Evaluation and Management of Extremity Fracture Emergencies


Algorithm: Evaluation and management of extremity fracture emergencies

Must-Know Essentials: Emergencies in Extremity Injuries

Potentially Life-threatening Injuries

  • Major arterial hemorrhage

  • Crush injury (rhabdomyolysis)

  • Fat embolism

Potentially Limb-threatening Injuries

  • Open-fracture and joint injury

  • Vascular injury

  • Traumatic amputation

  • Compartment syndrome

  • Neurologic injuries

Must-Know Essentials: Extremity Vascular Injuries

Fractures with High Incidence of Vascular Injuries

  • Distal femur fracture

  • Open femur fracture

  • Tibial plateau fractures

  • Floating knee (ipsilateral tibia and femur fractures) injury

  • Knee dislocations

  • Elbow fracture/dislocation

  • Ankle fracture/dislocation

Hard Signs of Vascular Injuries

  • Expanding hematoma

  • Pulsatile hematoma

  • Cold, pale, and pulseless extremities

Indications for Angiogram in Suspected Arterial Injuries

  • Diminished peripheral pulses

  • Absent Doppler in the artery

  • Ankle brachial index <0.9 in lower-extremity injuries

  • Injury in the proximity of a major vessel

Management of Vascular Injuries

  • Patients with hard signs of vascular injury require emergent surgical exploration and revascularization.

  • Revascularization must be performed as soon as possible.

  • Muscle ischemia for >6 hours results in irreversible injury and muscle necrosis.

  • Unstable fractures should be stabilized with an external fixation before revascularization.

  • Revascularization procedures

    • Vascular repair

    • Vein grafting

    • Arterial stents

    • Temporary shunts indicated in the following:

      • Unstable patients with concomitant life-threatening injuries

      • >3-4 hours of delay in arterial revascularization

  • Fasciotomy should be performed in high-risk patients with vascular injury:

    • Prolonged ischemia time (>3-4 hours)

    • Significant preoperative hypotension

    • Associated crush injury

    • Combined arterial and venous injury

    • Major venous ligation in the popliteal or femoral area

Must-Know Essentials: Crush Injuries (Rhabdomyolysis)

Etiology

  • Direct muscle injury

  • Muscle ischemia

  • Myoglobin release

Pathophysiology

  • Disruption of the sarcolemma of the muscle cells

  • Cellular adenosine triphosphate (ATP) depletion

  • Cellular sodium-potassium pumps failure

  • Generation of oxidative free radicals

Diagnosis

  • Elevated creatine kinase (CK)

  • Amber-colored urine, positive for hemoglobin

  • Myoglobinuria

  • Renal function test for acute kidney injury (AKI)

Management

  • Aggressive IV crystalloid solution infusion

    • 0.9% normal saline solution preferred

    • Infusion rate may range from 200 mL/hr to 1000 mL/hr based on the response.

  • Renal protection

    • Use of sodium bicarbonate is controversial.

    • Sodium bicarbonate may cause hypocalcemia.

    • Alkalinization of the urine and diuresis are considered renal protective in myoglobinuria because myoglobin is more soluble in alkaline solution.

    • IV fluid with bicarbonate may be considered in patients with significant myoglobinuria.

    • May consider mannitol 1 g/kg after resuscitation with crystalloid.

    • Close monitoring of urine output with a goal of 1–2 mL/kg/hr

    • Monitor for complications including the following:

      • Acute renal failure

      • disseminated intravascular coagulation (DIC)

      • Hyperkalemia

      • Hypocalcemia

    • Compartment syndrome

Must-Know Essentials: Fat Embolism Syndrome

Etiology

  • Long bone fractures

  • Pelvic fractures

Pathophysiology

  • Fat globules release in peripheral circulation.

  • Interaction of fat globules with platelets and clotting cascades, causing intravascular coagulation.

  • Leukocyte activation

  • Intravascular endothelial damage

  • Increased capillary permeability

  • Decreased level of functional surfactant leading to pulmonary edema and acute respiratory distress syndrome (ARDS)

Manifestations

  • Early persistent tachycardia

  • Acute respiratory failure/ARDS

  • High temperature

  • Petechial rash

    • Over the upper body, especially in the axillae

    • Usually develops 24–36 hours after the injury

    • Seen in in 20%–50% of patients

  • Subconjunctival hemorrhage

  • Mental status changes

    • Agitation

    • Delirium

    • Seizures

    • Stupor or coma

  • Retinal hemorrhages with intraarterial fat globules seen in fundoscopy

Diagnosis

  • High index of suspicion

  • No specific tests

  • Lipiduria

  • Fat globules in alveolar macrophage on bronchoalveolar lavage

Management

  • Supportive care

  • Management of respiratory distress, including mechanical ventilation

  • Corticosteroid: Controversial

  • Early (<24 hours after injury) fixation of long bone fractures are associated with decreased incidence of fat embolism syndrome.

Must-Know Essentials: Mangled Extremities

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