CHAPTER 3 Trauma 230 Acromioclavicular dislocations Cause Acromioclavicular dislocations are commonly seen follo wing falls when the patient rolls onto the shoulder. This is a common injury of rugby playe rs. Signs and symptoms Various degrees of injury occur, from simple sprains presenting as local tenderness and swelling, to dislocations where the dislocated outer end of the clavicle is obviously prominent. Treatment Support in a broad arm sling. Potential problems There are no specific frequent complications of acromioclavicular joint dislocation. In patients with a component of crush injury, other injuries should be exclude d. REGIONAL INJURIES: UPPER LIMB1 231 Dislocations of the shoulder: anterior Cause This is the most common type of shoulder dislo cation occurring commonly in males aged 18 \200\22325yrs, caused by falls on the outstretch ed hand followed by external rotation of the shoulder. Anterior dislocations are common spo rts injuries, but also occur as a result of simple falls and, occasionally, road traffic co llisions. Signs and symptoms Patients are often in severe pain and support their arm in the most com- fortable position. The arm is held with the elbow flexed and the shoulder internally rotat ed. The normal contour of the shoulder is lost (Fig. 3.15). Treatment The arm should be supported. It cannot be splinted by the side and should be kept in a comfortable position. The patient is likely to have found this for themselves, but su pport on a pillow may help. Analgesia should be given, using Entonox, an NSAID, or opiates (titrated to need). Occasionally, it may be appropriate to attempt reduction in the pre- ho spital environment, although this should only be considered by those with appropriate exper ience. Adequate analgesia or sedation should be given and gentle external rotation of the humerus should be attempted, with the elbow flexed to 90o. This may achieve reduction, or reduction may occur when the elbow is adducted across the chest. Successful relocation of the head o f the humerus can usually be felt by the manipulator. Otherwise, if the hand on the affecte d side can reach to grasp the opposite shoulder without difficulty, successful reduction ha s been achieved. Potential problems Neurological complications are relatively common, especially damage to t he axillary (circumflex) nerve tested for sensation over the regimental badge area on the s ide of the upper arm. The neurological deficit can be more dense and, rarely, there is an a ccompanying axillary artery injury. CHAPTER 3 Trauma 232 Fig. 3.15 Shoulder contour: anterior dislocation. REGIONAL INJURIES: UPPER LIMB1 233 Dislocations of the shoulder: posterior Cause Posterior dislocation of the shoulder may res ult from a direct blow to the front of the shoulder or a fall on the outstretched hand with the arm internally rotated. Posterior dislocation classically, but rarely, complicates epi leptic fits or electrocution. Signs and symptoms - Pain - Deformity - Local tenderness. Treatment The arm should be supported and analgesia should be given. Potential problems Neurological complications, whilst recognized, are rare. Dislocations of the shoulder: inferior (luxatio erecta) Cause The usual cause is a superior blow with the shoulder in an abducted position. Superior dislocation of the shoulder is ex tremely rare. Signs and symptoms - Pain - Deformity - Loss of function. Treatment The arm should be supported and pain relief given. Potential problems Inferior dislocation may be associated with injuries to the brachial ple xus or the axillary artery. There may be problems fitting the patient onto a stretcher and they may have to be transported in a sitting position. CHAPTER 3 Trauma 234 Humeral fractures: proximal Cause Proximal humeral fractures may occur due to direct falls on the upper humerus or by transmitted force following a fall on the outstretched hand. Signs and symptoms - Pain - Tenderness - Deformity - Loss of function. Treatment Analgesia should be considered before moving the arm. Pain may in part be relieve d by immobilizing the arm. The elbow can be bent and the arm splinted in a sling with the a ddition of a broad bandage around the chest. Alternatively, the arm can be positioned by th e patient \200\231s side and secured by a series of broad bandages around the chest and tru nk. Some patients may prefer to support the arm themselves for transportation to hospital. Potential problems If the fracture occurs as a result of significant direct violence, the p ossibility of other injuries (for example, chest wall injuries) should be considered. REGIONAL INJURIES: UPPER LIMB1 235 Humeral fractures: shaft fractures Cause Humeral shaft fractures are usually due to direct violence (falls, road traffic collisions). They may also occur due to indirect force such a s a fall onto the outstretched hand. Signs and symptoms - Pain - Angulation - Loss of function - The patient