Case Study - Fractures in Disasters and Conflict

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kalyani Yajnanarayan, Kim Jackson, Rachael Lowe, Jess Bell and Olajumoke Ogunleye      

Title

Polytrauma with Complex Fracture following Explosion

Thanks to Humanity and Inclusion for Case Study taken from Early Rehabilitation in Conflicts and Disasters.

Abstract

Mr Abukhair is aged 34 years old and he presented to the emergency room (ER) following an explosion. Injuries obtained include: a displaced pelvic fracture, bilateral femoral fractures and left tibial fracture with extensive blood loss. Consequently, Mr Abukhair had an external fixation of the left tibia, intramedullary (IM) nail fixation of bilateral femurs and conservative management of the pelvic fracture. This resulted in an extensive stay in ICU followed by bed rest, impacting early rehabilitation.

Key Words 

Polytrauma, Fractures, Explosion, Conflict

Patient Characteristics

Past Medical History

Mr Abukhair aged 34 years old, presented to the emergency room (ER) following an explosion, where he was thrown approximately 100m from the blast site. Approximately three hours later, he was brought in by ambulance in a semi-conscious state with extreme blood loss. He was immediately admitted to the intensive care unit (ICU) following initial conservative management.

On further investigation, CT head scan revealed no abnormal findings and he presented with a normal neurovascular exam. However, various views on x-ray (AP, lateral and oblique) confirmed multiple fractures: displaced pelvic fracture, bilateral femoral fractures and left tibial fracture.

ICU treatments included:

• Blood transfusions
• Intramedullary (IM) nails of bilateral femurs
• Left tibia external fixation
• Conservative management of pelvic fractures

After 18 days in the ICU, Mr Abukhair was transferred to the orthopaedic ward. Due to the pelvic fracture, bed rest was advised for six weeks, with no movement at the hip joint permitted. He did not receive any rehabilitation treatment during his stay in the ICU.

Social History

Chronic smoker for 12 years and chewed khat (a local stimulant)

Family History: 6 children. His brother was his main carer while in hospital.

Examination Findings

Observations

Positioning: Supine position with head in slight elevation

Lines in-situ: IV cannula and urinary catheter

Hardware: External fixation of the left tibia

Scar: Long scar along the lateral aspect of bilateral thighs

Swelling: Bilateral lower limb swelling (knees to toes)

Skin: Dry, broken, pale skin over foot and ankle

Muscle: Bilateral quadricep atrophy

Pain: Obvious pain on movement of toes and ankles

Pain Assessment

Numeric Pain Rating Scale (NPRS): 7/10 (in rest), 9/10 (slight movement)

Aggravating factors: Movement of the lower extremity

Relieving factors: Medication, rest and lying in a supine position with slight abduction and external rotation of hip

Location of pain: At the hip joint, knee and over the buttock areas

Physical Examination

Range of Movement

Passive ROM:

• Ankle/toes: Slight limitation in bilateral ankle and toes due to pain
• Knee flexion; right 20 degrees, left 35 degrees

Active ROM:

• Achieved slight movement, unable to reach full range secondary to pain

Strength

Dorsiflexion 3+/5

Plantarflexion 4/5

Unable to perform isometric quadriceps contraction due to pain 1/5

Resources

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion