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

References

[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 Surg1985; 202(3): 283–295

[2] Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures: a prospective randomized study. 1989. Clin Orthop Relat Res2004; (422): 11–16

[3] Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF. Damage control: collective review. J Trauma2000; 49(5): 969–978

[4] 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 Trauma2010; 68(3): 633–640

[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 Trauma2002; 53(3): 452–461

[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 Trauma2005; 19(8): 551–562

[7] Giannoudis PV. Current concepts of the inflammatory response after major trauma: an update. Injury2003; 34(6): 397–404

[8] Tachakra SS, Sevitt S. Hypoxaemia after fractures. J Bone Joint Surg Br1975; 57(2): 197–203

[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 Surg2007; 246(3): 491–499, discussion 499–501

[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 Trauma2003; 55(1): 7–13

[11] Tsukamoto T, Chanthaphavong RS, Pape HC. Current theories on the pathophysiology of multiple organ failure after trauma. Injury2010; 41(1): 21–26

[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 Med2000; 28(10): 3441–3448

[13] Pape HC, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg2002; 183(6): 622–629

[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 Trauma2000; 48(4): 613–621

[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 Trauma2005; 58(3): 446–452

[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 Am2009; 91(1): 3–13

[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 Trauma2005; 59(2): 409–416, discussion 417

[18] Pelias ME, Townsend MC, Flancbaum L. Long bone fractures predispose to pulmonary dysfunction in blunt chest trauma despite early operative fixation. Surgery1992; 111(5): 576–579

[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 Trauma2007; 62(3): 692–696

[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 Trauma2006; 20(6): 384–387

[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 Trauma2011; 71(1): 175–185

[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 Trauma2009; 67(5): 1013–1021

[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 Trauma2009; 67(3): 602–605

[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 Trauma2010; 69(2): 405–410

[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 Trauma2002; 52(2): 299–307

[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 Surg1998; 176(4): 324–329, discussion 329–330

[27] Jaicks RR, Cohn SM, Moller BA. Early fracture fixation may be deleterious after head injury. J Trauma1997; 42(1): 1–5, discussion 5–6

[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 Surg2002; 183(3): 261–267

[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 Trauma2002; 53(3): 446–450, discussion 450–451

[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 Trauma2008; 64(2): 449–455

[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 Trauma1990; 30(7): 848–856

[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 Trauma1989; 29(7): 981–1000, discussion 1000–1002

[33] Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ. Predicting blood loss in isolated pelvic and acetabular high-energy trauma. J Orthop Trauma2007; 21(9): 603–607

[34] Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury2004; 35(7): 671–677

[35] Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma2006; 20(1 Suppl): S3–S6

[36] Gardner MJ, Parada S, Chip Routt ML Jr. Internal rotation and taping of the lower extremities for closed pelvic reduction. J Orthop Trauma2009; 23(5): 361–364

[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 Trauma2009; 23(9): 668–674

[38] Vallier HA, Cureton BA, Ekstein C, Oldenburg FP, Wilber JH. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. J Trauma2010; 69(3): 677–684

[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 Trauma2007; 62(4): 834–839

[40] Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability: efficacy of pelvic packing, a systematic review. Injury2009; 40(Suppl 4): S53–S61

[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 Trauma1997; 43(3): 395–399

[42] Perez JV, Hughes TM, Bowers K. Angiographic embolisation in pelvic fracture. Injury1998; 29(3): 187–191

[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 Orthop2011; 35(9): 1381–1390

[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 Trauma2003; 54(3): 437–443

[45] Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury2006; 37(7): 602–613

[46] O’Neill PA, Riina J, Sclafani S, Tornetta P 3rd. Angiographic findings in pelvic fractures. Clin Orthop Relat Res1996; 329(329): 60–67

[47] GourlayD, HofferE, RouttM, BulgerE. Pelvic angiography for recurrent traumatic pelvic arterial hemorrhage. J Trauma2005; 59(5): 1168–1173

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