Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XIX: Wounds and Injuries of Bones and Joints

Fractures

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

In the early stages of treatment, certain principles of war wound management should be adhered to:

1. The neurovascular status of all injured extremities must be accurately established and recorded.
2. All open fractures require open debridement and irrigation.
3. The fractures should be reduced and aligned as accurately as possible and initially splinted in some fashion. As previously stated, the neurovascular status of the extremity must be established and care must be taken not to compromise the vascular status of the extremity. If fracture reduction results in circulatory insufficiency, the fracture must be repositioned and/or the cause of circulatory insufficiency delineated. Biplanar radiographs are desirable to optimally treat any fracture. It should be kept in mind that the primary objective in management of extremity wounds is to optimize the situation such that early wound healing can be obtained, infection prevented, and function restored.
4. Internal fixation of fractures resulting from war wounds is generally contraindicated in the initial stage of wound management. While there are some exceptions, this should be considered a generally universal principle. Fractures in extremities where vascular repairs have been performed are no exception; past combat experience has demonstrated that traction or other forms of external immobilization can be utilized with vascular repairs. The addition of internal fixation material to a wound containing a vascular repair results in an unacceptably high risk of infection and breakdown of the vascular repair.
5. Fractures can be stabilized by the use of splints, circular dressings, pins incorporated in plaster casts (Figure 25A), or external fixators (Figure 25B). An external fixator should only be applied only by a surgeon familiar with its indications, application, and potential complications. The fixator can be extremely useful in the management of large open wounds in which there has been considerable bone or soft tissue loss or where vascular repair is to be performed. The advantages in these types of situations are rapid application, ability to maintain length and position, the ease of access to the wound for dressing changes and repeat wound debridement, and control of pain because of the stability provided. The rigid fixation attained frees adjacent joints that would be immobilized in plaster casts and eliminates the additional weight of the cast, allowing crutch ambulation or transportation in a sitting position in many patients who would otherwise be litterbound. Additional uses are the control of hemorrhage in displaced pelvic fractures, and the care and mobilization of patients with humeral, pelvic or femoral fractures with associated chest or abdominal wounds. Sufficient rigidity can be obtained in most longbone fractures with the use of a single frame configuration, consisting of one longitudinal bar attached by two or three pins distal and proximal to the fracture, to, allow early care and transportation. The use of half-pins, which pass through the soft tissues on one side to engage the bone but do not penetrate the soft tissues on the opposite side, minimize the risk to adjacent nerves, vessels, and muscles. Predrilling the bone with a drill bit and daily local pin care minimize the complications of pin loosening and pin tract infection.
   
   Figure 25.
6. A circular plaster dressing (cast) is applied for immobilization of the joints above and below a fracture Once applied it must be immediately bivalved to, the skin. A monovalved cast has no place in the early treatment of a combat casualty. Bivalving the cast for transportation and evacuation is mandatory. Plaster casts should be marked with identifying information pertinent to the underlying injury and the date of cast application for use during transit and by receiving personnel. In general, plaster splinting is inadequate for anything other than temporary field immobilization. If a spica cast is constructed, one should avoid making the cast much wider than a standard litter; this will facilitate movement during medical evacuation.
7. When skeletal traction is employed, Steinmann pins are preferable to Kirschner wires. They can be easily incorporated into the plaster cast for evacuation and are less likely to bend. In general, the larger diameter pins should be utilized to prevent loosening and pin traction infection. Incorporation of traction bows into the cast is unnecessary.
8. Fractures of the humerus or injuries to the shoulder girdle, with or without brachial artery repairs, are best transported in a Velpeau dressing with the extremity strapped across the chest; a "sling and swath" can be substituted if necessary (Figure 26).
   
