Orthopaedic Emergencies A Manual for Medical Students,

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vi Contents

11 Water Wounds���������������������������������������������������������������� 73
Reference ������������������������������������������������������������������������ 75
12 Displaced
 Femoral Neck Fractures������������������������������ 77
References������������������������������������������������������������������������ 81
13 Displaced Talar Neck Fractures������������������������������������ 83
References������������������������������������������������������������������������ 88
14 Slipped
 Capital Femoral Epiphysis������������������������������ 89
References������������������������������������������������������������������������ 93
15 Compartment Syndrome���������������������������������������������� 95
References������������������������������������������������������������������������103
Index����������������������������������������������������������������������������������������105
Unstable Pelvic Fracture
1

A 25-year-old male is involved in a motorcycle cycle accident in

which he strikes a utility pole. He arrives in the emergency
department awake and alert with a HR of 108 bpm and blood
pressure 80/52 mmHg. He complains of pain in his pelvic area.
His initial anteroposterior (AP) X-ray of the pelvis is shown (Fig.
1.1). What is his likelihood that he will die from this injury?
This patient is hemodynamically unstable and has an unstable
pelvis fracture. His expected mortality rate is 25% [1]. This is a
fairly high mortality rate for a traumatic injury.
Why is the mortality rate so high?
Pelvis injuries tend to bleed, and displaced (mechanically
unstable) pelvis injuries bleed more. The bleeding comes from the
fracture, from the traumatized venous plexus anterior to the sacral
bone at the posterior pelvis, and occasionally from injury to the
arteries of the pelvis [2]. Total blood loss from an unstable pelvis
fracture can be as high as 4–6 units (2–3 l) of blood, which can
result in death by exsanguination [1]. Typically, blood volume is
7% of a patient’s mass, so a 70 kg patient will have a blood vol-
ume of 4.9 l, and could lose more than half of that from the unsta-
ble pelvis injury alone.
Additionally, patients with pelvic fractures often have other
injuries that contribute to the high mortality rate.

© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2024
J. T. Gorczyca, Orthopaedic Emergencies,
https://doi.org/10.1007/978-3-031-62011-9_1
2 1 Unstable Pelvic Fracture

Fig. 1.1 Anteroposterior (AP) radiograph of the pelvis demonstrates obvious

diastasis at the anterior pelvis, with more subtle findings of left sacral fracture
and right sacroiliac joint displacement. This amount of displacement (>2.5 cm
anteriorly and >1 cm posteriorly) is indicative of an unstable pelvis injury that
has a high capacity for hemorrhage, warrants close hemodynamic monitoring
and aggressive resuscitation as needed, benefits from provisional external sta-
bilization of the pelvis, and ultimately is treated with definitive surgical stabi-
lization when the patient is stable enough to have surgery

What are the radiographic features that mark this pelvis

injury as having the potential to bleed significantly?
In general, pelvis injuries that have displacement of the poste-
rior pelvis (in the sacroiliac region) on the initial AP pelvis X-ray
have sustained enough force to cause not only displacement of the
fracture, but also disruption of the soft tissues and vascular plexus
anterior to the sacroiliac region [2, 3] (Fig. 1.2). Thus, displace-
ment of the posterior pelvis by 1 cm or more on the initial AP
pelvis X-ray taken in the trauma bay will identify patients at risk
for significant hemorrhage and serves as an important piece of
information in the prioritization of this patient’s care.
Fractures with more than 2.5 cm separation (diastasis) of the
anterior pelvis at the pubic symphysis are also at risk for signifi-
cant hemorrhage [4]. It has been demonstrated in the laboratory
that in order for a pubic symphyseal diastasis of 2.5 cm to occur,
1 Unstable Pelvic Fracture 3

