Polytrauma Care

Polytrauma Care

Heather A. Vallier, MD

Dr. Vallier or an immediate family member serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association.

Keywords: damage control; fixation; resuscitation; polytrauma


Most trauma-related deaths are associated with closed head injuries or exsanguination, often at the scene of the injury. Survivors are at risk for various life-threatening complications, many of which are directly related to their musculoskeletal injuries. Trauma care has evolved to expedite assessment and resuscitation in the prehospital setting and within the minutes following arrival to a trauma center. Musculoskeletal injuries often play a large role in the initial burden of hemorrhage. Essential principles include multidisciplinary assessment, resuscitation, and provisional management of fractures and dislocations. Type and timing of orthopaedic treatment will vary depending on the response to resuscitation, and the scope and complexity of injuries to all systems.

Initial Assessment of the Trauma Patient

The American College of Surgeons has developed advanced trauma life support (ATLS) algorithms for initial evaluation and resuscitation of the trauma patient.1 These familiar protocols involve primary, secondary, and tertiary surveys of the patient. The primary survey is still a stepwise evaluation of Airway, Breathing, Circulation, Disability, and Exposure. This primary survey is followed by a secondary survey in which a detailed history and physical examination is completed. The tertiary survey involves serial evaluations during the initial hospital course.

The primary survey has changed little in recent years and is designed to identify the location and severity of most injuries, with an emphasis on life-threatening conditions. The airway is secured, using oral or nasal intubation as indicated. Severe head injuries and/or facial fractures are two conditions often necessitating emergent intubation. The cervical spine should remain immobilized during this time. Breathing is assessed by physical examination, and supplemental oxygen is delivered as needed. Patients with evolving chest or neck injuries may require emergent assistance, employing techniques such as mechanical ventilation, tube thoracostomy for pneumothorax, or pericardiocentesis for effusion. Continuous reassessment of circulation is critical including peripheral perfusion by palpating pulses and monitoring vital signs, as well as end-organ perfusion by monitoring hypo-oxygenation and resultant acidemia. The orthopaedic surgeon may play a key role in the initial assessment and care of the patient. Their presence will promote communication about injury severity and treatment goals. Initial wound management and reduction of fractures and dislocations should be undertaken.

Shock and Resuscitation: Assessment and Initial Management

Inadequate end-organ perfusion defines shock. There are four types of shock: hypovolemic, cardiogenic, obstructive, and septic.1 Most musculoskeletal injuries are associated with hemorrhage (Table 1), and hypovolemic shock is most frequently encountered in trauma patients, especially those with pelvis and long bone fractures. Shock results in tissue hypoperfusion, hypoxemia, inflammation, and immune dysfunction.2 It is displayed as tachycardia, then by hypotension3. Reduction and fixation of fractures is thought to promote control of hemorrhage and aids in resuscitation of a patient in hypovolemic shock. Cardiogenic shock is caused by inadequate heart function. Most often this results from myocardial infarction, due to preexisting disease; however, blunt cardiac injury may contribute. Presence of cardiogenic shock is manifested by hypotension, then bradycardia. Spinal cord injuries may cause neurogenic shock.4 Loss of sympathetic tone results in hypotension and bradycardia, which can be confusing, as it is often concurrent with other injuries, which generate hemorrhage. Failure to respond to fluid resuscitation should be rapidly noted, and judicious usage of inotropic agents may be necessary.

Injuries to Other Systems: Assessment and Initial Management

Injury Severity Score

The Injury Severity Score (ISS) is an anatomic, validated scoring system that is used to predict mortality.5 The ISS score is a value from 0 to 75. Each body area is graded for severity using the Abbreviated Injury Scale (AIS), and the sum of the squares of the scores of the three highest areas quantifies the overall injury (Table 2). Only the highest AIS score in each body region is used. Limitations of the ISS include difficulty calculating it during an initial evaluation, as the extent of injuries may not be appreciated. The ISS also does not take into account multiple injuries over a single body area. The New Injury Severity Score (NISS) was developed to include the three highest scores, regardless of anatomic area, and has been shown to be potentially more predictive of survival than ISS.6

