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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

Postal Subscription Code 80-967

2018 Impact Factor: 1.847

Front Med    2012, Vol. 6 Issue (3) : 234-242    https://doi.org/10.1007/s11684-012-0218-2
REVIEW
Orthopedic management in the polytrauma patient
Jason J. Halvorson, Holly T-P. Pilson(), Eben A. Carroll, Zhongyu John Li
Department of Orthopaedic Surgery, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27103, USA
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Abstract

The past century has seen many changes in the management of the polytraumatized orthopedic patient. Early recommendations for non-operative treatment have evolved into early total care (ETC) and damage control orthopedic (DCO) treatment principles. These principles force the treating orthopaedist to take into account multiple patient parameters including hypothermia, coagulopathy and volume status before deciding upon the operative plan. This requires a multidisciplinary approach involving critical care physicians, anesthesiologists and others.

Keywords damage control orthopedics      early total care      polytrauma     
Corresponding Author(s): Pilson Holly T-P.,Email:hpilson@wakehealth.edu   
Issue Date: 05 September 2012
 Cite this article:   
Jason J. Halvorson,Holly T-P. Pilson,Eben A. Carroll, et al. Orthopedic management in the polytrauma patient[J]. Front Med, 2012, 6(3): 234-242.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-012-0218-2
https://academic.hep.com.cn/fmd/EN/Y2012/V6/I3/234
Clinical parameterParameter indicative of high-risk patientsTime to normalization in uneventful courseParameter indicative of high-risk patients
Admission (day 1)Clinical course (2 day)Comment
ShockBP<90 mmHgTransfusion requirement>2 Units/2 hLactate>2.5 mmol/LBase excess>8 mmol/L<1 dayCatecholamine dependency>2 daysIrrelevant after resuscitation
CoagulationPlatelet count<90 0001-2 days>3 days below 100 000 or failure to increaseSimple parameter, good indicator
Core temperature<33°CHoursIrrelevant after re-warming
Soft tissue injuryPaO2/FiO2<300Lung contusions, AIS>2Chest trauma score; TTS>IIAbdominal trauma (Moore>II)Complex pelvic trauma<2-4 daysPaO2/FiO2<300 for>2 daysPathologic extravascular lung water (>10 ml/kg BW)Lung function often close to normal for 2-3 days (PaO2/FiO2>300)
Tab.1  Temporal relationship of four parameters involved in the natural progression of the polytrauma patient (Adapted with permission from Pape [])
ParameterStable(Grade I)Borderline(Grade II)Unstable(Grade III)In extremis(Grade IV)
ShockBP (mmHg)≥10080-10060-90<50-60
Blood units (2 h)0-22-85-15>15
Lactate levelsNormal rangeApprox 2.5>2.5Severe acidosis
Base deficit (mmol/L)Normal rangeNo dataNo data>6-18
ATLS classificationIII-IIIIII-IVIV
UO (ml/h)>15050-150<100<50
CoagulationPlatelet count (μg/ml)>110 00090 000-110 000<70 000-90 000<70 000
Factor II and V (%)90-10070-8050-70<50
Fibrinogen (g/dl)>1Approx 1<1DIC
D-DimerNormal rangeAbnormalAbnormalDIC
Temperature>34°C33-35°C30-32°C30°C or less
Soft tissue injuriesLung function; PaO2/FiO2>350300200-300<200
Chest trauma scores; AISAIS I or IIAIS≥2AIS≥2AIS≥3
TSSOI-IIII-IIIIV
Abdominal trauma (Moore)≤II≤IIIIII≥III
Pelvic trauma (AO classification)AB or CCC (crush, rollover with abd trauma)
ExtremitiesAIS I or IIAIS II-IIIAIS III-IVCrush, rollover, extremities
Surgical strategyDCO or definitive surgery (ETC)ETCETC if stableDCODCO
Tab.2  Assessment of four clinical grades and parameters for determining them in the polytrauma patient (Adapted with permission from Pape [])
Fig.1  Treatment protocol for major fractures in polytrauma (Adapted with permission from Pape []). ABG, arterial blood gas; SBP, systolic blood pressure; FAST, focused assessment with sonography in trauma; UO, urine output.
Fig.2  Utilization of DCO in bilateral femoral shaft fractures. (A) CT scanogram showing bilateral femoral shaft fractures. (B) Post-operative CT scanogram demonstrating use of spanning external fixation in the temporary stabilization of bilateral femoral shaft fractures.
Fig.3  Utilization of DCO in a 46-year-old woman with an open book (APC-III) pelvic ring injury. (A) Injury AP pelvis radiograph. (B) AP pelvis radiograph after application of a TPOD pelvic binder. (C) Clinical picture of the patient on the operating table with the TPOD replaced with a sheet binder to facilitate operative fixation of the pelvic ring injury while maintaining compression with the binder. (D) Post-operative outlet pelvis radiograph showing definitive fixation. (E) Post-operative AP pelvis radiograph showing definitive fixation.
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