supports the arm wi th the other hand - There may be evidence of radial nerve palsy (motor and sensory). Treatment Analgesia should be offered and the patient allowed to support their own arm. Use of a sling or pad inside the arm and splinting to the chest with broad bandages should be considered. Potential problems Radial nerve palsy may occur in midshaft fractures. Very rarely, injurie s to the brachial artery may occur, as can a compartmental syndrome. There is a high incidence of associated chest injuries when humeral fracture occurs in a pedestrian hit by a vehicle. CHAPTER 3 Trauma 236 Supracondylar fractures in adults Cause These commonly result from a fall directly onto the elbow. By definition, the fracture occurs in the distal third of the humerus. The fracture is invariably transverse but may have an intra-articular component. Signs and symptoms - Pain - Swelling and deformity - Loss of function - The patient will be in pain and will usually support their own arm. Treatment The arm should be immobilized in the most comfortable position. If the arm is ext ended, it may be immobilized in a padded box splint or by padding and bandages to the trunk . If the elbow is flexed, the arm may be best supported in a broad arm sling. Potential problems As in children \200\231s fractures, although less frequently, there may be associated injuries to the brachial artery and the median nerve. REGIONAL INJURIES: UPPER LIMB1 237 Supracondylar fractures in children Cause This is a common fracture following a fall on the outstretched hand. Signs and symptoms Typical features include: - Pain - Swelling and deformity - Loss of func tion. There is a risk of vascular compromise due to trauma to the brachial artery when the features may include pallor, coldness, parasthesae, and pulslessness in the forearm and han d. Neurological injury to the median, radial, and ulna nerves have all been recorded and cl inical features will include appropriate sensory and motor signs. Treatment Appropriate analgesia should be given and the limb realigned, if this can be tole rated. Splintage to the trunk or a padded box splint or broad arm sling should be used to p rovide immobilization. Potential problems The main problems relate to neurological or vascular injury, particularl y the latter. Regular circulatory assessment is mandatory. The late manifes- tations of an unrecognized ischaemic limb include compartment syndrome and the risk of developing a Volkm an \200\231s ischaemic contracture. There are other configurations of fractures about the elbow that occur particularly in chil dren, for example, fractures of the medial and lateral condyles. The presentation is as abo ve, although they are usually without complications, and these injuries can normally be imm obilized in a broad arm sling. CHAPTER 3 Trauma 238 Olecranon fractures Cause The olecranon is most commonly fractured by a fall on the point o f the elbow. Following this, bony separation of the fragments occurs due to the action of t he triceps muscle. Less frequently, fracture results from an unopposed forceful contraction of the triceps muscle. Signs and symptoms - Pain - Inability to straighten the arm (not always found) - Bruising a nd swelling. The bone ends, particularly in the elderly, are often palpable and, in some pa tients, the skin is stretched and at risk of breaking down. Occasionally, these fractures a re compound at the outset. Treatment If the fracture is compound, a sterile dressing should be applied. A broad arm sl ing will give adequate support in most cases. If the arm is held extended or the skin is vu lnerable, it should be splinted in extension using a box splint. Potential problems In direct trauma, because of its close proximity, the ulna nerve may be damaged. REGIONAL INJURIES: UPPER LIMB1 239 Radial head and neck fractures Cause The majority of radial head and neck fractures occur b ecause of falls onto the outstretched hand, the fracture occurring as the force is transmit ted along the radius. Rarely, the radial head may be injured by direct trauma. Signs and symptoms The patient complains of elbow pain, swelling, and later bruising. Forea rm rotation (pronation and supination) is restricted, as is elbow extension. Treatment Pain may be relieved by placing the arm at 90 degrees in a broad arm sling. An ic e pack may help relieve pain. Potential complications No significant pre-hospital complications. CHAPTER 3 Trauma 240 Dislocations of the elbow Cause These commonly occur following a fall onto the outstretched hand. The majority are posterior \200\224the ulna is displaced posterior relative to the h umerus. Direct blows to the proximal forearm bones in an upwards direction may result in an terior elbow dislocation. Signs and symptoms - Pain - Swelling and deformity. There is obvi ous loss of the normal bony contours. The patient often supports their elbow for pain relie f. Treatment The patient should be offered analgesia (Entonox is effective), and the elbo w should be supported or splinted in the most comfortable position. This may involve paddin g and splintage to the side of the body or padding and immobilization in a box splint. Pote ntial problems Injuries to the brachial artery and the ulna and median nerves have been rec orded. REGIONAL INJURIES: UPPER LIMB1 241 Fractures of the shafts of the radius and ulna There are three specific types of fracture c onfiguration of the bones of the forearm: 1. Fractures of the shaft of the ulna, or radius, or both. 2. A fracture of the ulna with a dislocation of the radial head (Monteggia fracture). 