2.1 Primary survey and resuscitation

The primary survey and resuscitation are undertaken simultaneously, ideally by a multidisciplinary trauma team. The aim of the primary survey is to identify all immediately life-threatening conditions and commence treatment following cABCDE

c – Control exsanguinating external hemorrhage

A – Airway with cervical spine control

B – Breathing

C – Circulation

D – Disability assessment

E – Exposure and temperature control

If a trauma team is available, these phases can be performed simultaneously by different members of the team ( Fig 2.1-2 ). Exsanguinating external hemorrhage is usually due to open injury to a large artery and must be controlled immediately by application of direct pressure. A proximal tourniquet can be applied if the site of injury allows. The neck and spine must be protected until the spine is cleared according to local guidelines. The most common life-threatening injuries occur to the chest, abdomen, and head. They must be dealt with rapidly. Early radiological assessment is essential: ideally this is achieved with an early whole body (trauma) computed tomographic (WBCT) scan with IV contrast from head to pelvis with a scout view that includes the femurs [1]. If immediate access to CT is not available, early chest and pelvic x-rays must be obtained. Excess movement of the pelvis must also be avoided, as this can dislodge blood clots from pelvic fractures and increase bleeding. Pelvic binders are now commonly used to splint the pelvis but a simple belt or tied bed sheet may be effective in the short term.

Bone injuries are rarely life-threatening unless there is severe hemorrhage from pelvic, open, or multiple long-bone fractures. Hemorrhage from fractures can be reduced by early splinting, which restricts movement and allows clots to form. It is essential that hypothermia is prevented, as this inhibits the coagulation cascade. Victims of blunt or penetrating trauma who have evidence of significant blood loss should receive intravenous tranexamic acid within 3 hours of injury [2, 3]. Early infusion of blood products, such as fresh frozen plasma, platelets, and cryoprecipitate should be considered in all patients with hypovolemic shock using a “Massive Transfusion Protocol” that aims to provide packed red blood cells, plasma, and platelets in a 1:1:1 ratio [4].

2.2 Secondary survey

The secondary survey takes place once the primary survey has been completed. A full history of the accident should be taken from the patient (if possible), paramedics, and relatives. A medical and drug history must be obtained.

A thorough examination from head to toe, front and back, should identify remaining injuries.

In the limbs, each bone and joint should be tested for tenderness and stability and a neurovascular assessment of each limb is mandatory. All wounds should be carefully inspected and any gross contaminants removed. If possible, photographs should be taken before the wounds are covered with saline-soaked, sterile dressings. These must be left undisturbed until definitive wound management in the operating room. Appropriate tetanus coverage and antibiotics should be administered. X-rays of all suspected fractures must be obtained. Computed tomographic scans can be helpful in the evaluation of spine, pelvis, and complex articular fractures.

2.3 Definitive care

Decision making is difficult in polytrauma patients and experienced, senior surgeons should be involved early. A key strategic decision in polytrauma is to undertake damage-control surgery, early total care, or early appropriate care, which is an evolving concept.

2.3.1 Damage-control surgery

Damage-control surgery should be considered in patients who remain hemodynamically unstable or those with hypothermia, abnormal base deficit, increased lactate, or blood-clotting abnormalities.

No single investigation gives a clear guide to decision making and at the present time the overall physiological status of the patient provides the best guide. The immunological response of the patient appears to be an important factor [5] but there is no quick and reliable immunological test that can be used in clinical practice. In patients who remain under-resuscitated with abnormal physiology, only life- and limb-saving surgery should be performed during the early phase. Long-bone fractures can be splinted with casts, splints, or skeletal traction or rapidly stabilized with simple, temporary external fixation. The fixation pins should be outside the zone of injury and, if possible, outside the zone of any future surgery for definitive care ( Fig 2.1-3a–c ). Decision making is difficult in patients who have a vascular injury that needs repair (to save limb) but remain physiologically unstable. In this situation, prolonged vascular reconstruction may put the patient′s life at risk and primary amputation should be considered. Damage-limitation surgery must be undertaken as quickly and safely as possible and the patient should be transferred to the intensive care unit as soon as possible. Definitive surgery is delayed until the patient′s condition is optimal, often at 5–10 days posttrauma [6].

2.4 Isolated injuries

The first questions to ask when presented with an apparently isolated injury are:

• 
  

  What else is injured?

  
  
• 
  

  Does the mechanism of injury suggest the patient could have polytrauma?

  
  
• 
  

  Is there an injury to the joint above or below?

In polytrauma, each individual injury should have the same thorough evaluation that is undertaken for single injuries. In each case patient factors, such as multiple comorbidities, may have a profound effect on decision making. The local evaluation of each injury has two key facets: the soft tissues and the fracture pattern. These factors, together with patient factors, will determine the personality of the injury and subsequent decision making and treatment.

