Common Outdoor Injury Management: Focus on Femoral Shaft Fractures

Mechanisms of Injury Relevant Vascular and Bony Anatomy Field Assessment and Stabilization Transport and Communication

2009 Cycle B

Important Information for Instructors

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2009 Cycle B

Mid-Shaft Femur Fracture

OEC Cycle B musculoskeletal objectives Anatomy and physiology Mechanisms of injury Types of injury involving bone and soft tissue Assessment and immobilization Initial field management Transport and communication

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Mechanisms of Injury
High Energy Often high-speed impact or rapid deceleration But may take surprisingly little energy in children Direct blow Twisting Injury Compression with angulation Fall from height High speed collisions Often seen in combination with other significant injuries
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Initial Assessment
Scene size-up MOI Scene safety ABCs Treat shock Maintain airway Distal CMS Manually stabilize injury site Expose injury site Open wound? Visible bone?
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Overview For All Fractures

Initiate BSI Precautions Assess limb/joint for MOI, CMS, & bleeding Manually stabilize limb, realign as needed while maintaining stabilization Expose & control bleeding Dress & bandage wound Prepare immobilization device Apply immobilization device without excessive movement, padding all voids Immobilize fracture site and joints above and below Reassess CMS
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Anatomy
Femur is the longest and sturdiest bone in humans Muscular attachments tend to displace distal fracture fragments medially, even without flailing mechanism Flailing proximal or distal shaft with sharp edges may injure adjacent structures Nerve Artery Vein Proximity to skin results in relatively frequent open fracture, especially with high speed tumbling falls or high energy impact

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Anatomy
Blood vessels and nerves run along medial side of femur, then dive posteriorly to pass behind the knee Femoral artery Femoral vein Sciatic nerve Nerves and blood vessels highly vulnerable to injury from bone fragments
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Displacement
Can occur violently during the injury and subsequent tumbling High potential for laceration or impingement of nearby vascular and neural elements Bone may actually come out through the skin to be an open fracture

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Cross Sectional Anatomy

Neurovascular structures more anterior proximally Distally, all vascular and neural structures pass medially and then very close to posterior margin of the femur just above the knee Note high potential for neurovascular injury from flailing bone during fall Skin is only several centimeters away from bone anterolaterally, so

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Radiographic Appearance
Note displacement and overriding despite visible traction splint in place. Even with this, overall alignment is straight and bone motion will be minimized with good traction. Also note high potential for soft tissue injury if bone ends are free to move around, not only during the fall but also during stabilization and transport.

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Field Management
Control bleeding, treat shock Dress wounds Distal CMS Manual stabilization Traction splint for mid-shaft fracture Backboard without traction for hip injury Re-check CMS Address other injuries as needed Early coordination with EMS agencies ALS transport criteria per local protocol Frequent vital sign checks and documentation Expedited transport to definitive care
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Pre and Post Splint CMS Evaluation FACTS F - Function A - Arterial pulse C - Capillary refill T - Temperature (skin) S - Sensation
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Mid-Shaft Femur Fracture

Traction Splinting
Re-aligns fragments Lessens risk of neurovascular injury May relieve compressive occlusion of arterial or venous structures Relieves pain due to bone fragments moving against each other Note need to re-check distal CMS after application of splint If proximal injury such as hip dislocation or femoral neck fracture suspected, immobilize on backboard without traction splint
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Take Home Points

Traumatic femur fracture rarely occurs without associated shock or multi-system injury ALS (Advanced Life Support) transport criteria include: Multi-system trauma Unstable vital signs Signs and symptoms of shock Sustained tachycardia Sustained systolic BP less than 90mmHg Gut feeling based on MOI, Sick/Not sick criteria Compromised distal CMS Traction splint for mid-shaft femur fracture Back board for proximal femur/hip fracture Early communication and coordination with local EMS transport agencies is in the patients best

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