3. Fracture of the shaft of radius with a dislocation of the distal end of the ulna (Galeazzi fracture). Cause Direct violence to the forearm may fracture one or both bones at the point of impact. A common self-defense injury is the so called \200\230night-stick fracture \200\231 which results when the forearm is presented in self defense and is subjected to a direct blow. M ore commonly, fractures occur as a result of indirect violence following a fall on the outs tretched hand. The applied force and angle of rotation of the forearm dictate the type of f racture pattern. Although a radiological diagnosis, isolated displaced fractures of a singl e bone of the forearm must be associated with an injury elsewhere, as in the Monteggia and Galeazzi fracture patterns. In children, greenstick fractures commonly occur. Signs and symptoms - Pain - Swelling and deformity, including angulation and rotation - The forearm is usually supported. These injuries are only rarely compound. Treatment A broad arm sling maintaining elevation may be all that is necessary. Alternative ly, the arm can be splinted in a padded boxed splint. Potential problems In fractures of both bones of the forearm, there is a risk that a closed injury may become compound if the arm is not immobilized. Associated neurovascular deficit may occur. If there is delay in presentation and the histo ry is of a high impact injury, acute compartmental syndrome is possible. The clinical featu res of this include: - Extreme pain - Marked pain on passive extension of the fingers - Alt ered sensation in the hand. CHAPTER 3 Trauma 242 The wrist There are four main types of wrist fractures: 1. Colles \200\231 fracture 2. Smit h \200\231s fracture 3. Volar Barton \200\231s fracture 4. Epiphyseal injuries in children. Cause The Colles \200\231 fracture is one of the most common wrist fractures and results fr om a fall on the outstretched hand. It usually occurs in middle-aged and elderly osteoporot ic women. In displaced fractures, the appearance of the wrist is commonly described as a di nner fork deformity. The dorsal prominence is produced by the displaced distal end of the r adius and carpus. The Smith \200\231s fracture, often referred to as the \200\230reversed Colles \200\231 fr acture, \200\231 results from a fall landing on the back of the hand (a flexed wrist). It i s relatively common in motorcyclists who receive their injuries whilst still gripping the h andlebars or as a consequence of landing. These fractures also occur with a dorsal wrist pr ominence, this time due to the volar slippage of the distal radius, carpus, and hand. The Volar Barton \200\231s fracture occurs in a similar way to the Smith \200\231s fracture . Only the anterior portion of the distal radius is fractured and may be displaced. The dif ferentiation from a Smith \200\231s fracture is made by X-ray. Falls on the outstretched hand in children commonly produce a fracture involving the epiphyseal plate. Signs and symptoms - Pain - Swelling and deformity. - The wrist is commonly supported by th e patient \200\231s other hand. Treatment Pain relief and the use of a broad arm sling. In more severe injuries, a padded b ox splint may be useful, especially in those patients with other associated injuries who re quire transportation in the supine position. Potential problems In high-energy trauma, there is a significant association between wrist fractures and fractures and injuries elsewhere in the body including the head, chest, pelvi s, and other limbs. Displaced fractures may be associated with median nerve symptoms. Less frequently, the ulna nerve may be affected. REGIONAL INJURIES: UPPER LIMB1 243 Carpal bone fractures Cause The most common carpal bone fracture is the scaphoid fracture c ommonly resulting from a fall on an outstretched hand. Traditionally, it was described as a n injury complicating a \200\230kick-back \200\231 when using a starting handle. Scaphoid fracture is well known for its difficulty in hospital diagnosis and the typical delay in th e appearance of a fracture on X-rays. Other common carpal injuries may follow forced palmar flexion producing simple dorsal bony avulsion injuries. Isolated fractures of the other carpal bones can rarely occur, all of wh ich will present with