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Difficulty: EasyOrthopedic Surgery

Emergency medical services bring a 45-year-old male construction worker to the trauma bay after he fell two stories from scaffolding. On arrival, he is restless, agitated, and diaphoretic. Vital signs show a heart rate of 135/min and a blood pressure of 82/45 mmHg. Oxygen saturation is 96% on room air. Primary survey reveals clear lungs and a non-distended abdomen. A bedside ultrasound for trauma is negative for free fluid. His pelvis is stable to gentle compression. The right thigh is tense, markedly swollen, and shortened compared to the left, but there is no break in the overlying skin. Bilateral pedal pulses are faint but palpable. Following securing of intravenous access and initiation of crystalloid fluids, which of the following is the most appropriate next step in management?

  1. A
    Transport to the radiology suite for a computed tomography scan of the abdomen
  2. B
    Delay intervention to obtain informed consent from the next of kin
  3. C
    Administration of intravenous haloperidol for acute agitation
  4. Application of a traction splint to the right lower extremityAnswer
  5. E
    Administration of empiric broad-spectrum intravenous antibiotics

Answer

Application of a traction splint to the right lower extremity
The correct answer is the application of a traction splint to the right lower extremity. This patient presents with hemorrhagic shock (hypotension, tachycardia, altered mental status) following blunt trauma. With a negative FAST exam, clear lungs, and a stable pelvis, the swollen, tense, and shortened right thigh indicates a femoral shaft fracture as the primary source of hemorrhage. A closed femur fracture can conceal 1 to 1.5 liters of blood within the thigh compartment. Applying a traction splint provides longitudinal traction, which aligns the bone fragments, significantly reduces pain, and decreases the volume of the fascial compartment, effectively helping to tamponade the bleeding until definitive surgical fixation can be performed.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status.
The patient is in severe hypovolemic shock (hypotension, tachycardia, diaphoresis, and agitation).
Identifying shock is the first priority in trauma to direct immediate life-saving interventions.
2
Identify the primary source of hemorrhage.
The chest, abdomen (negative FAST), and pelvis are clear, but the right thigh is swollen, tense, and shortened.
Locating the bleeding source dictates the specific mechanical intervention needed to achieve hemostasis.
3
Select the appropriate acute management for a bleeding closed femur fracture.
Apply a traction splint to the affected limb.
Traction splinting aligns the fracture fragments and reduces the volume of the thigh compartment, which effectively tamponades further blood loss.

Key Concept

Hemorrhagic shock from a closed femoral shaft fracture is a life-threatening emergency that must be managed with fluid resuscitation and immediate mechanical stabilization using a traction splint to tamponade bleeding.
Estimated Time:1m 0s
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