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.
. Orthopedic management in the polytrauma patient[J]. Frontiers of Medicine, 2012, 6(3): 234-242.
Jason J. Halvorson, Holly T-P. Pilson, Eben A. Carroll, Zhongyu John Li. Orthopedic management in the polytrauma patient. Front Med, 2012, 6(3): 234-242.
PaO2/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
Parameter
Stable(Grade I)
Borderline(Grade II)
Unstable(Grade III)
In extremis(Grade IV)
Shock
BP (mmHg)
≥100
80-100
60-90
<50-60
Blood units (2 h)
0-2
2-8
5-15
>15
Lactate levels
Normal range
Approx 2.5
>2.5
Severe acidosis
Base deficit (mmol/L)
Normal range
No data
No data
>6-18
ATLS classification
I
II-III
III-IV
IV
UO (ml/h)
>150
50-150
<100
<50
Coagulation
Platelet count (μg/ml)
>110 000
90 000-110 000
<70 000-90 000
<70 000
Factor II and V (%)
90-100
70-80
50-70
<50
Fibrinogen (g/dl)
>1
Approx 1
<1
DIC
D-Dimer
Normal range
Abnormal
Abnormal
DIC
Temperature
>34°C
33-35°C
30-32°C
30°C or less
Soft tissue injuries
Lung function; PaO2/FiO2
>350
300
200-300
<200
Chest trauma scores; AIS
AIS I or II
AIS≥2
AIS≥2
AIS≥3
TSS
O
I-II
II-III
IV
Abdominal trauma (Moore)
≤II
≤III
III
≥III
Pelvic trauma (AO classification)
A
B or C
C
C (crush, rollover with abd trauma)
Extremities
AIS I or II
AIS II-III
AIS III-IV
Crush, rollover, extremities
Surgical strategy
DCO or definitive surgery (ETC)
ETC
ETC if stable
DCO
DCO
Tab.2
Fig.1
Fig.2
Fig.3
1
Seibel R, LaDuca J, Hassett JM, Babikian G, Mills B, Border DO, Border JR. Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state. Ann Surg 1985; 202(3): 283–295 doi: 10.1097/00000658-198509000-00003 pmid:4037903
2
Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures: a prospective randomized study. 1989. Clin Orthop Relat Res 2004; (422): 11–16 doi: 10.1097/01.blo.0000130947.07861.7e pmid:15187827
Scannell BP, Waldrop NE, Sasser HC, Sing RF, Bosse MJ. Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients. J Trauma 2010; 68(3): 633–640 doi: 10.1097/TA.0b013e3181cef471 pmid:20220421
5
Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, Krettek C, Reed RL 2nd. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma 2002; 53(3): 452–461 doi: 10.1097/00005373-200209000-00010 pmid:12352480
6
Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma 2005; 19(8): 551–562 doi: 10.1097/01.bot.0000161712.87129.80 pmid:16118563
7
Giannoudis PV. Current concepts of the inflammatory response after major trauma: an update. Injury 2003; 34(6): 397–404 doi: 10.1016/S0020-1383(02)00416-3 pmid:12767787
8
Tachakra SS, Sevitt S. Hypoxaemia after fractures. J Bone Joint Surg Br 1975; 57(2): 197–203 pmid:1141286
9
Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, Gruner A, Oestern HJ, Bayeff-Filoff M, Garving C, Pardini D, van Griensven M, Krettek C, Giannoudis P; EPOFF Study Group. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg 2007; 246(3): 491–499 , discussion 499–501 doi: 10.1097/SLA.0b013e3181485750 pmid:17717453
10
Pape HC, Grimme K, Van Griensven M, Sott AH, Giannoudis P, Morley J, Roise O, Ellingsen E, Hildebrand F, Wiese B, Krettek C; EPOFF Study Group.. Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. J Trauma 2003; 55(1): 7–13 doi: 10.1097/01.TA.0000075787.69695.4E pmid:12855874
11
Tsukamoto T, Chanthaphavong RS, Pape HC. Current theories on the pathophysiology of multiple organ failure after trauma. Injury 2010; 41(1): 21–26 doi: 10.1016/j.injury.2009.07.010 pmid:19729158
12
Pape HC, Schmidt RE, Rice J, van Griensven M, das Gupta R, Krettek C, Tscherne H. Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden. Crit Care Med 2000; 28(10): 3441–3448 doi: 10.1097/00003246-200010000-00012 pmid:11057799
13
Pape HC, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg 2002; 183(6): 622–629 doi: 10.1016/S0002-9610(02)00865-6 pmid:12095590
14
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma 2000; 48(4): 613–621 doi: 10.1097/00005373-200004000-00006 pmid:10780592
15
Harwood PJ, Giannoudis PV, van Griensven M, Krettek C, Pape HC. Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 2005; 58(3): 446–452 doi: 10.1097/01.TA.0000153942.28015.77 pmid:15761335
16
Morshed S, Miclau T 3rd, Bembom O, Cohen M, Knudson MM, Colford JM Jr. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am 2009; 91(1): 3–13 doi: 10.2106/JBJS.H.00338 pmid:19122073
17
Taeger G, Ruchholtz S, Waydhas C, Lewan U, Schmidt B, Nast-Kolb D. Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma 2005; 59(2): 409–416 , discussion 417 doi: 10.1097/01.ta.0000175088.29170.3e pmid:16294083
18
Pelias ME, Townsend MC, Flancbaum L. Long bone fractures predispose to pulmonary dysfunction in blunt chest trauma despite early operative fixation. Surgery 1992; 111(5): 576–579 pmid:1598678
19
Weninger P, Figl M, Spitaler R, Mauritz W, Hertz H. Early unreamed intramedullary nailing of femoral fractures is safe in patients with severe thoracic trauma. J Trauma 2007; 62(3): 692–696 doi: 10.1097/01.ta.0000243203.38466.e0 pmid:17414349