pain and local tenderness. There are a variety of complex fracture dislocations of the carpus which are delineated by radiographic investigation. These usually occur in high-velocity trauma, though they should be managed in line with other wrist fractures. Signs and symptoms - Wrist pain - Tenderness in the anatomical snuff box (scaphoid fracture ). Other signs of scaphoid fracture include pain in the scaphoid on axial pressure through the thumb and pain on compression of the dorsum of the scaphoid. The patient may have restr icted movement in the wrist and impaired grip. Treatment The patient usually supports the injured wrist. Analgesia should be given and the limb should be placed in a supporting high broad arm sling. Potential problems Scaphoid fracture may be associated with median nerve symptoms. The diff erential diagnosis of tenderness in the region of the anatomical snuff box, the distal radi us, and the radial styloid includes Colles \200\231 fracture, scaphoid fracture, and wrist sprain. A definitive diagnosis should be made in hospital. In pre-hospital care, they shoul d all be treated as potential fractures. CHAPTER 3 Trauma 244 Finger fractures Cause Metacarpal and phalangeal fractures are common hand injuries and fol low both direct and indirect forces. Spiral fractures often occur as a result of rotational forces. Specific fractures within the hand complex include: - Fractures of the base of the thumb (B ennett \200\231s fracture) - Ulnar collateral ligament of the thumb sprain or rupture - Mal let finger - Fracture of the fifth metacarpal (boxer \200\231s fracture) - Finger dislocati ons. Bennett \200\231s fracture is better described as a fracture dislocation at the base o f the thumb metacarpal. This is an intra-articular fracture resulting in dislocation of the main component of the metacarpal. The ulna collateral ligament of the thumb may be ruptured, often in conjunction with a bony avulsion. These injuries result from a forced abduction of the thumb, traditionally in gam ekeepers but, more com- monly now, as a result of falls on the dry ski slope. Forced flexion of the extended finger may produce a bony avulsion of the extensor insertion to the distal phalanx resulting in a mallet finger deformity. These are caused by direct f orce (commonly a ball striking the tip of the finger) and are usually obvious clinically. Fracture of the fifth metacarpal (often spiral in nature) commonly results from the adminis tration of a bare knuckle punch (which is why this fracture is almost never seen in boxers) . Common assailants include walls and wardrobes (allegedly). Dislocations of the finger at the metacarpo-phalangeal joint or either interphalangeal joint (rarely both) are usually clinically obvious. Signs and symptoms Common signs and symptoms include pain, swelling, and deformity. When at tempting to flex the finger into the palm, obvious rotation of the digit may be apparent in phalangeal or metacarpal fractures. Treatment The arm should be placed in a broad arm sling ensuring that the hand is supported and elevated. Light companion strapping of the injured finger, if practical, may offer som e symptomatic relief, although this can usually be delayed until arrival in hospital. Simple interphalangeal dislocations can usually be reduced in the field by longitudinal tra ction under analgesia (Entonox is effective) by appro- priately trained personnel. Rings and jewelry should be removed from the injured hand as soon as possible. Potential problems Compartment syndrome rarely occurs following severe crush injuries to th e hand. This page intentionally left blank CHAPTER 3 Trauma 246 Regional injuries: the thorax Rib fractures Cause Most rib fractures result form direct for ce, for example, direct blows to the chest. They occur frequently in road traffic collision s, falls, sport, and assaults. Signs and symptoms - Pain - Tenderness - Shortness of breath. The pain is usually well loca lized to the fracture site and is made worse by movement, including inspiration. The patien t may well support the chest wall manually. Rarely, the patient will complain of clicking o f the broken rib ends. Treatment Adequate analgesia should be provided to enable the patient to breath comfortably . Self help includes splintage of the chest wall. The patient should be allowed to position themselves in the most comfortable position, which is usually sitting up. This will also a ssist in making breathing easier. Potential problems Rib fractures on their own, occurring in fit healthy people are usually benign, albeit painful injuries. However, the elderly and those with pre-existing chest dis ease (for example, chronic obstructive pulmonary disease) are at serious risk of complicati ons associated with reduced chest wall movement and underlying pulmonary contusion. Patients suffering rib fractures may sustain intra-thoracic complications including pneumot