13.

1 Basic Trauma Life Support

Multiple trauma

High-velocity trauma is the number one cause of death in the 18–44-year age group worldwide. Blunt
trauma accounts for 80% of mortality in the less than 34-year age group. Trauma patient survival is
associated with the severity of head injuries. Initial neurologic assessment and management of head injuries
are priorities in the earliest phase of multiple trauma treatment. A history of prolonged unconsciousness with
focal neurologic signs might be caused by cerebral contusion; loss of consciousness with an intervening
lucid interval, followed by severe loss of consciousness, might be caused by epidural hemorrhage (tear of
the middle meningeal artery), or subdural hemorrhage (tear of subdural veins); loss of consciousness
followed by signs of meningeal irritation might be the result of subarachnoid hemorrhage.
Thoracic injuries might result from blunt (i.e., crush), penetrating (i.e., gunshot), or deceleration (i.e.,
motor vehicle accident) mechanisms, and might include disruption of great vessels, aortic dissection, sternal
fracture, and cardiac or pulmonary contusions. An anterior-posterior (AP) plain radiograph might reveal
mediastinal widening, hemothorax, pneumothorax, or musculoskeletal injuries, and if indicated, is usually
followed by a CT scan with intravenous contrast. In the case of severe hemodynamic instability an
emergency thoracotomy might be indicated.

Injury Severity Score (ISS)

This anatomic scoring system is based on the Abbreviated Injury Scale (AIS), a standardized system of
classification for the severity of individual injuries from 1 (mild) to 6 (fatal).

Each injury is assigned an AIS score and is allocated to one of the six body regions (head, face, chest,
abdomen, extremities including pelvis, and external structures).

The total ISS score is calculated from the sum of the squares of the three worst regional values.

It is imperative that only the worst injury in each body region is used.

The ISS ranges from 1 to 75, with any region scoring 6 automatically giving a score of 75.

The ISS limits the total number of contributing injuries to three only, one each from the three most
injured regions, which may result in underscoring the degree of trauma sustained if a patient has more
than one significant injury in more than three regions or multiple severe injuries in one region.

Abdominal injuries might accompany blunt or penetrating trauma. An ED ultrasound examination might
evaluate fluid present in the abdominal and chest cavities, and if indicated, diagnostic peritoneal lavage
should be performed. Peritoneal lavage is positive in the case of gross blood, bile, or fecal material present,
>100,000 red blood cells/mL, and/or >500 white blood cells/mL present.
Genitourinary injuries might accompany blunt or penetrating trauma (15% of abdominal trauma results in
genitourinary injury). During ED assessment a retrograde urethrogram should be performed before
indwelling bladder catheter insertion. If hematuria is present, a voiding urethrogram, cystogram, and
intravenous pyelogram are indicated.
The polytrauma patient is defined as follows: Injury Severity Score (ISS) >18, hemodynamic instability,
coagulopathy, closed head injury, pulmonary injury, and abdominal injury. In the field triage management
priorities are: 1. Assessment and establishment of airway and ventilation; 2. Assessment of circulation and
perfusion; 3. Hemorrhage control; 4. Patient extrication; 5. Shock management; 6. Fracture stabilization; and
7. Patient transport.
Trauma deaths tend to occur in three phases:

Immediate: usually the result of severe brain injury or disruption of the heart, aorta, or large vessels.

Early (minutes to few hours): usually as a result of intracranial bleeding, hemopneumothorax, splenic
rupture, liver laceration, or multiple injuries with significant blood loss.

Late (days to weeks): related to sepsis or multiple organ failure.

The term golden hour emphasizes the need for emergency transport of the severely injured patient to a
trauma center because the chance of survival diminishes rapidly after one hour, with a threefold increase in
mortality for every 30 minutes.

Multiple trauma patient initial assessment includes resuscitation following the airway, breathing,
circulation, disability, exposure (ABCDE) algorithm:

Airway control
 Inspect the upper airway;
 Remove foreign objects, and suction secretions;
 Establish a nasal, endotracheal, or nasotracheal airway, tracheostomy if necessary;
 Manage the patient as if a cervical spine injury is present. Gentle maneuvers are usually possible to
allow for safe intubation without neurologic compromise.

