What are the conservative and operative management options for a patient with closed right iliac (pelvic) fracture, closed right mid‑shaft femur fracture, closed right tibial plateau fracture, and closed right proximal fibula fracture?

Management of Multiple Ipsilateral Lower Extremity Fractures

This patient with multiple ipsilateral closed fractures (iliac/pelvic, mid-shaft femur, tibial plateau, and proximal fibula) requires urgent surgical stabilization of the femur within 24 hours if hemodynamically stable, followed by staged fixation of the tibial plateau, with the pelvic fracture managed based on stability assessment. 1

Conservative Management

Initial Resuscitation and Stabilization

• Administer regular paracetamol immediately as first-line analgesia unless contraindicated, as this is the foundation of pain management for multiple fractures 1, 2
• Add opioid analgesia cautiously with reduced dosing (approximately half the standard dose) until renal function is confirmed, as 40% of fracture patients have moderate renal dysfunction 1, 2
• Avoid NSAIDs entirely until renal function is documented, as they are relatively contraindicated in this high-risk population 1, 2
• Immobilize all fracture sites immediately to minimize pain and prevent further soft tissue injury; the femur fracture will present with characteristic shortening and external rotation 1, 2

Advanced Pain Control Options

• Consider femoral nerve block or fascia iliaca block for superior analgesia of the femur and proximal injuries, though these may not reliably block all three nerves (femoral, obturator, lateral cutaneous) 1, 2
• Psoas compartment block is the most reliable method for blocking all three nerves but carries risks of neuraxial blockade and deep hematoma formation in anticoagulated patients 3

Supportive Care

• Initiate intravenous fluid resuscitation with optimized peri-operative fluid management to reduce morbidity, as many patients become hypovolaemic before surgery 3
• Implement active warming strategies immediately and continue throughout treatment, as patients are highly susceptible to hypothermia 3
• Apply thromboembolism stockings or intermittent compression devices along with ensuring the patient remains warm and well-hydrated 3

Pelvic Fracture-Specific Conservative Management

• Closed pelvic fractures that are minimally displaced and stable can be managed non-operatively with protected weight-bearing, though operative treatment of unstable pelvic fractures carries consistently high complication rates and should be considered carefully 4

Surgical Management

Femur Fracture (Priority #1)

• Plan early definitive fixation within 24 hours in hemodynamically stable patients without severe visceral injuries, as this reduces local and systemic complications 1
• Intramedullary nailing is the treatment of choice for unstable mid-shaft femoral fractures, providing load-sharing and allowing early mobilization 5
• Consider damage control orthopedics (temporary external fixation) only if the patient has severe visceral injuries, circulatory shock, or respiratory failure, with delayed definitive fixation once stabilized 1

Tibial Plateau Fracture (Priority #2)

• Displaced tibial plateau fractures require surgical reduction and stabilization to restore a congruent joint surface, typically with bone grafting and buttress plating to allow early range of motion 6
• Timing of surgery is critical and depends on careful evaluation of both the fracture pattern and the soft-tissue envelope; handle soft tissue meticulously in this region 6
• Minimally displaced stable tibial plateau fractures should be treated with protected mobilization rather than surgery 6

Proximal Fibula Fracture

• Proximal fibula fractures typically do not require isolated fixation and are managed in conjunction with the tibial plateau repair, as the fibula provides minimal weight-bearing support 5

Pelvic Fracture Surgical Considerations

• Operative treatment of pelvic fractures should be considered experimental surgery due to consistently high frequency of serious complications and should be reserved for clearly unstable fractures with hemodynamic compromise 4
• Most closed pelvic fractures can be managed non-operatively with protected weight-bearing once other injuries are stabilized 4

Perioperative Management

Anesthesia Considerations

• Spinal anesthesia with lower doses of intrathecal bupivacaine (<10 mg) reduces associated hypotension and is preferred for elderly patients 3
• General anesthesia with reduced doses of induction agents is an alternative, with debate about whether mechanical ventilation or spontaneous ventilation is preferred 3

Intraoperative Monitoring

• Minimum monitoring includes pulse oximetry, capnography, ECG, non-invasive blood pressure, and core temperature monitoring routinely 3
• Point-of-care hemoglobin analyzers should be used routinely at the end of surgery to assess anemia and guide transfusion 3

Infection Prophylaxis

• Administer antibiotics within one hour of skin incision following hospital protocols 3

Thromboprophylaxis

• Prescribe fondaparinux or low molecular weight heparin with timing adjusted to minimize bleeding risk with neuraxial anesthesia (administer between 18:00-20:00 for daytime trauma lists) 3

Critical Pitfalls to Avoid

• Do not delay pain assessment and management while focusing on imaging or other interventions; document pain scores before and after analgesia 1, 2
• Do not use standard opioid dosing without considering renal function, particularly in elderly patients 1, 2
• Do not prescribe NSAIDs without checking renal function first, as this population has extremely high rates of renal impairment 1, 2
• Do not delay femur fixation beyond 24 hours in stable patients, as this increases complications 1
• Do not rush to operate on the pelvic fracture without careful assessment of stability, as operative treatment carries high complication rates 4
• Do not handle tibial plateau soft tissues roughly, as the timing and technique of surgery are critical to success 6