horax, haemothorax, atelectasis, and chest infection due to alveolar hypoventilation (see p p.208 \200\22317). There is generally a tendency to underestimate the magnitude of chest trauma. Entonox should not be used if there is any possibility of pneumothorax. REGIONAL INJURIES: THE THORAX1 247 Flail chest Cause A flail chest occurs when two or more ribs are broken in two places resul ting in a flail segment. This results from substantial chest trauma, for example, road traf fic collision or falls from a height. As a consequence, during inspiration and the generati on of negative intrathoracic pressure, the flail segment is sucked in and the lung remains underventilated. This pattern of breathing is called paradoxical movement. Lateral flail chests are easy to see with full chest exposure. Anterior flail chests may be more difficult to visualize unless the patient is supine and the chest is viewed at trolle y height from the patient \200\231s feet. The mechanism of injury should alert one to the p ossible presence of a flail chest: the whole of the anterior chest wall may be flail if, du ring an RTC, the chest has struck the steering wheel. Posterior flail chests are com- monly supported by the muscle mass of the back and may only become apparent when the patient bec omes exhausted. Signs and symptoms - Pain - Respiratory distress. The definitive diagnosis is made by the d etection of paradoxical movements. Air entry may be decreased. The percussion note may vary depending on associated intrathoracic injuries \200\224it will be hyper-resonant in the pr esence of a pneumothorax and dull due to haemothorax. Treatment The patient should receive high-flow oxygen at a rate of 15L per minute via a mas k with a non-rebreath reservoir bag. Manual stabilization and splintage may be achieved by applying the flat of the hand to the flail segment and maintaining the indrawn position. Th is may also be achieved with a half liter or liter bag of saline or postural positioning ov er some- thing firm to compress the flail segment. Adequate analgesia is essential. Potential problems These are related to associated intrathoracic injuries, in particular, p ulmonary contusion. Other complications include pneumothorax, haemothorax, and, in the long er term, chest infections. Major flail chest may be associated with mechanical failure of r espiration and the necessity for artificial ventilation in hospital. CHAPTER 3 Trauma 248 Sternal fractures Cause The most common mechanism of injury is a direct blow to the sternum where the injury pattern may range from unicortical cracks (often seen in seatbelt injurie s) to complete fractures, sometimes with overlap of the bone ends. Sternal fractures can also occur in conjunction with thoracic wedge compression fractures d ue to forced flexion of the thoracic spine (for example, in falls from a motorbike). Signs and symptoms - Pain and tenderness at the fracture site - The patient may hold their chest. Other signs and symptoms may relate to associated intrathoracic injuries. Treatment Treatment includes analgesia, oxygen therapy, and manual support for the chest. V ery rarely, in prolonged transportation times, local anesthetic can be injected into the fr acture site. Potential problems These relate to the underlying injuries and include cardiac contusion, c ardiac arrhythmias, thoracic aorta tears, and pulmonary contusion. This page intentionally left blank CHAPTER 3 Trauma 250 Regional injuries: the pelvis Fractures of the pelvis are produced by three main mechanisms : 1. Antero-posterior compression 2. Lateral compression 3. Vertical compression. These fra ctures can be classified by appreciating that the pelvis is a com- plete ring where instabi lity occurs if there are two or more major areas of injury. Type A: stable fractures Include fractures not involving the complete pelvic ring (for exam ple, the iliac crest, the anterior inferior iliac spine) or minimally displaced pelvic ring fractures that are stable (for example, fractures of the superior pubic rami). Type B: rotationally unstable, vertically stable fractures For example, open-book fractures . Type C: rotationally and vertically unstable fractures Involve major damage to two or more areas in the pelvic ring. These may be seen following falls from a height. Minor pelvic fractures: pubic ramus Cause Fractures of the pubic rami are common, especiall y in elderly osteoporotic women following a fall onto the affected side. Anteroposterior (A P) compression may produce isolated ipsilateral superior and inferior pubic rami fractures and, following significant falls (for example, if rolled on following a fall from a horse), may affect both superior and inferior pubic rami ( \200\230butterfly fracture \200\231). Signs and symptoms The patient will complain of pain in the groin and will be tender to pal pation over the fracture. Hip movements may be painful because of the close proximity of th e