Chapter 3

Ovid: Rockwood & Green's Fractures in Adults
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Editors: Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M. Title: Roc kwood & Green's Fractures in Adults, 6th Edition Copyright 2006 Lippincott Williams & Wilkins
> T a b l e o f C o n t e n ts > V o l u m e 1 > S e c t i o n O n e - G en e r a l P r i n c i pl e s > C h a pt e r 3 - M a n a g e m e nt o f t he M u l ti p l y I n ju r ed P a t i en t
Chapter 3 Management of the Multiply Injured Patient

Hans-Christoph Pape Peter V. Giannoudis
DEFINITIONS OF POLYTRAUMA: INCIDENCE, INJURY DISTRIBUTION, AND MORTALITY

Tr auma is a major he alth proble m and a l eading cause of de ath, particu larly i n younger adu lts and adolesc ents. The severity of consequent ill ness and the resulti ng disability is high compared with other disease processes (1). Ye t it fails to attract the kind of research and cl inical funding given to other major pathological processes. In some countries trauma services continue to be poorly coordinated and steps to remedy thi s are only beginning (2). As such, i t has been conside red the negle cted dis ease of the modern socie ty. In 1998 it was estimated that 5.8 million people died worldwide from accidental i njuries (3). In the United States, 12,400 p eople die each month following trauma (4). According to data from major t rauma registries, the mean age of patients wi th polytrauma is 29 to 34 years and the males are affected in 60% to 80% of t he cases. Th us, the burden on soci ety du e to lost earnings and long-term disabil ity of young, able people is huge (5). Ov er the years, s everal studi es have been published concerning the epidemi ology of ma jor injuries, although these are by no means homogenous and comparable. One of the main limitations has been the lack of clear and accepted definitions especially in the presence of multiple i njuries. The defini tion of multi ple trauma varies among surgeons from different spec ialt ie s and between diff erent c enters and countries. Th is has led to the development of standardize d scoring sys tems to all ow comparable stratification of injurie s between centers and to aid predi ction of morbidity and mortali ty. Tr auma scoring syst ems have been developed to convert the severity of injury into numeric v alues, allowing clinicians to communicate by means of quality assurance and quality control programs. In order for a scoring system to be considered as rational, it s hould ful fill such requirements as accuracy, reliability, and specificity. Th e Injury Severity Score (ISS), an anatomical scoring system that provides an overall sc ore for patients wi th multiple inj uries, i s still one of the most wid ely employed methods (6). This i s based on the Abbreviated Injury Sc ale (AIS), a standardized sys tem of class ification f or the sev erity of individ ual injuries from 1 (mild ) to 6 (usually fatal). Each injury is assigned an AIS score and is allocated to one of six body regions: head, face, chest, abdomen, extremities (in clud ing pelvi s), and external structures. The total ISS score is calc ulated from the sum of the squares of the three worst regional values. I t i s imp ortant t o emp hasize that only the worst i njury in each body region is used. The ISS ranges from 1 to 75, with any region scoring 6 automatically given a score of 75. Th e ISS limits the total number of contrib uting inju ries to three only, one each from the three most i njured regions, which may result in underscoring the deg ree of trauma sustained if a patien t has more than one signi ficant in jury in mor e than three regions. More imp ortantly perhaps, the ISS only takes into account one i njury per body region resulting in inability to account f or multiple injuri es to the same body region. This is p artic ularly trouble some in patients wi th mu ltip le extremity trauma. To addr ess some of these limitations, Osle r et al proposed a modification to the system which they t ermed the New Injury Seve rity Score (NISS) (7). Th is is d efined as the sum of squares of the AIS scores of each of a p atient's three most se vere injuries rega rdless of the body region i n whi ch they occur. Both systems have bee n shown to be good predictors of outcome in multiple trauma patients (7,8,9,10). An atomical injury distribu tion is not the onl y factor which wil l determine outcome in traumatized patients. A number of other systems have been introduced which use init ial vital signs to determine the degree of physiologic al response to inju ry. For example , the Revis ed Trauma Score (RTS) uses values based on the Glasgow Coma Scale (GCS), systolic blood pressure and respiratory rate to give a total score (11). This is combine d using a complex weigh ted method with t he ISS and the age of the patie nt in the Trauma Injury Se verity Score (TR ISS) (12). Thoug h such sys tems improve upon the anatomic sy stems alone in prediction of morbidity and mortal ity, they become increasingly complex and unwieldy, making bed side estimation impossi ble. Ot her systems exi st, s uch as those based on the International Classifi cation of Dis eases (ICD). These have been shown to have greater accuracy in predi cting outcome, though again many have found them too complex to be p ractical. The selection of scoring systems for use in diff erent si tuations remains a controve rsial and keenly debated topi c (13). In general terms, polytrauma can be defined as injury to at least two organ systems that causse a poten tially l ife- threatening condit ion. In practical terms this has been represented as those patients wi th an ISS of 16 or above, a nd it has been proposed that all such patients should be cared for in a des ignated trauma center (14). Recently data published from t he Trauma Audit and Research Network f or the epi demiology of t rauma in the United Kingdom revealed that of a total 159,746 patients, 18.2% had an ISS greater or equal to 16 (15). The overall mortality rate was 6.6%. Analysis of survivors versus nonsurvivors revealed a significantly higher ISS, i ncid ence of systolic blood pressure below 90 mm Hg, GCS le ss than 15, and highe r fluid resuscitation
mk:@MSITStore:D:\!medicina\!Ortopedie\traumatologie\Rockwood\Rockwood%20and%20Green's%20Fractures%20in%20A... 03.05.2010
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req uir ements in the nonsurvivor group of pati ents. Nonsurvi vors had al so a signific antly higher prevalen ce of chest trauma, h ead in juries , solid abdominal organ in jury or fracture of more than on e long bone. Th e prevalence of polytrauma (ISS >16) in the elde rly has been give n only cursory attention in t he literature. An aly sis of da ta from major trauma centers revealed an incidence of 1.94%. Th e mean age of the patients was 75.7 years (range 65100 years) and the mean ISS 25.3 poi nts (range 1675 points). Head injury was sustained by 73.6% of the patients, 35.4 % had an injury to the thorax, 33.5 % lower extremity injuries, 27.7% i njuries to the upper extremiti es, 1 9.1% had spinal injuries , 18.2% had an injury to the face, 1 2.8% had an i njury to t heir pelv is and abdomen, and 5.9% had sustained burns. The overall mortality rate was 42.3%, signi ficantly higher than the reported i ncidence of mortality in younger patients with similar injuries. Increased age, the presence of physiologi cal derangement on P.61 admis sion, highe r incidence of lower l imb i njuries, and more severe head or chest injuries were independently predictive of reduced survival rates. Diminished physiologic reserve, preexisting comorbid conditi ons, and d efic iencies in management may contribute to the high er rates of morbidity and mortality in the el derly patient with trauma as compared with the young patient with equiv alent trauma. Age should therefore be considered as an important factor in contemporary scoring systems and treatment algorithms.
STAGED APPROACH TO CARE

Primary care of severely injured patients depends on knowle dge of typical posttraumatic courses. This allows anticip ation of potential problems and sensible de cision making regarding the timing of in terventions using a systematic approach (16). Four dif ferent phases of the posttraumatic c ourse can be diffe rentiated.
1. 2. 3. 4.
Acute reanimation period (13 hours) Primary stabilizati on period (148 hours) Secondary regeneration peri od (210 days) Terti ary reconstruction and rehabilitation period (weeks to months after trauma)
Acute Reanimation Period

This phase includes the time from admission to the control of the acute life-threatening conditions. More recently wi th increased emphasis on prehospital care this phase can be extended to the first point of contact with medi cal service at the scene. Rapid s ystematic assess ment i s performed to i mmediately iden tify poten tially l ife- threatening condit ions. Diagnosis s hould be followed by prioritize d management of the airway and any breathing dis orders fol lowed by circulatory support as set down in Advanced Trauma Life Sup port (ATLS) (17) and prehospi tal care guideli nes (18). This may inv olve rapid in stitution of various emergency proced ures, i ncluding airway control, t horacocentesis, rapid con trol of external bleeding, and vigorous flui d and/or blood rep lacement therapy. This is foll owed by the secondary survey, a complete acute diagnostic checkup, but this should onl y be undertaken if there is no acute life -threatening situation, which would make immedia te su rgery necessary. In these cases this secondary assessment intended to identify all in juries sustained should be delayed until the p atient is properly stabiliz ed.
Primary Stabilization Period

This phase begins when any acute life-threatening situation has been remedied and there is complete stability of the respi ratory , hem odynamic, and neurologic systems of the patient. This is the usual phase where ma jor extremity injuries are managed, including acute management of fractures associated with arterial inj uries or the presence of acute compartment syndrome. Fractures can be temporary stabilized with external fixation and the compartments released where appropriate. The primary period should not exceed 48 hours.
Secondary Regeneration Period

In this phase the general condition of the patient is stabilized and monitored. It is vital to regularly re-evaluate the constantly evolving cl inic al picture to avoid harmful impa ct from intensiv e care treatment or the burden of complex operative procedures. Unneces sary surgical in terventions should not be performed duri ng the acute response phase followi ng trauma. Physiological and intensi ve care scoring systems may be employed to monitor clinical progress. In the presence of systemic inflammation and multiple organ dy sfunction syndrome (MODS), appropriate supportive measures should be undertaken i n an intensive care environment.
Tertiary Reconstruction and Rehabilitation Period

This final rehabi litation pe riod is accompanied by any necessary surgical procedures, including final reconstructive measures. Only when adequate recovery is demonstrated should c ompl ex surgica l procedures be contempla ted. Such interventions include the d efinitive management of comple x mi dface fractures, sp inal or pelvic fractures, or joint reconstruction.
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IMPACT OF RESCUE CONDITIONS ON THE CLINICAL COURSE

