23.1

Extremity Fractures

Chapter 23

Extremity Fractures

Introduction

This chapter discusses two techniques for safe transportation

of a wounded soldier with a long bone fracture: transportation

casts and temporary external fixation. Both of these methods

are acceptable for initial treatment of a patient who will be

evacuated out of theater. Precise indications for external fixator

use versus casting have not been established.

In general, good indications for external fixator use include

when the soft tissues need to be evaluated while en route, such

as with a vascular injury; when other injuries make use of casting

impractical, such as with a femur fracture and abdominal injury;

or when the patients have extensive burns. Advantages of

external fixation are that it allows for soft tissue access, can be

used for polytrauma patients, and has a minimal physiologic

impact on the patient. Disadvantages are the potential for pin

site sepsis or colonization and less soft tissue support than casts.

Advantages of transportation casts are that they preserve the

maximum number of options for the receiving surgeon; the soft

tissues are well supported, and the casts are relatively low tech.

Disadvantages are that casts cover soft tissues, may not be

suitable for polytrauma patients, and are more labor-intensive

than external fixators.

Both transportation casts and external fixators are equally

acceptable methods for the initial management of long bone

fractures. In the end, the choice of initial fracture stabilization

must be made on a case-by-case basis by the treating surgeon.

That decision should be based on the surgeon’s experience, his

assessment of the evacuation process, the materials available,
23.2

Emergency War Surgery

the nature of the patient’s wounds and the patient’s overall

condition.

Though standard in civilian trauma centers, intramedullary

nailing of major long bone fractures is contraindicated in

combat zone hospitals because of a variety of logistical

and physiologic constraints. This method may be used

once a patient reaches an echelon above corps (EAC) or

other site where more definitive care can be provided.

In this chapter, the term casting material is used in place of

describing either plaster or fiberglass for constructing casts. Both

are acceptable materials for application of transportation casts.

General Considerations of Wound Management

 Initial management.

ο Treat by irrigation and debridement as soon as feasible to

prevent infection.

ο Femur fractures are at high risk for infection (about 40%,

historically).

ο Biplanar radiographs should be obtained.

ο Neurovascular status of the extremity should be documented

and checked repeatedly.

ο Internal fixation is contraindicated.

ο Begin IV antibiotics as soon as possible and maintain

throughout the evacuation chain. Use a broad spectrum

cephalosporin (cefazolin 1 g q 8 h). An aminoglycoside

may be harmful for someone in shock or dehydrated. The

two most harmful bacteria—clostridia and streptococci—

are covered by a 1st generation cephalosporin.

 Wound incision/excision.

ο Guidelines as per soft tissue injury section.

ο Longitudinal incisions to obtain exposure.

ο Fascia incised longitudinally to expose underlying

structures and compartment release.

ο All foreign material in the operative field must be removed

(Fig. 23-1a, b, c).
23.3

Extremity Fractures

ο Bone fragments should be retained if they have a soft tissue

attachment.

a b

c d

Fig. 23-1. Wound incision/excision.
23.4

Emergency War Surgery

ο Detached bone fragments smaller than a thumbnail are

discarded.

ο Larger fragments that contribute to the structural integrity

of the long bone should be retained.

ο Irrigation is essential (Fig. 23-1d).

 Closure of wounds.

ο Primary closure is never indicated. Loose approximation

of tissues with one or two retention sutures is appropriate

to cover nerves, vessels, and tendons, but there must be a

provision for substantial free drainage.

ο Skin grafts, local flaps, and relaxing incisions are

contraindicated in the initial management.

ο Delayed primary closure may be attempted as described

in the section on soft tissue wounds. This should be

accomplished in a stable environment.

Transportation Casts

 Introduction.

ο A transportation cast is a well-padded cast that is unique

to the treatment of combat casualties. It is used to transport

patients between hospitals and not intended as a means

of definitive care.

ο Definitive reduction is not required with the initial surgical

procedure.

ο The goal of transportation casts is to immobilize a fracture

along the evacuation chain. The cast must meet the

dimensions of the standard NATO litter (FM 8-10-6).

ο Transportation casts are applied prior to evacuation.

ο All casts must be bivalved prior to evacuation. (Hip spica

— univalved.)

ο If a patient is expected to have multiple procedures at the

same hospital, balanced skeletal traction should be utilized

until the last procedure prior to transportation. The traction

pin may be incorporated into the transportation cast.

