Pelvic fracture with bleeding:
Pelvic
fractures may cause significant bleeding. Hemorrhage is the most life
threatening complication with pelvic fractures. When bleeding is severe, the
superior gluteal artery is responsible for the majority of bleeding, however
the bleeding is usually venous from the fracture. Patients older than 55 years
of age are more likely to have bleeding from a pelvic fracture that requires
transfusion and may need angiography.
Mortality
rate is directly related to shock at the time of presentation. Fracture patterns
that are highly unstable to both rotational and vertical stress, usually
anteroposterior compression and vertical shear injuries are consistently
associated with a higher risk of mortality from bleeding.
Abdominal
and pelvic CT scan will clearly define the bony injury and extent of bleeding.
Emergency pelvic stabilization with external fixator is thought to tamponade
bleeding by decreasing pelvic volume. Pelvic binder can be used in the ER in
case of open book injury. Angiography and embolization may be useful to control
arterial bleeding especially if the patient is given four units of blood and is
still in shock. Massive blood transfusion is required for unstable patient.
Femoral neck
fracture in young adults:
Most
often results from high energy trauma. The fracture is a high angle shear type
fracture and the blood supply to the femoral head could be at risk. There is
high incidence of avascular necrosis and non-union. Fixation must be achieved within 12 hours of injury
or as soon as possible. Anatomic reduction must be obtained through closed
manipulation or open reduction if necessary. Fracture is usually fixed with
multiple cancellous screws.
Fractures
with vascular injury:
Arterial
injury can be associated with fractures in areas where the arteries are held
close to the bony structures or in a fixed position by muscles and ligaments.
The femoral artery is vulnerable to injury along the entire femoral shaft
because of its proximity to the femur.
Fractures
involving the femoral condyles or tibial plateau, particularly if there is
posterior displacement of the fragments carry a high risk of vascular injury
because of the relatively fixed position of the popliteal artery. If vascular
injury is not corrected it can lead to gangrene and amputation. The presence of shock with vascular injury
may result in early soft tissue necrosis due to hypotension and ischemia.
Skeletal stabilization with simultaneous vascular exploration or repair offers
the best chances of limb survival.
Compartment syndrome:
It is increased pressure in a closed space that decreases the tissue
perfusion resulting in tissue ischemia and necrosis. The leg is the most common
side affected followed by the forearm.
There are four compartments within the leg: anterior compartment conations
deep peroneal nerve and if involved results in numbness in the first web space
of the foot. It is the most commonly affected compartment. Lateral compartment contains the superficial peroneal nerve and
if involved results in numbness on the dorsum of the foot. The deep posterior
compartment is the one that is commonly missed and may lead to claw toe and
cavus foot deformity. The deep posterior
compartment is supplied by the tibial nerve and if involved it results in
numbness on the sole of the foot. The superficial posterior compartment is
supplied by the sural nerve, which if involved, results in numbness of the
lateral border of the foot.
Pain on
passive stretch is the most important diagnostic sign for compartment syndrome,
while pallor, pulselessness, paralysis and paresthesia are late findings. Late
diagnosis of compartment syndrome will result in weakness and Volkmann’s
ischemic contracture.
Hip
dislocation:
There are
two types:
A-posterior:
more common. The lower limb will be flexed, adducted and internally rotated.
B- Anterior:
less common. The lower limb will be flexed, abducted and externally rotated.
Posterior
hip dislocation with injury to ascending cervical arteries results in avascular
necrosis. Urgent reduction of the hip within 6 hours of dislocation decreases
the risk of avascular necrosis. Always check sciatic nerve function, both
before and after reduction and look for foot drop or weakness of foot
dorsiflexion. Dislocation can also be associated with fractures of the femoral
head acetabulum. Fracture dislocation is treated with closed reduction of the
hip joint dislocation followed by stabilization of the femoral head or
acetabular fracture if needed. Open reduction is required for irreducible
dislocations and incongruent reductions.