Th e trimodal distribution of deaths foll owing severe i njury has been well describe d. Early death rates from remediable causes have been reduced by the i mplementation of ATLS protocols and the centraliz ation of trauma service s. Improvements in critical care have reduced late death from seps is and multiple organ failure, although understandin g of these phenomena is far f rom complete (19). Immedia te and very early de aths are on the whole only reduced by improvements in safety and accident prevention. Howev er, i t is increasingly recogni zed that i nterventions such as end otrache al int ubation at a very early s tage can inf lue nce the later cl inical course. To this end, progressive ly more interest is being directed to prehospital care of polyt rauma p atients. Studies have demonstrated that early access by trained emergency med ical physicians capable of deliv ering advanced life support on scene can i ncrease survival (20,21,22,23). Procedures such as endotracheal intubation, thoracic drainage, sedation, and resuscitati on can be provided as appropriate (18,24). Subsequent evacuation by air ambulance to a de signated trauma cen ter c an further im prove long-term outcome (25,2 6).
Entrapment
Motor vehicle accidents with entrapment are particularly challenging to emergency sys tems because of the severity of the ensuing trauma a nd the inherent complexity of rescue procedures. P.62 Th e extric ation procedure of entrapped trauma patients after motor vehicle accidents requires cl ose cooperation between the medica l and the technical rescue team. A practical approach t o extric ation consists of ini tial assessment, rapid access for a single pe rson, extended access for advanced li fe support where necessary, and the extrication itself . During the extrication process the trauma victim is at hi gh risk of additional injury or of the aggravation of exist ing les ions. Improper handling during extrication without consi deration of the ong oing resuscitation proce ss may inc rease the time spent at the scene and expose the patient to unnecessary risks. Earlier studies report a significant number of neurologic in jurie s that appear to be a result of the extrication process or of inadequate immobil ization during transport. Re cent work also underlines the need for appropriate and situation adapted Advanced Lif e Support (ALS) procedures to improve outcome after prehospital trauma res usci tation (27). Ensuri ng an unobs tructed air way and adequate oxygenation are fi rst priorit ies in the res usci tation of the entrapp ed trauma patient; a high pr oporti on of patients may have to b e in tuba ted while still entrapped. Conventional intubation by use of the laryngoscope is the gol den standard using rapid sequence i ntubation. However, this acces s mig ht be impossib le i n case of entrapment. Other techniques include ventral i ntuba tion, blind endotrach eal intubat ion, larynge al mask ai rway, retrograd e intuba tion, and eme rge ncy cricothyroidotomy (28,29). Ag gressive prehosp ital resuscitation is commenced at initial access to the patient, including basic monitoring, airway management, hemorrhage control, fluid i nfusion, analges ia, and cervica l spine stabi lization. If the patient d eteriorates, rapid e xtrication procedures have to b e performed. Ag gressive fi eld resuscitation and im mediate transport to a l evel 1 trauma center is associated with mortality l ower than that predicted by TRISS and ASCOT (A Seve rity Characterization of Trauma) scores in spite of the prolonged prehospital time (23,30).
Hypothermia
Tr auma patients are inherently predisposed to hy pothermia from a variety of intrinsic and iatrogenic causes. In contrast to t he percei ved benefit s in elec tiv e surgery, clin ical experien ce with trauma patien ts has identif ied hypothermia as a significant contribu ting factor to su bseq uent morbid ity and mortality (31,32). A core temperature below 34C is associated wi th a significantly increased mortality (33). It is hypothesized that this diverse effect of hypothe rmia is related to deple tion of high- energy phosphates lik e adenosine-triph osphate (ATP) in trauma pat ients (34). Furthermore, hypotherm ia has be en demons trated to induc e coagulopa thic states by disordered enzymatic function, reduced pla telet activ ity, and altered fibrinolysis (35,36). Coagulation and cardia c sequelae are the most pertinent physi ologic al concerns in hemorrhagic m odels of hypothermic shock despite adequate vol ume replacement (37,38). Hypothermia and coagulopathy often mandate a s implified approach to complex surgic al problems. There are few controlled investigations, but cli nical opinion strongly supports the active prevention of hypothe rmia in the acutely traumatize d patient. Both passive and active rewarming technique s, includ ing the use of warming blankets and other c onductive heat device s, p reclini cal use of fluid warmers, and extracorporeal devices in sev ere cases, have been successfully utiliz ed (39). The ideal method of rewarming is unclear but must be individualized to the patient and it is institution speci fic. C onversel y, hypothermi a has sel ected clini cal benefi ts when appropriately used in cases of trauma under clinical conditions. Severe hypothermia has allowed remarkable survivals in the course of accidental circulatory a rrest. The sel ective application of mild hypothermia in severe traumatic brain injury is an area with p romise , th ough exi sting studies are somewhat contrad ictory and work is ongoing (40).
INITIAL ASSESSMENT AND EARLY MANAGEMENT

The nex t pha se in p atient manage men t i s acut e treatme nt in the emergency depa rtmen t at the pr imary hospital. Th e trauma team has t o quickly ascertain the extent of the injury as wel l as asses s the pulmonary and hemodynamic status of the pati ent. Carefully pl anned diagnostic and operative tactics should be appl ied and coordinated to avoid mistakes that could impact negatively on the patient's prognosis. The decisi ons made depend on the level of expertise of the treating surgeon and the trauma team and the ir experience of managing trauma case s. During the treatment course, the clinical scenario c an chang e rapidly and manag ement plans must b e able to adapt accordingly.
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Management by i nexperienced surgeons can lead to ineffic ient handlin g of the changing sit uation and negatively i mpact on patient pr ognosis (41). Use of standardize d care protocols has been shown to improve timing, pr ocess and outcome (42). Because of logistical restraints, significant numbers of traumatized pat ients are still initially managed by inexperienced personnel. I n these situations, a structured approach or alg orithm to guide management has proven to be of increased benefit. A systematic, proble m solvi ng approach is directed with proper guida nce as to initial assess ment and therapeutic proced ures in diffe rent situations, while minimizing unnecessary and prolonged diagnostic pursuits (43). This approach has proved i nvaluable in saving time, minim izin g mistakes, and guiding inexperienced personnel to providing better care (44,45,46). It h as been demonstrated that the use of the algorithm has especi ally reduced mortality i n patients with moderately severe polytrauma, represented by an ISS of 20 and 50 (4 7). For patients with an ISS ab ove 50, however, the algorithm did not influence thei r clinical outcome (47). These patients usual ly have life-threatening conditi ons, where the severest prognosis is gi ven. Patients with less severe injuries are likely to have good outcomes even where initial management is suboptimal. P.63 The primary goal of i nitial management is to rapidly diagnose and immediately treat life-threatening conditions. Th ese in clude:
Airway obstruction or inj ury and asphyxia (e.g., laryngeal trauma) Tension pneumothorax or hemothorax Open thoracic injury and f lail chest Cardiac tamponade Massive i nternal or external hemorrhage
In these situation s accurate rapid diagnosis, together with i mmedi ate administration of lif e saving procedures, is necessary. This may necess itate that the patient be taken urgently to the operating room without f urther i nvestigations. Again, good knowledge of treatment alg orithms is of paramount importance in achieving this goal to avoid distraction from occult immediately threatening problems to obvious or spectacular but less dangerous secondary lesions. A pertinent example wou ld be neglect of in tra-abdominal exsanguination while attempting to d eal with severe extremity injury.
Respiratory Function
Management of the airway and breathing systems should be prioritized as they represent the most rapid threat to survival . Ai rway obstruction may be a resul t of
Midfacial fractures with obstruction of the nasopharynx Mandi bular fractures with the obs truction of the pharynx by the base of the tong ue Direct l aryngeal or tracheal injury Blood or vomit aspi ration Foreig n bodies (e.g., dentures)
Tr eatment should prioritize removal of any air way obstruction. If the obstruction is subgl ottic, emergency cric othyroidotomy or tracheostomy can be lifesavin g. Obstruction of the trachea i n the region of the mediastinum can cause severe respiratory impairment. This can lead to severe medias tinal emphysema and perforation of the endotracheal tube. The next prior ity is to maintain respiration , which could be compromis ed by thoracic or central nervous d ysfunction. D isorders of the respiratory system can be diagnosed clinic ally from symptoms and si gns, i ncluding dyspnea, cyanosis, st ridor, depressed conscious level, abnormal ch est e xpansion and the presence of major thoracic injuries. Thoracic injury might cause acute respiratory derangement, including l ung contusi on, tension pneumothorax, and hemothorax. Tension pneumothorax is a life-threatening condition and should be diagnosed clini call y and treated with out delay. The managem ent of pne umothorax and hemothorax should inc lude the i nsertion of a chest drain to decompress the chest. Pulmonary edem a can be caused by cardiac dysfunction, occu rring as a consequence of di rect cardiac trauma (48,49) or secondary myocardial infarction. Alternative ly, isolated bl unt t horacic trauma may cause highp ressure edem a, whic h has been observed followin g thoracic compressi on. Manageme nt of these two conditions d iffers one requiring fluid rep lace men t therapy and the other the use of di ureti cs. However , th e initial management of both types of edema involves continues suction and the use of positi ve end-expi ratory pressure (PEEP). Se vere head injury can cause central respi ratory impairment, whic h can be best verified through the use of a p hysical component summary. Sev ere shock may result in severe cerebral hypoxia and sub sequent r esp iratory i mpai rment. It is important that the emergency physician does not underestimate the effect of hemorrhagic shock. Continuous obser vation of the spontaneously breathing patient with min or injurie s in these cases can be
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j ustified. In the severely or multiple inju red patient, immedia te intubation a nd ventil ation f or adequate oxygenation is indicated. A ti dal volume of 8 to 10 mL/kg body wei ght, PEEP of 5 mL, and 50% O 2 saturation are prerequisites for adequate ventilation.
Cardiovascular Function
Following assessment of the resp iratory system, investigation of the cardiovascular system is necessary in the p resence of shock. Hemorrhagic shock shoul d be distinguished from other causes, such as cardiogenic and neurogenic shock. Th e presence of flat jugu lar veins mig ht indicate the presence of hemorrhagic shock. An elevated jugular ve nous pressure ca n b e diagnostic of cardiogenic shock, caused by coronary heart dise ase, myocardia l infarction (MI), cardiac contusion, tension pneumothorax , or cardiac tamponade. To establish this diagnosis the insertion of a pulmonary artery catheter may be necess ary.
Neurogenic Shock
Relative hypovolemi a i s the cause of neurogenic s hock, usually due to spinal i njury. L oss of the autonomic suppl y leads to a decrease in vascular tone wi th blood pooling in the periphe ry. This c an occur without significant blood loss. The resultant increase in skin perfusion lead to warm periphery and a decrease in central blood delivery. This type of sh ock may be diffic ult to disting uish from hypovolemia.
Cardiogenic Shock
Cardiogenic shock requires immed iate attention and frequently im mediate surgery. The he art can be impaired by cardiac tamponade, tension pneumothorax, and hemothorax, or in rare cas es by intra-abdominal ble edin g. These pathologies may n ecessitate immediate surgical intervention, including placement of a chest drain, pericardiocentesis, and emergency thoracotomy. If there is indir ect impairment of cardiac function, me dica l treatment sh ould be introduced and normovolem ia should be restored. Ra ise d jugular venous pressure in cardiogenic shock may be the result of right-sided heart f ail ure. This should b e con firmed through measurement of the central venous pressure. Ri ght heart failure may result i n bl ood p ooling in the pul monary system. This can be diffic ult to disting uish from pe rip heral P.64 blood loss. The two c an coexi st and may impair cardiac function. These conditions inc lude :
Cardiac tamponade Tension pneumothorax Myocardial infarction Cardiac contusion
The presence of penetrating cardiac trauma associated with an elevated central pressure and a decreased peripheral systemic pressure shoul d alert the treating doctor to the possibilit y of cardiac tamponade. A normal chest x-ray may not rule out this possibili ty, b ut ul trasound should provid e an immed iate diagnosis. The treatment of this condi tion should in clu de emergency pericardiocentesis. Following aspi ration of 10 mL of fluid from the peric ardial sac, an im mediate imp rovement of the heart stroke volume is seen wi th an increase in the p eriphe ral systemic perfusion. Emergency thoracotomy is rarely indicated. If required it can be performed through an incisi on betwee n the fourth and fif th ribs on the left side, f ollowed by opening the pericardium in a craniocauda l di rec tion to a void i njury to t he ph renic nerve . One or t wo transmural stitches al low tem porary cardiac closure and c ardiac massage can then be conducted. Tensi on pneumothorax causes rapidly increasing cyanosis, a rapid deterioration of respiratory function and can cause acute ri ght ve ntricular failure. As the conditi on progresses, raised intrathoracic pressure causes reduced righ t-sided ve nous return to t he heart. As me diastinal shifting occ urs , kinking or obstruct ion of the ven acaval system can lead to compl ete obstruction resulting in cardiac arrest. Rapi d diagnosi s followed by immediate d ecompression is a lifesaving measure. Cardia c failu re ma y cause MI i ndependent f rom the trauma. This dia gnosis should be consider ed in elderly people followi ng road traffic acciden ts. In these patients MI may have been caused by hypovolemia, hypoxia, or the acute rel ease of catecholam ines in the blood stream at the tim e of the accid ent or alternatively occurred i ncid ental ly causing the accid ent. A di agnosi s of MI can be confirmed from acute ch anges on electroca rdiography and an increase of blood markers (creatine kinase MB). Th e tr eatment of MI should inc lude medical therapy to control arrhythmi as. Patien ts with MI should be treated in the intensive care un it (IC U) with continuous monitoring from the medic al team. Cardia c contusion can be diff icul t to dif ferentiate from MI. Contusion is usually seen followin g blu nt a nterior thoracic wall trauma as sociated with a fracture of t he sternum. Differentiating this condition from MI in the acute setting is of secondary importance to the initial management as both diagnoses require similar management, including control of cardiac arrhythmias and heart failu re wi th continuous invasive moni toring.
Hypovolemic/Hemorrhagic Shock
He morrhag ic shock can be diagnosed through classical clinical parameters though physiol ogic al reserve can
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mean that alterations in puls e and blood pressure are a rel atively late sign . The extent of hypovolemi a i s oft en underestimated. Perhaps the most sensi tive indicator of intravascular volume is periphe ral capillary blood flow, evaluated by assess ing the nail beds and conjunctiva. Urine output is also a sensi tive parameter that can be used for the diag nosis of shock, to d etermine severity and moni tor the response to treatment. As a rough estimate, n ormal urine output should exceed 1 mL/ kg/hr or 30 mL in 30 minutes. Anuria is extremely unusual and often indi cates obstruction. Th is should be inv estigated by imag ing the renal tract as a matter of urgency, though in the face of ongoing deterioration of other parameters hyp ovolemia should be assum ed i n the trauma p atient unt il this can be un dertaken . Measurements of the right-sided fil ling pressu re can be achie ved using subc lav ian or jugular central ve nous catheters. Th e central venous press ure is likely to increase where there is an increase in the intrathoracic pressure (e.g., in thorac ic trauma or mechanical ventilation with PEEP) and thus is often of little value when i nitial ly assessin g shock. Use of a pulmonary arterial catheter (Swan-Ganz catheter) all ows much more a ccurate and reliable estimation of cardi ac function in compl ex cases. However, Swan-Ganz catheter insertion i s a ski lled p roced ure, particul arly in the acute setting and certainly requi res ICU monitori ng. Laboratory parame ters provide further information when ev aluating shock status and can be espe cial ly useful in asse ssing response to therapy. In particular, the arterial pH, base exc ess, and plasma lac tate levels have bee n used. Abnormal values reflect ongoing tis sue ischemia and various clinical and experimental studies have shown a corre lation between these parameters and the grade of shock (50,51,52). Furthermore, abnormal ityparticul arly where it is ongoing and fails to correct with therapyhas been shown to correlate with poor outcome (53,54). These parameters indi cate generalized or local tissue is chemia and giv e no i nformation rega rding the etiology of t he condition. Th e general management of shock inc lude s rapi d and adequate restoration of the hemodynamic status of the p atient th rough the use of flui d and blood conce ntrate replacement t herapy ; thi s is det ai led below. Blood should be ordered immedi ately when shock has been di agnosed clinic ally . If the rescue team has indicated the possibility of massive bleeding, erythrocyte concentrate should be available when the patient arrives in the emergency room. Once volume restoration has been started, any external or i nternal blee din g should b e i dentified. External blood loss is usually obvious though the volume lost prior to admission is usually unclear. Furthermore , the identification of ex ternal sites of hemorr hage should not distract fr om a ri gorous search for i nternal bleeding, the identification of whic h can be more proble matic. Internal blood loss shou ld be suspected in all patients, particularly where shock is recalcitrant. This usually occurs i n on e of three body regionsthe thorax, abdomen, or pelvi s. Diff erentiation of the site of internal bl eedi ng can us ually be made by using a combin ation of clinical judgme nt, thoraci c and pelvi c anteri or-posterior radi ograp hs and ab dom inal ultrasonograp hy. P.65 Ab domi nal ultrasound should be conducted in the fir st few minutes of the patien t's arri val to the emergency room where this is avail able. In creasingly emergency dep artment and trauma personnel are bein g trained in ultrasound examination and appropri ate equip ment i s being made availabl e.
Neurologic Status
If a patient has to be i ntubated and sedated, it is important for the emergency doctor to fully evaluate the neurological status prior to this. The size and reaction of the pupils are important indic ators of the presence of any central imp airment (abn ormal pupillary r eaction and size). The ligh t reflex refle cts the function of the second and third cranial nerves, oculocephalic reflex depends on the integrity of the third and fourth cranial nerves , and the corneal refle x represents intact fi fth and sev enth cranial nerves . The GCS also provid es i mportant information reg arding the neurological status of patients, p articularly when se rial m eas urements are p ossible and can provi de a u seful aid in clini cal decision maki ng. It i s argued that computed tomogr aphy (CT) should be performed if the GCS is less than 10; and whe re the GCS is l ess than 8, continuous intracranial pressure monitoring may be necess ary. These figu res only act as a guide ; however, trauma sev erity and ove rall clinical condition should al so be taken into account.
Management of Hemorrhagic Shock

