3.20 Polytrauma
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1 Introduction
Older adults and, in particular those over 80 years (ie, the oldest old), are the most rapidly growing segment of the world population. They often still participate in a number of activities that render them at risk for high-energy injuries or polytrauma, including driving, cycling, and working at heights. Taken together, society can expect a continued increase in geriatric polytrauma, which requires an understanding of the unique aspects of standard adult trauma [1]:
The interpretation of the literature regarding geriatric polytrauma is limited due to the lack of agreement on the age criteria and definition of “older” for these studies.
Increased life expectancy, increased independence, and increasingly active lifestyles predispose older individuals to polytrauma.
2 Epidemiology and etiology
Approximately 20–30% of all trauma occurs in individuals older than 35 years [2].
Most polytrauma occurs in men until approximately the age of 70 years; after 70 years, women are more commonly injured. Although few studies have focused on older trauma patients, reports of Swiss, Belgian, and Australian trauma populations have estimated the number of older individuals who have sustained polytrauma to be between 9% and 41% [3–5].
For older adults who sustain polytrauma, falls and motor vehicle accidents are the most common injury mechanisms and result in the highest mortality [6].
Falls in older adults, even falls from a low height, have been shown to result in injuries of similar nature to those sustained by younger individuals in higher-energy accidents [3].
In individuals younger than 55 years, the incidence of trauma is decreasing. However, in all age groups older than 55 years, the incidence of trauma is steadily increasing [8–11].
Injury patterns in the older trauma patient are different than in the younger patient with substantially higher rates of fractures, greater morbidity, and higher mortality [1].
3 Specific injuries
The distribution and pattern of injuries are different in older patients than for younger cohorts; older patients are more likely to sustain closed head injuries, cervical spine injuries, and bony thoracic injuries, ie, rib, sternal, and/or clavicular fractures [12]. Additional common injuries include thoracic injuries, pelvic fractures, and extremity fractures [13, 14].
3.1 Closed head injuries
3.2 Spinal injuries
Cervical spine injuries are common [16].
Common spondyloarthritic conditions, such as spinal stenosis and diffuse idiopathic skeletal hyperostosis, predispose to more catastrophic injury.
3.3 Chest injuries, including clavicle, ribs, and sternum
3.4 Pelvic and acetabular injuries
For a given pelvic fracture pattern, there is a greater mortality risk in older adults compared to a younger cohort [19].
Lateral compression pelvic fracture patterns and anterior column acetabular fractures are more common [20].
Friability of pelvic vessels in older adults may contribute to blood loss, morbidity, and mortality [21].
3.5 Lower extremity injuries
The severity of lower extremity injuries sustained in motor vehicle injuries is significantly higher in older adults [15].
4 Triage
Since 1986, the American College of Surgeons Committee on Trauma has published guidelines for field trauma triage. Unfortunately, older individuals who have sustained polytrauma are less likely to be transported to a higher acuity or level I trauma center [22, 23]. This apparent lack of understanding of the urgency or acuity in multiply injured older adults occurs despite the publication of studies that have demonstrated improved outcomes when older patients are triaged to hospitals with dedicated trauma resources ( Case 1: Fig 3.20-1 ) [24, 25].
CASE 1
Patient
A 76-year-old male driver involved in a motor vehicle collision suffered polytrauma and was initially triaged to a nearby level III trauma center. His injuries were identified as an intracranial hemorrhage, pelvic ring fracture, right distal radial fracture, and left tibial plateau fracture. The patient had a Glasgow Coma Scale of 7.
Comorbidities
Hypertension
Hypercholesterolemia
Treatment and outcome
At the level III trauma center, the patient was found to be hemodynamically unstable and underwent an emergent exploratory laparotomy, symphyseal plating, placement of a pelvic C-clamp, and pelvic packing ( Fig 3.20-1a–b ). The remainder of his fractures were splinted and the patient was subsequently transferred to a level I trauma center for further management.
AP and lateral x-rays were obtained for the distal radius indicating volar shear intraarticular distal radial fracture (AO/OTA 2R3B3) ( Fig 3.20-1c–d). Given the unstable nature of this pattern in a polytrauma patient, operative treatment was undertaken.
In addition, the AP and lateral injury views of the left knee identify a partial articular lateral tibial plateau fracture (AO/OTA 41B1.1), which may be treated either operatively or nonoperatively given its minimal displacement ( Fig 3.20-1e–f ). However, because of its Btype pattern and associated injuries, the patient received definitive surgical stabilization.
Upon arrival at the level I trauma center, the patient underwent computed tomographic angiography, where no arterial bleeding was identified. Intraoperative images of transsacral screw placement, with the C-clamp still in place, were obtained. The C-clamp was adjusted to obtain and maintain reduction while posterior fixation was completed. Once fixation was achieved, the C-clamp was removed and repeat exploratory laparotomy was completed, which did not identify any further pelvic injury, but a grade II splenic laceration and a small bowel contusion were noted. Postoperative AP, inlet, and outlet x-rays showed restoration of the pelvic ring ( Fig 3.20-1g–h ). The orientation of the transsacral screws was perpendicular to the plane of the midsagittal sacral fracture.
