17. Orthopaedic Injuries
Femoral shaft fracture. Adults shoul, if possible, have such fractures stabilized before repratiation.
Photo: Dept. of Radiology.
There are no contraindications to the transportation of patients with fractures by means of flying.
The regulations for the transportation of patients with fractures should be complied with, i.e. fractures must be stabilised before evacuation.
The correct mode of transportation – e.g. ambulance, train, commercial aircraft, air ambulance, or PTC – should be determined based on the overall condition of the patient, as there are often other injuries or diseases present. If a patient with lower-extremity fractures is to be seated, the airline company should be informed about which leg on the MEDIF in order to seat the patient correctly on-board the aircraft. The airline company also needs to be informed about whether the patient has a high (from proximal femur to foot) or a low (from below knee to foot) cast or brace.
Before initiating the transportation, any fractures should be stabilised either surgically (by internal or external fixation) or by means of external support, i.e. plaster, plastic or metal braces, vacuum mattress, traction splint or combinations of the above.
Airline companies demand that circular plasters or synthetic circular plasters be split open. This is done in order to avoid a situation where an oedema of the extremity results in a compression of nerves or vessels during the transportation. If the patient has an unsplit circular plaster, he or she will not be accepted on-board until after 48 hours; however, it is the opinion of the author that it should be avoided altogether. Whenever possible, the patient should have a plaster splint rather than a circular plaster.
A traction splint is used to maintain traction on the unoperated femur fracture or tibia fracture during transportation. The traction is applied between the ischial tuberosity and the foot and must be dynamic, i.e. based upon, for example, gas hydraulics. The traction splint is often used together with a vacuum mattress.
Extremity fractures should be elevated during transportation, which normally means at heart level.
Patients with fractures of the ankle or the lower leg, which may need surgery, should have the leg elevated to heart level in order to avoid the development of oedema, which may inhibit surgery. It is therefore generally recommended that these patients be transported on a stretcher for the entire journey.
In the case of minor fractures or distortions in the lower extremities that do not need surgery, it is often appropriate to travel sitting upright with a leg-rest. This normally means that the patient is placed with the leg resting on the seat in front, where the backrest has been leaned forward. If there is sufficient space in front of the first row and the airline is able to provide a leg-rest, the patient can be placed there. For safety reasons, a leg-rest may not be placed in the aisles or near emergency exits. If the patient needs to have an elevated leg, he or she can also be placed so the leg rests on the two seats next to him or her, i.e. three seats side-by-side, if the general condition of the patient permits it.
If a patient is to be seated with an elevated lower extremity, it is necessary to ensure that the patient can actually sit. For example, hip diseases/conditions or spinal diseases may inhibit a patient from being able to sit, in which case the patient will have to be transported lying on a stretcher or in business class, if the patient is able to sit upright during take-off and landing.
Patients on stretchers must be escorted by a physician or a nurse. Patients with large and not fully immobilised fractures or with traction-treated fractures must be escorted by a physician. It is necessary to arrange an escort (physician, nurse, or non-medical escort) for a seated patient if the patient cannot walk from the seat to the exit, if the patient cannot manage toilet visits on his/her own, or if the patient is incapable of handling the seatbelt due to bandages or casts on the hands.
Patients with fractures to the spine, the pelvis, or the lower extremities have an increased risk of thromboembolic episodes. A long flight may increase this risk and therefore the appropriate anticoagulant should be considered during transportation. Please see chapter 1, “Thromboembolic prophylaxis”.
Fractures of the upper extremity and shoulder girdle
These fractures usually do not give rise to aeromedical problems.
The patient can fly unescorted if he or she is able to take care of him- or herself, i.e. eat, drink, walk to the toilet, and handle the seatbelt.
Fractures to the lower extremity
Fracture of femur
Hip fractures, unoperated (femoral neck, pertrochanteric, subtrochanteric)
These fractures should be operated on, on site if at all possible.
If the patient needs to be transported, he or she must be lying on a stretcher escorted by a physician, with a vacuum mattress, and/or a traction splint. If traction-splint is used the escort should be an orthopedic surgeon.
Hip fractures, newly operated
The vast majority of these patients need to be transported lying on a stretcher and escorted by a nurse. In a few cases, it may be appropriate to seat the patient on the aircraft, but this should be assessed in relation to the general condition of the patient, the complexity of the performed surgery, the time since surgery, and, lastly, the mode of transportation should be presented and discussed with the patient him- or herself.
Femoral body and supracondylar fractures
As with hip fractures.
Lower leg fractures
Tibia fractures, unoperated or newly operated
Immobilised with a high plaster or a high cast.
Transportation: Sitting with a leg-rest.
Immobilised with a high, circular, cut open plaster or a high cast.
Dislocated fractures should generally be reduced and preferably be operated on before transportation. If this is not possible, a traction splint is used in order to reduce the pain and dislocation during the transportation. In addition, a vacuum mattress may be used.
Ankle fracture (lateral, bi- or trimalleolar)
Ankle fractures with an indication for surgery should be operated on at the location.