fracture. The patient can usually manage a straight leg raise. Anterior and lateral pelvi c compression is painful. Treatment The mainstay of pre-hospital treatment is providing pain relief, appropriate pack aging, and transportation to hospital. The legs should be splinted together using a pad and broad bandages and the patient should be transported in a supine position. Potential problems Simple falls onto the side producing pubic rami fractures are usually un complicated and are classified as minimally displaced or undisplaced fractures of the pelvi c ring. The anteroposterior crush injuries, depending on the mechanism of injury, may be as sociated with significant blood loss, damage to the urethra, and, in some cases, sacroiliac injuries. (a) (b) (c) (d) R E G O N A L I I N U R J Fig. 3.16 Mechanisms of pelvic fractures: (a) stable fracture of a single pubic ramus; (b) \200\230butterfly fracture \200\231 (AP compression); (c) vertical shear fracture; (d) \200\230open book \200\231 pelvis. (a \200\223c) reprinted with permission from McRae Pract ical fracture treatment Churchill Livingstone. I E S : T H E P E L V I S 1 2 5 1 CHAPTER 3 Trauma 252 Minor pelvic fractures: avulsion fractures Cause These are fractures of the pelvis not invo lving the pelvic ring and are frequently seen in sports injuries, most commonly athletics, resulting from sudden muscle contraction. Common sites include the anterior superior iliac spine (sartorius muscle), the anterior inferior iliac spine (the rectus muscle), and the is chial tuberosity (the hamstrings). Signs and symptoms - Pain - Local tenderness - Variable loss of function. Treatment No specific treatment is necessary. Analgesia may be required. The patient should be transported to hospital. Potential problems In the pre-hospital phase of care, there are no specific potential probl ems. REGIONAL INJURIES: THE PELVIS1 253 Regional injuries: the pelvis Major pelvic fractures Cause Major compression fractures and the rotationally and vertically unstable injuries are most commonly the result of road traffic collisions. These fractures nearly always involve disruption of the pelvic ring although, rarely, isolated fractures of the iliac crest may occur. Signs and symptoms The patient will (depending on injuries elsewhere) complain of pain, ten derness, and sometimes deformity. There may be clear signs and symptoms of shock (pallor, s weating, tachycardia, tachypnoea, hypotension, and increased capillary refill time). The ci rculatory assessment should include a single careful examination of the pelvis (gentle cont rolled anteroposterior, lateral, and vertical movement of the pelvis with the hands over th e iliac crest) which may demonstrate instability and pain. This examination should NOT be r epeated as this may precipitate bleeding. Depending on the pattern of injury, there may be associated urethral trauma presenting with blood per urethram and associated perineal or sc rotal swelling which may or may not be recognized in the pre-hospital situation. Treatment The patient should be assessed following the ABCDE system. Measures to reduce blo od loss include splinting the patient \200\231s legs together with the legs internally rota ted, elevation of the legs, tilting the patient head down on a spinal board, the use of a c ommercial external pelvic splint (which has been shown convincingly to reduce the pelvic vo lume), or wrapping in sheet (or similar) around the pelvis and applying circumferential pre ssure. Intravenous access should be obtained and fluid infused to restore or just maintain the rad ial pulse (non-compressible, non-controllable hemorrhage). Appropriate titrated opiate anal gesia should be given. Potential complications The main pre-hospital complication is hypovolaemia. Patients with p elvic fractures often, as their mechanism of injury may suggest, have injuries elsewhere. In the presence of a significant pelvic injury, a scoop stretcher should be used for the transfer to a spine board rather than a log roll. CHAPTER 3 Trauma 254 Regional injuries: lower limb Acetabular fractures/hip dislocations Cause Most fractures of the acetabulum occur as a result of force transmitted along the longitudinal axis of the f emur (for example, due to impact from the dashboard in front seat car occupants) or followi ng lateral compression injuries to the greater trochanter region (as in side impact road tr affic accidents or a fall onto the side). In some instances, not only is the acetabulum fra ctured but the head of the femur is driven through the acetabulum producing a central fract ure dislocation of the hip. Most dislocations are posterior (the head of the femur is displ aced posteriorly), unless the injury is associated with excessive hip extension when the he ad of the femur dislocates anteriorly. Signs and symptoms The patient is in pain. In posterior dislocation, the hip is held flexed , internally rotated, and