Breathing
 Evaluate spontaneous breathing, artificial ventilation, and oxygenation;
 Assess reasons for ineffective ventilation after establishment of an airway: malposition of the
endotracheal tube, pneumothorax, or hemothorax;
  Indications for intubation (GCS 8, airway control, prevention of aspiration in an unconscious patient,
hyperventilation connected with increased intracranial pressure (ICP), and airway obstruction in the
patient with facial trauma and edema).

Circulation
 Hemodynamic stability means normal vital signs maintained with volume resuscitation;
 In trauma patients, shock is hemorrhagic until proven otherwise;
 Serial monitoring of blood pressure (palpable peripheral pulse), hematocrit, and urine output is
necessary.

Disability (neurological assessment)

 Assessment of consciousness (Glasgow Coma Score), pupillary response, sensation and motor
response in extremities;
 GCS <13, SBP <90 mmHg, or a respiratory rate >29 or <10 breaths per minute should be sent to a
trauma center immediately.

Exposure
 Undress the trauma patient completely and examine the entire body for signs and symptoms of
injury.

Initial management of the patient in shock comprises:

 Control of obvious bleeding (direct pressure control);
 IV access, volume resuscitation, monitoring of urine output (Foley catheter insertion), central
venous pressure, and arterial blood gases and blood pH;
 Blood replacement as indicated by serial hematocrit monitoring;
 Traction or extremity splints to limit hemorrhage from unstable fractures;
 Operative intervention for hemorrhage control.

Emergency department blood transfusion should preferably be done with fully cross-matched blood
(proceeding time is approximately one hour); type O negative blood is indicated only in life-threatening
exsanguination. Blood warming is necessary for prevention of hypothermia, while coagulation factors,
platelets, and calcium levels monitoring will indicate concomitant platelet and fresh frozen plasma
transfusion.
Indications for immediate surgery include hemorrhage secondary to: depressed skull fracture or acute
intracranial hemorrhage (craniotomy), aortic, caval, or pulmonary vessel tears (thoracotomy), and liver,
splenic, renal parenchymal injury (laparotomy).
If possible, an ED radiographic trauma series involves the following:
 Lateral cervical X-ray (all seven vertebrae) or swimmer view on CT scan must be seen, and lateral thoraco-
lumbar spine X-ray;
Anterior-posterior (AP) chest and pelvis X-ray;
Possibly a CT scan of the head, cervical spine (if not cleared by plain radiographs), thorax, abdomen, or
pelvis with or without contrast as dictated by the injury pattern.

Emergency department multiple trauma patient stabilization consists of: restoration of adequate
oxygenation and organ perfusion, restoration of stable hemodynamics and adequate kidney function, and
treatment of bleeding disorders. The ED physician must be aware that pulmonary injuries (i.e., contusion),
sepsis, multiple organ dysfunction syndrome (MODS) (i.e., because of prolonged shock), massive blood
replacement, and pelvic or long bone fractures may result in early development of adult respiratory distress
syndrome (ARDS), and ICU admission.
Most patients’ cardiopulmonary function is stabilized within 4 to 6 hours of ED presentation. The
surgeon’s timing and decision to operate are based on the determination of the patient’s medical stability
estimated by adequacy of resuscitation, vital signs, laboratory parameters, and no evidence of coagulopathy.
Patients who are hemodynamically stable without immediate indication for surgery should receive medical
optimization (i.e., cardiac risk stratification and clearance) before operative treatment. In case of incomplete
resuscitation based on physiological assessment, ICU care includes invasive monitoring, further
resuscitation, re-warming, and correction of metabolic and coagulopathy derangement. When the patient is
warm and well oxygenated, the surgeon should reconsider further operative procedures. Early operative
intervention is indicated in the case of: femur or pelvic fractures (high risk of pulmonary complications, e.g.,
fat embolus syndrome, ARDS), active or impending compartment syndrome (tibia or forearm fractures),
open fractures, vascular disruption, unstable cervical or thoraco-lumbar spine injuries, and femoral neck and
talar neck fractures, or other bones in which the fracture has a high risk of osteonecrosis.

