Orthopedic management in the polytrauma patient

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

Introduction

The management of the poly-traumatized orthopedic patient is ever-changing and wrought with controversy. It can be daunting, confusing and intimidating. Great advances in understanding the physiology, treatment strategies, and outcomes in this patient population have occurred over the past five decades as both overall resuscitation measures and advances in orthopedic trauma techniques have evolved. Despite advances in knowledge, timing and method of fracture fixation continues to be the subject of debate as further understanding of the body’s response to both traumatic insult as well as surgical/resuscitative measures continues.

Early total care

Prior to the 1970s, multi-trauma patients with orthopedic injuries were typically treated conservatively, as the thought was that these patients were “too sick” to undergo surgery. This primarily stemmed from the recognition of fat emboli syndrome and pulmonary complications in this population. However, as AO (Arbeitsgemeinschaft für Osteosynthesefragen) techniques advanced and fracture care and trauma resuscitation efforts improved, the 1980s brought about a decade of early total care (ETC) in which poly-traumatized patients with orthopedic injuries were not only being treated, but being treated within a short window of time post-injury [1]. ETC can be defined as complete, primary, definitive fracture stabilization within the first 24-48 h of injury. Bone et al. further strengthened this movement with their prospective study in the late 1980s, confirming that multi-injured patients treated with ETC appeared to do better in regards to pulmonary complications, length of ICU stay, and total number of days in the hospital [2]. At this point, many orthopedic surgeons adopted the philosophy that these patients were “too sick not to operate on.” This change in practice allowed patients to mobilize earlier, begin rehabilitation sooner and be discharged more timely. In addition, complications associated with prolonged bed rest (pneumonia, decubitus ulcers, infection, muscle atrophy/deconditioning) were decreased. However, as with many new trends within orthopedics, early stabilization of all multi-injured patients began to prove to be deleterious in certain patient populations, namely those with significant thoracic trauma/pulmonary injuries. Thereafter, emphasis began to shift toward expeditious temporary stabilization of fractures with the goal to decrease future operative time and blood loss.

Damage control orthopedics

The term “damage control orthopedics” (DCO) was adopted from the US Navy’s strategy for keeping heavily damaged ships/vessels afloat despite their tremendous insults. Originally coined “damage control surgery,” this philosophy was applied to abdominal trauma surgery in which three phases were developed. Phase I was immediate surgery for contamination and hemorrhage. This was followed by Phase II — resuscitation in the ICU for reversal of hypothermia, coagulopathy and hypovolemia. Phase III then consisted of return to the operating room for definitive surgery, once the patient stabilized [3]. This was later extrapolated to orthopedics, where Phase I consisted of control of hemorrhage and stabilization of fractures, Phase II by resuscitation in the ICU, and Phase III by the conversion to definitive fixation of fractures. While the work-horse of orthopedic damage control has become the external fixator, one must not forget about the important role that temporary fracture reduction, splinting and skeletal traction can play in the stabilization of the multi-injured patient. In at least one study, skeletal traction was found to be equal to the external fixation of femur fractures in regards to the rate of development of acute respiratory distress syndrome (ARDS), multi-organ system failure, pneumonia, deep venous thromboembolism (DVT), pulmonary embolism (PE), ICU stay, and death [4].

Pape et al. temporally delineate the eras of ECT and DCO as being from January 1, 1981 to December 31, 1989 for the former and from January 1, 1993 to December 31, 2000 for the later, with an intermediate period in between, January 1, 1990 to December 31, 1992 [5].

