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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

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    Major arterial hemorrhage

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    Crush injury (rhabdomyolysis)

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    Fat embolism

Potentially Limb-threatening Injuries

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    Open-fracture and joint injury

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    Vascular injury

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    Traumatic amputation

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    Compartment syndrome

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    Neurologic injuries

Must-Know Essentials: Extremity Vascular Injuries

Fractures with High Incidence of Vascular Injuries

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    Distal femur fracture

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    Open femur fracture

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    Tibial plateau fractures

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    Floating knee (ipsilateral tibia and femur fractures) injury

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    Knee dislocations

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    Elbow fracture/dislocation

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    Ankle fracture/dislocation

Hard Signs of Vascular Injuries

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    Expanding hematoma

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    Pulsatile hematoma

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    Cold, pale, and pulseless extremities

Indications for Angiogram in Suspected Arterial Injuries

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    Diminished peripheral pulses

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    Absent Doppler in the artery

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    Ankle brachial index <0.9 in lower-extremity injuries

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    Injury in the proximity of a major vessel

Management of Vascular Injuries

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

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    Revascularization must be performed as soon as possible.

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

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

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    Revascularization procedures

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      Vascular repair

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      Vein grafting

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      Arterial stents

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      Temporary shunts indicated in the following:

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        Unstable patients with concomitant life-threatening injuries

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        >3-4 hours of delay in arterial revascularization

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

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      Prolonged ischemia time (>3-4 hours)

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      Significant preoperative hypotension

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      Associated crush injury

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      Combined arterial and venous injury

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      Major venous ligation in the popliteal or femoral area

Must-Know Essentials: Crush Injuries (Rhabdomyolysis)

Etiology

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    Direct muscle injury

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    Muscle ischemia

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    Myoglobin release

Pathophysiology

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    Disruption of the sarcolemma of the muscle cells

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    Cellular adenosine triphosphate (ATP) depletion

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    Cellular sodium-potassium pumps failure

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    Generation of oxidative free radicals

Diagnosis

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    Elevated creatine kinase (CK)

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    Amber-colored urine, positive for hemoglobin

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    Myoglobinuria

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    Renal function test for acute kidney injury (AKI)

Management

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    Aggressive IV crystalloid solution infusion

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      0.9% normal saline solution preferred

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

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    Renal protection

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      Use of sodium bicarbonate is controversial.

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      Sodium bicarbonate may cause hypocalcemia.

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

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

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

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

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      Monitor for complications including the following:

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        Acute renal failure

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        disseminated intravascular coagulation (DIC)

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        Hyperkalemia

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        Hypocalcemia

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      Compartment syndrome

Must-Know Essentials: Fat Embolism Syndrome

Etiology

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    Long bone fractures

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    Pelvic fractures

Pathophysiology

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    Fat globules release in peripheral circulation.

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

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    Leukocyte activation

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    Intravascular endothelial damage

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    Increased capillary permeability

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

Manifestations

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    Early persistent tachycardia

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    Acute respiratory failure/ARDS

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    High temperature

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    Petechial rash

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      Over the upper body, especially in the axillae

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      Usually develops 24–36 hours after the injury

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      Seen in in 20%–50% of patients

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    Subconjunctival hemorrhage

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    Mental status changes

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      Agitation

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      Delirium

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      Seizures

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      Stupor or coma

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    Retinal hemorrhages with intraarterial fat globules seen in fundoscopy

Diagnosis

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    High index of suspicion

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    No specific tests

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    Lipiduria

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    Fat globules in alveolar macrophage on bronchoalveolar lavage

Management

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    Supportive care

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    Management of respiratory distress, including mechanical ventilation

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    Corticosteroid: Controversial

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    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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