Head injury

The most common causes of head injury include falls, road traffic accidents (RTAs), and assaults. The
majority of patients with head injury (75–80%) have mild head injuries, while 10% have moderate, and 10%
have severe injuries. The incidence of moderate and severe head injuries ranges 200–300 per 100,000 cases
in the European population, with a mortality rate of 3.1%. Appropriate management of head injuries requires
an understanding of their anatomy and pathophysiology. Mild head injuries are generally defined as those
associated with a GCS of 13–15, while moderate head injuries are associated with a GCS score of 9–12. A
GCS score of 8 or less defines a severe head injury.

Intracranial pressure (ICP) is determined by the relationship between the skull, a rigid box of fixed volume,
and the volumes of the brain, cerebrospinal fluid (CSF) and blood. Only small increases in volume within
the intracranial compartment can be tolerated before pressure rises dramatically, above the normal range of
5–13 mmHg. Cerebral perfusion pressure (CPP) is defined as the difference between the mean arterial
pressure (MAP) and the ICP. When the MAP is less than 50 mmHg or greater than 150 mmHg, the brain
arterioles are unable to autoregulate, and blood flow becomes entirely dependent on the blood pressure. The
cerebral blood flow is no longer constant but is dependent on the CPP. Following a head injury CPP above
60–70 mmHg is needed to maintain an adequate cerebral blood flow to prevent ischemia and neuronal death.
If blood flow is interrupted for as little as 4 minutes, neurons rapidly fail and die.

Head injuries are divided into closed and open injuries. Open head injuries include penetrating and non-
penetrating head injury, depending on the presence of dura injury.
Head trauma patients may experience one or a combination of primary injuries, depending on the severity
and mechanism of the trauma. Specific types of primary injury include scalp injury, skull fracture, fracture
to the base of the skull, concussion, contusion, intracerebral, intraventricular, and subarachnoid hemorrhage,
epidural and subdural hematoma, penetrating injuries, and diffuse axonal injury. Secondary brain injury is
damage that occurs after the primary brain injury as a result of: hypoxia, hypotension, and delay in diagnosis
and/or in treatment, seizures, raised ICP, and suboptimal management of other injuries.
Inertial forces can produce injuries that result in a significantly worse outcome than that of damage
resulting from direct contact. A spectrum of injury exists ranging from concussion (the mildest) to diffuse
axonal injury (the most severe).

Concussion might occur after minor inertial forces to the head. The patient does not have localising signs,
but might have nausea, vomiting and headaches, and might suffer loss of consciousness for up to five
minutes. The patient always has some degree of amnesia of the injuring event. There might be amnesia for
events that occurred before (antegrade amnesia) or after (postgrade amnesia) the trauma. Recovery is
complete.
Contusion might occur after a direct injury to the head, and is an area of bruising or tearing of the brain
tissue. Because of their anatomical relationship with the bony protuberances of the calvaria, the temporal
and frontal lobes are the most vulnerable areas. The patient typically has a progressive neurologic
deterioration secondary to local cerebral edema, infarctions, and/or late-developing hematomas.
Hematomas might occur outside the dura (extradural) or beneath the dura (intradural).
Extradural hematoma (EDH) is associated with a fractured skull in 90% of cases. Most often it develops
in the temporo-parietal area following a tear in the middle meningeal artery. It develops quickly as the
source of bleeding is arterial. The classical presentation of an EDH occurs in only one third of cases. The
commonest clinical signs are loss of consciousness and pupillary changes, although these can develop
rapidly or late. An EDH is a neurosurgical emergency, as early evacuation will result in a better patient
outcome by reduction of a secondary injury for the underlying brain.
Intradural hematomas (IDH) are either subdural (SDH) or intracerebral (ICH). Both are often sustained
simultaneously. IDHs are three to four times more common than extradural hematomas. They are produced
by inertial or rotational forces, although considerably more force is needed to produce an ICH. IDHs are
often associated with and are more severe in patients with coagulation disorders (i.e., therapeutic
anticoagulation, chronic alcohol ingestion).
Subarachnoid hemorrhage (SAH) might occur following head trauma and is associated with a worse
outcome following traumatic brain injury. Although often an incidental finding on a CT scan following
severe trauma, it is important that it is differentiated from aneurysmal arachnoid hemorrhage. The classical
presentation of headache, photophobia, or other signs of meningism are far more suggestive of aneurysmal
than traumatic SAH. If the former is suspected, the patient needs urgent neurosurgical referral. Management
of patients with traumatic SAH should be the same as for any other head injury patient.