adducted. Attempts to straighten the leg are unsuccessful: the he ad is held behind the posterior aspect of the acetabulum, where in many cases there is an a ssociated fracture of the posterior wall. Treatment The patient should be given high-flow oxygen and opiates titrated to achieve pain relief. The limb should be supported and splinted by opposing the good leg, insertion of p adding between the legs, and the use of circumferential broad bandages or Frac straps . Be cause the limbs are splinted in a flexed position, a blanket should be placed under the pat ient \200\231s knees. Potential problems Posterior dislocation of the hip is associated with sciatic nerve palsy in 10% of cases. Urgent reduction in hospital is necessary. Anterior dislocations are associated with a risk of damage to the femoral nerve and the femoral vein and artery. Acetabular fractures are often seen in association with more serious injury. An ABCDE appro ach and a secondary survey (when clinically appropriate) should be undertaken. REGIONAL INJURIES: LOWER LIMB1 255 Fractures of the neck of the femur The term \200\230fractured neck of the femur \200\231 i ncludes intracapsular (subcapital and transcervical) and extracapsular fractures (pertrocha nteric and inter- trochanteric fractures). Cause Fractures of the neck of the femur most co mmonly occur in the elderly osteoporotic female population, usually following falls onto th e affected side. Occasionally, the lucid and astute patient may report their leg giving way followed by a fall, suggesting a fracture due to underlying bony weakness. Fractures in the younger age group, including children, usually follow significant violence as in road traffic collisions, falls from significant heights, or industrial accidents. A slipped upper femoral epiphysis in children may occur after minor or insignificant trauma and present clinically like a fractured neck of femur. Signs and sympt oms The patient will be in pain, often lying in the position that they were in immediately after the fall. Depending on the fracture pattern, which will not be known until X-rays are taken, there may be anterior hip tender- ness (intracapsular fractures) or tenderness over the greater trochanter (extracapsular intertrochanteric fractures). Bruising, if seen, sug gests a time delay and is usually only present in extracapsular fractures. Except in the mo st minor of hip fractures (undisplaced intracapsular incomplete neck fractures), the patien t is unable to do a straight leg raise. In dis- placed fractures, the leg is classically sh ortened and externally rotated. Treatment Initially, assessment should follow the ABCDE sys tem. The patient should receive analgesia and the leg should be repositioned and secured to the good leg using padding and broad bandages. The neurovascular status should be determin ed before and after any manipulation. Potential problems It is important to ascertain wheth er there was any medical reason for the fall, for example, a transient ischemic episode, ep ileptic fit, or collapse due to a cardiac cause. The patient \200\231s prescribed drugs sho uld be taken to hospital. Some patients may have been lying on the floor all night and have become hypoglycaemic and dehydrated. A blood glucose assessment is necessary. If there is a prolonged journey time t o hospital, fluid replace- ment should be considered for correction of dehydration. Similar ly, the elderly patient is at risk of developing pressure sores. Particular care should be taken to handle them carefully, especially when the patient has been lying still for any le ngth of time, avoiding hard surfaces such as scoop stretchers or spinal boards if possible. Otherwise, the time on one of these must be kept to a minimum. A vacuum mattress, if avail able, should be considered in this group of vulnerable patients. Any patient with hip pain should be transported to hospital to exclude femoral neck fractur e \200\224in those patients with no leg deformity, there may be fractures of the adjacent p ubic rami. The proximal femur is not an uncommon site of pathological femoral neck or intertrochanteric fractures due to malignancy. CHAPTER 3 Trauma 256 Fractures of the shaft of the femur Cause Fractures of the shaft of the femur are common fo llowing road traffic collisions, falls from significant heights, and crush injury (for exam ple, under falling masonry). A fracture that occurs spontaneously or after minimal trauma suggests that it is a patholog ical fracture, for example, secondary to carcinoma or myeloma. Signs and symptoms - Extreme pain - Deformity and swelling of the thigh - External rotation of the leg Palpation may reveal crepitus and mobility at the fracture site. Many high- vel ocity injuries are compound, some associated with extensive soft tissue injuries and blood loss. Treatment The initial assessment and treatment should follow the ABCDE system. High-flow ox ygen should be