Usin g a pa rallel approach it is usual to commence immedi ate management of posttraumatic shock while full evaluation of respi ratory , neurologic, and cardiovascular status is ongoing. Prolonged shock can lead to further p osttraumatic compli cations and theref ore impact neg atively on the pati ent's prognosis. Two l arge b ore i ntravenous cannulae shoul d be inserted during the preclinical phase and rapid fluid replacement therapy should commence as soon as possibl e. The cannulae are usually placed i n the antecubital f ossae and fastened sec urely to prevent dislodgement. On arrival in the emergency room, fu rther IV lines can be inserted as appropriate. Single internal jugul ar or subcl avian vei n li nes have the disadvantage of n ot allowi ng rapid transfusi on of large amounts of fluid. If lines i n the peripheral veins are not f easible, v enous cutdowns can be conducted by using the long saphenous vein around the ankl e. The choice of fluid for trauma resuscitation remains a controversial issue (55). Hi stor ical ly, crystall oid solutions were consid ered unsuitable as they were rapidly lost from circ ulation with pla sma or serum bein g preferred. Work in the 1960s, however, revealed that res uscitation with crystalloid led to lower rates of renal impa irment and mortali ty. It was considered that during hemorrhage, fluid i s redist ributed to the circulation from the extracell ular compartment and these losses must also be repl aced. Therefore infusion of a combi nation of crystalloid and blood at a 3:1 ratio was recommended. However, widespread application of these princi ples,
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particularly in military confli ct, c oincided with the e mergence of adult respiratory distress syndrome or shock l ung as a clin ical entity in surviv ors of major trauma. Whether thi s was a consequence of large volume crystalloid infusion was uncl ear. Interest in the use of colloid products was therefore renewed, but early results were conflicting, partly due to shortcomings i n trial desig n. Meta-analysis of these smaller studi es revealed no overall d iffe rence in the rate of pulmonary insufficiency following resusc itation with either fl uid type. Moreover, when final mortality was considered, particularly in the subg roup of trauma patients, a signifi cant improvement i n the overall survival rate was observed in the group administered crystalloid (56,57). Crystal loi d fluid is therefore consider ed to be the first treatment choice in most cen ters and is particularly favored in US trauma centers. Ri ngers lactate has various theoretical advantages over isotonic sal ine though clinical trials have not shown di fferences in outcome. Research into flui d selection for resusci tation is ongoing, particularly as much early evide nce is based on the use of albumin as a colloid. Since then, newer products with high er molecular weights have become available that sh ould b e more effi cient in maintaini ng flui d in the intravascul ar space. Th ere is further evid ence however that i n cases of severe hemorrhagic shock, increased capil lary permeabi lity allows these molecules to le ak into the intersti tium, worsening tissue edema and oxygen del iver y (55). Animal studi es demonstrating that small bol us admi nistrati on of hypertonic sali ne was as effective as large vol ume crystalloid have provoked consi derable interest in potential clinical applications (58). This effect was enhanced by combination with dextran (59). Though improvements in microvascular c irculation were observed, this also appeared to increase bleeding. Meta-analysis of early cli nical trials revealed that hypertonic salin e offer ed no a dvantage over standar d crys talloid resuscitation though hypertonic sali ne dextran migh t (60). This effect was particul arly striking in patients with closed head injury, and further animal studies have revealed that hypertonic sali ne can increase cerebral perfusion while decreasing cerebral edema (61).
Blood Replacement
Seconda ry to m aintaining in travasc ular volume , preservation of the pat ient's oxyge n carryi ng capacity is essential. In cases of massive hemorrhage this will inevitably requi re the repl acement of red bl ood cells. Fu rthermore, lost, depleted, and dil uted components of the coagulation cascade will also requir e replacement. It i s becoming increasingly apparent, however, particularly in young healthy trauma victims, that much lowe r hemoglobin concentrations than previousl y thought optimal are tol erated and indeed may be benefi cial (62). Not only is blood a precious resource, b ut transfusion also carries the risk of various compli cations, i ncluding the transmissi on of i nfective agents. Traditional ly, target hemoglobin concentrations of 10 g/L have been advocated, b ut it has recently been shown that concentrations as low as 5 g/L are acceptable in normovolemic healthy volunteers (63). R andomized trials in selec ted normovolemic intensive care patie nts showed that maintenance of hemoglobin P.66 concentrations between 7 and 9 g/ L resulted in equiv alent and perhaps superior outcome to m aintenance above 10 g/L (64) and transfusi on requirement has been shown to constitute an independent risk factor for mortality in trauma (65). Th is may be related to the potential of blood products to cause an inflammatory response in the recipient (66,67). In cases wit h severe blood loss, transfusion i s currently unavoidable and indeed, there is no clear point where continued admin istration becomes futile (68). I deally, fully crossmatched blood should be used but in an emergency universal donor O-negative blood can be used immediately. A sa mple should b e drawn for cross match prior to administration as the transfusion of O-negative blood can interfere with subsequent analysis. The blood bank should be able to deliver type-specific blood wi thin 15 to 20 minutes of the patient's arrival in the emergency room. This blood is not ful ly crossmatched and therefore st ill carries a relative risk of transfusi on reaction. Crossmatched blood shoul d be avail able within 30 to 40 minutes in most cas es. Coagulopathy should be anticipated in the vict ims of se vere trauma as a result of hemodilution, hypothermia, consumption, and disseminated intravascul ar coagulation. Correction and avoidance of hypothermia and the admin ist ration of warmed fluids is of utmost importance. The adminis tration of pla telets, fresh frozen pla sma and other blood products should be g uided by laboratory results alongside clin ical ju dgment. Expert hematological advi ce i s often required (69,70). Procoagulant therapy for severe coagulopathy remains experimental, t hough early results are promising. For exampl e, recombin ant activated factor VII has shown the potential to activate clotting cascades at sites of in jury without inducing excessive systemic coagulability (55,71,72). With the cost and potential adverse effects of autologous blood transfusion becoming increasingly relevant, i nterest in alternatives continues. Hemogl obi n-based oxyge n carrying flui ds have be en under investigation since the 1930s. Modern solutions using tetrameric polym erized human h emoglobin have been shown to be safe and phase III clinical trials are underway (55).
Monitoring Response to Fluid Replacement Therapy

