Patients with fractures are very common in air rescues, and fracture medicine is a very important subject in the training and qualification of air medical personnel. There are a variety of fractures that can be experienced by air medical patients, each with dedicated procedures to follow. In this feature on fracture medicine, we investigate the types of fractures handled in helicopter emergency medical services (HEMS) missions, the applicable protocols and equipment, and training for fracture treatment.

Fractures handled in HEMS missions

High-energy trauma can affect all body regions, and it should be observed that brain trauma includes both fractures of the skull and brain injury without fractures, affirmed Wolfgang Voelckel, Chief Medical Officer at ÖAMTC-Flugrettung. “Depending on the mechanism, HEMS physicians and rescuers will overlook a wide variety of injuries and fractures. Some of them are evident on the first pre-hospital examination, while others will be diagnosed by X-ray or computed tomography (CT) scan in the hospital,” he said. “Air rescuers respond to an increasing number of elderly patients, many of whom suffer from frailty and osteoporosis. In these patients even low-energy trauma can cause significant fractures, such as proximal femur fractures, spine or rib fractures, as well as other fractures of the upper and lower extremities.”

A spokesperson from Hamilton Medical pointed out the difference between being susceptible to fractures and being exposed to situations that may result in fractures, especially in the context of ventilation: “Usually, the elderly are most susceptible to fractures due to a combination of age-related physiological changes and certain health conditions. They rarely need ventilation though. One of the main reasons a patient requires ventilation for a fracture injury is to relieve them from a severe state of pain, debilitating chest wall injuries like flail chest, pneumothorax/hemothorax and severe multisystem trauma situations. The main demographic sustaining injuries in high-energy accidents, work-related accidents, or falls from a significant height are adolescents up to middle-aged adults.”

According to Ahmad Almigdad et al in a 2022 journal article entitled ‘Bone Fracture Patterns and Distributions according to Trauma Energy’¹, in individuals aged one to 44, trauma is the leading cause of death. In high-income countries, road traffic injuries and self-inflicted and violent injuries are the leading cause of death in people aged 15 to 29, with 75% of these deaths occurring in men. “The majority of injuries are preventable. However, ninety percent of trauma-related deaths occur in low- and middle-income countries, secondary to many factors such as lack of prevention and immediate and quality trauma care,” the researchers said.

The predominant fractures seen in the pre-hospital setting are in the context of patients with multiple injuries

The predominant fractures seen in the pre-hospital setting are in the context of patients with multiple injuries, mainly from motor vehicle accidents: motorcycles, automobiles and, increasingly, e-scooters, according to Dr Jeff Hooper, Medical Director at LifeFlight. “High-mechanism injuries include pelvic, femoral, and humeral fractures, but pre-hospital providers often encounter open/displaced extremity fractures in the context of other multiple injuries,” he observed.

Factors that contribute to musculoskeletal injury patterns include patient age, bone quality, and the mechanism of injury, according to Almigdad et al. “Simple falls are the most common injury mechanism in both genders, while males are more prone to high-energy fractures. Each injury mechanism contributes to specific fracture patterns in each gender. Therefore, knowing the trauma mechanism is essential to expect the extent of injuries and plan preventive measures accordingly,” they wrote.

In motor vehicle collisions, the types of injuries vary depending on the direction of impact, with frontal impact collisions causing knee, thigh, and hip injuries. The position of the femur, whether adducted or abducted, affects the force vector and determines the acetabular fracture pattern and associated hip dislocation, according to Almigdad et al. “Additionally, spine fracture occurs especially in the cervical region with acceleration/deceleration injuries, which cause whiplash-associated disorders. Motorcycle crashes may result in open-book pelvic fracture secondary to the pelvis striking the handlebars,” they stated.

Most high-energy trauma mechanisms surround falling from height and motor vehicle accidents. Other high-energy mechanisms include industrial accidents and ballistics, explained Tegan Fletcher, Critical Care Paramedic and Program Lead – Continuous Professional Development and Certification at Ornge. “The majority of high-energy trauma we see at Ornge surrounds motor vehicle accidents, including all-terrain or recreational off-road vehicles. Long-bone fractures are the most common high-energy fracture we see in a pre-hospital and retrieval environment, followed by pelvic and thoracic cage fractures,” she said.