NICE guideline for immediate CT scan after a head injury

Further workup is partly determined by the stability of the patient. Performing skull X-rays is prior
to CT. If the patient is stable after the completion of the secondary survey, then a CT scan is the
investigation of choice, as it allows earlier detection and possible earlier neurosurgical treatment of
intracranial complications with an improved outcome. The National Institute for Health and
Clinical Exellence (NICE) guideline for the management of head injury (2007) regarding
recommendations for immediate CT scan includes:

GCS less than 13 at any time since injury;

GCS equal to 13 or 14 at 2 hours after injury;

Suspected open or depressed skull fracture;

Any sign of a basal skull fracture (hematotympanum, panda eyes, Battle’s sign, CSF ottorhea);

Post-traumatic seizure;

Focal neurological deficit;

More than one episode of vomiting (use clinical judgement if less than 12 years of age);

Amnesia for more than 30 minutes of events before impact (not possible in very young children).

Also in patients with the following risk factors providing they have experienced some loss of
consciousness or amnesia:

Age equal to or greater than 65 years;

Coagulopathy (history of bleeding, known clotting disorder, warfarin treatment);

Dangerous mechanism of injury (e.g., pedestrian hit by car, fall more than one meter or down five
 steps).

The initial ED evaluation of the patient with head injury involves a systemic trauma evaluation according
to the Advanced trauma life support (ATLS) guidelines. Once this has been completed and the patient is
stable regarding cardiopulmonary function, attention may be directed to a focused head injury evaluation.
1. Airway and cervical spine control
 Clear and secure the airway and maintain cervical spine control;
 Maintain adequate oxygenation and blood pressure avoiding secondary brain injury;
 Maintain continuous verbal communication with the patient wherever possible and determine
consciousness level on GCS;
 Involve anesthesiologist to provide appropriate airway management and perform tracheal intubation
if needed.
2. Breathing and ventilation
 Because of the importance of avoiding hypoxia and hypercarbia, the respiratory pattern must be
continually monitored.
3. Circulation and control of hemorrhage
 If the patient is not in shock, fluid administration should be maintained with normal saline, Ringer
or Hartmann’s solution (compound sodium lactate);
 If the patient is in shock, the aim is to control the hemorrhage and restore blood pressure to a level
of >110 mmHg;
 Glucose-containing fluids (5% dextrose) should be avoided because of lowering plasma osmolality
and exacerbating cerebral edema.
4. Neurological assessment
 Examination of skull vault;
 Neurological assessment, pupillary responses, and detection of any lateralizing (focal) signs;
 Re-assessment of vital signs and consciousness level;
 Assessment of signs of basal skull fractures (hematotympanum, otorrhea or rhinorrhea, scleral
hemorrhages with no posterior margin, Battle’s sign, orbital bruising or panda eyes).