administered. Obvious external bleeding should be controlled, usually by dir ect pressure using a dressing and bandage. Very rarely, control may only be achieved using the windlass technique or a tourniquet. Vascular access should be obtained and intravenous fluid should be given if there is signif icant external blood loss or a delay in transporta- tion. Intravenous morphine titrated to the patient \200\231s clinical need should be given with an antiemetic. Femoral nerve block (see pp.393 \200\2234) can be considered in entrapments or prolonged transfer times. In patients with grossly contaminated wounds, obvious contaminating material should be wipe d or washed away and a sterile moist dressing applied. Externalized bone should be relocate d by traction if possible. The fracture should be realigned and approximated to the intact femur. This is achieved by a combination of longitudinal traction and rotation and should b e performed in a controlled way with an assistant or bystander gripping the proximal femur. The neurovascular status of the limb should be assessed and recorded before and after any manipulation. Should the peripheral pulse be lost as a result of a manipulation, the leg sh ould be re-positioned such that the pulse is restored. An appropriately applied traction sp lint will stabilize and immobilize the femur for transportation. Potential problems With an increasing number of patients undergoing hip replacements, peri- prosthetic fractures are common. These often present with a history of fairly minor trauma. However, the physical signs are similar to uncom- plicated femoral shaft fractures. Should the distal pulses be absent both before and after realigning the femur, this should be regarded as a time-critical emergency. Rapid transfer to hospital is necessary. REGIONAL INJURIES: LOWER LIMB1 257 Fig. 3.17 Using the windlass technique to control bleeding. Reprinted with permission from Greaves I et al. (2005). Emergency care: a textbook for paramedics, 2nd edn. W.B. Saunders Co. Ltd. CHAPTER 3 Trauma 258 Supracondylar fractures of the femur Cause Supracondylar fractures are commonly seen in the osteoporotic elderly female population, usually following a fall. The presence of a total knee replacement produces a stress interface at the proximal end, making this area particul arly vulnerable to fracture. Signs and symptoms - Pain - Swelling - Tenderness and deformity just above the knee, associ ated with loss of function. Treatment Treatment should follow the same principles as for fractures of the shaft of the femur. However, the pull of the gastrocnemius muscle tends to pull the distal fragment post eriorly. Attempting to straighten the leg worsens this problem and may compromise the circu lation. This fracture, which is relatively easy to recognize, should be treated by support under the knee, padding between the legs, and broad bandages to maintain the position. The distal vascular status should be assessed before and after the application of splintage. Fe moral nerve block is ineffective in supra- condylar fracture and traction splintage is cont raindicated as it allows the distal femoral fragment to angulate posteriorly. Potential problems Regular circulatory assessment is necessary as this fracture is commonly associated with vascular trauma. REGIONAL INJURIES: LOWER LIMB1 259 Patella fractures Cause Patellar fracture most commonly follows a direct injury, for exampl e, on the dashboard of a car or a fall onto a hard surface. An occasional cause is crush, f or example, falling masonry. Uncommonly, patellar fracture may follow a resisted extension force, for example, when catc hing a shoe on the sidewalk whilst extending the leg, or a blocked, tackle playing football . Signs and symptoms - The patient is often unable to walk or stand unaided. - The knee is sw ollen and after some time may become bruised. Associated wounds make the injury compound, f or example, dashboard injuries may be associated with transverse skin wounds, whereas falls to the ground are associated with abrasions, local contusions, and ragged lacerations. Treatment Wounds should be covered with a sterile dressing, the leg should be straightened, and position maintained in a long leg box splint. Potential problems In significant front end road traffic accidents producing femoral shaft fractures, there is often an associated knee injury, the differential diagnosis of which in cludes patella fracture. A patient suffering a simple undisplaced patella fracture with intact medial and lateral pa tella retinaculae may be able to perform a straight leg raise. However, there is usually an associated extensor lag. Resisted extension forces may also produce rupture of the quadriceps tendon at its insertio n, rupture of the patella tendon, or avulsion of the tibial tubercle. In the presence of sw elling, it may be difficult to differentiate these from a patella fracture. CHAPTER 3 Trauma 260