Response to volume repl acement therapy is initiall y usually monitored using the cli nical response of t he patient and simple measurements, including pulse, blood pressure, capillary refill, and urine output. Uri nary catheterization is mandatory . In the severely injured or c omplex patient, i nvasive techniques, i ncluding arterial monitoring and central venous or pulmonary artery pressure recording shoul d be considered at an e arly stage. Though controversy st ill exists in specific sit uations, current goals include normal ization of vi tal signs and maintenance of central venous press ure betwee n 8 and 15 mm Hg. Ser ial recording of acid -base parameters, t he b ase ex cess and serum lactate in par ticular, have be en shown to be pa rticu larly use ful in ass essi ng res ponse to therapy and detecting the presence of occu lt hypoperfusion in apparently stable patients (53,54,73). Ongoing requirement for blood transfusion should be monitored by regular measurement of the hemoglobin
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concentration. This c an be rapidly estimated where necessary usin g most bedside arterial blood gas analyzers. On going excessiv e fluid or b lood requirement sh ould always prompt a repeated search for sources of hemor rhage. Shock tr eatment is a d ynamic process and in cases where there is ongoing b leeding, s urgica l i ntervention is often indicated. More recently, sev eral m ethods for im proved monitoring of cardiovascul ar status and tissu e perfusion have bee n i ntroduced, including gastric tonometry, near infrared spect roscopy, transthoracic impedance cardiography, central venous oximetry, a nd skel etal muscle acid-base esti mation. Many of these technique s remain experimental and are not available on a widespread basis. They may be available in certain centers and expert advi ce is essential.
SecondaryTertiary Survey
As discussed previously it may be necessary to postpone a full head to toe examination until life-threatening p roblems have be en remedied and the patient has been stabiliz ed. A systematic secondary survey should never b e omitted, however. M issed comparatively minor injuries whic h subsequently receive suboptimal treatment can cause long-term loss of function and considerable morbidit y. Su ch incidents have b een the subj ect of successful l itigation despite lifesaving therapy for other more serious injuries. Mor eover, it is sensible to repeat the secondary survey, once the immedia te danger has passed, a way fr om the b usy emergency dep artment. This way omis sions and missed opportunitie s to prevent long-term problems should be mi nimiz ed. For similar reasons, a thorough, s ystematic approach should always be employed, with each patient being examined in the same manner, proceedin g in a craniocaudal dir ection and inc ludi ng all body regions. A low threshold for x-ray examination of peripheral injuries should be employed particularly in the presence of major t rauma. As an absolute minimum, x-rays of the chest, pel vis, and cervica l sp ine should be obtained as advocated in ATLS teaching. On ly through the use of such a structured approach wi ll the morbid ity and mortality of patients be d ecreased. Diag nostic errors have been shown to occur frequently when t reating isolated inju ries (74). In polytrauma patients, the cl inical picture is more comple x and it is more likel y that some injuries may be mis sed or overlooked. A retrospective anal ysis of diagnostic omission following pol ytrauma described 327 patients d ocumenting the type and incide nce of misse d injuries (75). Th e majority of patients had suffered road traffic acci dents in which 50% were car drivers, 24% motorcycle riders, and 26% ped estrians. The overall inci dence of misse d injuries was 12%; that is, 4% of the total 1205 injuries were misse d. The most common typ e of overlooked inj uries were fr actures, particularly around large joints. The majority of missed inj uries were P.67 picked up within 3 days following admission , though longer intervals have also been reported. Th e reasons for overlookin g injuries usually relate to poor primary assess ment and are significantly more common with the le ss experienced physician. I t was found that m istakes in the init ial cl inical examination were based on insufficient or nonsystematic examination or misinterpretation of the i njury site (75). The in itial examination is more difficult in unconscious or sedated pati ents with major injuries. I n these cases the usual i ndic ator of pain cannot reliably be used to direct examination. Sign s such as crepi tus, deformity, hematoma, swelling, or j oint effusi on must be used to direct investigation . Poor x-ray quality, misinterpretation of x-rays, admis sion, and the total number of inj uries present were al so important factors in the inciden ce of missed i njuries. Th e tertiary survey provid es another opportunity to eva lu ate any newly discovered physi cal fin dings and diagnose any miss ed inju ries. It also consists of a repeated head-to-toe ev aluation of the trauma patient. Daily l aboratory data and new radiological examination in the form of plai n x-rays, CT, or magnetic resonance imagin g (MRI) should be considered along with the clinical signs. Repeated physical exami nation is of paramount i mportance and contri but es fav orab ly to the pat ient's long- term outcome .
DEFINITION OF THE PATIENT'S CONDITION

Once initial assessment and intervention is complete patients should be placed into one of four categories in order to guide the subsequent approach to their care. This is done on the basis of overall injury severity, the presence of spe cific injuries and current hemodynamic status as detailed above (73). Any deterioration in clinical state or physiological parameters should prompt rapid reassess ment and adj ustment of management approach as appropriate (76). Achievi ng the end poi nts of resusci tation is of paramount importance for the stratifi cation of the pat ient into th e appropriate category. End poi nts of res usc itation inc lude stab le hemodynamics, stable oxy gen saturation, lactate level below 2 mmol/L, no coagulation disturbances, normal temperature, urinary output a bove 1 mL/kg /hr, and no requirement for inotropic support.
Stable
Stable patients have no immediately li fe-threatening i njuries, respond to init ial therapy, and are hemodynamical ly stable without i notropic support. Th ere is no evidence of physiologic disturbance such as coagulopathy or respiratory distress nor ongoi ng occult hypoperfusion manif esting as abnormalities of acid base status. They are not hypothermic. These patients have the physiological reserve to withstand prolonged operative intervention where this is appropri ate and can be managed using an ETC approach, with reconstruction of complex injuries.
Borderline
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Borderline patients have stabilize d in response to initial resusci tative attempts but have cli nical f eatures or combinations of inju ry, which have been associated with poor outcome and put t hem at risk of rapid d eteri oration. These have bee n de fin ed as follows (126):
ISS <40 Hypothermia <35 Initi al mean pulmonary arterial pressure >24 mm Hg or a >6mm Hg rise in p ulmonary artery pressure du ring intrame dull ary naili ng or other operative interven ti on Multiple injuri es (ISS >20) in association with thoracic trauma (AIS >2) Multiple injuri es i n associati on with severe abdominal or pelvic in jury and hemorrhagic shock at presentation (systolic BP <90 mm Hg) Radiographi c evidence of pulmonary contusion Patients wi th bilateral femoral fracture Patients with moder ate or severe head injur ies (AIS l3 )
Th is group of pati ents can be ini tially manage d using an ETC approach but this should be undertaken with caution and forethough t give n to operative strategy s hould the patient req uire a rapid ch ange of treatme nt rationale. Addition al invasive monitoring should be instituted and provision made for ICU admission. A low threshold should be used for conversion to a damage control approach to management as detailed below at the first sign of deterior ation.
Unstable
Patients who remain hemodynamically unstable despite initial i ntervention are at greatly increased ri sk of rapid d eteri oration, subse quent multiple organ failure and death. Treatment in these cases has evolved to use a damage control approach. This entails rapid lifesaving surgery only as absolutely necessary and timely transfer to the ICU for further s tabiliz ation a nd monitoring. Temporary stabi lization of fractures usin g external fixation, hemorrhage control, and exteriorization of gastrointestinal injuries where possible is advocated. Complex reconstructive procedures should be delayed unti l stability is achieved and the acute i mmunoinflammator y response to in jury has sub sided. This rationale is intended to reduce in magnitude the second hit of operative i ntervention or at least delay it until the patient i s physiologically equipped to cope.
In Extremis
Th ese patients are very close to d eath havin g suffered severe injuries and often have ong oing uncontroll ed blood l oss. They remain severely unstable despite ongoing resusc itative efforts and are u sually suffering the effects of a deadly triad of hypothermia, acidosis, and coagulopathy. A damage control approach is certainly advocated, and only lif esaving procedures P.68 should be attempted so as not to d rive this process further. The pa tients should then be transferred directly to i ntensive care for inva sive moni tori ng and advanced hematologi cal, p ulmonary, and cardiovasc ular support. Or thopedic inj uries can be stabi lized rapidl y in t he eme rgency dep artment or intensive care unit using external fixation and this should not delay other therapy. Any reconstructive surgery is again delayed and can be performed if t he patient survive s.
SURGICAL PRIORITIES IN POLYTRAUMA: WHAT COMES FIRST?

