It is important to realise that the patient may have multiple injuries. Knowledge of the mechanism of the injury is important in this: a fall from a height can result in cervical spine and other vertebral fractures and/or fractures of the long bones. Some fractures are not easy to detect and are found only after repeated examination. Assistance from an orthopaedic/ emergency physician should be summoned immediately.

Major pelvic disruption with haemorrhage

There is limited literature concerning serious pelvic injuries in the later stages of pregnancy. However, uncontrolled haemorrhage from pelvic fractures continues to be a cause of potentially avoidable death after major trauma in the nonpregnant population, and the management principles are common to both groups.

Pelvic fractures in pregnant women may cause fracture to the fetal head, especially if the head is engaged. The precise mechanism of injury provides considerable information as to the type of pelvic injury sustained. An anteroposterior radiograph of the pelvis is an important investigation in any major trauma. Serious pelvic injuries are usually obvious, although the pelvis may only be confirmed as the source of bleeding once abdominal, thoracic and external sources have been excluded. Where a pelvic injury is suspected, the patient should be resuscitated and the pelvis immobilised.

Only a very gentle examination of the pelvis should be attempted if a fracture is suspected. This should be by a single experienced person gently pressing inwards on the pelvic bones. Under no circumstances should there be an attempt to demonstrate the ‘open book fracture’. Massive retroperitoneal bleeding from pelvic fracture is more likely in pregnancy because of engorgement of the pelvic vessels. Major pelvic disruption tears the pelvic venous plexus.

The input of an orthopaedic surgeon is required urgently as stabilisation of the pelvis by external fixation may be part of resuscitation, in order to ‘turn off the tap’.

Venous and arterial haemorrhage should be treated initially with manual attempts to return the pelvis to its anatomical position. The pelvis should be immobilised, preferably with a pelvic binder, but a sheet can be wrapped around the pelvis as a sling. These manoeuvres and the application of an external fixator (required to maintain anatomical reduction) may be difficult in the later stages of pregnancy. Often, delivery by CS will be required to salvage the baby, and to achieve control of pelvic haemorrhage. It may be necessary to empty the uterus by CS, even if the baby is dead, in order to gain access and to control haemorrhage. A high index of suspicion of the pelvis as a potential source of life-threatening bleeding should be maintained until control by other means has been established.

Long-bone fractures

Assess for bleeding and suspect arterial damage if there are changes in colour, temperature or pulse volume in the extremity concerned. Treatment of visible external bleeding comprises compression, resuscitation and immediate orthopaedic input. Haemorrhage from limb injuries is often compressible. Compression is carried out by:

With open limb wounds, the loss may be evident. Loss may be suspected when a limb is swollen and deformed. Equally, loss may only be detected by recognising the signs of hypovolaemia; a closed fracture of the femoral shaft may easily result in the loss of 2litres into the surrounding tissues. Loss into long bones is one of the areas for major occult blood loss (chest, abdomen, pelvis and retroperitoneum and long-bone fractures). This requires resuscitation, immobilisation and immediate orthopaedic input.