Fig. 1.2 Sawbone pelvis model depicts pelvis fracture with displacement at
pubic symphysis anteriorly as well as at the left sacrum posteriorly. The dis-
placement of the fracture >1 cm posteriorly is disruptive to the stabilizing soft
tissues, numerous blood vessels, and in some cases, the nerves in the vicinity

there must be disruption of at least the anterior sacroiliac liga-

ments at the posterior pelvis, which in turn is associated with dis-
ruption of the posterior pelvis venous plexus and significant
hemorrhage. Thus, this “open book pelvis” injury in this patient is
associated with significant hemorrhage (Fig. 1.3).
Initial radiographs can be misleading because some severe
pelvis injuries with significant displacement at the time of impact
will recoil or will assume an alignment that is less displaced at
the time that the X-ray is taken. In some cases, the instability of
the pelvis can be detected by physical examination or by CT
scan. It is prudent to assume that a pelvis injury is mechanically
unstable in the early evaluation and resuscitation of trauma
patients. It is for this reason that many EMTs and paramedics
will presumptively place an external pelvis immobilizer on a
patient based on the nature of the accident (e.g., fall greater than
10 feet, motor vehicle collision with greater than one foot of
intrusion, MVC in which the patient is ejected from the vehicle,
and motorcycle accident).
4 1 Unstable Pelvic Fracture

a b

Fig. 1.3 (a) AP pelvis radiograph demonstrates classic “open book pelvis
fracture” with diastasis (separation) of the pubic symphysis >2.5 cm, which is
pathognomonic for pelvic instability and potential for significant hemor-
rhage. (b) Bone model depicts pubic symphysis diastasis and anterior sacro-
iliac joint displacement. Although the posterior sacroiliac ligaments are not
disrupted in this case, the displacement at the anterior aspect of the sacroiliac
joint is associated with mechanical instability and significant hemorrhage. (c)
CT scan demonstrates sacroiliac joint in open book pelvis injury, with dis-
placement anteriorly despite intact posterior ligaments, which function like
the binding of a book when the book is opened

For a pelvis fracture with an unclear degree of instability after

X-rays, physical examination, and CT scan, stress evaluation of
the pelvis with fluoroscopy can be helpful in identifying which of
the patients with a minimally displaced injury on initial x-ray
have an unstable injury that has the ongoing potential for
­significant hemorrhage, and determining whether or not surgery
should be performed to stabilize the pelvis (Fig. 1.4).
1 Unstable Pelvic Fracture 5

a b

Fig. 1.4 (a) AP pelvis radiograph has displacement at right superior pubic
ramus fracture. The exact degree of instability is unclear. (b) Intraoperative
“stress” radiographs show significantly more displacement at the superior
pubic ramus (black arrow) and establish that there is significant instability of
the fracture

What steps should be taken to maximize survival of this

patient?
After assuring that the patient has an adequate airway and is
breathing and ventilating well, the next priority is his circulation.
The patient should be treated with immediate resuscitation using
intravenous fluids and/or blood products and by provisionally sta-
bilizing the pelvis [1].
The first step in this resuscitation involves obtaining intrave-
nous access and administering fluids.
Provisional stabilization of the pelvis can be provided by tightly
wrapping a sheet around the pelvis or by a using a circumferential
pelvic band which, when tightened will, decrease the size of the
pelvic ring, and provide enough stability to the pelvic tissues to
facilitate stable clot formation (Fig. 1.5). The net effect will be to
decrease the rate of hemorrhage as much as possible so that the
patient can respond to the intravenous fluids and blood products.
What fluids should this patient receive for resuscitation?
This patient has a systolic BP <90 mmHg and a HR >100 bpm,
either of which by itself meets the criteria for hemodynamic insta-
bility and according to ATLS guidelines, and warrants an immedi-
6 1 Unstable Pelvic Fracture

Fig. 1.5 Photograph depicts the position of a simple sheet that is wrapped
and tightened around the pelvis in a model patient in order to provide some
stability to the pelvis. Note that in an actual patient, the clothing would have
been removed

ate bolus of 1000 cc crystalloid solution (lactated Ringers solution

or 1/2 normal saline). This serves as a quick means to improve the
patient’s intravascular volume and evaluates the degree of hemo-
dynamic instability to determine the need for further resuscitation.
If the patient’s vital signs improve enough that they become hemo-
dynamically stable and remain hemodynamically stable, then the
bolus was effective. If the patient becomes hemodynamically sta-
ble and later drifts into hemodynamic instability, then further
resuscitation will be necessary. The worst possibility is if the
patient’s hemodynamic status does not return to the normal range
after the initial bolus—in this case, the patient is in critical danger
and immediate further resuscitation with packed red blood cells
(PRBCs) and other blood products is essential. Early identification
of the patient who will not respond to the initial bolus is crucial to
their survival, and it is for this reason that the entire initial liter of
intravenous fluid should be infused as quickly as possible—the
patient’s life will depend on it [5].
1 Unstable Pelvic Fracture 7