Table 1 Classification for Hemorrhagic Shock in a 70 kg Male1

Class 1

Class 2

Class 3

Class 4

Blood loss (mL)

Up to 750




Blood loss (% of volume)

Up to 15%




Heart rate





Blood pressure





Pulse pressure (mmHg)





Respiratory rate





Urine output (mL/hr)





Mental status

Slightly anxious

Mildly anxious



Head Injury

Primary traumatic brain injury results directly from the traumatic event via tissue injury or hematoma formation. Secondary injuries, which are commonly iatrogenic, occur subsequently and include hypoxia, hypotension, seizures, fevers, and hypoglycemia, which impede recovery from the primary injury. Maintenance of euvolemia and normothermia will mitigate secondary injury.7 Traumatic cerebral edema generates increased intracranial pressures (ICPs) that can further injure the brain. Hyperosmolar therapy, hyperventilation, and elevation of the head of bed, may all aid in reduction of ICP. Hypertension and bradycardia in this setting suggest impending herniation, and immediate interventions are required based on the specific injury.

Chest Injury

Chest injuries are very common in polytrauma patients. Chest injuries are painful and cause splinting and poor inspiratory effort in conscious patients. Recumbency results in poor ventilation, and narcotic medications suppress respiratory drive. Both increase the risk of pulmonary complications. Direct parenchymal lung damage
in patients with pulmonary contusions and other severe chest trauma will further diminish oxygenation within the days after injury. Tube thoracostomy will alleviate pneumothoraces and hemothoraces. Reduction and stabilization of axial and extremity fractures promote pain relief, upright posture, and mobility from bed, all of which reduce risks of pulmonary and other complications.

Table 2 Injury Severity Score (ISS) is Determined by Identifying the Three Most Injured Areas, Then Determining the Severity of Each as Defined by the Abbreviated Injury Scale (AIS) Designated as A, B, and C.5 The ISS = A2 + B2 + C2

AIS body areas

Soft tissue

Head and neck



Extremity and/or pelvis

AIS severity code

1 = Minor

2 = Moderate

3 = Severe (non-life-threatening)

4 = Severe (life-threatening) 5 = Critical (survival uncertain)

6 = Fatal

Rib fixation techniques have been recently described to provide mechanical support for ventilation and to relieve pain. Indications are evolving, but could include three or more ribs with severe bicortical displacement or within a flail segment.8 A recent study indicates less mechanical ventilation time, shorter hospital stay, less pneumonia, and lower mortality after rib fixation.8

Abdominal Injury

Abdominal injuries occur commonly, and treatment over the past decade has become more nonsurgical.9 Selective angiography and embolization for solid organ injury, such as the liver or spleen, is also more common.10 Hepatic bleeding may be exacerbated by surgical exploration; however, some severe abdominal injuries may be better managed surgically. Persistent active bleeding within the spleen or kidney, pseudoaneurysms, or renovascular pedicle avulsions are surgical indications.

Pelvic Injury

Very large forces are required to disrupt the stability of the pelvis. Associated injuries and blood loss depend on the fracture pattern, based on the direction of impact. Certain pelvic fractures can be associated with blood loss of several liters, related to magnitude of displacement of the posterior pelvic ring. Anterior-posterior compression injuries with complete disruption of the posterior ring or vertical shear injuries may be associated with life-threatening hemorrhage. Emergent circumferential pelvic reduction with a sheet or binder reduces the pelvic ring diameter toward normal and promotes tamponade of venous bleeding.11 Distal femoral skeletal traction can further improve ring alignment for patients with cephalad displacement of one hemipelvis. In up to 10% of mechanically unstable pelvic fractures major arterial bleeding is present.12 Such a patient will typically not respond to pelvis reduction and fluid resuscitation. Emergent angiography and embolization or pelvic packing are lifesaving measures.1 Early reports suggest utility of resuscitative endovascular balloon occlusion of the aorta (REBOA) in reducing mortality from exsanguination after major intrapelvic, abdominal, and/or proximal lower extremity injury.13,14 It can be a temporizing measure until arterial embolization or surgical control of hemorrhage is possible. Adverse consequences related to REBOA have been infrequently reported, including distal tissue necrosis and renal failure.

