Cause of death
50% central nervous system (CNS), most occur in the field
30% CNS within days
20% infection and multisystem organ failure
Injury Severity Score (ISS)
Sum of square of highest three Abbreviated Injury Scale scores for patient (Table 5.1)
ISS > 15 is polytrauma
Correlated with mortality and length of stay
Glasgow Coma Scale (GCS)
See Table 5.2.
Intubate if GCS is less than 8.
Systolic pressure decreases after loss of 30% blood volume (class III blood loss) from 1500 to 2000 mL.
Tachycardia occurs with class III blood loss.
Most common cause of shock in trauma patients is hypovolemic shock.
Patient is in shock if serum lactate is more than 2.5.
Elevated lactate correlates with mortality.
Compensated shock: normal BP, urine output, improved with resuscitation by other measures, but lactate more than 2.5
FAST (focused assessment with sonography in trauma) examination
Accurate for intraperitoneal fluid, pericardial fluid, right upper quadrant, left upper quadrant, and pelvis
Table 5.1 Abbreviated Injury Scale
Maximal, possibly fatal
Table 5.2 Glasgow Coma Scale
Withdraws from pain
Flexion to pain
Extension to pain
Unreliable for retroperitoneal injury
May not detect retroperitoneal hemorrhage
Borderline patients: ISS > 40, ISS > 20 with thoracic trauma, hypothermia, large pulmonary contusion, bilateral femoral fractures, moderate or severe traumatic brain injury
Damage control—external fixation is stabilization of fractures, and limited incision and drainage (I&D)/wound stabilization to assist in early resuscitation for borderline patients
Polytrauma patients have high physiologic inflammatory response 2 to 5 days following trauma.
Nonessential operations should be avoided during this time to prevent “second hit” phenomenon, causing adult respiratory distress syndrome (ARDS) or multiple system organ failure.
Early total care
Immediate long-bone surgery in the setting of polytrauma
Fewer intensive care unit (ICU) days
Less ARDS for femur fracture patients in polytrauma
Elevated IL-6 predicts acute lung injury: decrease pulmonary complications and ICU days
Gustilo and Anderson classification
Type I—minimal periosteal stripping; less than 1-cm wound
Type II—moderate periosteal stripping; >1cm wound
Type III—first generation cephalosporin
Type IIIa—significant periosteal stripping; wound closes at time of debridement
Type IIIb—significant periosteal stripping; wound does not close and requires free soft-tissue transfer
Type IIIc—significant soft-tissue wound with a vascular injury that requires repair
Infection and nonunion increase with Gustilo grade.
Antibiotics based on Gustilo and Anderson classification
All open wounds warrant tetanus prophylaxis.
Type I—first-generation cephalosporin
Type II—first-generation cephalosporin
Type III—first-generation cephalosporin
Addition of Zosyn is controversial.
Addition of percutaneous nephrostomy for gram-negative exposure and soil contamination
Timing of antibiotics less than 1 hour after injury is greatest predictor of lack of infection.
Timing of surgery
There is no absolute rule on when an open fracture must go to the operating room (OR) for I&D.
Consensus is that all open fractures should be irrigated and, more importantly, debrided within 24 hours.
Grossly contaminated open fractures should be brought to the OR urgently, taking into account the patient’s overall condition.
Best irrigation fluid is low pressure, high volume.
High pressure irrigation is associated with deep penetration of contamination.
No additive value of antibiotics or Castile soap in irrigant fluid
Amputated part treatment: rinse, moist gauze, plastic bag over ice
High velocity (>2000 ft/s) versus low velocity (<2000 ft/s)
Implication for injury pattern
Low-velocity gunshot wound (GSW) open fractures can be treated with local wound care, I&D in the ED, and closed treatment principles.
High-velocity GSW open fractures should be debrided in the OR with possible second-look surgery to assess progression of normal-appearing tissue to death over 1 to 3 days.
Nerve injury/neuropraxia in the setting of GSW is usually caused by traction/concussive injury and should be observed.
Definition—high pressure inside closed tissue space leads to tissue necrosis (tissue pressure falls below critical level for perfusion)
Diagnosis—pain out of proportion, pain on passive stretch of the compartment
Measurement—in unreliable, anesthetized, and intoxicated patients, patients with distracting injuries and children
Timing of intervention
Compartment syndrome is a surgical emergency.
Operative intervention should be performed prior to 6 hours of warm ischemia time to prevent nerve and muscle death.