ο Slab splinting may not be adequate for transportation,

particularly for severely unstable fractures. Splinting is

appropriate for stable fractures, particularly in the hand,

wrist, forearm, foot, ankle and lower leg.
23.5

Extremity Fractures

ο Portable skeletal traction should not be used for transportation of a patient.

ο Tobruk splint (a Thomas splint with circular plaster)

should not be used.

 Hip, femur, and knee, and some proximal tibia fractures.

ο Low hip spica transportation cast.

ο Disadvantages: Limited soft tissue access. Not suitable in

polytrauma.

ο Technique.

♦ Adequate anesthesia is given, and patient is placed on

fracture table (Fig. 23-2).

♦ Irrigation and debridement as indicated above.

♦ Precise reduction not necessary, but usually requires two

assistants.

♦ Stockinette over abdomen, distal thigh of uninvolved

side, and foot of the involved side (Fig. 23-3).

Fig. 23-2. Portable fracture table.

Fig. 23-3. Patient position on fracture table.
23.6

Emergency War Surgery

♦ Felt padding is placed over sacrum and anterior

superior iliac spine (ASIS) and other bony prominences.

♦ Towel is placed over abdomen to allow breathing space.

♦ Six-inch Webril or similar cotton batting is wrapped, 2-

4 layers.

♦ Six-inch casting material is then rolled over the Webril

from ASIS to the foot on the affected side to the distal

thigh on the unaffected side (Fig. 23-4). Splints are

applied over the posterior, lateral, or groin areas to

reinforce the groin (Fig. 23-5). Use a finishing roll after

turning down the edges of the stockinette to give a neat

appearance.

♦ An adequate perineal

space must be left for

hygiene.

♦ Use a 1/2" dowel or

similar material to

make anterior/posterior crossbars.

♦ Affected knee bent

about 20°.

♦ Space between feet

must not exceed standard litter, although

this makes perineal

access difficult.

♦ Towel is removed,

cast is bivalved, and

a circular area over

the abdomen is cut

out.

Fig. 23-4. Hip spica transportation cast.

Fig. 23-5. Reinforce cast at hip with

splints.
23.7

Extremity Fractures

♦ Use an indelible marker to draw the fracture configuration,

and note the dates of surgery and wounding on the cast.

♦ Support the cast with towels, blankets, or pillows to

relieve pressure on the cast, especially the back edge.

 Proximal/mid/distal tibia and ankle fractures.

ο Long Leg Cast (Fig. 23-6).

Fig 23-6. Long leg cast.

Fig. 23-7. Supracondylar mold of long leg cast.

ο Technique.

♦ The foot, leg, and thigh are placed in a stockinette at

the conclusion of the operation for the open wounds.

♦ Two people are needed to maintain the reduction and

apply the cast. Hold the knee flexed about 20°.

♦ Webril applied from the toes to the groin.

♦ Six-inch wide casting material is then rolled over this

region, with a turn down of the stockinette prior to the

final layer, to make a neat edge.

♦ Reinforce the knee to strengthen the cast.

♦ Make a supracondylar mold to provide support (Fig. 23-7).
23.8

Emergency War Surgery

♦ Bivalve the cast.

♦ Label the cast with the dates of injury and surgery, and

draw the fracture on outside of the cast.

♦ Elevate the leg so the tibia is parallel to the litter or bed.

 Shoulder and humeral shaft fractures.

ο Velpeau technique. (External fixator is an acceptable

alternative, however without direct visualization there is

a high risk of iatrogenic injury to the radial nerve and

vascular structures. Review anatomy carefully.)

♦ At the conclusion of open wound treatment, the

extremity is manipulated on the fracture table to obtain

the best alignment.

♦ Large cotton pads are placed under the axilla and arm

(Fig. 23-8a).

♦ The Webril is wrapped around the torso and affected

extremity to the wrist (Fig. 23-8b).

♦ Six-inch wide casting material is then wrapped over the

extremity and the torso. The first wrap should start

around the trunk, go over the shoulder posteriorly,

down the arm anteriorly, around the elbow, and then

up the posterior aspect of the arm (Fig. 23-8c).

♦ The trunk and the extremity should be wrapped in

plaster to stabilize the cast.

♦ Four layers should be sufficient (Fig. 23-8d).