DCO versus ETC

Management of the poly-traumatized orthopedic trauma patient is often a team effort among several specialists including orthopedic surgeons, general surgery traumatologists, critical care practitioners, neurosurgeons, plastic surgeons, emergency medicine physicians and interventional radiologists, and should always begin with the Advanced Trauma Life Support (ATLS) principles in mind. Airway, breathing, and circulation are of critical importance and should be addressed prior to any orthopedic interventions. This is followed by attempts at reversing the so-called lethal triad of hypothermia, coagulopathy, and acidosis. Hypothermia begins at traumatic insult and is exacerbated thereafter by hypoperfusion, prolonged exposure and inactivity, and age [3]. Historically, patients have been considered clinically hypothermic when their temperature drops below 35°C. Studies have shown that up to 21% of trauma patients are hypothermic at presentation, which increases to 46% when leaving the operating room [3]. Acidosis, the abnormal increase in acidity of the blood, is often a byproduct of hemorrhage and the state of shock and is routinely corrected via aggressive fluid resuscitation. Acidosis is usually defined by a blood pH of less than 7.4. Multiple markers for adequate resuscitation have been determined and will be discussed later. Coagulopathy, a state of disorder in the blood’s ability to control the balance between bleeding and clotting, is caused by multiple factors including dilution from resuscitation, hypothermia, acidosis and even calcium levels, which have all been shown to affect both the intrinsic and extrinsic clotting cascades [3]. Recently, a fourth parameter, soft tissue injury, has been added to encompass thoracic and abdominal trauma and extensive orthopedic injury. Table 1 highlights these parameters as adopted form Pape et al. [6]

The use of these parameters has been helpful in developing four “clinical conditions,” established at initial presentation: stable, borderline, unstable, and in extremis (Table 2) [6].

Based on these data, it has been advocated by some that definitive surgery be performed either within 24 h (ETC), or after a 4-day waiting period (DCO), to allow normalization of these parameters. Fig. 1 provides a treatment algorithm for management of these patients.

If ETC is to be undertaken, minimizing the amount of time in the operating room (OR) to less than two hours total is of paramount importance. Prolonged operations have been attributed to the “second hit” phenomenon. The patient’s initial response to the traumatic stimulus heightens the immune system and inflammatory response, causing increased neutrophil adherence to cell walls, release of autolytic enzymes and subsequent edema [7]. This, in turn, may promote multi-system organ failure and/or ARDS. Surgery can also influence this cascade by increasing the inflammatory response, perhaps pushing the borderline patient into an unstable or in extremis category and causing a “second hit.” [7] Fat emboli and hypoxic events which may result from early surgery can add insult to injury in the setting of lungs already damaged by pulmonary contusions, rib fractures, etc. This has been implicated as a primary cause of early organ failure and ARDS in this patient population. Tachhakra et al. followed arterial blood gases in patients with long bone (femur or tibia) fractures from admission through their hospitalization [8]. They found that roughly 64% of patients were “hypoxic” on admission. In addition, hypoxic events were demonstrated in over 50% of patients undergoing fracture manipulation, with 12 out of 17 (70%) patients with hypoxia prior to the operation having worsening of hypoxia afterwards, versus only 9 of 21 (43%) patients having worsening hypoxia when their oxygenation was normal going into surgery. Pape et al. demonstrated an overall six times greater risk of developing pulmonary complications if intramedullary nailing was undertaken within the first 24 h in borderline compared with stable patients [9].

Further evidence to support the increased inflammatory response in multi-injured patients comes from direct monitoring of the inflammatory cascade, more specifically, levels of Il-6 or IL-8 [10]. After trauma, pro-inflammatory cytokines such as TNF-α, IL-1, IL-6, and IL-8 are released from macrophages and monocytes [11]. This, in turn, increases the presence of adhesion molecules, raising endothelial cell permeability and allowing migration of cells into tissues. While trauma patients have been shown to have increased levels of TNF-α, its relationship to sepsis has not been fully proven [11]. IL-6 helps regulate the acute phase response and the complement cascade, and its increase has been shown to directly correlate with tissue damage and multiple organ failure [11]. IL-6 has also been shown to increase after primary intramedullary nailing (IMN), but not with DCO [11], supporting the argument of the second hit phenomenon. Pape et al. [12] compared the insertion of an unreamed femoral nail to that of an uncemented femoral total hip prosthesis. In his study, IL-6 levels increased post-operatively in all patients, but those with the highest burden of IL-6 pre-operatively had larger increases post-operatively. This was also correlated with prolonged ventilation times.

