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Difficulty: MediumOrthopedic Surgery

A 30-year-old man is brought to the emergency department after a fall from a height of 6 meters (20 feet). He is confused and agitated. His temperature is 36.8°C (98.2°F), blood pressure is 75/40 mm Hg, and pulse is 135/min. Primary survey reveals a patent airway and clear, equal breath sounds bilaterally. A focused assessment with sonography for trauma (FAST) examination is negative for intraperitoneal or pericardial fluid. Pelvic examination shows stability to anteroposterior and lateral compression, and a portable anteroposterior pelvic radiograph is normal. Examination of the left lower extremity reveals a visibly deformed, shortened thigh with tense swelling. There are no open wounds. Distal pulses are palpable but diminished in the left foot compared to the right. Which of the following is the most appropriate next step in management?

  1. A
    Transport the patient to the radiology suite for a computed tomography (CT) scan of the abdomen and lower extremity
  2. B
    Administer broad-spectrum intravenous antibiotics such as vancomycin and piperacillin-tazobactam
  3. Initiate intravenous fluid resuscitation and apply a traction splint to the left lower extremityAnswer
  4. D
    Delay immediate interventions to identify and contact a legally appointed surrogate decision-maker for consent
  5. E
    Administer intravenous furosemide to rapidly decrease the tense swelling in the left thigh

Answer

Initiate intravenous fluid resuscitation and apply a traction splint to the left lower extremity
This patient is presenting with hemorrhagic shock resulting from a closed femoral shaft fracture. In the setting of trauma, a patient with hypotension, tachycardia, and altered mental status is presumed to have hemorrhagic shock until proven otherwise. The major areas where a patient can bleed enough to cause shock are the chest, abdomen, pelvis, and thighs (long bones). With a negative FAST exam, normal pelvic radiograph, and clear breath sounds, the internal hemorrhage is localized to the visibly deformed and swollen left thigh. A fractured femur can easily conceal 1,000 to 2,000 mL of blood loss. The most appropriate immediate management is to initiate intravenous fluid (and likely blood) resuscitation while simultaneously applying a traction splint. Traction splinting pulls the limb out to length, which geometrically decreases the volume of the thigh compartment. This helps to tamponade the bleeding, stabilize the fracture fragments, and provide significant pain relief before definitive surgical fixation.

Step-by-Step Solution

1
Assess the patient's hemodynamic status based on vital signs.
The patient is in hemorrhagic shock, evidenced by a blood pressure of 75/40 mm Hg, heart rate of 135/min, and confusion.
Recognizing shock is the first step in trauma management to prioritize life-saving interventions over definitive diagnostic imaging.
2
Identify the source of the hemorrhage using the primary survey and adjuncts.
The chest, abdomen, and pelvis have been ruled out as major sources of bleeding (clear breath sounds, negative FAST, stable normal pelvis). The tense, deformed left thigh points to a femoral shaft fracture.
A single closed femur fracture can result in 1 to 2 liters of internal blood loss into the thigh compartment, which is sufficient to cause severe shock.
3
Determine the appropriate acute intervention for a bleeding femur fracture.
The patient requires immediate volume resuscitation and the application of a traction splint.
A traction splint restores anatomical bone length, which reduces the cylindrical volume of the thigh compartment. This increases the internal tissue pressure and helps to tamponade the bleeding vessels.

Key Concept

Management of hemorrhagic shock secondary to a closed femoral shaft fracture using a traction splint
Estimated Time:1m 15s
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Topics

Orthopedic Surgery

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