3.1 The patient

A holistic approach to the patient is essential. A full case history and examination must be performed together with appropriate investigations.

Important factors that will influence decision making include age, general health status, mental health, occupation, and social factors.

3.2 Age

Age is obviously important, especially in childhood when the growing skeleton has potential to remodel and injuries may result in growth disturbance. The development of osteoporosis in the aging skeleton has a major influence on surgical techniques, but age alone is not sufficient when assessing elderly patients. Pre-injury mobility, residential status, cognitive function, long-term medication, and preexisting medical conditions are all important and influence decision making [9, 10].

3.3 General health status

Cardiorespiratory problems will influence the anesthetic used and are important factors when determining a patient′s fitness for surgery. The increasing use of anticoagulation and antiplatelet therapy for many cardiovascular diseases is also an important factor to consider.

Diabetes alters a patient′s metabolic response to trauma and requires careful management during the perioperative period. In patients with diabetes neutrophil granulocytes do not function normally, which predisposes them to infection. They also suffer from small vessel disease, which may cause delayed healing and a further increase in the risk of infection. These patients can develop neuropathic nonunion and joint destruction (Charcot′s joint). A careful evaluation of the neurovascular status of the limb is essential and patients must be aware of the increased risks [11].

Peripheral arterial disease will have an important influence on soft-tissue and fracture healing. The ankle-brachial index should be measured in all these cases.

Venous disease in the legs can cause chronic swelling, venous congestion, and ulceration that will affect treatment and prognosis. Surgery must be avoided, if at all possible, in patients with acute vasculitis. The presence of this problem should always be considered in patients with systemic inflammatory diseases, such as rheumatoid arthritis and systemic lupus erythematosus.

Renal disease and chronic renal failure can result in abnormal bone metabolism and it is not unusual to treat fractures in patients receiving dialysis. These patients may have electrolyte and coagulation disorders and are at increased risk of infection and nonunion. It is essential that renal physicians are involved in the perioperative management, as preexisting renal disease is a key factor in the development of acute kidney injury following surgery.

Liver disease also predisposes to osteoporosis and fracture. Patients with cirrhosis may have coagulation disorders. Liver function and coagulation must always be tested before surgery. Viral hepatitis may put the nursing and surgical team at risk of cross infection.

Neurological conditions, such as stroke and Parkinson disease, may alter a patient′s ability to bear weight and comply with rehabilitation. These patients are at risk of further falls and may require additional external splints for protection. Patients with head injury are more prone to heterotopic bone formation and may have muscle spasticity that results in joint contractures. These must be prevented by physical therapy and splints.

Malignant disease should always raise the possibility of pathological fracture and the presence of a primary bone tumor must be considered in young patients presenting with pathological fracture. Decision making in patients with pathological fractures and advanced malignancy is always difficult and should involve the patient, relatives, and the palliative care team.

Joint disease, such as osteoarthritis or rheumatoid arthritis, must be evaluated when assessing any fracture.

Some articular and periarticular fractures may be managed by primary joint replacement if there is advanced arthritis.

The presence of a joint replacement and periprosthetic fracture will require careful assessment to determine preexisting loosening or infection, the etiology of the fracture, and the relationship between the fracture lines and the prosthesis.

Obesity is a major healthcare problem in the Western world and an increasing problem in the developing world. Morbid obesity presents the trauma surgeon and anesthetist with some unique problems. Patients may be too large for a CT or magnetic resonance imaging scanner and standard operating tables and poor respiratory function may preclude the usual supine positioning. Compliance with rehabilitation programs can be a problem and splints or plaster casts may be difficult to apply [12].

Medications, such as corticosteroids, can result in osteoporosis, poor healing, and increased risk of infection. Patients may also be at risk of Addisonian crisis if they have been taking high doses of steroids. Patients given immunosuppressive medications require careful management and have a similar increased risk of infection together with potential coagulation disorders. Patients receiving beta-blockers and other cardiac drugs may be unable to mount a normal response to hypovolemia. Anticoagulants, such as coumadin, are now prescribed commonly and require close hematological monitoring. Nonsteroidal antiinflammatory drugs may be implicated in the pathogenesis of some nonunions and some surgeons limit their use following nonunion surgery [13]. The development of stress fractures in patients given bisphosphonates to treat osteoporosis has recently been recognized with fractures occurring in the subtrochanteric region and shaft of the femur. Healing times are slower and selection of surgical technique and implant must take this into account [14]. Many patients are suffering from hypovitaminosis D and need vitamin D supplementation [15].