Therefore, the question remains-if DCO is undertaken, at what point is it safe to convert to definitive stabilization? Days 2-4 post injury are generally considered by many to be a “danger time” in which the patient may be inadequately resuscitated, with fluid shifts equilibrating, and the inflammatory response just beginning to normalize. This is supported in a study of over 4 000 patients in which those receiving an operation within 2-4 days of greater than 3 h duration were found to have a statistically significant increase in multiple organ failure compared with those who underwent definitive fixation at 6-8 days [13]. According to Pape [6], subtle clinical changes should be respected when planning a secondary definitive procedure. These include a positive fluid balance (In/Out ratio above 500 ml/day) that has not cleared after days 2 to 3 after injury, and airway pressures (>30 cm H₂O), both of which are indicative of systemic and/or pulmonary interstitial fluid accumulation. Also, any evidence of coagulopathy, such as failure of the platelet count to rise>100 000 should be seen as a warning sign. Scalea et al. demonstrated minimal complications in conversion from external-fixation to intramedullary nailing of femoral shaft fractures in 43 patients at an average of 4.8 days after the index procedure [14].

Femur fractures and DCO vs. ETC

Much of the literature examining the timing of fracture fixation in the poly-trauma patient focuses on femoral shaft fractures, with DCO utilizing external fixation as initial treatment and ETC either reamed or unreamed intramedullary nailing. Advocates of DCO demonstrate a decreased systemic inflammatory response in those patients treated with initial external fixation followed by conversion to intramedullary nailing [15]. Fig. 2 demonstrates the use of spanning external fixation in the temporary stabilization of an unstable polytruma patient with bilateral femoral shaft fractures.

In examining the United States National Trauma Database over a 4-year period from 2000 to 2004, a 50% decrease in mortality was found in patients under-going ETC for femur fractures if performed greater than 12 h after arrival, compared to those fixed within the first 12 h [16]. It was also found that those with serious abdominal trauma benefitted the most from a delay in ETC. Pape et al. [5] found statistically better outcomes in regards to multi-organ failure and ARDS in the “era” of DCO (January 1, 1993 to December 31, 2000), compared to previous time periods at their institution imploring ETC and a more intermediate treatment algorithm. While one could argue that medical advances (i.e., respiratory care, evaluation and treatment of abdominal and thoracic trauma, etc.) also contributed to this difference in outcome, they also found statistically higher rates of ARDS in those patients treated with IMN versus primary external fixation in the DCO era [5]. Taeger et al. [17] supported this claim, showing decreased initial operating time and blood loss with overall decreased predicted mortality with DCO compared to ETC. In at least one study, overall pulmonary morbidity and death did not seem to be decreased with early definitive care (<48 h) in patients with severe chest trauma and long bone fracture as compared to those patients with severe chest trauma without long bone fracture [18]. This is in contrast to a study by Weninger et al. who demonstrated no difference in those patients with thoracic trauma with and without femur fracture who received unreamed intramedullary nailing within 24 h [19]. Likewise, the Canadian Orthopedic Trauma Society conducted a prospective randomized trial of multiply injured trauma patients (defined as Injury Severity Score>18) receiving either reamed or unreamed femoral nails. In their study, no difference was found in the incidence of ARDS or other pulmonary complications between groups, leading them to conclude that reamed and unreamed nails are safe for early stabilization of femur fractures in the poly-trauma patient [20]. Nahm et al. found fewer complications when femur fractures were treated with ETC, with an overall complication rate of 18.9% (treatment<24 h), compared to a rate of 42% (treatment>24 h) [21]. Interestingly, they admit that preferential treatment was given to the femur and that other fractures within these patients were not treated with ETC (i.e., forearm fractures were splinted, etc.). Therefore, their true definition of ETC is used loosely as it relates only to femur fracture fixation. O’Toole et al. [22] propose that ETC is safe and can be performed within the first day, pointing to their cohort of reamed IMN for femur fracture at an average of 14 h after injury with minimal incidence of ARDS or complication. They propose that 14 h post-injury provides adequate time for the patient time to be resuscitated and stabilized. Tuttle et al. [23] also found no difference between femur fractures originally treated with external fixation versus those treated primarily with intramedullary nailing in regards to ICU length of stay, hospital length of stay, ventilator days, multi-system organ failure, or ARDS score. They did, however, find that a DCO approach caused overall less initial OR time and blood loss. Those patients with bilateral femur fractures deserve special attention as mortality is proven to be increased in this patient population; upwards of 30% in one study [24]. In addition, the association of bilateral femur fractures with injuries in different systems (up to 80%) may heighten the mortality risk. There is a paucity of literature to guide treatment strategies of this special circumstance. Therefore, we feel that the best strategy is to assess the overall patient status and attempt to classify them as stable, borderline, or unstable and act accordingly.

