ISS > 40
Body temperature below 95 °F
Multiple injuries (ISS > 20) in combination with thorax trauma
Multiple injuries in combination with severe abdominal or pelvic injury and hemorrhagic shock in the moment of administration
Radiographic evidence of pulmonary contusion
Patients with bilateral femur fractures
Patients with moderate or severe head trauma
These patients have a higher risk of rapid deterioration. Nevertheless, if these patients are stabilized appropriately, early definitive care can be used safely in the treatment of their major fractures [8]. In the appearance of deterioration, conversion to “damage control” techniques has to be considered. Some authors consider damage control nailing to minimize the duration of initial surgery. In these cases, an unreamed, unlocked nail is used initially, and locking and/or further reduction is performed secondarily.
Unstable
Patients who do not respond to the initial procedures and remain hemodynamically unstable have a high risk of rapid deterioration, multiple organ failure, and death in the course. Therefore surgical treatment consists of lifesaving surgery followed by temporary stabilization of major fractures [9]. Afterwards the patient should be stabilized on an intensive care unit.
Essential operations are:
Hemorrhage control
Exteriorization of gastrointestinal injuries
Temporary fixation of unstable fractures using external fixation
Complex reconstruction procedures should be postponed until stability is achieved and the acute immunoinflammatory response has subsided.
In Extremis
These patients are very close to death because of severe injuries and ongoing uncontrolled bleeding. They show an inadequate response to continuous resuscitation maneuver and are suffering from the effects of hypothermia, acidosis, and coagulopathy which are known as the “deadly triad.” Thus only lifesaving procedures are indicated. Reconstructive operations can be done in course, if the patient survives [10].
The Concept of “Damage Control Orthopedics”
Fracture stabilization is important to reduce pain, minimize fat embolization, and allow for early patient mobilization. The optimal way to achieve this goal is primary definitive osteosynthesis. Usually, temporary external fixation, splints, or casts should be avoided. Exceptions may apply according to the status of the patient.
The concept of “damage control” has been established for the treatment of borderline patients and patients in an unstable or extremis condition. The intent is to control but not to definitively repair injuries early after trauma in the sequence of their urgency.
The treatment is separated in three stages:
1.
The first step involves the early temporary stabilization of unstable fractures and stopping the hemorrhage.
2.
The second step is to optimize the patient’s condition in the ICU.
3.
In the third stage, delayed definitive fracture reconstruction is indicated if the patient’s condition allows.
The goal is to minimize the additional biological stress (“second hit”) due to prolonged surgical procedures in the initial phase [11]. Application of an external fixator can achieve sufficient stabilization of unstable long bone and pelvis fractures with minimal invasiveness and without prolonged operation time [9, 12, 13].
The optimal timing to perform the definitive reconstruction is an individual decision based on clinical judgement in combination with laboratory tests. It has been shown that major surgical procedures should be avoided in days 2–4.
The conversation of an external fixator to a definitive internal osteosynthesis should be done within the first 2 weeks to minimize the risk of infection.
Priorities in Fracture Care
The sequence of fracture treatment in multiply injured patient is a crucial part of the management concept. Due to their anatomy, some body sections are more vulnerable for progressive soft tissue damage. Therefore, in hemodynamically stable patients, the generally recommended sequence of treatment is tibia, femur, pelvis, spine, and upper extremity.
In multiply injured patients, the simultaneous approach to different extremity injured should be considered if certain logistic requirements are fulfilled.
Tibial Fractures
Especially in tibial fractures, the treatment strategy depends not only on the fracture type and the patient’s condition but also on the status of the soft tissue. Unstable fractures in multiply injured patients should be stabilized initially. Primary definitive internal osteosynthesis is preferable in stable patients; in unstable patients, fracture stabilization can be reached by an external fixator. Early secondary conversion to a definitive osteosynthesis can be performed after stabilization of the patient’s condition.
Bilateral Tibial Fractures
Simultaneous treatment can be a useful concept for the treatment of bilateral fractures. In bilateral tibia factures, both legs can be prepped and draped simultaneously. Because of the handling of the fluoroscope, fixation should be performed sequentially.
Compartment Syndrome
An increasing intrafascial pressure induces a compartment syndrome which can lead to irreversible damage of muscles, vessels, and especially nerves. A manifest compartment syndrome is defined with a pressure difference of <20 mmHg between the subfascial pressure and diastolic blood pressure. Due to the decreased blood pressure in patients in hemorrhagic shock in combination with the limited possibility to communicate (intubation, sedation, brain injuries), the risk for development of a compartment syndrome is increased in multiply injured patients [14]. Therefore prophylactic fasciotomy is recommended with a generous range of indication.