♦ Bivalve this cast, and wrap with elastic bandages. There

are no cast saws available on the aircraft. If a patient in

a Velpeau cast develops any respiratory problems,

emergency measures cannot be taken if the cast cannot

be removed.

 Elbow/forearm.

ο Long arm cast.

ο Technique.

♦ After treatment of open wounds, the extremity is

wrapped in stockinette from the fingers to the axilla.

♦ Gross alignment of fractures is the goal. Precise

reduction is not necessary.

♦ Four-inch wide Webril is wrapped from metacarpal

heads to axilla.
23.9

Extremity Fractures

♦ Four-inch wide casting material is applied from

metacarpal heads to axilla.

♦ Fold the stockinette before finishing layer for a neat edge.

♦ Bivalve cast after drying.

♦ Reassess neurovascular status.

Bivalving Casts

When a cast is bivalved, it is completely split longitudinally

along opposing sides of the cast. Splitting the cast into anterior

and posterior halves is preferred. The purpose of bivalving is

to allow room for soft tissue swelling, thus lessening the chance

a b

c d

Fig. 23-8a. Padding Velpeau.

Fig. 23-8b–c. Webril application for Velpeau cast.

Fig. 23-8d. Completed Velpeau cast.
23.10

Emergency War Surgery

of postcasting compartment syndrome. It is important that the

underlying cast padding also be completely split underneath

the cast cuts; otherwise, the cast padding can restrict swelling

and a compartment syndrome could still develop.

External Fixation

 General technique: The surgeon should be familiar with four

types of standard constructs of external fixation for use in

the initial care of battle casualties: femur, tibia, knee, and

ankle. External fixation can also be applied for humerus and

ulna fractures as needed.

ο A thorough understanding of the anatomy of the lower

extremity is essential for application of the pins in a safe

corridor.

ο The external fixator for military purposes should be modular

and allow for building up or down as healing progresses.

ο Application of the external fixator may be done without

the use of plain films or fluoroscopy.

ο Pins can be inserted by hand using a brace without power

instruments.

ο Enough pins should be used to adequately stabilize the

fracture for transport. This is usually two per clamp, but

three may occasionally be required.

ο The present external fixation system (Hoffmann II) allows

for the use of either single pin clamps or multipin clamps.

Both clamps are acceptable to use in standard constructs.

ο Multipin clamps provide geater stability and are the

current fixators fielded. Dual pin placement (with multipin

clamps) is described here. The technique for single pin

placement is similar.

 Femur diaphyseal fracture technique.

ο The entire limb is prepared for surgery, from the ASIS to the toes.

ο A standard OR table or portable fracture table may be used.

ο An assistant should apply counter pressure while pins are

inserted.

ο Precise reduction is not necessary. A padded “bump”

under the thigh will help reduce the fracture (Fig. 23-9).
23.11

Extremity Fractures

ο The position of the proximal femur should be identified

by palpation. A 1-cm longitudinal stab incision is made

over the midaxis, or midlateral axis, of the femur (Fig. 23-

10). The pin closest to the fracture should be outside of the

fracture hematoma, and at least three fingerbreadths from

the fracture (Fig. 23-11).

ο Bluntly spread with a clamp down to bone. Put the pin

down on the bone, and determine the midportion of the

bone by moving the pin back and forth across the width

of the femur. You do not want to plunge to one or the other

side. Your assistant should provide stability and counter

Fig. 23-9. Placing a towel underneath the thigh helps to reproduce

the bow of the femur.

Fig. 23-10. A 1-cm or so incision Fig. 23-11. Femur pin placement.

directly over the middle of the bone,

cut in a longitudinal direction.
23.12

Emergency War Surgery

pressure. Two taps on the end of the bit brace should

provide an indent in the bone and allow you to start

insertion. Apex pins are placed by hand. There is no

predrill nor power insertion. 5-mm half-pins should be

used. Insert the pin in the midportion of the bone through

both the near and far cortex of the

bone (Fig. 23-12). The pin will

move easier as it enters the intermedullary canal, and then get

more difficult to drive as it enters

the far cortex.

ο Place a multipin clamp over the

inserted pin (Fig. 23-13). Ideally,

the pin should occupy one of the

end positions (eg, position 1, Fig.

23-14).

ο Using the clamp as a guide, insert

a second pin through the clamp.