There are also data to support ETC for femur fractures in patients with severe head injuries. In their study, Brundage et al. [25] found improved outcomes in this population (primarily improved Glasgow Coma Scale at discharge) in patients with femoral shaft fractures treated within 24 h compared to those treated within 2-5 days. In addition, fixation within 24 h did not lead to increased mortality. A retrospective review of patients with severe head injuries (GCS≤8) and long bone fractures requiring surgical fixation found no difference in terms of intra- and post-operative hypoxic and hypotensive episodes, neurologic, orthopedic or general complications between those who underwent early versus late fixation [26]. On the other hand, another retrospective review of patients with significant closed head injuries requiring operative fracture fixation found increased rates of hypoxemia and hypotension (both risk factors for secondary brain injury) in those undergoing early (<24 h) versus late (>24 h) surgery [27]. This was felt to be due, in part, to the significantly higher amount of fluids received by this population in the first 48 h following injury, likely resulting in deleterious increases in intracranial pressure, fluid shifts and edema. Although the available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries, the trend is toward a better outcome with earlier fixation [28].

Pelvic ring injuries

Perhaps where the orthopedic surgeon can be of most benefit in the early management and resuscitation of the multiply-injured trauma patient is in the area of pelvic trauma. Accounting for approximately 3%-8% of all fractures, a high rate of mortality has been assigned to pelvic ring disruption, especially in association with hemorrhagic shock, and has been reported to be as high as 50% in one series [29]. With advances in resuscitation and management, mortality directly related to pelvic trauma is most likely closer to 7% [30]. Although many classification systems for pelvic ring disruption exist, perhaps the most widely used for both mechanism of injury as well as prediction of resuscitation, hemorrhage and associated injury is that of Young-Burgess. While a comprehensive overview of pelvic ring classification is beyond the scope of this review, pelvic ring disruptions can be combined into lateral compression (LC) in which an internal rotation force is directed to the hemi-pelvis, anteroposterior compression (APC) in which an anteriorly directed force exerts external rotation deformities to the pelvic ring (the so-called “open book pelvis”), vertical shear (VS) in which one hemi-pelvis is sheared cranial/caudal, and finally a combined mechanism [31]. It is important for us to note the classification of pelvic ring disruption as this has been shown to have prognostic influence in regards to mortality and transfusion requirement [29,30]. For example, anteroposterior compression (APC) injuries are associated with the highest mortality and blood transfusion requirements, being on average 20% and 14.8 units, respectively, as opposed to lateral compression injuries 7% and 3.6 units [31]. In addition, the stability of the pelvic ring can help with diagnosis of the most likely source of hemorrhage. In one series, patients with stable pelvic ring disruptions (LC I and APC I) and hypotension were found to have an intra-abdominal source of hemorrhage in 85% of cases [29]. This is in contrast to unstable pelvic ring injuries where bleeding was found from a pelvic source in 59% of patients. This is also supported by Dalal et al. who found that as APC grade increased, intra-abdominal injury, pelvic vessel injury, retroperitoneal hematoma, shock, sepsis, ARDS and volume needs increased [32]. In addition, APC III patterns carried the highest mortality risk. Likewise, LC injuries increased rates of pelvic vessel disease, retroperitoneal hemorrhage, shock and resuscitation needs with increasing grade [32]. While the majority of the literature focuses on pelvic ring disruption and transfusion requirements, acetabular fractures are also associated with increased transfusion requirements. More specifically, T-type patterns and fractures involving the anterior column are noted to have increased transfusion requirements over the first 24 hours than other fracture patterns [33]. The orthopaedic surgeon is in a unique position to help guide resuscitation efforts in those patients with pelvic ring disruption to help identify the most common location of bleeding resulting in hypotension.