In patients with polytrauma, decision making as to which injury to address first can be difficult, particularly i f they appe ar immi nently dangerous or may be contribu ting to hemodynamic instability. With dif ferent inju ries fall ing under the remit of different surgical specialties, disagreements as to surgical priority can occur and it is of utmost importance that a cooperative multid iscipl inary approach is adopted. Epidemiological mortality studie s and clinical experience reveal that certain injuries can be rapidly fatal and should be considered i n precedence to others, although careful i ndiv idual decision making must be used as every case is d iffe rent. Rarely, early operative treatment without prolonged diagnostic procedures may be lifesaving. These include penetrating thoracic injuries resulting in cardiac tamponade, open arterial injuries, and pelvic trauma. Continuou s bleedin g with shock resistant to supportive therapy in the thorac ic, abdominal, or pelvi c regions are primary indicators for surgical intervention. With the use of thoracic and pelvic radiographs and abdominal sonography 95% of sources of major bleed ing should be identified immedia tely.
Urgent Lifesaving Surgery

Hemothorax
Hemothorax is usually easily diagnosed from the chest x-ray; however, in the p resence of extensive lu ng contusion or atelectasis the dia gnosis can be diffic ult. Ultrasound examination has shown the potential to
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i dentif y free thoracic flu id though CT remains the gold standard and often reveals the source of any bleed ing (77). Si gnificant bleeding into the pleural space and resultant hemothorax is treated during the primary survey by a chest tube. Us ually, the indication comes from the chest x-r ay, and only occasi onally are clinica l findings the sol e basis for chest tube insertion, as chest x-ray can usually be p erformed very rapidly. It is standard practice to insert the chest tube in the mid- axillary line at the fi fth intercostal space Lower insertion risk s injury to the diaphragm or intra-abdominal organs. Blunt dissection should prevent structural injury and is important even where the operator is confident of positioning as intra-abdominal injuri es may lead to increased intra-abdominal p ressure and diaphragm atic elevation or eve n rupture. A tradi tional chest tube of at least 28-gauge should be used to dr ain a he mothorax; modern percutaneous drains used in thoracic medic ine are not sufficient f or this indi cation. A l arge diameter red uces the danger of coagul ation, al lows rapid blood eva cua ti on, an d allows relative confidence that drai ned contents are representative of thoraci c blood loss . It is usual to di rect the tube cordally to drain blood and cranially in the p resence of a pneumothorax. Th e presence of a hemothorax is not diagnostic of major thorac ic hemorrhage. In most cas es, bleedin g is the result of injury to an intercostal vessel, and this will usually arrest spontaneous ly. Emergency department thoracotomy remains controversial, although recognized i ndicati ons include traumatic arrest or recalcitrant profound hypotension in penetrating trauma, r apid exsanguination (>1,500 mL initially or 250 mL/hr), and unresponsive hypotension in blunt thoracic trauma. As a last resort to control catastrophic subdi aphragmatic hemorrhage, the aorta can be cross-cla mped . These interventions are regarded as futile in patie nts with bl unt thoracic trauma in cardiac arrest where there has been no witnessed cardi ac output and in patients with sev ere head injuries . There is recent e vidence that increased caution shoul d be emp loyed before undertaki ng emergency thoracotomy in blunt trauma pa tients for all indications, pa rticu larly in the emergency department, d ue to a relativ ely hig h rate of nontherapeutic procedures and poor outcome (78,79).
Mediastinal Hemorrhage and Thoracic Aortic Injury

Medi astinal hemorrhage due to injury to the thoracic aor ta is commonly dia gnosed errone ously due to poor quality chest radiography obtained in emergency situations with a supine position and insufficient inspiration. Medi astinal enlargement ob served on plain chest radiography is rather nonspe cific. In this context, one should pay careful attention t o the presence of dilated jugular vei ns, which offer some dif ferentiation of cardiac from aortic i njuries. Nonetheless, further imaging should be rapi dly obtained in the hemodynamicall y stable p atient by contrast-enhanced thoracic CT. Although traditional CT scanni ng sometimes lead to false-positi ve results and ang iography has been regar ded as the gol d standar d in diagn osis, many centers believe that contrast-e nhanc ed high-resolution spiral CT is preferable (80,81,82). Free intrathoracic rupture in inj ury to the thoracic aorta is exceedingly rare in patients surviving long enough to reach the emergency room alive. In most cases, the adventitia is preserved and further intrathoracic blood loss i s prevented by the parietal pl eura. Furthermore there is i ncreasing evi dence that repai r can be delayed in the presenc e of other life-threatening inj uri es and occa sionally conservativ e manageme nt can be succ essful (83,84,85). Thes e pati ents should , however , al ways be treated in a center with an acute thoracic su rgical service . Nonoperative treatment of incomplete aortic ruptures in hemodynamica lly stable patients consists of a controlled hypotension or active reduction of blood pressure while controlling for a dif ference in blood pressure b etween the uppe r and lower parts of the body. Indic ations for i mmedi ate intervention include the development P.69 of hemodynamic instability without alternate explanation, hemorrhage via the chest tubes (>500 mL/hr), or a b lood pressure gradie nt between upper and lower extremities leading to an i mpaired perfusion of the lower l imbs (difference of mean blood pressure >30 mm Hg ). Gi ven the high mortality rate associa ted with emergency repair i n cases of traumatic aortic injury, there is increasing interest in the use of endovascul ar stenting in su ch situations (86,87,88). If the clinical situation arouses the suspicion of cardiac injury in the presence of radiological mediastinal abnormality, the diagnosis is generall y cardiac tamponade. Pericardiocentesis shou ld be performed. I f there is acute dec ompensation, an emergent thoracocentesis is indicated. Further di agnostics are too time- consuming in this immediately l ife-threateni ng situation. If the patient is still hemodynami call y stable, a very sensitive and readily available test is the transthoracic echocardiogram.
Severe Pelvic Trauma and Packing

Pel vic fracture is often seen in conjunction with multisystem trauma and can lead to rapid occult hemorrhage. Tr eatment should be thought of as part of the resusc itative effort and early intervention can be life savin g (89). Bl eedi ng is commonly from multiple small si tes rather than inju red major vess els and, due to the large volume of the retroperitoneum, in severe cases sp ontaneous arrest is unlikely ( 90). Furthermore, i t is common for the retroperitoneum to be breached during the injury further d ecreasing the barrier to ongoin g hematoma expansion. Treatment with the p neumatic antis hock garment or pelvic belt-straps can giv e some temporary stabilization (91), but results are inconclusive and severe complications have been reported in relation to their use. Al though there has been increasing interest in the use of sele cti ve angiography in these cases to embolize b leed ing vess els, this intervention is often time consuming to organize and perform. Patients must be relatively stable and careful selection is crucial. Embolization can be used as an adju nct t o other interventions where continued arterial hemorrhage is suspec ted. In sev ere in juries with profound hemodynamic inst ability, external
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fixation with a pel vic C-cl amp, and open tamponade by packi ng is recommended (Fig. 3-1) (92,93). With the patient supine, pr eparation f rom the subcostal margin to the pubic s ymphysis is p erformed with the abdomen and pelvis completely exposed. If a C-clamp has already been applied for posterior pel vic instability, it should be l oosened. In verti cal pelvic instability (C-type i njury), the l eg should be accessible to allow reduction where req uired. Following application of an external fixation device, if there is prior evidence of free intraperitoneal flui d a midline laparotomy should be performed and the intra-abdominal organs examined for bleeding following standard management protocols for blu nt ab dominal trauma. If , however, initial d iagnostic imaging has shown no eviden ce of in tra-abdominal flui d and a major source of pel vic hemor rhage is suspected a lower mi dline l aparot omy can be employed. Initial attention should be dir ected to the retroperitoneum. Following skin incisi on ruptured pel vic soft tis sues are usual ly readily visi ble. Any hematoma is evacuated and the paravesical space explored for bl eeding sources. Major bleeding vessels should be ligated where possible; in diffuse bleeding, welld irected packi ng with ext ernal stabilization is most recommended.
FIGURE 3-1 Application of pelvic packing in a patient with hemodynamic instability.
If hemor rhage is obviously origi nating from a deep dorsal source, p articularly in cases of posterior pelvic i nst abi lity, at tempts at further extrap eri toneal exploration should be made in the pre sac ral region. Maj or bleeding sources can be identified and treated appropriately . In cases of catastrophic a rterial hemorrhage, temporary control can be achieved by cross-clamping the aorta. In ve nous hemorrhage, often no sin gle bleeding source is ide ntifiable. Usually, bleeding originates from disruption of the presacral venous plexus or the fracture site itself. Agai n, well- directed packing can often adequately control bl eeding. Following this intervention, temporary abdominal closure i s performed and correction of physiological abn ormal ities should be und ertaken without delay, with particular regard to coagu lopathy and hypotherm ia. Packing is lef t in situ a nd changed routinely at 24 to 48 hours, though in cases of suspe cted ongoing hemor rhage and recalcitr ant shock, earlier reintervention should be considered. At planned revision the cavity should be thoroughly examined for sites of ongoing hemorrhage followi ng debrideme nt as necessary and removal of hematoma. Further bl eeding p oints can be dealt with, but if diffuse hemorrhage persists, further packing with subsequent surgi cal revision is required. A staged approach to the management of pelv ic fractures i s shown in Fig ure 3-2.
Treat Exsanguinating Abdominal Hemorrhage or Expanding Intracranial Hematoma First?

Controversy remains over such dif ficu lt situations with compelling arguments bei ng presented for each case. Th ere is in creasing evidence for conservative management of abdominal i njuries except i n the most unstable patients, and apparent i ntra-abdomi nal P.70 hemorrhage is often pelvic in origi n. Ev acuating an intracranial hematoma if the patient exsanguinates is obv iously futile. However, there is equall y little benefit in saving a patient's life if the result is profoundly d isab ling brain inj ury or death from ten torial herniation. Once compensatory autor egulatory mechanisms are overwhelmed , intracrani al pre ssure rapidly inc reases. There is evide nce that in p atients with he ad injury, death from extracranial causes alone is unusual. In a study of al most 50,000 trauma patients 70% of deaths were attributed to the head inj ury alone and only 7% to extracranial trauma, with the rest caused by a combin ation of both (94). However, craniotomy should not be undertaken without imagin g to confirm a surgically treatable l esion except in the rarest of circumstances. C T scanning is time-consuming and can cause a sig nifi cant delay in
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treatment. This time might be better spent rapidly attempting hemodynamic stabili zation. There is also evi dence that in hypotensive patients undergoing head CT, emergency laparotomy is required far more frequently than craniotomy (21% vs. 2.5%) (95). Furthermore, inf erior outcome has been dem onstrated in head injured patients with shock, sugge sting that early correction of hypotensi on may protect agains t secondary brain injury (96).
FIGURE 3-2 Algorithm of management of pelvic fractures.
It is clear that in these patients, r apid comple x management decisions must be made and clinical experience is essential. Th ankfully, such dilemmas seldom occur. I n a r evi ew of 800 patients with significant head and abdominal inju ries, 52 required craniotomy , 40 laparotomy, a nd only 3 required both (97).
MOLECULAR ASPECTS OF TRAUMA