The majority of patients attending EDs because of head injury have minor head injuries (minimal
disturbance of conscious level (GCS 14–15), amnesia <10 minutes duration, no neurological signs or
symptoms at the time of examination, and no skull fractures, clinically or radiologically). The patient might
be discharged from the ED with appropriate written instructions, and/or with a responsible adult.
Patients with moderate head injuries require admission for observation and investigation. This will include
patients with: confusion or any depression of the level of consciousness (GCS 9–13), a skull fracture, on X-
ray or clinically, difficulty in assessment e.g., alcohol, drug intoxication, epilepsy, and patients with relevant
co-existent medical disorders or treatment, e.g., blood clotting disorders or anticoagulants. In a case of any
deterioration in their condition during admission their status must be discussed with a neurosurgeon.
 Patients with severe head injuries (coma (GCS <9) after full resuscitation, a skull fracture and neurological
signs, a compound or depressed skull fracture, basal skull fracture, post-traumatic epilepsy, deteriorating
consciousness or neurological state, or neurological disturbance >6 hours, amnesia >10 minutes, and
abnormal head CT scan) need urgent neurosurgical referral.

Burns

Burns are devastating conditions and although most burns are not life-threatening, each burn causes a
significant amount of pain for the patient and often some degree of psychological trauma.
The most common type of burns are thermal burns. Soft tissue is burned when it is exposed to
temperatures above 46 °C. Thermal burns are further classified according to skin depth and percentage of
total body area burned. Accurate documentation of the burn location and measurement of the involved
surface area are essential for follow-up and further management.

Result from contact with hot liquids. About 70% of burns in children are caused by
Scalds:
scalds, and they also often occur in the elderly.

Flame
Contact with an open flame causes direct injury to the tissue (50% of adult burns).
burns:

Contact
Result from direct contact with a hot object.
burns:

Electrical burns produce heat injuries by passing through tissue. Some 3–4% of burn unit admissions are
caused by electrocution injuries. The voltage is the main determinant of the degree of tissue damage.
Chemical injuries are usually a result of industrial accidents but also occur with household chemical
products. These burns tend to be deep as the corrosive agent causes coagulative necrosis. Alkaline
substances tend to penetrate deeper and cause worse burns than acids. An estimated 3–10% of pediatric
burns are due to non-accidental injury, mainly in abused children.

The body’s response to a burn is local and systemic. There are three zones of a burn:

Zone of Occurs at the point of maximum damage with irreversible tissue loss due to
coagulation: coagulative necrosis.

Zone of The surrounding zone is characterized by decreased tissue perfusion, tissue is

stasis: potentially salvageable. Target zone for burns resuscitation: increasing of tissue
 perfusion and prevention of prolonged hypotension, infection, or edema.

Zone of Tissue perfusion is increased, there is a strong possibility for tissue recovery
hyperemia: unless severe sepsis or prolonged hypoperfusion occur.

Burns might cause a hypermetabolic state manifested by fever, increased capillary permeability (leading to
loss of intravascular proteins and fluids to the interstitial compartment), increased minute ventilation,
cardiac output, gluconeogenesis resistant to glucose infusion, and skeletal and visceral muscle catabolism.
As inflammatory mediators cause bronchoconstriction, in severe burns adult respiratory distress syndrome
(ARDS) might develop.

Assessment of burn area

Several formulas have been devised to estimate the risk of death following burn injury. Increased risk of
death is associated with increasing age, burn size, and the presence of an inhalation injury. The more body
surface area (BSA) is involved in a burn, the greater the morbidity and mortality rates and the difficulty in
management.
The surface area of a patient’s palm (including the fingers) is roughly 0.8% of the total body surface area.
The palmar surface can be used to estimate relatively small burns (<15% of the total surface area) but is
inaccurate for medium-sized burns. The rule of nines is a widely used quick method to estimate the extent of
burn injury (Slika 13.3).
By depth burns can be classified into three groups: superficial (first-degree), partial thickness (second-
degree), or full-thickness burns (third-degree). Most burns are a mixture of different depths and a certain
depth will change depending on the effectiveness of the treatment involved.
Superficial (first-degree) burns involve only the epidermis. These wounds are red, dry, painful, and
generally heal in 3–6 days without scarring.
Partial-thickness burns (second-degree) are often further delineated involving the epidermis and
portions of the dermis. These wounds are red, wet, and painful (with decreasing pain, color, and moisture
with increasing depth into the dermis), and the healing time may vary from 7–21 days, or even more than 21
days in the case of deep dermis burns.
Full-thickness (third-degree) burns extend completely through the skin to the subcutaneous tissue and
may involve underlying structures such as tendons, nerves, muscle, or bone. These wounds vary from waxy
white, to char and black, are dry and usually painless to touch. They generally do not heal spontaneously.