In the patient with hypotension and a pelvic ring disruption, acute management should focus on stopping and controlling death from hemorrhage. Common sites of bleeding include the iliac vessels and their branches. However, venous disruption/hemorrhage as well as bleeding from cancellous bone is also a major contributor. The pelvis and retroperitoneum can hold up the 4 L of fluid volume [34]. While bleeding eventually stops from tamponade, this may not be the case in pelvic ring disruption, as pelvic integrity is compromised, allowing more and more expansion as bleeding continues. The pelvis can be thought of as either a cylinder or a sphere, as defined by the equation πr² or 4/3πr³, respectively. Regardless of which three dimensional structure one wishes to assign to the pelvis, the bottom line is that as the radius increases, there is exponential increase in volume. It is rare that ETC is undertaken in the patient with hypotension and a pelvic ring disruption. External fixation (either in the iliac wing or in the anterior inferior iliac spine) to help control pelvic disruption is less utilized as in the past. One thought is that the pivot point of external fixation is located anterior. Therefore, in pelvic ring injuries which are predominantly unstable posteriorly, compression through an external fixation device, while compressing the front, may actually widen the posterior pelvis and worsen the problem. While external fixation can certainly still play a role in pelvic stabilization, pelvic binding ,either with use of commercial devices such as the TPOD^®, or with a sheet, are efficient, easy, and effective ways to decrease intra-pelvic volume and stabilize the unstable pelvic ring disruption [35]. It should be noted that these methods are typically used for APC varietal fracture patterns where the pelvic volume continues to expand. Fig. 3 demonstrates the use of DCO with pelvic binding utilizing a TPOD^®.

In lateral compression type injuries, pelvic sheets and binders do little to improve hypotension/prevent hemorrhage. Simple internal rotation of both feet to help close down pelvic volume has also been advocated [36]. In extreme cases, damage control iliosacral screws, even through a pelvic binder, may be used safely and effectively [37]. There is some support to consider pelvic and acetabular fractures within the same realm as femur fractures in that multi-trauma patients benefit from earlier total care of these injuries than delayed. In a study of 645 patients, Vallier et al. found an overall complication rate of 12.4% vs. 19.7% in this patient population treated in less than and greater than 24 h from injury, respectively, including less ARDS and pneumonia [38]. As pelvic and acetabular fractures are often treated with traction and prolonged recumbency, early fixation gives the benefit of earlier mobilization, pulmonary rehabilitation, pain control, and therapy.

Pelvic packing for help with hemostasis has been advocated by some as method of DCO in unstable patients with pelvic ring disruption [39,40]. In a systematic review of three studies, Papakostidis et al. stated that pelvic packing may be useful in select patients as part of a general damage control philosophy [40]. However, complication rates were not insignificant and included infection (35%), multiple organ failure (9%), and an overall mortality of 23%.

The use of angiography and embolization is also routinely used as a first-line therapy for pelvic hemorrhage. While venous bleeding and bone bleeding are unable to be controlled by angiography, significant arterial bleeding occurs in roughly 2%-8% of patients[41-43]. Patients with a pelvic fracture who are not responding to resuscitative efforts are the ones who benefit most from angiography. In this select group of patients, the negative and positive predictive value for angiography was 100% and 73%, respectively [44]. The most common sites of arterial bleeding include the superior gluteal, lateral sacral, internal pudendal, inferior gluteal and obturator arteries [45]. Karadimis et al. [43] in a systematic review of 26 studies demonstrated an overall rate of embolization of 8.4% in pelvic fractures. Mortality from pelvic hemorrhage was found to be 25%, however, effectiveness of arteriography and embolization varies from 59%-100%. While a powerful tool for controlling hemorrhage in pelvic trauma, arteriography does have negatives. Institutions caring for pelvic trauma require this service to be available 24 h/day, 7 days/week. In addition, the angiography suite should be located near the Emergency Department to limit transport of unstable patients. In the setting of hypotension, false negative angiography may also be found, with some series reporting undiagnosed arterial bleeding in up to 50% of patients [46]. Certain patients who may be a set-up for repeat angiography include those with a widened pubic symphysis, increasing resuscitation needs, two arterial bleeders, and pre-hospital hypotension [47].

Summary

The management of orthopedic injuries in the polytraumatized patient can be very difficult and requires the concerted efforts of a multidisciplinary team. Complex systems and processes are at play and are constantly changing in this population, leaving short windows of opportunity to effectively treat orthopedic injuries without causing additional harm. Various patient parameters such as blood pressure, base deficit and core body temperature to name a few, allow for the treating surgeon to classify this population into a range of clinical conditions from “stable” to “in extremis” which can be very useful in guiding treatment.

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