Tr auma and surgery induce changes in the inflammator y immunologica l and coagulatory cascades. The availability of techniques to measure biological markers of immune reacti vity has vastly expanded our knowledge of the events that occur at the cellular level. Bef ore referring to the immunologic events occurring following trauma, it is essential to understand the pathogenesi s of the most severe posttraumatic compl ications, adult respiratory di stress syndrome (ARDS) and MODS in these circumstances. MODS is characterized by generalize d i nflammation and tiss ue damage. In the early 1970s Tilney et a l (98) were given credit for first describing sequential failure of multiple organs in 18 consecutive patients with ruptured abdominal aorti c aneurysm who required postoperative hemodialy sis. Th ese authors concluded that this was the resu lt of a combi nation of preexisting dis ease and hemorrhagi c shock. Eisman et al (99) introduced the term multiple-organ failure to d escr ibe the clinical course of 42 patients with pr ogres sive orga n fail ure; hal f of these pa tients had an intraabdominal abscess impli cated as the i nciting event. Thus, se psis was adde d to the list of risk factors for MODS. Subseq uently, Fry et a l (100) retrospe ctively reviewed 553 pa tients who required emergency operations; two thirds had sustained major trauma. Thirty-eigh t (7%) patients developed MODS and 90% were septic. Th e authors proposed that MODS was a fatal expression of uncontrolled infection. This l ed to an aggressi ve policy of mandatory laparotomy to rule out intra-abdominal abscess (100). Faist et al (101) publ ished a review of 433 trauma patients who required emergency operati ons (99% blunt mechanism); 50 (12%) developed ARDS and 34 (8%) devel oped MODS. The authors desc ribe d two distinct patterns of MODS: rapid singl e-phase MODS due to massive tissue injury and shock or delayed two-phase MODS due to m oderate trauma a nd shock followed by del ayed sepsis. Goris et al (102) reviewed 92 MODS patients wh o had clinical si gns of se psis. Th ey separated these patients into two g roups : 55 trauma patients (all bl unt mechanism) versus 37 nontrauma pa tients who had undergone eme rgency lap arotomy. Bacterial sepsis was confirmed in only 33% of the trauma-related MODS patients, compared with 65% of the nontrauma patients (102). In addition, a provocative report by Norton (103) showed that drainage of an abdominal abscess reverses MODS i n a disappointingly small proporti on of patients. Thus, the above clinical observations suggested that MODS f requently may occur in the absence of infection and the inflammatory sy stem was impl icated as a causative factor. It is known today that the activation of the inflammatory system is the norm after traumatic i njury and this leads to the development of the sys temic i nflammator y response syndrome (SIRS).
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Th is is followed by a period of recovery medi ated by a counterregulatory anti-inflammatory resp onse (104). It appears that the key players in this host inflammatory response are the cytokines, the leukocy tes , th e endothel ium, and sub sequ ent l eukocyteendothelial cell interactions. Reactiv e oxyg en spec ies, e icosanoids, and microcirculatory disturbances also play pivotal roles (105). Within this inflammatory process, a fine balance exist s between the beneficial effects of inflammation a nd the p otential for the pr ocess itself to cause and ag gra vate tissue injury le adi ng P.71 to ARDS and MODS. If this infl ammatory resp onse is exaggerated or perpetuated, patients enter a state of malig nant sys temic inflammation (moderate or s evere SIRS) that can evolve into overt ARDS or MODS. In these patients, p ulmonary failure occurs firs t, then the other organs fail b ecause the lungs are ei ther more vulnerable or our cli nical tools to detect lung failure are more sensi tive. Proposed mechanisms for the nonseptic (inflammatory) development of M ODS include the following:
Macrophage theoryincreased production of cytokines and other inflammatory mediators by activated macrophages Mi crocirculatory theoryprolonged hy povolemic shock promotes MODS through inadequate global oxyge n delivery and is chemia reperfusion phenomena Endothelial cellleukocyte interactions leading to remote organ injury Gut hypothesisgut origin bacteria or their products contribu te to MODS. It has been used to explain why no obvious site of infection can be found in as many as 30% of the bacteremic patients who die from MODS. One- and two-hit theoriesIn the one-hit mode l the ini tial in jury and shock give rise to an intense sys temic i nfl ammatory response with the potential for remote organ inj ury. In the two-hit model, the initial stimulus is less in tense and normally resolves but the patient is vulnerable to a secondary inflammatory ins ult that c an reactivate the sys temic i nflammator y response and precipitate late multiple organ dysfunction. Secondary ins ults to the inf lamm atory system in the two-hit model can be caused by factors such as surgical proce dures and sepsis (Fig. 3-3)
It is believed that sig nificant overlap exis ts in the diffe rent inflammatory theories of the development of MODS. In most patients, irrespective of t he triggering event, MODS foll ows a pred ictable course, generally beginning with the lungs and progressin g to liv er, g astrointestinal tract, and kidney. The mortality rate progressi vely rises from 20% with one failed organ system to 100% when four systems fail (100). Lately, increased knowledge of posttraumatic immunologic al responses has resulted in a clearer appreciation of these processes (106,107). Specifi c markers of the systemic inflammatory response have been identifie d and can now be in cluded i n the assessment of these patients (108). The clin ical course of the patient following p oly trauma therefore is pr imarily determined by three fac tors : the initial trauma ( fi rst hit ); the pat ient's b iol ogi cal constitution; and the timi ng and quality of any medical i ntervention, which can be thought of a s additional trauma ( second hit ) if the procedure is l arge enoug h. The treating physician can modul ate onl y the me dical interventions. The more severely traumatized the patient is, t he more critic al the strategy bec omes.
FIGURE 3-3 One and two hit inflammatory models.
Systemic Impact of Trauma ( First Hit )

Th e development of a trauma-induced inflammatory response is recognized as a part of the p hysi ologic reaction after trauma (1 09). Th e extent of this i nflammation is influenced by external (inju ry severity) as well as internal
Page 14 of 50
factors (individual genetic predisposition) and can be quantified by specific markers such as cytoki nes (Table 31). An injured or a surgic al patient is a veritable stew of cytokines. An overwhelming systemi c inflammation (SIRS) has been attributed to a state that predisposes to further posttraumatic complications (MODS) (110). Certain inju ries have been observed to occur more frequently in patie nts who go on to develop these complications in the posttraumatic course. Among the ex tremity inju ries, fe moral shaft fracture has been associated wit h an inc reased risk of adverse outcome (111). This appears to be based on the fact that a femoral fracture is associated with sig nificant soft tissue damage and blood loss in view of the fact that the largest soft tissue envelope of any long bone surrounds the femoral shaft (112). Osseous and soft tissue in juries initiate a l ocal infl ammatory response with increased sys temic concentrations of proi nflammatory cytokines. These cytokine levels correlate with the degree of tissue damage and the severity of fracture. These findings support our understanding that inflammatory mediators are locall y generated (113,114). Se veral studie s have demonstrated the biological profile of the first hit in trauma patients and have sh own a direct correlation between the level of the release of the infl ammator y (stimulation) and anti-infl ammator y media tors (suppress ion) and the degree of injury (115,116,117). The development of a massi ve immune reaction by a patient with bil ateral femoral fractures who P.72 showed a ma ssive inflammator y reaction and his i nflammator y profile was subsequently hyperstimulated by the surgical procedure itself (bi lateral reamed femoral nailing) further su pports the imp ortance of the firs t hit (118). Al though there was no obvi ous additional risk factor (no chest injury) the patie nt died from full-blown ARDS 3 days after injury. This case clearly not only illu strates the existence of biological variation in the inflammatory response to i njury but also confirm s the importance of the deg ree of response to the first hit and the response to the second hit (surgical) that created the fi nal fatal event (Fig. 3-4). The above studies suggest that the degree of t he ini tial injury is important in determining a patient's susceptibility t o posttraumatic complications.
TABLE 3-1 Variety of Defined Cytokines

Group Examples
Interleukins (IL )
IL-1, IL-2, IL-3, IL-4, IL -5, IL-6, IL-7, IL-8, IL-10, IL-11, IL-12, IL-13, I L-18
Tu mor necrosis factors (TNF)
TNF, lymphotoxin (L T)
Interferons (IFN)
IFN-, INF- , INF-
Colony stimulating factors (CSF)
G-CSF, M-CSF, GM-CSF
Comparison of different inflammatory markers has demonstrated that measurement of proinflammatory cytokines appears to be most useful for routine clinical work (Tabl e 3-2). Roumen et al (119,120) reported that l evels of the primary inflammatory cytokines, tumour necrosis factor- (TNF-) and interleukin-1 (IL-1 ) had a good correlation with the ini tial degree of hemorrhage and nonsurvival after ARDS and MODS. This f ind ing i s, however, not c onsistent (121,1 22). Previous results from our group demonstrated that the reliabi lity of both TNF- and IL-1 concentrations as acute markers for trauma and surgery is low. In other clinical studi es, t he use of TNF- as a marker has been dis appointing. This is in part due to its pharmacokin etics: TNF- has a short plasma half-life of 1418 minutes. Binding to soluble TNF- receptors and natural TNF-binding proteins can also interfere with measured p lasma levels ( 123). In contrast, I L-6 appears to b e a more reliable marker. A c linical study confirmed early elevation of IL-6 le vels i mmedi ately after trauma; patients with the most severe injuries had the highe st IL-6 concentrations (124). The associat ion between early elevations in IL-6 plasma concentrations, high ISS, and late adverse outcome is well establi shed (125). Level s remained elevated for more than 5 days in patients with a hig h ISS (124). An early rise of IL-6 exceeding 800 pg/m L on admi ssion was able to d iscriminate trauma patients who later devel oped MODS (124).
Systemic Impact of Operative Procedures ( Second Hit )

Th e second hit is observed to be c ompounded by factors such as the type of surgical proced ure, blood l oss, sep sis, and isch emia, all of which wil l heighten the inflammatory response (1 26). Furthermore, one can consider any su bsequent physiologi cal stresses as serial subsequent hits, including septic episodes, blood transfus ion, dehydration, and surgical intervention. When considered in these terms it b ecomes easy to understand how, even in a patient with onl y a moderate first hit, the clinical situati on can rapidly deteriorate if further insults are allowed to take pla ce. The ove rriding princ iple of da mage con trol surgery is therefore to
Page 15 of 50
minimize subsequent stresses subjected on unstable patients at high risk for posttraumatic complic ations. In trauma patients undergoing orthopedic procedures, subsequent in creases i n IL-6 plasma levels were proportional to the magnitude of the operati on. Most investigations exami ning quantification of the second hit response induced by orthopedic surgery deal with the st abilization of long bone fractures. Femoral nail ing was found to have a si gnif ica nt impa ct on inflammator y P.73 P.74 response, and lead to a marked increase in IL-6 concentrations (127,128). Our recent clinical findings support these results, demonstrati ng that IL-6 concentrations varied accordi ng to the type of orthopedi c surgery performed. The inflammatory response induced by fe moral nailing was comparable to that induced by uncemented total hip arthroplasty (110).
FIGURE 3-4 Plasma el astase levels illustrating the 1st and 2nd hit phenomenon following femoral nail ing. The dashed line represents the patient who developed adult respiratory distress syndrome (ARDS) and di ed. (From Giannoudis PV. St imulation of the inflammator y system by reamed and undreamed naili ng an analysis of the second hit. Thesis, Unive rsity of Leeds, 1999.)
TABLE 3-2 Type, Source, and Common Actions of the Relevant Cytokines
Cytokine Source Actions
Pro-i nflammator y release
Macrophages/monocytes
Promotes muscl e metabolism, cachexia, apoptosis, and ICAM
TFN-
T Lymphocytes/macrophages
Cardio dep res sant
IL-1
Expressi on of COX-2, iNOS, ICAM-1
IL-6
Endogenous pyrogen
IL-8
Macrophages
Synergizes with TNF-
IL-12
T-lymphocytes
Mediates acute hepatic phase response
Page 16 of 50
IL-18
T-lymphocytes, NK cells
Activates HPA axis
IFN-
T-lymphocytes
Pyrogen and downregul ates TNF- and IL-1 (anti-infl amma tory)
Fas ligand
T-lymphocytes
Anti-inflammatory
T-lymphocytes
Chemoattractant
Recruits neutrophils, releases superoxides and proteases
IL-4
Associated with IL-6
IL-10
Differentiation of T cells
IL-13
Promotes neutrop hil and coag ulation activation
Synergistic with IL-18
Induces IFN-
Syn ergize s with IL-1 and IL-12
Down regulates Fas ligand and TNF-
Promotes IL-2, IL -12, IL- 18
Activates macrophage-acute lun g in jur y
Induces apopt osis, tumor surveillance
Control of hyper-inflammation
Growth factor for T cells, NK cel ls
Downregulates IL-1, TNF, IL -6, I L-8
Increases effects of glucocorticoids
Su ppression of TNF, IL- 1, and IL-18
Promotes p roduction of TNF-receptor-1
Downregulates TNF- and IL-1-
and IL -8.
Page 17 of 50
Inhibits the antibody dependent cellular cytotoxicity and LPS- induced IL-6 secretion.
Af ter the initial proinflammatory response, a secondary im mune suppressi ve eff ect of operative treatment is described. This was characteri zed by raised concentrations of the anti-inflammatory IL-10 and reduced class II human leu kocyte antigen (HLA) expression on pe rip heral blood mononuclear cel ls. Again, the effect of femoral nai ling was investigated, demonstrating that reamed femoral nai ling was associ ated with greater impairment of i mmune reactivity than the unreamed nai ling technique (129). Th e second hit appe ars to be addi tive to the prim ary insult, and if the combin ation is sufficiently severe, the patient's physiological reserve is overcome. The resul t i s either rapid deterioration, or a prolonged clinical course characterized by systemic inflammation. The inflammatory response ultimately results in mi crovascular d amage. This p rocess is medi ated in part by activated polymorphonuclear leukocytes. A c rucial p athophysiolog ical step in this process is neutrophil adherence to capillary endothelial cells and subseq uent extravas ation (130). The neutrophils are then stimula ted to r elease oxygen-f ree radicals and proteases, resulting in injury t o the vessel wal l (131). This contributes to increased capillary permeability, leading to i nterstitial edema. All these factors are known to be in volved in the devel opment of MODS.
MANAGEMENT OF SKELETAL INJURIES Evolution of Treatment of Major Fractures: Historical Perspective