Figure 1.6 depicts a patient with an unstable pelvis injury

while in the ICU the day following injury. What else do you
see that will affect this patient’s survival rate?
In addition to the pelvic binder, the patient has (1) a chest tube
indicative of hemothorax and or pneumothorax. This is typically
caused by rib fractures caused by significant force to the chest
wall, which usually causes pulmonary contusion and explains the
(2) endotracheal tube and mechanical ventilation. He also has a
(3) sterile seal/dressing covering his open abdomen which could
not be closed after emergency laparotomy due to post-ischemic
swelling of the abdominal organs which would cause elevated
intra-abdominal pressure and impaired organ perfusion (i.e.,
abdominal compartment syndrome). (4) A cervical collar is in
place as a cervical spine injury has not yet been ruled out. This
polytrauma patient with an unstable pelvis is not unusual in the
number of associated injuries, and it is the constellation of inju-
ries in such patients that contributes to the high mortality rate.

Fig. 1.6 Photograph of trauma patient with unstable pelvis fracture in pelvic
immobilizing device the day following injury. Note that the patient appears to have
multiple other injuries, which is not unusual when patients have pelvic fractures,
and contributes to the high mortality rate of patients with unstable pelvis fractures
8 1 Unstable Pelvic Fracture

Figure 1.7 shows an unstable pelvis injury and a common

iliac artery occlusion. The artery was repaired and circulation
was returned to the leg. How long will this patient be at risk of
significant hemorrhage?
The risk of hemorrhage is high at the time of injury, at the time
of resuscitation, and remains high until after the unstable injury is
operatively stabilized. This particular patient remained critically
unstable for 5 days after injury, and on the sixth day, during open
reduction of the pelvis, died from exsanguination. Thus, the risk
of significant hemorrhage can last many days, and patients are at
risk of exsanguination at the scene of the accident, in the
Emergency Room resuscitation bay, in the Intensive Care unit,
and in the operating room.

Fig. 1.7 AP lumbosacral spine radiograph depicts markedly unstable right

iliac fracture and thrombosed external and internal iliac arteries. This patient
ultimately exsanguinated from the pelvis fracture
1 Unstable Pelvic Fracture 9

Figure 1.8 shows the radiograph of a patient with an unsta-

ble, complex pelvis fracture with a pubic symphysis diastasis.
What are some of the benefits of surgery for this patient?

Fig. 1.8 (a) AP pelvis radiograph demonstrates highly unstable bilateral pel-
vis injury. Surgery is warranted to stabilize the pelvis to decrease ongoing
hemorrhage, to improve comfort, and to restore alignment of the pelvis. (b)
AP pelvis radiograph taken postoperatively demonstrates the extent of the
stabilization procedure that was required for this pelvis injury
10 1 Unstable Pelvic Fracture

(1) Surgery to stabilize the mechanically unstable pelvis will

control motion of the pelvis and thus decrease the risk of ongoing
hemorrhage; (2) decrease the amount of pain experienced when
the patient moves, allowing repositioning for improved ­pulmonary
and skin care; (3) restore alignment of the pelvis for proper heal-
ing, which is associated with improved long term functional
­outcomes.
How does the shape of the pelvis affect its mechanics and
surgical considerations?
The pelvis is a bony-ligamentous ring comprised of the sacrum
and the two innominate bones, which are connected to each other
by the pubic symphysis anteriorly and to each side of the sacrum
posteriorly by the sacroiliac ligamentous complex. When the liga-
ments are disrupted or the bone is fractured and displaced, the
displaced area should be realigned (”reduced”) and held in place
with plates and screws (or in some cases by an external fixation
system, although these are being used less frequently these days).
The plates and screws are not strong enough to allow the patient
to stand or walk on the side(s) of the injury, so the patient will be
mobilized with restricted weight bearing on one or both lower
extremities for 2–3 months until the fracture has healed (Fig. 1.9).
Once the injury has healed, it may take 2 more months for the
patient to regain enough strength, comfort, and balance control to
walk without any assistive devices (Fig. 1.10).
1 Unstable Pelvic Fracture 11

