What is the emergency management of a patient with a severe comminuted fracture that may require amputation?

Emergency Management of Severe Comminuted Fractures with Potential Amputation

Immediately apply a tourniquet if there is active limb hemorrhage uncontrolled by direct compression, amputation, foreign body in the wound, absent radial pulse, or multiple simultaneous resuscitation actions required, and transport the patient to a specialized trauma center within 4 hours of presentation. 1

Immediate Hemorrhage Control

The priority is stopping life-threatening bleeding to prevent exsanguination and the lethal triad of hypothermia, acidosis, and coagulopathy. 1

• Apply direct manual compression with a pressure dressing for initial bleeding control in wounds where this technique can achieve hemostasis 1, 2
• Apply a tactical tourniquet immediately if direct compression fails, in cases of traumatic amputation, when a foreign body prevents effective compression, when the patient has no radial pulse (indicating hemorrhagic shock), or when multiple simultaneous resuscitation actions are required 1
• The tourniquet is the fastest and potentially life-saving technique in catastrophic hemorrhage and should not be delayed 1
• Re-evaluate tourniquet effectiveness, usefulness, and location as soon as possible (even in the prehospital phase) to minimize ischemic time and tissue damage 1
• Never perform iterative tourniquet releases for ischemic sparing, as this aggravates local muscle injury and systemic rhabdomyolysis 1

Trauma Center Admission Criteria

Transport to a specialized trauma center reduces both morbidity and mortality—with an additional 3-4 patients surviving per 100 patients with Injury Severity Score >15. 1

Vittel criteria indicating severe limb trauma requiring trauma center admission include: 1

• Two or more long bone fractures
• Proximal amputation above the wrist or ankle
• Degloving injuries
• Crushing injuries
• Acute limb ischemia

Initial Wound Management

• Irrigate the wound with simple saline solution only—additives such as soap or antiseptics provide no benefit and may cause harm 2
• Wrap the wound in a sterile wet dressing to prevent desiccation and contamination 2
• Initiate antibiotics immediately upon presentation, as early prophylaxis significantly reduces infection rates 2
• Use cefazolin for all open fractures (or clindamycin for beta-lactam allergy) 2
• Add gram-negative coverage (aminoglycoside or piperacillin-tazobactam) for wounds with significant tissue damage and bone exposure 2

Hemodynamic Status Assessment and Treatment Algorithm

The patient's circulatory status determines whether to pursue early definitive surgery versus damage control strategy. 1

Hemodynamically Stable Patients (No vasopressors, <1 unit transfusion, lactate <2.5 mmol/L):

• Proceed with early safe definitive orthopaedic surgery within 24-36 hours, including thorough debridement, fracture stabilization, and wound coverage 1, 2
• In hemodynamically stable patients, limb salvage is recommended as psychological outcomes and quality of life are superior with successful limb preservation 1, 2

Hemodynamically Unstable Patients (Vasopressors >2 mg/h norepinephrine, transfusion >1 unit, lactate >2.5 mmol/L):

• Apply a damage control orthopaedics (DCO) strategy with temporary stabilization rather than definitive fixation 1
• Use external fixators for temporary stabilization when definitive osteosynthesis is not anticipated within 24-36 hours 1
• Schedule delayed definitive osteosynthesis as early as possible once stable clinical status is obtained through daily reassessment of hemodynamic, respiratory, coagulation, and acid-base status 1

Severe Hemorrhagic Shock (Vasopressors >4 mg/h, transfusion ≥5 units, lactate >4 mmol/L):

• Apply damage control strategy with consideration of early amputation if hemorrhage cannot be controlled 1
• Factors suggesting possible amputation include: complete traumatic amputation, massive tissue loss preventing skin coverage, proven tibial nerve section, multiple fractures with bone loss, or ischemic vascular lesions 1
• However, no single severity criterion mandates amputation—comprehensive clinical assessment is necessary 1, 2

Surgical Priorities

• Perform urgent surgical debridement with thorough wound irrigation 2
• Investigate neurovascular injuries during debridement, particularly if fracture extends into the greater sciatic notch (which warrants pelvic angiography) 2
• Assess for vascular injury by checking for absent pulses, pallor, neurological deficits, or presence of a thrill 1
• Immobilize the extremity immediately to prevent further soft tissue and neurovascular injury 2

Thromboprophylaxis

• Initiate early pharmacological thromboprophylaxis with low molecular weight heparin after hemorrhage control and hemostasis are achieved 2
• Begin thromboprophylaxis ideally within 36 hours of injury if bleeding is controlled 2

Critical Pitfalls to Avoid

• Never delay antibiotic administration—early prophylaxis significantly reduces infection rates 2
• Avoid using wound additives (antiseptics, soap) during irrigation, as they provide no benefit over saline alone 2
• Do not rely solely on severity scores (MESS, MESI) for amputation decisions—comprehensive clinical assessment is necessary 2
• Never perform iterative tourniquet releases in an attempt to spare ischemic tissue, as this worsens outcomes 1
• Do not apply tourniquets to patients with stable wounds controlled by direct compression, as unnecessary tourniquet use increases morbidity 1