Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 8 n Musculoskeletal Trauma
Bilateral Femur Fractures
Patients who have sustained bilateral femur fractures
are at significantly greater risk of complications
and death. Such fractures indicate the patient has
been subjected to significant force and should alert
clinicians to the possibility of associated injuries.
Compared with patients with unilateral femur
fractures, patients with bilateral femur fractures
are at higher risk for significant blood loss, severe
associated injuries, pulmonary complications, multiple
organ failure, and death. These patients should be
assessed and managed in the same way as those with
unilateral femur fractures. Consider early transfer to a
trauma center.
Pitfall
Delayed transfer to a
trauma center
Crush Syndrome
prevention
• Transfer patients with
vascular injury and
concomitant fracture
to a trauma center with
vascular and orthopedic
surgical capabilities.
• Bilateral femur fractures
result in a significantly
increased risk of complications
and death; these
patients benefit from early
transfer to a trauma center.
Management
Initiating early and aggressive intravenous fluid
therapy during resuscitation is critical to protecting
the kidneys and preventing renal failure in patients
with rhabdomyolysis. Myoglobin-induced renal
failure can be prevented with intravascular fluid
expansion, alkalinization of the urine by intravenous
administration of bicarbonate, and osmotic diuresis.
Adjuncts to the PrimARy
Survey
Adjuncts to the primary survey of patients with
musculoskeletal trauma include fracture immobilization
and x-ray examination, when fracture is
suspected as a cause of shock.
Fracture Immobilization
The goal of initial fracture immobilization is to
realign the injured extremity in as close to anatomic
position as possible and prevent excessive motion at
the fracture site. This is accomplished by applying
inline traction to realign the extremity and maintaining
traction with an immobilization device (n FIGURE 8-3).
Proper application of a splint helps control blood
loss, reduces pain, and prevents further neurovascular
compromise and soft-tissue injury. If an open
fracture is present, pull the exposed bone back into
the wound, because open fractures require surgical
Crush syndrome, or traumatic rhabdomyolysis, refers
to the clinical effects of injured muscle that, if left
untreated, can lead to acute renal failure and shock.
This condition is seen in individuals who have sustained
a compression injury to significant muscle mass,
most often to a thigh or calf. The muscular insult is a
combination of direct muscle injury, muscle ischemia,
and cell death with release of myoglobin.
Assessment
Myoglobin produces dark amber urine that tests
positive for hemoglobin. A myoglobin assay may be
requested to confirm its presence. Amber-colored urine
in the presence of serum creatine kinase of 10,000 U/L
or more is indicative of rhabdomyolysis when urine
myoglobin levels are not available. Rhabdomyolysis can
lead to metabolic acidosis, hyperkalemia, hypocalcemia,
and disseminated intravascular coagulation.
A
n FIGURE 8-3 The goal of initial fracture immobilization is to realign
the injured extremity in as close to anatomic position as possible
and prevent excessive fracture-site motion. A. Shortening and
external rotation of right leg due to a mid-shaft femur fracture B.
Application of in-line traction with stabilization of the leg in normal
anatomic position.
B
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