If operation on-site is not possible the patient should be repatriated without delay as the surgery is considered to be acute.
Transportation: Sitting with leg-rest. In case of surgical indication a stretcher may be considered in order to ensure that oedema around the fracture will not delay the possibility of surgery. On longer overseas flights, a business class or first class sleeper/reclining seat may be used if the
seat can recline fully, a so-called full-flat seat. In cases of very short transportations times (from hospital to hospital), seating the patient with a leg-rest may be acceptable.
Escort: If a stretcher is used, a nurse should accompany the patient.
Seated with leg rest, business class or first class/sleeper: Unescorted if the patient is able to manage by him- or herself. If not: Nurse.
Ligamentous injuries of the knee
The lower extremity will usually be immobilized by a long cast or with a locked or open dynamic brace (e.g. DonJoy™). In the case of a lesion to the cruciate ligament(s) and/or menisci, the cast or brace should not be removed.
In isolated injuries to the collateral ligaments, the cast or brace can often be removed during transportation and the patient will thus be able to sit on a normal seat. If needed the treating doctor should be consulted as to the question of removing the brace or not during transportation.
Transportation with cast/locked brace:
Sitting with leg-rest or 2-3 seats side-by-side
Stable pelvic fractures such as simple pubic ramus fractures in elderly patients do not usually pose any problems regarding transportation.
Unstable fractures should undergo surgical treatment before transportation. If this is not possible, the use of a plaster shield and/or a pelvic clamp and/or a vacuum mattress should be used. Occasionally, an unstable pelvic fracture develops a lethal retroperitoneal haemorrhage.
Transportation: Stretcher and, if needed, the above stabilisation method(s). Sometimes an air ambulance may be indicated if a direct flight on a commercial aircraft is not available.
Escort: Physician, preferably an orthopaedic surgeon.
Non-dislocated and stable
Transportation: Stretcher and vacuum mattress.
Non-dislocated or dislocated and unstable
Should always be surgically stabilised before transportation. If this is not possible, the hip joint should be stabilised with a traction splint before transportation.
Transportation: Stretcher and vacuum mattress and traction splint.
In the case of pelvic and acetabular fractures, it must be established that there are no undiagnosed abdominal injuries, e.g. bladder lesion, and/or a larger retroperitoneal haemorrhage.
Hip dislocation without alloplastic
Most often caused by high-energy trauma in traffic accidents. The dislocation must be reduced prior to transportation. After reduction, the hip joint will be stable in the majority of cases if there is no concomitant acetabular fracture.
Transportation: Depends on general injury pattern, normally by stretcher.
Escort: Physician or nurse.
Hip dislocation with alloplastic
The dislocation must be reduced prior to transportation.
It is important to obtain information from the treating physician regarding estimation of the hip as being stable or unstable. If the hip joint is unstable, the patient must be transported lying on a stretcher for the duration of transportation – from hospital bed to hospital bed. It may be advisable to fit a high cast on the affected leg in order to prevent excess movement of the hip joint. This cast in combination with a vacuum mattress will normally be sufficient to ensure a successful transportation.
Transportation: If the joint is stable, then, sitting up; the patient must not sit in low automobile seats when being transported to and from the airport. If the joint is unstable, then a stretcher should be used all the way.
Escort: Nurse or physician.
Stable fractures (compression fractures without fractures of the posterior wall)
Transportation should not be rushed. The patient will often be treated with a cervical collar. After some time, he or she can often be transported in a seated position with the cervical collar.
Transportation: Seated or stretcher
More severe or multiple fractures
Often demands transportation by stretcher and with a stiff collar.
Transportation: Stretcher and possibly vacuum mattress.
Unstable fractures with or without medullary damage
Should be surgically treated before transportation. If this is not possible, the patient should be transported on a stretcher with a vacuum mattress and stabilising pillows at the head and neck. Cranial traction is generally inappropriate to use during transportation.
In the case of fractures with medullary damage or unstable fractures with the risk of medullary damage, a partial or total paralysis of the intercostal respiratory muscles may occur or may already be present which may result in respiratory insufficiency. Thus, in these transportations, equipment for intubation and ventilation should be present.
Transportation: Stretcher and vacuum mattress, air ambulance.
Escort: Anaesthesiologist and anaesthetist nurse.
Thoracic and lumbar spine
Transportation: Usually a stretcher. In a minority of small fractures in relatively young patients, transportation may be undertaken with the patient seated, possibly in business class.
Complex or multiple fractures, stable
Transportation: Stretcher, possibly vacuum mattress.
Should be surgically stabilised before transportation. If this is not possible, the patient must be transported on a stretcher with a vacuum mattress.
Transportation: Stretcher and vacuum mattress. Air ambulance if a direct route on a commercial flight is not available.
001. Aeromedical Problems
013. Airline Requirements
016. Cardiac Disorders
012. Eye Disorders
013. Mental Disorders
016. Infectious Diseases
017. Orthopaedic Injuries
123. Jet Lag
124. The STEP System
27. The History of Air Transportation of Patients
28. Conversion Tables
Latest update: 19 - 04 - 2016