An assistant should hold the

clamp. Ensure that the clamp is aligned to the bone and

that bicortical purchase is obtained with the second pin.

The second pin must be parallel to the first (Fig. 23-15).

Use the pin sites that are the farthest apart on the clamp as

possible for biomechanical stability (clamp positions 1 and

Fig 23-12. Bicortical

placement of 5-mm

half-pin.

Fig. 23-13.
23.13

Extremity Fractures

5 are best, see Fig. 23-14). A third pin

may be inserted if needed for

additional clamp stability.

ο Apply a second multipin clamp and

pins in the same manner to the distal

femoral fracture fragment.

ο Connect the two clamps with elbows,

bar-to-bar clamps, and two

longitudinal bars placed parallel to

each other (Fig. 23-16).

Fig. 23-14.

Multipin clamp

showing pin

positions 1-5.

1

2

3

4

5

Fig. 23-15.

ο Reduce the fracture with longitudinal traction. Manipulating

the fracture fragments using the clamps may be helpful.

Once adequate reduction is achieved, tighten all the

connections. Precise reduction is not necessary.

 Tibia shaft fracture technique.

ο Palpate the anterior-medial border of the tibia. Place a 1-

cm longitudinal incision over the midportion of the surface

(Fig. 23-17). The pin closest to the fracture site should be

outside the hematoma and at least three fingerbreadths

away from the fracture site (Fig. 23-18).
23.14

Emergency War Surgery

ο Insert one pin into either the proximal or distal fragment,

engaging both cortices. This pin should be placed

perpendicular to the subcutaneous border of the tibia, and

centered across the width of the tibia (Fig. 23-19).

Fig 23-16.

Fig. 23-17. Palpation of the anterior and posterior margins of the

medial face of the tibia where a 1 cm incision has been made

midway between these two points.
23.15

Extremity Fractures

o Using the clamp as a guide, insert a second pin through

the clamp. An assistant should hold the clamp. Ensure that

the clamp is aligned to the bone and that bicortical

purchase is obtained with the second pin. The second pin

Fig. 23-18. The anteriomedial surface is the safest way to introduce pins

to the tibia. The pin should be a minimum of two or three fingerbreadths

from the fracture site.

Fig. 23-19. This is the ideal bicortical placement for a pin in the tibia.

must be parallel to the first. Use the pin sites as far apart

on the clamp as possible for biomechanical stability (Figure

23-20 and positions 1 and 5 in Fig. 23-14). The second pin

should be through the clamp farthest away from the

fracture site (Fig. 23-20).
23.16

Emergency War Surgery

ο Apply a second multipin clamp and two pins in the same

manner to the other main fracture fragment (Fig. 23-21).

Connect the two clamps via two elbows, bar–bar clamps,

and a single bar (Fig. 23-22).

ο Most battle caused fractures are comminuted; therefore, a

second bar should be added to the construct (Fig. 23-23).

Use a single bar for stable fractures only.

ο Check the reduction.

Fig. 23-20. Application of tibia external fixation with multipin clamps.

Fig. 23-21. Application of the second multipin clamp and two pins.

Repeat those steps with the other major fracture fragment so that

you have two sets of multipin clamps as shown here. You will then

add the 30 degree elbows as shown here, pointing them in a

direction that allows for the best access. At this point you should

have gross alignment of the fracture.
23.17

Extremity Fractures

 Technique to span knee.

ο Indications are proximal tibia fractures, distal femur

fractures, or extensive knee injuries, or vascular repairs in

the popliteal fossa.

Fig. 23-22. Addition of the cross bar and two bar-to-bar clamps.

Have your assistant apply longitudinal traction to reduce the frame,

and then tighten the frame in alignment.

Fig. 23-23. Two-bar apparatus. As the majority of tibia fractures are

unstable, it creates a more stable construct by adding a second bar.

This requires the use of two of the kits but makes little difference when

you are using the tub container at the CSH or equivalent hospitals.
23.18

Emergency War Surgery

ο Check the distal vascular status of the limb prior to and

after the procedure. If there is a vascular injury, refer to

Chapter 27, Vascular Injuries.

ο An assistant will be required to help apply the frame.

ο General reduction maneuver should be longitudinal

traction with slight (10°–15°) flexion at the knee.