20
Canadian Orthopaedic Trauma Society. Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma 2006; 20(6): 384–387 doi: 10.1097/00005131-200607000-00003 pmid:16825962
21
Nahm NJ, Como JJ, Wilber JH, Vallier HA. Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma 2011; 71(1): 175–185 doi: 10.1097/TA.0b013e3181fc93a2 pmid:21336198
22
O’Toole RV, O’Brien M, Scalea TM, Habashi N, Pollak AN, Turen CH. Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics. J Trauma 2009; 67(5): 1013–1021 doi: 10.1097/TA.0b013e3181b890be pmid:19901662
23
Tuttle MS, Smith WR, Williams AE, Agudelo JF, Hartshorn CJ, Moore EE, Morgan SJ. Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient. J Trauma 2009; 67(3): 602–605 doi: 10.1097/TA.0b013e3181aa21c0 pmid:19741407
24
Willett K, Al-Khateeb H, Kotnis R, Bouamra O, Lecky F. Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. J Trauma 2010; 69(2): 405–410 doi: 10.1097/TA.0b013e3181e6138a pmid:20699750
25
Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma 2002; 52(2): 299–307 doi: 10.1097/00005373-200202000-00016 pmid:11834992
26
Velmahos GC, Arroyo H, Ramicone E, Cornwell EE 3rd, Murray JA, Asensio JA, Berne TV, Demetriades D. Timing of fracture fixation in blunt trauma patients with severe head injuries. Am J Surg 1998; 176(4): 324–329 , discussion 329–330 doi: 10.1016/S0002-9610(98)00208-6 pmid:9817248
27
Jaicks RR, Cohn SM, Moller BA. Early fracture fixation may be deleterious after head injury. J Trauma 1997; 42(1): 1–5 , discussion 5–6 doi: 10.1097/00005373-199701000-00001 pmid:9003250
28
Giannoudis PV, Veysi VT, Pape HC, Krettek C, Smith MR. When should we operate on major fractures in patients with severe head injuries? Am J Surg 2002; 183(3): 261–267 doi: 10.1016/S0002-9610(02)00783-3 pmid:11943123
29
Eastridge BJ, Starr A, Minei JP, O’Keefe GE, Scalea TM. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002; 53(3): 446–450 , discussion 450–451 doi: 10.1097/00005373-200209000-00009 pmid:12352479
30
Hauschild O, Strohm PC, Culemann U, Pohlemann T, Suedkamp NP, Koestler W, Schmal H. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008; 64(2): 449–455 doi: 10.1097/TA.0b013e31815982b1 pmid:18301214
31
Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990; 30(7): 848–856 doi: 10.1097/00005373-199007000-00015 pmid:2381002
32
Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, Dunham CM, Gens D, Bathon H. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 1989; 29(7): 981–1000 , discussion 1000–1002 doi: 10.1097/00005373-198907000-00012 pmid:2746708
33
Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ. Predicting blood loss in isolated pelvic and acetabular high-energy trauma. J Orthop Trauma 2007; 21(9): 603–607 doi: 10.1097/BOT.0b013e3181599c27 pmid:17921834
34
Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury 2004; 35(7): 671–677 doi: 10.1016/j.injury.2004.03.003 pmid:15203307
35
Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma 2006; 20(1 Suppl): S3–S6 doi: 10.1097/01.bot.0000202386.86880.21 pmid:16385204
36
Gardner MJ, Parada S, Chip Routt ML Jr. Internal rotation and taping of the lower extremities for closed pelvic reduction. J Orthop Trauma 2009; 23(5): 361–364 doi: 10.1097/BOT.0b013e31819c4a3f pmid:19390364
37
Gardner MJ, Osgood G, Molnar R, Chip Routt ML Jr. Percutaneous pelvic fixation using working portals in a circumferential pelvic antishock sheet. J Orthop Trauma 2009; 23(9): 668–674 doi: 10.1097/BOT.0b013e3181a87c6c pmid:19897990
38
Vallier HA, Cureton BA, Ekstein C, Oldenburg FP, Wilber JH. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. J Trauma 2010; 69(3): 677–684 doi: 10.1097/TA.0b013e3181e50914 pmid:20838139
39
Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007; 62(4): 834–839 doi: 10.1097/TA.0b013e31803c7632 pmid:17426537
40
Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability: efficacy of pelvic packing, a systematic review. Injury 2009; 40(Suppl 4): S53–S61 doi: 10.1016/j.injury.2009.10.037 pmid:19895954
41
Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF 3rd. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 1997; 43(3): 395–399 doi: 10.1097/00005373-199709000-00001 pmid:9314298
42
Perez JV, Hughes TM, Bowers K. Angiographic embolisation in pelvic fracture. Injury 1998; 29(3): 187–191 doi: 10.1016/S0020-1383(97)00175-7 pmid:9709419
43
Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV. Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. Int Orthop 2011; 35(9): 1381–1390 doi: 10.1007/s00264-011-1271-1 pmid:21584644
44
Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003; 54(3): 437–443 doi: 10.1097/01.TA.0000053397.33827.DD pmid:12634521
45
Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury 2006; 37(7): 602–613 doi: 10.1016/j.injury.2005.09.007 pmid:16309680
46
O’Neill PA, Riina J, Sclafani S, Tornetta P 3rd. Angiographic findings in pelvic fractures. Clin Orthop Relat Res 1996; 329(329): 60–67 doi: 10.1097/00003086-199608000-00009 pmid:8769437