# Really bad tib/fib compound fracture



## ExpatMedic0 (Mar 7, 2015)

So I went on a ped vs car the other night. Guys main injuries where closed head and tib/fib, GCS 13. When it came to treating his tib/fib fracture I was a little thrown off. It was the worst compound fracture to a lower extremity Iv'e seen in my career. Both bones where sticking way out of the skin about a foot and pointing away from the leg. Obviously majority of the bone was exposed to open air. I'll tell you what we did, but I was hoping to get some feedback first as to what you would have done? How far would you have manipulated this injury to splint and transport it?  No pedal pulse in the injured extremity, but color of skin was good, however, bright red arterial bleeding was also present which we managed to stop with tourni and hemostatic agent


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## Ewok Jerky (Mar 7, 2015)

It's easy to say splint in place and control bleeding...

But this was one of those unique situations where "you had to be there". This is the type of trauma that your experience, critical thinking, and MacGyver skills earn your paycheck.


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## NomadicMedic (Mar 7, 2015)

If he was unconscious, I probably would have tried to manipulate it a little bit to at least try to regain a pedal pulse. I honestly don't know how much I would've messed with it. Probably splint in place as EJ says. At my current service, he would be flying on a helicopter to the trauma center.


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## Brandon O (Mar 7, 2015)

Arterial bleeding sorta suggests that the pulseless limb is due to that rather than compression. And in any case it takes priority. I would probably throw on a tourniquet and go from there.


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## ExpatMedic0 (Mar 8, 2015)

So here is what we what we did. Yes bleeding control was accomplished. However, the tricky part was the actual physical moving of the patient and the injured extremity. Due to the extent of extremity injury, there was really no way to move the patient with out manipulating the injury unintentionally, majority of the bone (12 inches or more) was exposed and pointing away from the direction the leg was in. It was impossible to splint in the position found and transport really. We ended up aligning the leg to a neutral anatomical position, however in the process of doing this, along with bleeding control, a large portion (maybe 7 inches) of the bone went back into the leg. We informed the doc when we got the ED, he did not seem to concerned about it. Obviously this is a little difficult to explain with out showing you what happened.  Just curious if anyone had any feedback or advice. Spoke to the doc last night, guy had multiple skull fractures, facial fractures, and of course his leg.... He sounded optimistic with the leg surgery.


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## ERDoc (Mar 8, 2015)

If you are concerned that some of the exposed bone went back into the leg, don't worry about it.  An injury like that will end up in the OR for a washout and repair, if not amputation.  Antibiotics were started in the ER.  Sometimes you just have to do what is needed to get the pt to the hospital.


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## Brandon O (Mar 8, 2015)

Just don't tuck everything away and not tell anybody. "Open fracture? No sir, not here. Why, this fella's good to go with a little Vicodin and good follow up."


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## ExpatMedic0 (Mar 8, 2015)

Ya in a nutshell I was worried about the bone going back into the leg as I know this is frowned upon in the prehospital setting. I suppose there was nothing we could have done about it, just curious what others thought. Thanks


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## Brandon O (Mar 8, 2015)

I would be less concerned about infection than about causing soft tissue or vascular damage, but as said, if you can't help it then you can't.


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## gotbeerz001 (Mar 8, 2015)

We had a guy who was hit by a car at about 25 (no braking) in the rain; rolled up un hood, cracked windshield etc. After pt rolled off the hood, the driver thought pt crawled off to side but couldn't see due to rain and cracked winshield, so she proceeded to pull off to the side of the road, running over and dragging pt an additional 20 feet. 

Pt suffered bilateral tib/fibs with arterial bleeding, flail chest, closed head injury. GCS 5. It was simply a toss on the gurney, control bleeding and race to the trauma center. We dis not place too much value on the open fx.