   Figure 26.
9. Elevation of an injured extremity facilitates venous return and minimizes swelling. Ice, when available, can also be applied in the early injury phase to help control swelling and make the patient more comfortable. The neurovascular status of the extremity should be carefully monitored after treatment, and in injuries of both the forearm and the leg the surgeon must be constantly alert to insure early recognition of compartment syndrome
10. When plaster casts or splints are utilized, particularly in the patient with impaired sensation, vigilance must be maintained to prevent skin breakdown from excessive cast pressure Complaints of pain under the cast must not and cannot be ignored. Patients in spica casts should be turned at intervals to prevent pressure sores over the sacrum and other bony prominences. Cast pressure I can be minimized by the use of properly padded and applied plaster.
11. The possibility of fat embolization should be considered in all patients with long-bone fractures. This is particularly true in patients developing signs of cerebral or pulmonary dysfunction. Adequate oxygenation is fundamental in the treatment of fat embolism syndrome and frequently requires the use of mechanical ventilation and positive-end-expiratory pressures. At the present time there is no hard evidence that validates the efficacy of intravenous alcohol, heparin, or steroids in the treatment of this primarily respiratory syndrome Treatment consists of supporting the patient's respiratory function.
12. Preferred regional splinting is as follows:
    1. The shoulder joint and humerus, depending on the injury, can be splinted or immobilized in several manners. As previously noted, a sling and swath or Velpeau-type of dressing is satisfactory for many injuries, A well-padded, plaster. shoulder spica for more significant injuries provides better support during transportation. The shoulder spica cast is extended to include the forearm but not the wrist. An external fixator applied on the lateral aspect of the humerus with half-pins is a useful alternative to the shoulder spica or in those with associated chest wounds.
    2. The elbow joint and forearm is normally immobilized with a plaster cast, with the elbow at approximately 90° of flexion and the wrist and forearm in a neutral position. The plaster extends from the proximal palmar crease to the axilla. A sling or a collar and cuff should be used to support the cast and will increase patient's mobility and comfort.
    3. If the injury is limited to the wrist itself, the plaster extends from just below the elbow to the proximal palmar crease (short arm, cast). The wrist should be hold in a position of approximately 30° of dorsiflexion. If the thumb is incorporated, it should be positioned such that the digits can oppose the distal thumb. The hand should be immobilized with the metacarpal-phalangeal joints flexed and the interphalangeal joints extended when possible An unaffected digit should not be incorporated into the splint or dressing. An external fixator or pins incorporated in a short arm plaster cast are especially useful to prevent shortening in severely comminuted fractures and those with bone loss.
    4. To immobilize the hip joint or a femoral fracture, a bilateral plaster spica extending from the axilla to the toes on the affected side can be used. The knee should not be immobilized in hyperextension nor should it be immobilized beyond 10-15° of flexion. The spica extends to just proximal of the knee on the unaffected side. When the spica includes the foot, care must be taken that the normal arch of the foot is maintained and that the foot is not held either in inversion or eversion. When a cast includes the toes, plaster must be trimmed away on the dorsum of the foot to a point just proximal to the base of the toes, thereby permitting the toes to move freely and protecting them from further injury. This precaution permits periodic evaluation of the distal neurovascular status. An external fixator applied on the lateral aspect of the femur with half-pins is especially useful in open femoral fractures. In fractures of the pelvis or hip associated with abdominal or perineal injuries, a pelvic frame alone, or one attached to a femoral frame, greatly aids nursing and wound care
    5. To immobilize the lower leg and ankle extend the cast from the groin to the toes. The knee is immobilized with slight flexion avoiding hyperextension or full extension. The foot is placed in neutral dorsiflexion (at a right angle to the leg). The same care is taken with respect to the foot as was described in the paragraph above. A single frame applied to the anterior tibia with half-pins allows mobilization of the ankle and knee with crutch ambulation, while maintaining length and easy wound access.
    6. A plaster cast for the foot and ankle is applied from just below the knee to include the toes as previously described (with the foot in neutral). Care must be taken that excessive pressure is not placed on the peroneal nerve which courses just below the lateral aspect of the fibular head.
13. joints not immobilized should be actively exercised on a frequent basis.

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