Treatment of burns

The aim of first aid for and treatment of minor burns is:
 Stop the burning process: The heat source should be removed; clothing might retain heat, and should be
removed as soon as possible; adherent material, such as nylon clothing, should be left on.
Cooling of the burn: This is effective if performed within 20 minutes of the injury. Irrigation with running
water (15 °C) should be continued for up to 20 minutes; iced water should not be used as intense
vasoconstriction can cause burn progression.
Provide pain relief: analgesia.
Covering the burn: dressings should cover the burn area and keep the patient warm; avoid use of wet
dressings, as heat loss during transfer to hospital might be considerable.

In managing these wounds it is important to be sure that the patient receives adequate follow-up care. The
ED physician should consult a referral burns unit if in doubt about the management. Facial burns should be
referred to a specialist unit. Burns that fail to heal within three weeks should be referred to a plastic surgery
unit for review.

ED management of these burns includes:

Cleaning of the burn: The area should be thoroughly cleaned with soap and water or mild antibacterial
wash; large blisters should be de-roofed, and dead skin removed with sterile scissors or a hypodermic
needle, while smaller blisters should be left intact. Routine use of antibiotics is not recommended.
Dressings: Cover the clean burn with a simple gauze dressing impregnated with paraffin; avoid using
topical creams; apply a gauze pad over the dressing followed by several layers of absorbent cotton wool.
A firm bandage applied in a Slika of eight manner and secured with adhesive tapes will prevent slippage.
Limb burns should be elevated.
Dressing changes for burns: Aseptic technique, first change after 48 hours, and every 3–5 days thereafter.
Criteria for early dressing change are: excessive secretion, smelly wound, contaminated or soiled
dressings, slipped dressings, and signs of infection (fever).

A major burn is defined as a burn covering 25% or more of the total body surface area.

Initial ED assessment and treatment of a major burn include:

ABCDEF primary survey: A – airway with cervical spine control, B – breathing, C – circulation, D –
neurological disability, E – exposure with environmental control, F – fluid resuscitation;
Assessment of burn size and depth;
Establishing of proper intravenous access and IV fluids, and analgesia management;
Fluid balance monitoring, Foley catheter insertion;
Baseline blood samples for investigation;
Wound dressing;
Safe transfer to specialist burns unit.
Fractures

The fractured bone loses its structural continuity, rendering it mechanically useless, being unable to bear
any load. Fractures are related to the force and to the rate of force applied. Lesser force is required to break
the bone if the force is applied slowly and over a long period of time compared to its being applied rapidly.
Bones are able to withstand the rapid onset of heavy force. The force is stored, however; when the bone can
no longer withstand it and finally breaks, it is dissipated in an explosive and implosive fashion, causing
considerable damage to the soft tissue envelope. The amount of energy and the rate of force application are
important factors since they determine the degree of associated damage to the soft tissue envelope. The
described mechanisms distinguish low- and high-velocity injuries.
Low-velocity injuries are usually the result of an indirect force application, such as a twist. The associated
fractures are spiral and the comminuting is rarely excessive, resulting with a better prognosis. Higher energy
dissipation and direct application of the force in high-velocity injuries result with more fragmented fractures
and greater damage to the enveloping soft tissues.

