Indications for transfer

Clinical Indications for Transfer of Musculoskeletal Injuries to a Major Trauma Service

• Limb threatening injuries.
• Suspected spinal injuries (see spinal trauma protocols).
• Serious crush injuries.
• Open fracture of pelvis.
• Severe closed pelvic ring and/or acetabular injury.

Patient Management Indications for Transfer to a Major Trauma Service

• Inability to manage open fractures with definitive surgery within 6 hours
• Inability to manage all long bone fractures within 24 hours

If there is an indication to transfer a patient for any of the above indications or for management of other injuries then:

• Notify the MTS within 15-30 min of patient arrival and
• Arrange transfer to the MTS within 60 min of arrival.

Any intention to undertake orthopaedic procedures should be discussed with the MTS orthopaedic service.

Musculoskeletal trauma management guidelines

Closed Limb Fractures

• Assess and record neurovascular status.
• Straighten / align the limb.
• Apply a splint in anatomical position.
• Continue to regularly monitor neurovascular status.
• If neurovascular compromise evident arrange orthopaedic consultation immediately.

Open Limb Fractures

• As per closed limb fractures above.
• Administer IV antibiotics (generally Keflin and Gentamycin). Be aware of any allergies.
• Perform simple emergency room toilet by removing any easily identified foreign objects/contamination.
• Apply Betadine soaked gauze dressing and bandage - leave intact.
• Immediate orthopaedic consultation.

Note: If definitive management occurs more than 6 hours after injury the likelihood of chronic infection is significantly increased, therefore IMMEDIATE transfer to a destination where early definitive management can be undertaken, is imperative.

It is NOT APPROPRIATE to treat other "simple", closed injuries locally prior to transfer for management of the complex and open injuries. The reverse must occur - immediate transfer for management of the open injuries and delayed management of closed injuries.

Joint Dislocation

• Joint dislocation may be associated with a fracture or may be mistaken for a juxta articular fracture - always obtain an x-ray before management.
• Neurovascular structures are at risk. Always assess and record findings.
• Reduce dislocated joints if possible and splint in stable position.
• Monitor neurovascular status after reduction.
• An open dislocation requires the same antiseptic precautions as an open fracture.
• Arrange immediate orthopaedic consultation.

Pelvic Injuries

• Life threatening injuries (due to blood loss) may exist in the pelvic area with minimal external evidence.
• Always assess the pelvis clinically and radiologically in any patient with major trauma.
• Vigorous resuscitation, immediate and ongoing, may be required including multiple IV lines and uncrossmatched blood on occasions.
• A urinary catheter should be inserted (if urethral injury does not preclude this).
• Any significant injury should be transferred to a MTS within 30 minutes of diagnosis, subject to constraints of other injuries.