Until the middle of the last century, e arly definitive fracture stabiliz ation was perfor med only as an exc eption, as i t was believed that multiply injured patients were too unstable to survive surgical intervention. Complex l aboratory investig ations and monitoring facili ties wer e not available. Consequently estimation of the patient's status was, on the whole, performed by clinical assessment only. Thus, complications were u sually identified only in their late stages . Signs of MODS in the first posttraumatic week were simil ar to those caused by fat embolism syndrome, which was due to unstabiliz ed fractures. This syndrome i s characterized by hypoxia, cerebral depress ion (c oma), c oagulopathy (petechial bleeding), and renal failure (anuria). Embolism was thought to be dir ectly related to the release of fat and intramedullary content fr om the fracture site by fracture or early surgical treatment (132,1 33). It was also beli eved, however, that pathological movements of the fr acture migh t be resp onsible for further liber ation of intramedullary contents into t he bloodstream. Early fracture stabiliz ation was then pe rformed, as more advanced technique s for the postoperative care were available, with i mproved outcome observed (134). This methodology was not widely accepted initially, however, since it seemed to be common sense that surgical fracture stabilization should b e performed only in patients who were in a stable condition (i.e., without sig ns of fat embolism syndrome). Furthermore, rapid f racture healing was observed when operations were performed later in the posttraumatic course. Therefore, a great number of patients were subject ed to p rolonged skeletal traction (135,136). Not until the early 1980s was the first meaningful study published, showing that early, definitive stabil ization of long bone fractures reduced the i ncid enc e of the fat embolism synd rome com par ed with trad itional nonsu rgi cal treatme nt (137). As further clinical studie s demonstrated the benefi t of early, def init ive fracture st abil ization, acceptance of this treatment method became more wi despread (138,139). Early operative treatment implied stabili zation withi n 24 hours (137). It was reported that the effect of early fracture stabi lization bec ame more eviden t wi th inc reasing i njury severi ty (140). The fi rst prospective, randomized trial was publi shed by Bone et al (141) and demonstrated the advantages of early fracture stabilization (ETC). Patients with delayed fracture stabilization had a prolonge d du ration of ven tilatory therapy and staye d long er in both cr iti cal car e and hosp ital (137,140). An essential prerequisite for ETC was an optimi zation of rescue condit ions and a reduction of the rescue t ime. Furthermore, the improvements in intensive care medicine with improved cardiovascular monitor ing and facilities for prolonged ventilatory support facilitated the development of a more aggressive surgical approach (142,143). Consequentl y, early definitive fracture stabilization represented a signifi cant progress, resulting in pain reduction, early mobili zation, and the associa ted reduction in thromboembolic and infective complications. Th e advantages gained by countless patie nts who were able to mobilize early are well desc ribe d (144). Some patients wi th a very high ISS did not appear to b enefit from this procedure, however. Even with excellent rescue
Page 18 of 50
conditions, an unacceptably high number of complications were observed. Se veral studie s supported the previous findings of Ecke et a l (145) that a hig her incidence of complications were obs erved in p atients wi th severe thoracic in juries or hemorrhagic shock and in unstabl e patients who underwent surgical procedures (146,147,148). The dynamic nature of parenchymal l ung inj uries and the diff icu lty in early determination of injury severity are still significant problems in the decision making process for the timing of fracture stabilization. Un expected complications after ETC were observed in those patients whose severity of chest injuries was initi ally underestimated (111). Concerns have also been rai sed about polytraumatized patients with associ ated head trauma. It was thought, that prolonged surgery could caus e intraope rative hypotension, hypoxi a, and coagulopathy in combination with i ncreased blood loss and fluid requirements during and after the orthopedi c operation. Th is would be detrimental to ce rebral pe rfusion and P.75 would be an additional insult to the already injured brain, thus outweighing the benefi ts of early fracture stabilization (149). Th e strict application of ETC, even in patients with a high ISS, brain injury, or severe chest trauma, limited d iscussion of best management for these polytraumatized patients. Patients submitted to ETC during the last three decades have demonstrated a progressive ly lower ISS (Tabl e 3-3). It could be concluded that a more cautious a pproach regar ding surgical treatment has been chosen. As it became eviden t that t hese specif ic subgroups of polytraumatized patients do not benefit from ETC, the borderline patient was identified. These patients were demonstrated to be at particul ar ri sk of late, poor ou tcome. Description of the clinical and laboratory characteristics of the borderline patient has been previously described. Th e concep t of damage control provide d a solution to the management of borderline patients and those in an unstable or extremis c ondit ion. The term damage control was i nitiall y described by the US Navy as the capacity of the ship to absorb damage and maintain missi on in tegrity. In the polytraumatiz ed patient, this concept of surgical treatment intends to control but not to definitively repair the trauma-induced inj uries early after trauma. Aft er restoration of normal physiology (core temperature, coagulation, h emodynamics, respi ratory status), definiti ve management of injuries is performed (150). Spec ific criteria have been developed, which should be fulfilled to apply this new concept (D CO) (150) . Indi cations for damage control i n abdominal surgery i nclude inability to achieve hemostasis due to coagul opathy, inaccessible major venous injury, time-consuming p roced ure in a patient with subopti mal response to resuscitation, management of extra-abdominal lifethreatening injury, reassessment of intra-abdominal contents, and inability to reapproximat e abdominal fascia due to visceral edema. The concept of temporary control of h emorrhage by compression, as undertaken i n abdominal damage control, h as a l ong tradit ion. In 1908, Pringle des crib ed for the fi rst time the principle s of compression via packing in order to control hepatic bleeding. This maneuver was modified by others and gained wid espread use i n severe abd ominal inj uries (150,151). The damage control concept consis ts of thr ee sep arate components:
1. 2. 3.
Resuscitati ve surgery for rapid hemorrhage control Restoration of normal physi ologic parameters Definitiv e surgical management
Based on the concepts of damage control s urgery, t he appl ication of the same principle s to the management of multiply inj ured patients with associated long bone and pelvic fractures was named damage control orthopedics (DCO) and was again separated into three stages. The first stage involves early temporary stabiliz ation of unstable fractures and the control of hemorrhage. The second stage consis ts of resuscitation of the patients i n the intensiv e care unit and optimization of their conditi on. The third stage involves del ayed d efinitive fracture manage men t when the patient's condition allows. The favori te tool of the trauma surgeon to achieve temporary stabilization of the fractured pelvis or a long bone fracture is the application of an external fixator. External fixation is an expedient and minimally invasive method of providing stabilization and can be used effici ently to accomplish early fracture stabilization but postpone the additional biological stresses posed b y prolonged surgical p roced ures. The delayed definite procedure to stabiliz e long bone fractures, and in particular femu r fr actures, i s most frequently P.76 i ntramedullary nailing and is carried out when the condition of the patient allows. Two studies recently have reported that the damage control orthoped ics approach was a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients (152,153). The application of DCO in multiply injured patients is i llustrated in Table 3-4.
TABLE 3-3 ISS of Patients Submitted to ETC in the Last Three Decades
Page 19 of 50
Author (Ref.)
Year
Inclusion Criteria
Range of Injury Sever ity Score (ISS)
Mean ISS Primary Definitive Surgery
Mean ISS Secondary Definiti ve Surgery
ARDS Incidence (%)
Mortality (%)
Johnson (140)
1985
ISS >18
38
38.2
38.0
739
4.5
Bone (141)
1989
3132
31.8
31.3
0.63.3
1.2
P ap e (111)
1993
ISS >18
3455
52.2
55.2
733
221
Van Os (225)
1994
2938
2026
5.3
Charash (226)
1994
ISS >18
2529
27
29
010
860
Bone (227)
1995
ISS >18
2629
033
8.2
Bosse (228)
1997
ISS >17
2330
13
2.7
Carlsson (229)
1998
1834
2172
06
Th e practice of del aying the definitiv e surgery in DCO attempts to r educe the biological l oad of surgical trauma on t he already tr aumatized patient. This hypothesis was assessed in a recent prospective randomized study by means of measuring proinflammator y cytokines. Clinicall y stable patients wi th an ISS greater than 16 and a femoral shaft fracture were r andomized to early total care (ETC; primary intramedullary nailing of the femur withi n 24 hours) and damage control orthopedics (i nitial temporary stabil iza tion of the femur with external fixator and subsequent intramedullary nailing). A sustained inflammatory response (highe r leve ls of IL-6) was measured after primary (<24 hours) intramedull ary femoral instrumentation, b ut not after init ial external fixation or aft er secondary conversi on to an intramedullary imp lant. The authors conclude d that DCO appe ars to minim ize the additional surgi cal impa ct ind uced by the acute stabi lization of the fe mur (154). Ot her issues that have been discussed with regard to the DC O concept inc lude the ideal time to perform the secondary definitiv e surgery and whether it i s safe to c onvert an ex ternal fixator to an intramedullary nail or is thus associated with an unacceptably high infection rate. It has been shown that days 2 to 4 do n ot offer optim al condit ions for definitive surgery. In general during this p eriod, marked immune reactions are ongoing (155) and enhanced generalize d edema is observed (156). Ne vertheless, these pati ents represent a highly diverse group and individual clinical judgment is more reliable, espe cial ly when combine d with i nformation from the newer laboratory tests. In a retrospective analysis of 4314 p atients treated in our cli nic, i t was found that a pr olonged second ary procedu re was ass oci ated with the d evelopment of MODS. Als o the p atients who dev eloped complications had their surgery performed between day 2 a nd 4, wh ereas patients who di d not go on to develop MODS were operated between da y 6 and 8 ( 157). Th e measurement of i nflammatory mediators has been shown to be sensi tive in gaugin g the ongoin g response in recoveri ng patients (158). A prospective study has recently shown that polytraumati zed patients submitted to secondary de fin itive surgery at day 2 to 4, dev eloped a significantly increased inf lam matory response, compared to t hose operated at day 6 to 8. It was conclude d that, i n different posttraumatic p eriods, a variab le i nflammator y response to comparable stimuli is observed. Th is may contribute t o variations in clinica l outcome that have been observed, e.g., the hig her in cidence of MODS ( 124). Ba sed on thi s concept, the following recommendations can be made for sp ecif ic groups of patients (Fi g. 3-5). With this evide nce, early major su rgery has to be judged as too great a burden for poly traumatized pat ients. Primary procedures of greater than 6 hours duration and major surgical procedures at day 2 to 4 should b e
Page 20 of 50
avoide d. Increased knowledge and adva nces in the fie ld of mol ecular biology and genetics may lead to new parameters, helpi ng to se lect patients with a high risk for adve rse outcome. Regarding the issue whether external fi xation can be converted safely to an intramedullary nail, the infection rates reported in the li terature are l ow, ranging from 1.7 % to 3% (152,1 53). P.77 According to these reports conversion of the external fixator to a nail should be done the first 2 weeks, thus minimizing the ris k of developing deep sepsis.
TABLE 3-4 Classification of Fractures with Open and Closed Soft Tissue Injury
Gustill o Classification Si mple Fractures, No Further Injury Complex Fractures
Closed
Open
C1
O1
II, IIIa
Superficial contusion by fragments Simple transverse or oblique fracture
C2
O2
IIIb
Deep, contaminated wound, limited soft tissue contusion by di rect trauma, in clu ding potential compartment s yndrome, multiple bony fragments
C3
O3
IIIc
Extensive soft ti ssue damage (contusion, degloving) with loss of periosteum, including compartment synd rome, c rush fracture and bone loss
C4
O4 O5
O3 + vascular in jury requiring operati on Complete or incomplete amputation with compl ete is chemia, no more than 1/4 of ci rcumferential soft tis sues preserved
Page 21 of 50
FIGURE 3-5 Treatment protocol b ased on patients' clinical condition (234).
In summary, ini tial temporary fracture stabilizati on appears to be an advantageous treatment strategy i n p atients with severe p oly trauma who are at hi gh risk for dev elopment of sy stemic complications, such as MODS.
Priorities in Fracture Care