Fig. 1.9 Clinical photograph demonstrates external fixator that was on this
patient who was non-weight bearing until the fracture healed in 3 months
12 1 Unstable Pelvic Fracture

a b

Fig. 1.10 Clinical photographs of patient 5 months after surgery bearing full
weight on each leg individually (a, b). He initially was restricted from bearing
weight for 3 months until the fracture healed, and it took another 2 months
before he could bear full weight in a single-leg stance, which is necessary in
order to walk without assistance
References 13

References
1. American College of Surgeons Committee on Trauma. Advanced trauma
life support: student course manual. 10th ed. Chicago: American College
of Surgeons; 2018.
2. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br.
1988;70(1):1–12. https://doi.org/10.1302/0301-­620X.70B1.3276697.
3. Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic frac-
tures: part 1. Evaluation, classification, and resuscitation. J Am Acad
Orthop Surg. 2013;21(8):448–57. https://doi.org/10.5435/JAAOS-­21-­
08-­448.
4. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of
plain radiography in early assessment and management. Radiology.
1986;160(2):445–51. https://doi.org/10.1148/radiology.160.2.3726125.
5. Hak DJ, Smith WR, Suzuki T. Management of hemorrhage in life-­
threatening pelvic fracture. J Am Acad Orthop Surg. 2009;17(7):447–57.
https://doi.org/10.5435/00124635-­200907000-­00005.
Traumatic Amputation
2

A man is run over by a train and sustains bilateral amputa-

tions (Fig. 2.1). What would be the most likely cause of death
from this injury?
Traumatic amputation is associated with massive hemorrhage
and death from exsanguination [1, 2]. Other potential problems
are infection from the open wound, and loss of function due to the
loss of the amputated limb [3].

Fig. 2.1 Clinical photograph demonstrates traumatic below knee amputation,

which is at high risk for severe hemorrhage and requires some form of pressure to
control the bleeding. In this patient, a tourniquet has been applied to the thigh

© The Author(s), under exclusive license to Springer Nature 15

Switzerland AG 2024
J. T. Gorczyca, Orthopaedic Emergencies,
https://doi.org/10.1007/978-3-031-62011-9_2
16 2 Traumatic Amputation

What can be done to control bleeding?

It is essential that bleeding is controlled early and effectively in
order to maximize chances for survival. In many cases, direct
pressure over the wound or compression of the main artery proxi-
mal to a wound (proximal arterial pressure) will control hemor-
rhage. Applying and inflating/tightening a tourniquet to the
amputated limb(s) can achieve effective control of hemorrhage,
and if it is secured in the tightened position, will not require a
person to continue to apply pressure.
Rapid application of tourniquets can be lifesaving, especially
with devastating injuries from explosives, high-energy gunshot
wounds, and cases of multiple extremity wounds.
Tourniquets work by applying a tight circumferential force
around the extremity to squeeze and compress the vessels.
Unfortunately, the tourniquet, if left in place for a long time, can
cause necrosis of all tissue distal to the level of the tourniquet.
Extensive necrosis of skin and soft tissue caused by prolonged use
of a tourniquet may necessitate a higher level of amputation and
consequent functional loss. Thus, tourniquets should not be used
for longer than is necessary. The sooner the tourniquet can safely
be removed, the better the chances for optimal function of the
residual (amputated) limb [4].
Occasionally, an amputated body part can be successfully reat-
tached (replanted) after amputation.
What should be done to preserve the amputated body part
in order to assure the greatest chance of successful replanta-
tion?
The amputated body part should be quickly cleaned of gross
debris, protected from drying by wrapping it in a moistened gauze
or clean towel, and placed in a clear plastic bag for easy identifica-
tion. In order to preserve the viability of the tissue, the body part
should be cooled as much as possible by placing it in a clear plas-
tic bag on crushed ice or in ice water. The body part should be
transported to the medical center as quickly as possible, with the
patient whenever possible.
The above thru-forearm amputation was delivered to the
hospital with the patient in hopes of replantation to restore