Femoral Fractures
In multiply injured patients, stabilization of the femur should be performed before admission to the ICU. An early fixation of the femur declines morbidity and mortality due to reduction of fat embolism and pneumonia, thromboembolic complications, MODS, and sepsis. Also nursing and positioning of the patients will be facilitated.
Primary definitive osteosynthesis is the method of choice in stable and stabilized borderline patients. In patients in an unstable condition, we recommend closed reduction and application of an external fixator.
Several studies could show that the intramedullary pressure increases during the insertion of the nail, and thereby proinflammatory mediators and fatty particles could be released. In patients with multiple fractures and especially in patients with pulmonary impairment, this could lead to rapid deterioration of the lung function [7]. Therefore we recommend primary intramedullary nailing in multiply injured patients only in the absence of severe thoracical injuries and if the ISS is below 25 points.
Bilateral Femoral Fractures
In case of bilateral femoral fractures, a higher kinetic energy has occurred. Additional injuries imply a higher risk of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) [15, 16]. Therefore we recommend to consider external fixation in these patients if resuscitation is difficult or the patient’s condition deteriorates during operation.
Ipsilateral Femoral and Tibial Fractures
For the management of ipsilateral femoral and tibial fractures, a staged management is advised as shown in Table 5.2.
Table 5.2
Staged approach for ipsilateral femoral and tibial fractures
Stable | Borderline | Unstable | In extremis | ||
|---|---|---|---|---|---|
Initial treatment | Femur | Nailing | Resuscitation successful: nail | Ex fix/traction | Traction |
Resuscitation difficult: ex fix,consider damage control nailing | |||||
Tibia | Nailing | Nailing | Ex fix/traction | Traction | |
Staged treatment | Femur | – | Nailing | Nailing | Nailing |
Tibia | – | Nailing | Nailing |
Unstable Pelvic Injuries
Unstable pelvic injuries with active bleeding in multiply injured patients are acute life-threatening situations which require immediate therapy. Therefore unstable pelvic injuries should be excluded as fast as possible within the first minutes after arrival in the ED.
Pelvic injuries can be classified roughly on the basis of the clinical and radiological examination results under consideration of the history of the trauma. A useful classification has to be practicable and should offer a guideline for further therapy. The following reduced and simple classification by the AO A B C system fulfills these requirements.
Type A fractures include stable fractures of the anterior pelvic ring with intact integrity of the dorsal structures which do not require operative treatment.
Type B injuries are characterized by partially intact dorsal structures. Rotational instability is possible. Especially open-book-type fractures with external rotated alae have an increased risk of hemorrhage complications. On the other hand, type B injuries may initially be in internal rotation (closed book fractures) which results in bony compression and self stabilization of the pelvis. Type B injuries require osteosynthesis only of the anterior pelvic ring.
Type C fractures are characterized by a translational instability of the dorsal pelvic rim due to completely destroyed posterior stabilizing structures. This results in a 3-dimensional instability of the pelvic ring and is associated with an extremely high risk of hemorrhagic complications and concomitant injuries of pelvic organs as urogenital lesions. The differentiation of type B and C fractures may often be difficult. A CT scan can give important additional information on stable patients. Type C injuries require a stabilization of the anterior and posterior pelvic ring.
Goal of the initial treatment of unstable pelvic injuries among multiply injured patients is an adequate stabilization and bony compression to avoid massive bleeding which predominantly is from venous vessels. In cases of arterial bleeding, selective angiography and embolization of the source of bleeding are becoming more common [17].
Stabilization techniques for a supine position of the patient are preferred during the primary period. Despite of the usage of pelvic slings, operative procedures as an external fixator or a pelvic C-clamp are the most common opportunities [18]. Internal stabilization techniques are normally time-consuming and technically difficult procedures which require stable patients. Therefore internal procedures in the initial phase are commonly only recommended in special cases. In the literature, for example, plate osteosynthesis of the symphysis or ventral plate osteosynthesis of the SI joint after laparotomy was described. In the last years, some authors recommend primary definitive osteosynthesis of pelvic fractures also in severely injured patients [13, 14, 19, 20].
In exceptional situations with exact closed reduction of the dorsal ring, initial percutaneous screw fixation of the SI joint is possible [12, 21].
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