According to Kelly Miller, Vice President of Clinical Services at Air Methods, the major fractures that require air medical transport include long-bone fractures of the humerus and femur, along with pelvic fractures. “Additionally, any open fracture where there is open skin at the site of the fracture possesses an increased risk for infection (osteomyelitis), which also increases risk for loss of the extremity and may be considered for air medical. The long-bone fractures of the humerus and femur have risk of neurovascular complications, emboli, and hemorrhage, which can be significant and lead to shock in a patient,” he said. “Pelvis fractures carry the highest mortality of all these fractures: from 5–16%, according to the American College of Surgeons. The pelvis is a highly vascular area with serious risk of life-threatening hemorrhage.”

Additionally, any open fracture where there is open skin at the site of the fracture possesses an increased risk for infection (osteomyelitis), which also increases risk for loss of the extremity and may be considered for air medical

The kind of injuries that result in fractures and also require ventilation are explained by the spokesperson from Hamilton Medical: “Mechanical ventilation is used in cases of polytrauma, severe pelvic injuries, and polytraumatic injuries where the patient is in compensated or decompensated shock, to stabilize vital functions. Traumatic brain injury (TBI) also greatly benefits from ventilatory support that maintains normocapnia and normoxia. Thoracic injuries, such as flail chest, may sometimes require ventilation to stabilize the chest wall, while severe head trauma – either blunt or penetrating with a reduced level of consciousness (LOC) – often necessitates an advanced airway and mechanical ventilation. Additionally, elderly patients with minor fracture injuries may benefit from noninvasive ventilation during rescue to manage underlying medical issues such as chronic obstructive pulmonary disease.”

Protocols and equipment

As to the kind of care fracture patients requiring air medical services need, Voelckel observed that key elements of pre-hospital care are in-line immobilization (splinting and/or vacuum mattress), analgesia, reduction in case of significant dislocation or in open fractures, and, if needed, fluid resuscitation.

According to Dr Hooper, fracture management in the pre-hospital setting includes some main principles:

• Assessment and management of life-threatening injuries (fractures may be part of a complex of injuries in major trauma)
• Assessment of limb fracture: position, open/closed, presence of neurovascular compromise
• Ensuring the patient has appropriate analgesia; local anesthetic nerve blocks are appropriate in some settings, particularly femoral fractures
• Exploring the potential for fracture reduction if the team is appropriately trained, including the use of femoral splint, pelvic splint, simple splint, air/vacuum splints
• Wound irrigation for compound fracture
• Splinting: simple SAM Splints, air/vacuum splints
• Transfer to an appropriate trauma center.

The first step while caring for fracture patients is to ensure that breathing and circulation are managed, according to Fletcher. “The ‘massive hemorrhage, airway, respiration, circulation, hypothermia’ (MARCH) [acronym] provides a systematic approach to guide the initial management priorities in trauma patients. Hemorrhage control includes compressible and non-compressible bleeding. This could be from an open fracture, a closed long-bone fracture or from a pelvic fracture,” she said. “There is still significant controversy over pelvic binders, but, given the quality of the best available evidence, it is still reasonable to place a pelvic binder if there is enough suspicion that a pelvic fracture is contributing to hemorrhagic shock.”

The ‘massive hemorrhage, airway, respiration, circulation, hypothermia’ (MARCH) acronym provides a systematic approach to guide the initial management priorities in trauma patients

Extremity fractures should be assessed for signs of impaired circulation, sensation, and motor control, explained Fletcher. “Realignment with subsequent splinting should be attempted using analgesia or procedural sedation. Ketamine is used for analgesia in trauma patients and has the added benefit of being less likely to cause hypotension, depending on the underlying pathophysiology. For suspected or obvious open fractures, we would consider prophylactic antibiotics as well as ensuring tetanus vaccinations are up to date,” she said. “In addition to managing initial concerns, standard trauma care resuscitation involves mitigating and managing hypothermia, acidosis, coagulopathy and hypocalcemia. For spine-related concerns we follow the Canadian C-spine rule [to assess for neck fractures and whether radiography will be required].”

Fracture patients require referral to an orthopedic surgeon and in some cases also a vascular surgeon and/or interventional radiologist, explained Miller. “Air medical clinicians are trained to stabilize the fractures, minimizing further damage from movement of the fracture. The stabilization of the femur fracture may include the application of traction to realign the bone, promoting hemorrhage control, treating open fractures with early antibiotics therapy, binding the pelvis to promote hemorrhage control, and administering both tranexamic acid along with blood products in the presence of hemorrhage,” he said.