ο Pins are placed anterior medial on the proximal tibia and

antero-lateral on the distal femur. Pin placement should

be outside of the zone of injury, at least three fingerbreadths

from a fracture site, and outside of the knee joint. At the

distal femur, a longitudinal stab incision is made over the

antero-lateral aspect of the bone, so that the pin may be

inserted into the center of the bone at about a 45° angle

from the horizontal. Depending on the fracture configuration, it may also be placed directly anteriorly, though

it is generally better to avoid the quadriceps tendon.

ο Blunt dissection is used to create a corridor to the bone.

ο A single pin is inserted by hand through both cortices of

the bone fragment.

ο A multipin clamp is used as a guide for a second pin. The

second pin must be parallel to the first and also bicortical

— care should be taken to maintain pin alignment. The

proximal tibia should be palpated on the anterior medial

surface and the anterior and posterior border should be

identified. Midway anterior/posterior, a 1-cm longitudinal

stab incision should be made and a blunt soft tissue

dissection made to bone.

ο A multipin clamp should be used as a guide to insert a

second pin in the proximal tibia.

ο The two pin clusters (femur and tibia) should be connected

via two elbows, two bar-bar clamps, and a single bar. The

knee should be aligned.

ο A second bar should be added in the manner described

above.

 Technique to span ankle.

ο An assistant will be required to help apply the frame and

reduce the ankle.
23.19

Extremity Fractures

ο General indications are for open distal tibia fractures and

open ankle wounds.

ο Pins should be inserted on the anterior medial surface of

the tibia and the medial aspect of the calcaneus.

ο Check the distal vascular status prior to and after the

procedure. Mark where the posterior tibial and dorsalis

pedis artery pulses can be felt.

ο Palpate the anterior medial border of the tibia. Make a 1-

cm longitudinal incision midway between the anterior and

posterior border of the tibia. Insert the most distal pin on

the tibia outside the zone of injury, at least three

fingerbreadths from the fracture site.

ο Using a multipin clamp as a guide, insert a second pin in

the tibia more proximal to the first. The pin must be parallel

and be aligned in the longitudinal axis to the first.

ο Palpate the medial border of the calcaneus. Make a

longitudinal incision over the calcaneus away from the

posterior neurovascular structures: dissect to the bone

with a clamp and insert the pin.

ο Using a multipin clamp as a guide, insert a second pin in

the calcaneus.

ο Connect the two clamps via two elbows, two bar–bar

clamps, and a single bar.

 Skeletal traction.

ο Skeletal traction provides a quick means to immobilize a

large number of fracture cases with a minimum of technical

support.

ο Indications.

♦ Patients who are expected to have more than one

procedure in the same forward hospital prior to

evacuation.

♦ Large casualty load.

ο Technique.

♦ Large threaded Steinman pins are used to obtain skeletal

traction of a femur or tibia.

♦ Aseptic preparation of a pin site is necessary prior to

placement.

♦ Apply local anesthetic to pin site.
23.20

Emergency War Surgery

♦ Incise skin and dissect to bone bluntly.

♦ For femur fractures, incision is made 2 cm posterior and

lateral to the tibial tuberosity (directly under, as in Fig.

23-24). Place pin from lateral to medial through and

through the proximal tibia.

♦ Apply a Thomas splint with Pierson device, with weight

applied midthigh (10–20 lb), to the leg (10–20 lb), and

to the traction pin (20–40 lb) to obtain balanced skeletal

traction as shown in Fig. 23-25.

♦ For tibia fractures, incise medially 2 cm anterior and 2

cm cephalad from the tip of the heel. Place the pin from

medial to lateral through and through the calcaneus.

Place the leg on a Bohler-Braun frame and apply traction

to the calcaneal pin (10–20 lb).

♦ Wait at least 1

/2 hour after applying traction to obtain

radiographs.

 Care in the evacuation

chain.

ο Patients do not

improve in the

evacuation system.

Fig. 23-24. Thomas splint with

Pierson device.

Fig. 23-25. Bohler-Braun frame with

traction.

Consider patient safety during evacuation when planning

procedures.

ο Medications should be arranged prior to departure. Ensure

adequate pain control.

ο Skeletal traction should not be used for transportation.
23.21

Extremity Fractures

ο Casts should be bivalved. Follow neurovascular status

during transport because casts may act as tourniquets due

to tissue swelling.

ο All documentation, including radiographs, should

accompany the patient.
23.22

Emergency War Surgery