ΔP = diastolic pressure – measured pressure
ΔP < 30 mm Hg means the patient has compartment syndrome.
ΔP more than diastolic pressure means the patient has compartment syndrome.
Leg—two incisions, four-compartment fasciotomy
Look for superficial peroneal nerve overlying lateral and anterior compartments in distal lateral incision
Incomplete deep posterior compartment release is the most common incompletely released compartment.
Thigh—two incisions, three-compartment syndrome
Three compartments—volar, dorsal, and mobile wad
Volar incision—release volar compartment and carpal tunnel
Pelvic floor ligaments
Posterior sacroiliac (SI) ligaments are the strongest.
Corona mortis: vascular anastomosis between obturator and external iliac/femoral/inferior epigastric systems (most frequently venous)
L5 nerve root lies on ala of S1 sacrum
Most common (88%) course of sciatic nerve is anterior to piriformis muscle and posterior to obturator internus muscle.
Most common variant (11%) is split piriformis and split nerve.
Radiographic anatomy (Figure 5.1)
L5 nerve root on anterior sacrum axial image
Lateral view of sacrum shows safe zone for iliosacral screws, avoiding L5 nerve root and S1, 2 nerve roots.
Obturator outlet shows teardrop for low anterior external fixation frame.
Anteroposterior (AP, Figure 5.2)
Inlet: detects rotational displacement and AP displacement
Outlet: detects cephalocaudal displacement
Appropriate for pelvic fracture with other sources of bleeding that require surgery
Any pelvic fracture with shock should have binder applied.
Potential volume into which pelvic ring can bleed is proportional to fourth power of radius of true pelvis.
Pelvic fracture in binder, still hypotensive and refractory to fluid and blood: definitive intervention is warranted
Angiogram and embolization
Posterior arterial bleed is usually superior gluteal artery.
Anterior arterial bleed is usually obturator or pudendal artery.
Retrograde urethrogram required for:
Blood at urethral meatus
High-riding prostate on rectal examination
Any clinical suspicion of genitourinary injury with pelvic fracture
Iliac crest pins
Anterior inferior iliac spine (AIIS) pins (Hannover frame)
Open reduction and internal fixation (ORIF): symphysial plate
Anterior percutaneous screws: superior ramus screws
Transiliac screws stronger
Two screws improve rotational stability
Posterior transiliac fixation
Wound complications in 33% to 50%
Fracture patterns (Figure 5.3)
Lateral compression (LC)
Most common pelvic fracture pattern
Almost always nonoperative
Weight bearing as tolerated (WBAT)
“BAD LC1” fractures: comminution through entire sacral fracture dissociating central sacrum from lateral iliac segment; posterior and anterior fixation indicated
Crescent fracture posteriorly
Closed treatment (rarely for undisplaced fractures) or anterior and posterior fixation
Anterior and posterior fixation
Associated head injury and abdominal injury is common.
Anterior posterior compression (APC)
Less than 2.5-cm anterior symphysis displacement
More than 2.5-cm anterior symphysis widening; anterior SI ligaments are torn but posterior SI ligaments are intact
Anterior ± posterior fixation
Posterior SI ligamentous disruption; posterior displacement seen on outlet; may have associated vertical displacement
Anterior and posterior fixation
Rotationally and vertically unstable
Vertical displacement preset and best seen on outlet view
Anterior and posterior internal fixation
Combined mechanism of injury: anterior and posterior internal fixation
Anatomy: dome of acetabulum is equivalent to cephalad 10 mm of acetabulum
Six acetabular lines
Sourcils (eyebrow) = acetabular dome
Posterior wall line
Anterior wall line
Roof arc angle of less than 45° (on AP view) means fracture is in dome of acetabulum.
Best view for spur sign
Posterior Kocher-Langenbeck approach
Extended iliofemoral and extensile T approaches are associated with significant wound healing and infection complications.
Indicated when reduction requirements for the individual patient can be achieved percutaneously, given risks of open operative intervention versus potential benefits of this long-duration surgery
May be adequate to achieve stabilization of acetabulum fractures to allow earlier mobilization than nonoperative treatment
Obturator oblique radiograph shows best
Computed tomography (CT) shows horizontal fracture line on axial view.
Iliac oblique radiograph shows best
Fracture through greater or lesser sciatic notch, or ischial spine
Fracture also through the obturator fossa/ring
CT shows horizontal fracture line on axial view.
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