When a fracture patient is determined to require ventilation, then a special ventilator is used, which can not only provide breathing support but also feed back important information and help prevent further injury, said the spokesperson from Hamilton Medical: “Mechanical ventilators basically provide a safe and high-quality level of ventilatory support, preventing barotrauma, volutrauma and hypoxia. The proximal flow sensor of the HAMILTON-T1 provides invaluable information about a patient’s lung condition. This, along with various alarm and monitoring functions, guarantee the safety of the applied ventilatory therapy. Additionally, the use of either SpO₂ [oxygen saturation] or EtCO₂ [end-tidal carbon dioxide] sensors attached to the ventilator will further assist the caregiver with a complete picture of their patient’s condition. Keeping these patients within a tightly controlled EtCO₂ and SpO₂ range is imperative.

“Adaptive support ventilation (ASV) is an advanced, automated mode of mechanical ventilation designed to optimize a patient’s breathing by continuously adjusting ventilatory support based on the patient’s needs. Even though ASV is a closed-loop system that adapts both the respiratory rate and tidal volume to match the patient’s lung mechanics, the medical care provider stays in full control of the ventilator at all times. It is used in both passive (fully ventilated) and active (spontaneously breathing) patients. By adjusting ventilation in real-time based on lung mechanics, ASV helps prevent complications like volutrauma (lung injury from overinflation), barotrauma (injury from high airway pressures), hypoventilation, and atelectasis (lung collapse).”

Even though ASV is a closed-loop system that adapts both the respiratory rate and tidal volume to match the patient’s lung mechanics, the medical care provider stays in full control of the ventilator at all times

The spokesperson from Hamilton Medical added: “Patients with pulmonary contusion, flail chest, pneumothorax, ARDS, aspiration airway obstruction, and hemothorax are difficult to ventilate, but ventilators can compensate for these complications from chest or head trauma by adjusting pressure, volume, and respiratory rate to match the patient’s specific needs. Modern ventilators offer advanced modes such as pressure-controlled or ASV to optimize lung mechanics, reduce further injury, and improve oxygenation, while careful attention is paid to complications like lung stiffness, airway obstruction, or impaired brain control over breathing.”

Training for fracture treatment

LifeFlight doctors are trained before they begin pre-hospital work with the helicopter service. They are typically taught splinting techniques: femoral splinting, SAM splinting, and pelvic splinting, and the appropriate use of analgesia and sedation for fracture reduction techniques. Doctors are also taught how to manage open fractures and are provided with scenario training to safely assess and manage orthopedic injuries and transfer a well-discharged patient into the helicopter, affirmed Dr Hooper.

Air Methods’ clinician training covers a variety of settings to provide a diverse platform of learning opportunities, explained Miller. “This includes high-fidelity simulation, virtual reality, and cadaver lab training to be able to give the team frequent exposure to these common complications of trauma,” he said.

This includes high-fidelity simulation, virtual reality, and cadaver lab training to be able to give the team frequent exposure to these common complications of trauma

Ornge does all of its training in-house. “Critical care paramedics go through a trauma and trauma care module within their critical care program,” said Fletcher. “Our paramedics also complete approximately 90–100 hours of continuous professional development a year, which also includes aspects of trauma management. There are various courses that teach principles of fracture management. Most paramedics are taught basic fracture management in their college programs.”

Concerning training and qualification, ÖAMTC-Flugrettung expects from all air rescue physicians board certification in either anesthesiology, surgery or trauma surgery, internal medicine or general medicine, explained Voelckel. “Moreover, experience in intensive care, as well as in acute medicine, including trauma care, is mandatory. Formal qualification further comprises a board-certified pre-hospital EMS physician course program and specific training in our air rescue service,” he said. “Recognized international training programs such as Advanced Trauma Life Support (ATLS) and European Trauma Course (ETC) are highly recommended, and most of our HEMS crew participated in one of these courses.”

References:

1. Ahmad A, Ayman M, Sattam A et al. Bone fracture patterns and distributions according to trauma energy. Advances in Orthopedics 2022;2022:8695916.