Presence of head injury with fractures makes a special situation. Whenever this occurs diagnosis and initial management of the head injury generally take priority in the earliest phase of treatment. Head injury if severe puts patient into danger of increased mortality.
Mortality rates in large trauma patient studies are driven by severe head injury more than any other organ system.
CT scan of the head is required to define the injury after the initial neurological examination is complete. it is important to splint the fractured limbs as primary care so as to avoid further injury during the shifting and moving. It is sometime difficult to assess spinal injury in patients with severe head injury. Spinal injury should be considered to be present if it cannot be assessed and ruled out. Accordingly, the arrangement and precautions for patient movement should be taken.
Great care must be taken to avoid hurried transfer of head-injured patients to neurological trauma specialty centers because noncranial, life-threatening injuries can frequently be overlooked in the rush to move the patient.
Head injury in itself is not a contraindication to stabilization of fractures. If a neurosurgical procedure is required to be undertaken, the opportunity should be utilized to fix the fractures as well. But when intracranial pressures are high or extremely labile and there exists no neurosurgical solution a proper line between risking raising the intracranial pressure due to fracture surgery and the morbidity unfixed injury can be chosen .
If surgery is chosen, it must be done quickly, limiting blood loss and consequent fluid shifts. Intraoperative hypoxia and hypotension may worsen neurologic functional outcomes. If these are avoided, there is usually no negative impact on neurological outcome.
Of all the fractures the pelvis and femur take priority. If time does not permit, the fracture should be stabilized with a gadget which can be quickly put and definitive surgery can be done at a later stage.
Prognosis based on the GCS score should not be used affect the decision making in determining not to treat the patient with optimum orthopaedic management. Each patient should be given a judicious evaluation.
Fractures in head injury unite faster because of release of humeral factors. That should be taken into account when making treatment decisions.
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