The most common classification of fractures is Müller’s Comprehensive Classification of Fractures of

Long Bones. It indicates the severity of the fracture assessing the morphological complexity of the fracture,
the difficulties to be anticipated in the treatment, and its prognosis. Fractures are divided into simple and
multi-fragmentary.
The multi-fragmentary fractures are subdivided into wedge and complex fractures (not on the basis of the
number of fragments, but according to whether after reduction the main fragments have retained contact or
not). A multi-fragmentary fracture with some contact between the main fragments is considered a wedge
fracture, while in complex fractures contact between the main fragments cannot be established after
reduction.
Articular fractures are defined as those that involve the articular surface, regardless of whether the fracture
is intracapsular or not. Stiffness in adjacent joints in non-articular fractures is the result of immobilization.
Prolonged immobilization leads to atrophy of the articular cartilage, to capsular and ligament contractures,
and to intraarticular adhesions. The joint space normally filled with synovial fluid becomes filled with
adhesions that bind the articular surfaces together.

In high-velocity injuries damage to the soft tissue envelope and devitalization of the involved bone makes
prognosis poor. Long-term disability following a fracture is almost never the result of the bone fracture
itself; it is the result of damage to the soft tissues and of the stiffness of neighboring joints. In a closed
fracture the injury to the surrounding tissue evokes an acute inflammatory response, which is associated with
an outpouring of fibrin and protein-containing fluid. If after the injury the tendons and muscles are not
encouraged to glide upon one another, inflammation may develop and lead to the obliteration of tissue
planes and to the matting of the soft tissue envelope into a functionless mass.
In an open fracture, in addition to the possible scarring from immobilization, there is direct injury to the
muscles and tendons, and in such cases the effects of infection must be considered. Infection is the most
serious complication of trauma because, in addition to the scarring related to the initial trauma, infection
compounds the fibrosis as a result of the associated tissue damage and the prolonged immobilization that is
frequently necessary until the infection is cured.

Treatment of fractured bones

Modern fracture treatment does not focus on bone union at the expense of function but addresses itself
principally to the restoration of function of the soft tissues and adjacent joints. A trauma surgeon will
therefore direct treatment to the early return of function and motion, with bone union being considered of
secondary importance. Early return of full function following fracture can be achieved only by sufficiently
stable internal fixation which will abolish fracture pain and which will allow early resumption of motion
with partial loading without the risk of failure of the fixation, and resultant mal-union or non-union. With
non-functional methods full return of function is rarely achieved, requiring a prolonged rehabilitation period.
Functional fracture treatment does not denote only operative fracture care. It makes use of specialized
splinting of the bone in special braces that allow an early return of function and motion. There are
limitations to the non-operative system. It can be applied to fractures where angulation, rotation, and
shortening can be controlled. Thus, it is limited only to certain long bone fractures.
Bone fracture ED management consists of closed reduction, and placement of splints and casts. Reduction
maneuvers are specific for particular locations and should correct or restore length, rotation, and angulations.
Fractures are reduced using axial traction and reversal of the mechanism of injury (analgesia and muscle
relaxation are critical for success). All displaced fractures, including those that will undergo internal fixation,
should be reduced to minimize soft tissue complications; the joints above and below the injury should be
immobilized respecting the soft tissue damage.
Skeletal traction is the preferred method of temporizing long bone, pelvic, and acetabular fractures until
operative treatment can be performed. It is a constant controlled force for initial stabilization of long bone
fractures and aids in reduction during operative procedures.
Acute complications of casts and splints are: loss of reduction, pressure necrosis, tight cast or compartment
syndrome, and thermal injury; possible delayed complications are: deep vein thrombosis complicated with
pulmonary embolism (increased with lower extremity fracture and immobilization), joint stiffness, and cuts
and burns during cast removal.

Suggested further reading

Hoyt DB, Coimbra R, Acosta J. Management of Acute -Trauma. In: Sabiston DC ed. Textbook of Surgery. 18th Edition.
Philadelphia (PA): WB Saunders Co; 2008. p. 477-585.
Slika 13.3. The rule of nines is a quick method to estimate the extent of burn injury. The body is divided into the areas of 9%, and
the body surface area that has been burned is estimated by using multiples of 9. The surface involved might be calculated as
follows: head (9%), the front chest and abdominal wall (9% + 9%), and left leg, front and back (9% + 9%). This would involve
45% of the body surface.