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Musculoskeletal Trauma 209

The fractures most commonly associated with vascular injuries are For seriously injured children, it is important to remember that no
supracondylar fracture of the humerus (brachial artery injury), posterior matter how severe the injured extremity, the patient’s life has priority
knee dislocation (popliteal artery injury), and distal femur fracture over the limb. In the initial hours after a child suffers a mangled
(distal femoral artery injury). extremity, the two most likely causes of death are hypovolaemia (from
In most cases, fracture reduction is all that is required to relieve haemorrhage) and hypothermia. The standard Advanced Trauma Life
®
compression of the artery and restore circulation. If many hours have Support (ATLS ) resuscitation protocol of the American College of
elapsed between injury and fracture reduction, however, fasciotomy Surgeons is designed to address these issues. Patients with complex open
may be required to restore adequate blood flow to the extremity. If fractures or fractures requiring internal or external fixation will likely
the combination of fracture reduction and fasciotomy does not restore require transfer to an orthopaedic unit. Proper attention to these injuries
perfusion to the extremity (as evidenced by return of pulse, capillary will improve their outcome.
refill, and sensation), it is likely that an arterial thrombosis is present. Wound Care, Damage Control, and Life-Saving
The choice at this point becomes vascular reconstruction or amputation Operations
if gangrene begins to set in and threatens life. Reconstruction can Care of the soft tissue trauma in association with fractures takes pre-
require an arteriogram, exploration of the arterial injury, a vein patch, cedence over the definitive treatment of the fracture. The bone needs
or even a reverse autologous vein graft, which is not likely to be an envelope of healthy soft tissue for optimal healing. Therefore
available in rural areas except in major teaching hospitals. wound cleaning and debridement are essential. Damaged muscle is an
Even in the absence of the suspicion of a fracture, it is important excellent growth media for bacteria. Copious irrigation with normal
to examine all soft tissue wounds for evidence of penetration into saline solution and manual debridement is probably as important as
the muscle, dirt contamination, and the presence of other foreign antibiotic coverage in preventing infection. This procedure may need
bodies. Deep contaminated wounds are setups for serious infections. to be repeated more than once to achieve a clean, healing wound. In
It is difficult to get children to cooperate with infiltration with local the absence of intravenous antibiotics, deep wounds involving muscle
anaesthetics for exploration of wounds; therefore, the use of general should probably be left open with twice daily dressing changes. These
anaesthetics is advocated for full exploration of deep wounds in wounds will gradually heal by secondary intention.
most cases. Damage control orthopaedics can be defined as an operation
Investigations that corrects that underlying pathophysiology (hypothermia, wound
Plain film radiography remains the standard diagnostic modality for contamination, vascular obstruction) without necessarily correcting the
most fractures. At least two images that are at right angles to each other pathology (such as a long bone fracture). The damage control philosophy
should be obtained. In addition, plain films should also include the joint emphasizes (1) prevention of hypothermia; (2) removal of all foreign
above and below (proximal and distal to) the fracture site. Not all frac- material and bacterial contamination from the wound; (3) reduction of
tures are immediately apparent on initial radiographs. Images should be fractures and traction, if necessary, to reduce vascular compromise; (4)
repeated 1 to 2 weeks after injury if pain persists. sterile dressings; and (5) a planned return trip to the operating room to
Plain film imaging, using lower energy “soft tissue” settings, can be complete the definitive repair. Damage control orthopaedics can also be
useful for identifying imbedded foreign bodies or undisplaced subtle considered a “life over limb” approach, meaning that saving the child’s
fractures (such as the fat pad sign seen in intraarticular fractures of the life is given priority over definitive repair of the extremity injury. In
elbow). The presence of gas bubbles in the soft tissues on plain film a worst-case scenario, amputation of a potential viable extremity may
imaging is an ominous sign of a potentially life-threatening anaerobic be contemplated. The consideration for amputation should be based on
soft tissue infection. Plain film radiography is also useful for detecting weighing the condition of the patient, the condition of the extremity,
dislocations in children. and the resources available to treat the patient.
Management Treatment of Musculoskeletal Trauma
Management of musculoskeletal trauma can be divided into three
Stabilising the Patient at Presentation phases:
A head-to-toe general examination of the fully undressed child should
be carried out on presentation. First, the patient is assessed for associ- 1. reduction of fracture;
ated injuries, particularly in injuries from high-energy mechanisms 2. immobilisation; and
such as motor vehicle crashes. Thereafter, when other life-threatening 3. rehabilitation.
injuries have been excluded, an examination of the injured limb is done. Reduction of fractures
After the examination of the injured extremity is complete, including a
thorough neurovascular examination, a splint is applied. Splinting the The goals of fracture management are (1) satisfactory bone healing
injured extremity reduces pain and discomfort, minimises further soft (return to full weight bearing), (2) full mobility of the limb, and (3) no
tissue trauma, preserves neurovascular function, prevents swelling of limb-length discrepancy. To accomplish these goals, the fracture must
the soft tissue, and makes future repairs easier. first be reduced.
If bone is protruding through an open wound in the skin (an Nonoperative treatment
open fracture), thorough pulsatile irrigation with isotonic saline The closed method (or nonoperative treatment) of fracture reduction
and coverage with sterile dressing soaked with the saline should be can be done under general or local anaesthesia. Local anaesthesia can
done. No attempt should be made to return the bone to the depths of be applied to the fracture haematoma for safe and effective fracture
the wound until debridement and cleansing have been achieved in reduction. This is particularly useful in situations where general anaes-
an orthopaedic unit. Splints can be made out of virtually any rigid thesia is not readily available. The use of longer-acting local anaes-
material; even folded magazines bound with loose mesh gauze can be thetics will provide pain relief for several hours after the reduction.
used to splint a forearm fracture. Sling and swath is used for fractures An injection of 0.5% bupivacaine with epinephrine (1:200,000) can
of the humerus or the shoulder girdle. Femur fractures typically can be administered locally at a dose of 0.5 ml/kg body weight. For
be bound to the other thigh with a splint or traction may be used. patients weighing less than 10 kg, 0.25% bupivacaine with epinephrine
All open fractures must be covered with parenteral third-generation (1:200,000) can be used at 1 ml/kg body weight. Care must be taken to
cephalosporins and tetanus prophylaxis, and the patient should receive avoid intravascular injection, and the injection should be performed at
pain medication. least 30–40 minutes before the procedure to allow maximal effect. In