When snowboarding goes wrong…

26 yo male comes into the ER after falling while attempting a jump during a snowboarding competition.  When he fell, he heard and felt a “snap” in his R leg.  He cannot bear weight on the R leg.  He has no other significant history.  He was helmeted, denies LOC, and has no head, neck, or back pain.  His pain is an 8/10 after EMS has given him 8 mg of morphine IV (he weighs ~80kg).

What’s the fracture?

What’s the treatment?

What is the timeframe to healing?

How would you consider pain controlling this patient?

What else matters for this patient?

Femur Fx 2

Posted in: Case Types, Orthopedics

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8 Comments on "When snowboarding goes wrong…"

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  1. MediMike says:

    R Midshaft femur fx
    Application of traction splint post additional analgesia (morphine/hydromorphone) with some versed added in if possible
    Other concerns would include any significant deformity/ecchymosis indicating possible internal bleeding
    The other questions have me at a complete loss! Just a simple paramedic here haha

    • rainesg says:

      No such thing as a simple paramedic… the xray shows that a traction splint was applied and the degree of alignment achieved is what ultimately gave the relief to the patient. Prior to having it placed, the patient received 400 mcg of fentanyl without good pain control. Re-aligning the bone ends is key to pain control as it limits spasm, tamponades further bleeding, and maintains comfort for any transport needs.

      • MediMike says:

        Gotcha! Didn’t zoom in on the xray and see the splint applied there. Thank you for the information!

  2. jd1368 says:

    I would agree with above, but also add that the patient should be further monitored for fat embolism given location and severity of fracture.

  3. rainesg says:

    jd1368,
    You make a good point about fat embolism. Midshaft femur fractures are the primary fracture associated with fat embolism. Time to definite repair is key in these fractures as the longer this goes unrepaired, the higher the probability of developing a fat embolism. For this patient, he was repaired within 90 minutes of arriving at the facility by our orthopedic surgeon (2.5 hours from initial injury). It was a rare day that we actually had coverage. This was fixed with an intramedullary rod and screws.

  4. eric says:

    I knew there was a reason I never ski or snowboard…I think I will just sick with the snowshoes thank you very much…

  5. dd1424 says:

    Are we looking at 8-12 weeks for initial healing? Plus however long PT will be.
    I think versed in this patient would be a good adjunct to pain control and to help relax the muscles when pulling traction.

  6. dd1424,
    Good question and a good point. Early mobilization is advised once the rod is placed, so PT will start early and often (days to 1-2 weeks even). To fully heal, the patient is looking at a timeframe of AT LEAST 4-6 months and more likely, 9 months to a year where they can return to sports at the prior level.

    Versed is a great choice here for both anxiolysis and muscle relaxation. Just remember though, once that traction splint is on and the bones aren’t rubbing against each other, the spasms will subside substantially and the prior narcotics administered will have a profound effect. This is why fentanyl was chosen – short half life – to allow for placement of the splint and so it would wear off quickly. Once the splint is placed and you have a better idea of what pain management is going to look like pre-op, then I would move to longer acting agents.

    G

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