Open fractures, urogenital trauma, and gastrointestinal injury in conjunction with pelvic fractures are infrequent and are also considered surgical emergencies. Mortality of open pelvic fractures has been up to 50% in some studies. Control of bleeding by emergently packing open wounds is likely the most important initial measure unique to open pelvis fractures. Patients with posterior or perineal wounds or rectal trauma can be treated with a diverting colostomy to eliminate fecal contamination.15 Extraperitoneal bladder tears are often repaired if the patient receives open fixation of the anterior pelvic ring.16 Urethral injuries are diagnosed with retrograde urethrogram before attempting Foley catheter insertion. Catheter realignment, with or without endoscopic guidance, is the preferred definitive management of urethral tears.

Emergent and Urgent Orthopaedic Management

Open Wounds

Open fractures are classified by their severity of soft-tissue injury and amount of contamination (see Chapter 18).1 Despite controversy regarding risk associated with surgical delay, urgent débridement and irrigation in the operating room is still recommended
and is generally combined with provisional or definitive fixation, as soon as is safely possible. Stabilization of an open fracture provides support to the surrounding soft tissues and decreases the risk of infection. Occasionally, provisional external fixation is preferred, because of massive contamination, surgical delay, or systemic instability, eg, severe hemorrhage or head injury.

Reduction of Fractures and Dislocations

Displaced fractures should be reduced and immobilized. Pelvic ring injuries with widening of the pelvic diameter and hemodynamic instability are reduced urgently via circumferential sheeting, but this treatment should also be considered for hemodynamically stable patients to reduce pain.11 Femoral shaft fractures and some high-energy proximal femoral fractures benefit from application of skeletal traction to restore length and to provide relief of pain and spasm.17 Dislocated joints cause pain and may result in neurologic and/or vascular compromise. Dislocations should be reduced urgently when possible and stabilized as indicated to prevent recurrence. Closed reductions are possible in most cases; however, some dislocations are most safely undertaken in the operating room under general anesthesia to provide muscular paralysis and to promote safe airway management.

Timing and Principles of Management of Orthopaedic Injury

Benefits of Early Care

Expeditious reduction and fixation of fractures may promote control of hemorrhage and further resuscitation of the patient. Initial provisional reduction of pelvis, acetabulum, and extremity injuries as described above is followed with timely definitive care. A stable fracture is typically less painful and is beneficial to patient physiology. Pain induces sympathetic discharge, which can contribute to the hyper-inflammatory response of injury. Pain can also lead to poor respiratory effort and impaired ventilation; atelectasis ensues and may progress to hypoxemia or pneumonia. Therefore, pain control is essential, especially in the care of the multiply injured patient. Fracture stabilization can provide pain relief. Early fracture fixation of certain fractures has been associated with reduced narcotic medication intake, and potentially less respiratory depression and other adverse effects.18,19

Fixation of certain fractures can also contribute to resuscitation. Reduction and fixation of pelvic ring injuries and long bone fractures reduces ongoing hemorrhage. There is evidence that fixation of these injuries as well as mechanically unstable thoracolumbar spine injuries and acetabulum fractures should also be expedited.19,20,21,22,23,24 Each of these injuries otherwise relegates a patient to lie recumbent in bed, further increasing their pulmonary and thrombotic risks. In stable patients evidence has emerged that these fractures are best definitively managed within the first 36 hours after injury.19,20,21,22,23 Even though some of the surgical approaches themselves may be associated with pain and bleeding, the net effect on patient physiology may be positive. Fixation is thought to promote mobility from bed, reducing risks of thrombotic complications, fat embolism, pneumonia, adult respiratory distress syndrome (ARDS), and sepsis. Multiple studies have documented the positive effects of early fracture management in general in diminishing morbidity and mortality.19,20,21,22,23,24,25,26,27,28,29,30,31

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Jul 10, 2020 | Posted by in ORTHOPEDIC | Comments Off on Polytrauma Care
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