Page 159 - ASOP ROT Study Guide

of the femoral neck where splintage is almost impossible to apply.

6.2 Blood Loss

For most upper limb and peripheral lower limb fractures, blood loss is in itself not too serious and is
tolerated even by an elderly person. In major long bone fractures, particularly of the femur and to
a lesser extent the tibia, blood loss is significant. In general, an injured person with a femoral fracture
will lose between two and three units of blood (one unit is about450ml or one pint) into the soft
tissues. A tibial fracture may result in the loss of one unit which is in itself tolerable, but combined with
other injuries may become significant.

Major pelvic fractures, particularly if unstable, are associated with major venous bleeding from the
pelvic plexuses. The blood loss can be considerable, amounting to six units or so. If it is
combined with other skeletal injury, this level of loss is potentially lethal unless the fluid is
replaced, preferably with blood, as soon as possible.

In general, all patients with major long bone injuries should be cross-matched for blood and a good
sized venous line for blood transfusion should be established as soon as possible. For pelvic
fractures two lines may be needed and a central venous line should be established to ensure that
transfusion is keeping up with loss.

6.3 Open Fractures

Open (also called compound) fractures are serious injuries in which the skin is broken. They tend
to occur in more violent injuries and result in the bone being contaminated by bacteria from the
environment. All wounds are contaminated, and the treatment strategy is to clean them out and
remove all dead tissue as soon as possible, to prevent a contamination becoming an infection.

An open fracture is a surgical emergency, and provided that the patient's general condition permits,
should be taken to the operating theatre as soon as possible. There the wound can be extended
surgically and all debris and suspected dead tissue removed. Even in small wounds, bits of clothing
which (inevitably have bacteria on them), dirt and fragments of wood or metal can be found.
These will only be discovered if a wide incision is made and exploration down to the bone is
performed.

Wounds are better left open if there is any doubt that closure can be achieved without any tension
on the skin. This means that the vast majority of wounds should be left open and closed either as a
secondary procedure after a few days or left to heal spontaneously. Such patients all need
supplementary broad spectrum antibiotics and some form of tetanus protection, but all these are
secondary to cleaning out the dirt debris and dead tissue.

7. DEFINITIVE MANAGEMENT OPTIONS

7.1 Definitive Management

The essential strategy of long term fracture management must be to return the injured person to
their pre-injury level of function by the safest means possible. The factors which will determine the
tactics used to achieve this aim will depend on the injured person, the injury and the surgeon.
Definitive management is defined as the technique used (after bleeding and pain have been
controlled) to restore normal function to the injured part of the body (usually a limb), after a
fracture.

7.2 The Injured Person

Functional requirements vary from individual to individual depending on many factors including the
age, physical health and occupation of the injured person.

For instance, older individuals with a fractured bone may also have poor bone quality due to
osteoporosis (Skeletal Anatomy and Physiology Unit 2) and may have medical problems such as
heart disease or diabetes. This would present a difficult managerial challenge, so in this situation
the clinical manager may opt for a less than perfect result, as long as this would not significantly
affect the daily activities of the individual concerned. An example of this is how fractures of the