Following pelvic fixation, minimally invasive plate osteosynthesis (MIPO) of the tibial plateau was completed using provisional K-wire fixation and subsequent interfragmentary screw placement across the articular surface, as well as buttress fixation at the apex of the fracture ( Fig 3.20-1i–j ).
Simultaneously with the tibial plateau, the contralateral volar sheer distal radial fracture was treated with buttress plating for the Btype articular fragment, and interfragmentary screw fixation for a proximal sagittal plane extension that was noted intraoperatively ( Fig 3.20-1k–l ).
Key points
Geriatric trauma patients are more likely to have intracranial injuries, pelvic injuries, and upper and lower extremity injuries (see topic 2 in this chapter).
Appropriate triage of multiply injured older adults to a level I trauma center may provide more rapid access to dedicated trauma resources and potentially avoid placement of temporizing devices such as the C-clamp.
While many distal radial fractures in older adults may be treated nonoperatively, recognition of unstable patterns is important to an improved functional outcome.
Adherence to MIPO principles helps to minimize the physiological burden of lengthy, extensive procedures.
Frailty is highly correlated with mortality, in-hospital complications, and “adverse” discharge disposition in older trauma patients [26].
The orthopedic injuries did heal, and the patient was working on mobilization, but recovery was slow due to his neurological injury.
5 Resuscitation and comorbidities
Even though data has shown that aggressive rehydration and life support decrease mortality in the population, older polytraumatized individuals are often underresuscitated once they have reached the hospital. Goal-directed care in older polytrauma patients is therefore especially important. Invasive monitoring and aggressive resuscitation have been shown to decrease mortality [24, 27].
Older adults have lower total blood volume and cardiac output than younger adults, and a history of coronary artery disease or congestive heart failure are common. Both conditions can complicate resuscitation and anesthetic provision, if required:
Higher resting preinjury blood pressure in older adults can mislead care providers into believing that patients are better resuscitated than they actually are.
Renal insufficiency can significantly change pharmacokinetics of drugs important to resuscitation, increasing their physiological effects and toxicities.
Pulmonary issues, such as chronic obstructive pulmonary disease, underlying pulmonary hypertension, and predisposition to pneumonia, can complicate management, especially if mechanical ventilation is warranted.
Preexisting neurological and cognitive conditions are common:
Conditions such as Alzheimer′s disease, Parkinson′s disease, and a history of a cerebrovascular accident (stroke) can make communication challenging.
Development of delirium is more common in polytrauma patients with “vulnerable brains” or dementia.
Osteoporosis, sarcopenia, and skin fragility contribute to infection risk and complications in older patients. Long-term medications, including beta-blockers, anticoagulants, corticosteroids, and angiotensin-converting enzyme inhibitors can interfere with evaluation and resuscitation efforts. Common previous orthopedic surgeries, such as total joint arthroplasty, can affect injury patterns and treatment plans.
CASE 2
Patient
An 82-year-old male pedestrian was struck by a pick-up truck at 40 km/h (25 mph). He sustained right segmental tibial and fibular fractures with a concomitant tibial plateau fracture, a left distal femoral shaft fracture, right pubic rami fractures with right iliosacral disruption and an L5 transverse process fracture indicating translational instability of the left hemipelvis ( Fig 3.20-2a–d ).
Comorbidities
Alzheimer′s dementia
Coronary artery disease with prior by-pass grafting surgery
Type 2 diabetes mellitus
Treatment and outcome
External fixators were placed on the bilateral lower extremities initially for damage control and to maintain reasonable alignment. With significant swelling in the right leg, hematoma extraction and fasciotomy of the superficial posterior and lateral compartments was performed and closed 3 days postoperatively.
Bilateral external fixators were removed and open reduction and internal fixation of the tibial and femoral fractures were performed 7 days after placement of the external fixator. Pelvic fixation with iliosacral screws and anterior “pelvic bridge” was performed 13 days after initial presentation ( Fig 3.20-2e–h ).
Key points
Older adult pedestrians who are victims of motor vehicle accidents are more likely to sustain comminuted pelvic and lower extremity fractures than younger individuals [15, 30].
It is important to establish goals of care with the patient and his or her family, if possible. Despite orthopedic solutions for his fractures, this patient had a traumatic brain injury as a result of the accident, and survived for just over 1 year following the accident. During this time, he remained ventilator-dependent and required parenteral nutrition.
Discussion
There is a higher mortality risk for older polytrauma patients even with the same Injury Severity Score as for younger patients. Additionally, death from multiple injuries is more common in older than in younger trauma patients due to traumatic head injury and multisystem organ failure.
Early discussions with the family and patient, if possible, about the possibility of considerable disability, difficulty with activities of daily living, changes in residence or level of independence, and likelihood of death, are warranted. These often long but important discussions are best approached when possible by multiple members of the healthcare team (eg, surgeons, internal medicine and general medicine hospitalists, palliative care specialists, ancillary staff) providing the patient and family with a consistent message.
Additionally, common comorbidities and frailty, including osteoporosis, sarcopenia, and atrophic skin, render management more challenging. These comorbidities require geriatric comanagement to optimize outcomes. Medication management, comorbidity treatment, and disposition facilitation are maximized with geriatric team comanagement [31]. These findings echo the reports in the hip fracture literature of the importance of medical or geriatric comanagement in positively affecting outcomes for older orthopedic patients [32, 33].
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