Orthopaedic Trauma: Extremity Fractures

GOALS

The purpose of this CPG is to describe the initial non-surgical and surgical management of extremity fractures; to demonstrate appropriate application of an external fixator with limited resources in order to stabilize for transport; and to define care guidelines for fractures of upper and lower extremities in the context of the host nation’s environment and the options available to different patient groups.

BACKGROUND

The majority of combat casualties sustain musculoskeletal injuries1,2 and the treatment of fractures and associated soft tissue wounds comprise the majority of Role 2 and 3 orthopaedic procedures.3 The prevalence of musculoskeletal injury requires that surgeons caring for victims of war must manage extremity fractures in the austere environment. Prior to the development of long bone stabilization, mortality from isolated femur fractures was 87% in WWI and reduced to <8% with appropriate splinting. During the recent conflicts, especially as surgical teams have gotten smaller and more dispersed, long bone extremity fracture stabilization will occasionally take second precedent to other injuries. The cumulative burden of femur fractures can make polytrauma patients sicker; so while resources such as imaging may be limited, early femur stabilization is critical for the overall outcomes. Appropriate wound management and fracture stabilization are the mainstays of treatment and are a critical aspect of the multidisciplinary treatment of combat casualties. While a patient’s overall physiology and associated wounds must be considered, the effective stabilization of long bone fractures and appropriate debridement of soft tissue injury contribute to effective resuscitation.