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## Jim37F (Mar 8, 2015)

Bright red arterial bleeding with a mangled mess of a wound full of sharp bone fragments that preclude direct pressure? Tourniquet without a second thought. If possible, placed between the injury and the knee, though the OP makes it sound like I'd have to place just above the knee. While I'm talking care of the Massive hemorrhage, I'll have my partner take care of Airway and Respirations. Take care of any additional bleeding and check for head injury, then stabilize for immediate transport to local trauma center. For this patient that'd most likely mean log rolled onto a backboard with splinting and the rest of the secondary done enroute. (Hopefully one of the 50 fire medics we have on scene will have been talking to bystanders and will have found out the history, allergies, meds, and all that before we get that far.

We're allowed to realign long bones, in fact our county skills sheet considers it an error if we don't make an attempt to realign a severely deformed long bone if it's pulseless and cyanotic, so that'd happen when they're being placed onto the board. Once in back get a set of vitals, head to toe physical assessment.  Once all that's done, depending on time to the TC, and how well our spider straps are keeping the leg secured, I'd be considering finishing off the splint by dressings the wound and securing with one of our vacuum splints  (love those things, quick and easy to apply whether we're staying an playing on scene or headed down the road and they do the job better than our backup cardboard splints).

Just like the Sager on femur fractures, the fact that it's an open wound won't change how we do things. It's already got whatever nasty it's gonna get on it and leaving it open does nothing to help the patient and the trauma surgeons are still gonna do their thing to clean it all up, our job is to keep it stabilized so the sharp bone fragments don't move around and cut up more muscle, vessels or nerves.


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## redundantbassist (Mar 9, 2015)

Jim37F said:


> Bright red arterial bleeding with a mangled mess of a wound full of sharp bone fragments that preclude direct pressure? Tourniquet without a second thought. If possible, placed between the injury and the knee, though the OP makes it sound like I'd have to place just above the knee. While I'm talking care of the Massive hemorrhage, I'll have my partner take care of Airway and Respirations. Take care of any additional bleeding and check for head injury, then stabilize for immediate transport to local trauma center. For this patient that'd most likely mean log rolled onto a backboard with splinting and the rest of the secondary done enroute. (Hopefully one of the 50 fire medics we have on scene will have been talking to bystanders and will have found out the history, allergies, meds, and all that before we get that far.
> 
> We're allowed to realign long bones, in fact our county skills sheet considers it an error if we don't make an attempt to realign a severely deformed long bone if it's pulseless and cyanotic, so that'd happen when they're being placed onto the board. Once in back get a set of vitals, head to toe physical assessment.  Once all that's done, depending on time to the TC, and how well our spider straps are keeping the leg secured, I'd be considering finishing off the splint by dressings the wound and securing with one of our vacuum splints  (love those things, quick and easy to apply whether we're staying an playing on scene or headed down the road and they do the job better than our backup cardboard splints).
> 
> Just like the Sager on femur fractures, the fact that it's an open wound won't change how we do things. It's already got whatever nasty it's gonna get on it and leaving it open does nothing to help the patient and the trauma surgeons are still gonna do their thing to clean it all up, our job is to keep it stabilized so the sharp bone fragments don't move around and cut up more muscle, vessels or nerves.


Would be really nice to see more emphasis on MARCH and quick transport for civillian EMS trauma patients.


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## Jim37F (Mar 9, 2015)

redundantbassist said:


> Would be really nice to see more emphasis on MARCH and quick transport for civillian EMS trauma patients.


I blame the Army lol IMO MARCH simply makes more sense for trauma patients and ABCD is better for medical patients...Of course for 90+% of trauma patients we treat who don't have massive hemorrhage then it essentially becomes ABCD as they teach in the books anyway. Plus if you have your partner take care of AR at the same time as you do M than it all gets done at the same time and satisfies both acronyms


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## Ewok Jerky (Mar 9, 2015)

MARCH?


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## Jim37F (Mar 9, 2015)

It's the trauma assessment protocol TCCC and CLS teach:

Massive Hemorrhage
Airway 
Respiration
Circulation
Head Injury


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