Th e sequence of fracture treatment in multip ly injured patients with serial inju ries to an extremity is a crucial part of the management concept. Some body sections are prone to progressive soft tiss ue damage because of their anatomy. Therefore, the recommended sequence of treatment is tibia, femur, pel vis, sp ine, and upper extremity. In this context, the si multaneous treatment of different e xtremit y injurie s should be considered. Yet, cer tain l ogistic requirements should be met f or si multaneous trauma surgery. To f ulfill the priorities of fracture care, the se quence of treatment in serial extremity injury and the management st rategy of contralateral fractures of both upper and lower extremities should be followed. Th e type of osteosy nthesis in multiply inju red patients depends not only on the local bony and soft t issue situation but much more on the general, pulmonary, and hemodynamic status of the patient. Again, a priority oriented management strategy i s usually extremely valuable.
Management of Unilateral Fracture Patterns

In serial inj uries of the upper extremity, the surgeon shoul d rather be aware of the overall fracture pattern than consider each fracture as an isolated problem. Even though early definitive osteosynthesis wou ld be preferred in all fractures, often the general status of the multiply inj ured patient or t he local conditions do not allow for l engthy procedures. In these ca ses, careful immobiliz ation of shaft f ractures is recommended as the first step of fracture management. If there a re periarticul ar fr actures of the large joints and immedia te open reduction and fi xation is im possible , transarticular external fixation should be performed (e.g., transfix ation of the elbow). Furthermor e, in any case with concomitant vas cular injury or any eviden ce of a developin g compartment syn drome, a fasciotomy of the forearm should not be delayed. In serial inj uries of the lower extremity (e.g., di stal femoral and proxi mal tib ial fractures on the sa me side, floating knee ), a flexible but structured and priority oriented management should be appl ied (159). Again, the general status of the patients is crucial to t he concept. I n our example of a fl oatin g knee in a stable patient, starting from a small i ncis ion at the 30 f lexe d knee joint, a retrograde distal unreamed femoral nail i s i nserted. Th en, an antegrade tibi a nail is ins erted through the same inci sion. In the same fracture p attern in an unstable patient, a cl osed reduction by extension and external fixation (transfixation of the knee joint) is p erformed as a temporarily s tabiliz ing proced ure to minimize additional damage, especia lly to the soft tissues. A
Page 22 of 50
secondary defin itiv e ost eosynthesis then can be done, when the patient h as safely recovered from the initial potentially life-threatening injuri es. During the whole procedure, good communication between the anesthes iol ogist and the surgeon is highly i mportant, si nce the proce dure may have to be adapted to any change i n the patient's vital parameters. In coexisting diametaphyseal and periarticular fractures, the pri oriti es of treatment are dictated by the extent of bone and soft tissue damage. High priority is giv en to f emoral head fractures (Pipk in IIII) and fractures of the talus. Ot her periarticu lar fractures are of lower priority, particu larly if other complicationssuch as compartment syndrome, a pulseless extremity, or an open fractureare present. Just a s important are the little injuries to the hand, fingers, tarsus, or toe s. They should be considered in the overall management concept as well and possi bly anat omically reduced and fixed, at least temporaril y.
Management of Bilateral Fracture Patterns

In bilateral fractures, simultaneous treatment is an attractive concept. Especially in bilateral tibial fractures, b oth legs are surgically cleaned and draped at the same time . The operative procedure i s pe rformed sequ entially because of the fluoroscopy (space, handling). If the vital signs of the patient deteriorate during the operati on the second leg may just be temporarily stabilized using an external fixator (e.g., the pinless fixator; Table 3-5). P.78 Th e defi nitive osteosynthesis then may be delayed until the gen eral status of the patient is stabilize d again.
TABLE 3-5 Management Concept of Bilateral Tibial Fractures Depending on the General Condition of the Patient
Bilateral Tibial Fractures
1. Un reamed nail 1st leg
2. Pat ient i n good c onditi on: Unreamed nail 2nd l eg
Patient in poor condition : External fixator
3. Secondary surgery Unreamed nail
Secondary surgery Unreamed n ail
Th e prioritie s in with worse being treated injuries fi rst.
Upper Extremity Injuries

Th e management of upp er extremit y fractures in multiply injured patients is usually secondary to inj uries to the head and trunk or to the lower ex tremity. If there is a closed fracture to the upper extremity without any associated injury (vascular or nerve damage or compartment sy ndrome), the proximal fractures (shoulder, proximal humerus, and humerus shaft) are fixe d by a shoulder body bandage (Gilc hrist bandage). The definitive osteosynthesi s may be performed during the secondary management, possibly after further imagi ng. Any humerus fracture should be fixe d with t he elb ow in full extension if the duration of the intensive care period i s going to be prolonged. Th is way of splinting seems adv antageous because of the decreased muscular tension pulling the joint i nto a varus position. Alternatively, this fracture may be fixed by an external fixator. In fractures about t he el bow, a transarticu lar external fixation sh ould b e used, i f the defini tive ost eosynthesis has to be delayed. Besides the tradition al cast, the external fixator is also useful in managing injuries t o the forearm, wrist, and hand if the patient is unstable or a reduction of the operation time is necess ary.
Lower Extremity Injuries

In our experience, long bone fractures associated with a severe head injury or chest trauma (lung contusions) require a sp ecially modified strategy. We strongly recommend the extended monitoring of respiratory f unction, ventilation (capnography), and pulmonary hemodynamics. Additionally, intracranial pressure monitoring is mandatory in patients with a severe head injury (160).
Unstable Pelvic Injuries

Essential for the assessment of pelvic injuries is a thorough clini cal and radiologic examination. Thi s
Page 23 of 50
examination is usuall y done during the initial c heckup. In conseq uence, the pelvic inju ry may be classi fied roughly with these data and with the history of the acc iden t. Th e simple classification by the AO-ABC system (Fig. 3-6) can assist in the decision-making process (134). Here, type A injuries include stable fractures such as fractures of the pelvic rim, avulsion fractures, and undisplaced anterior pelvic ring fractures. The posterior rim i s not injured at all. Type B i njuries comprise fractures with only partial ly intact posterior structures and rotational dislocations may be possi ble. Sometimes, this i njury may initially be an internal rotation dislocation, resulting in excellent bony compression and stabilization of the pelvis. Moreover, they still carry an increased risk of intra-abdominal injuries (161). If the injury resul ts in the open book type of fracture with both alae externally rotated, urogenital les ions and hemorrhagic complications are much more common. Si nce the diff erentiation of type B and C injuries may be dif ficu lt, a CT scan of the pelv is is recommended. If there is no CT available dia gonal x-rays (inle t and outlet) may serve as an alternative. In C type inj uries, the pelvis shows translational i nstabi lity of the dorsal pelvic ring, (i.e., the stabilizing structures are al l severed; Fig . 3-7). One or both pel vic halves are separated from the t runk. This injury is associated with an extremely P.79 high rate of hemorrhagic complications and other pelvic injuries.
FIGURE 3-6 Classifi cation of pel vic ring fractures in A-, B-, C- type fracture similar to the AO classification.
FIGURE 3-7 Type C pelvic fracture.
This simple classification has significant therapeutic implications:
In type A injuries, operative treatment is generally not required. Type B injuries are sufficiently stabilized by osteosynthesi s of the anterior pelvic ring allowing only for early mobilization.
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Type C injuries require anterior and posterior osteosynthesis for adequate stability.
Ad dition ally, the differentiation of several sectors of injury proved useful. Transsymphysis, transpubic, transacetabul ar, and transil iac fractures are diff erentiated from the transiliosacral and transsa cral fract ures. Th is process is easy to memorize and requires a structured analysis of the x-rays. For e ach of the injured regions, we have standardiz ed the recommendations for osteosynthesis . Si nce more than 8 0% of unstabl e pelvic inj uries are associated with multiple inj uries, the supine position is preferred during the primary treatment period. The supine position also allows reconstruction of the symphysis and sacroiliac joint. Generally spe aking, we recommend early stabilization ofr fractures of the pelvic ring to avoid ongoing blood loss and to simplif y ICU care and early ambulation (89).
Complex Pelvic Injuries

Pelvic injuries associated with any other inj ury to local pelvic organs are called complex pel vic injuries (162). Th ese injuries comprise about 10% of pelvic inj uries and show a si gnif icantly highe r mortality (30% to 60%) in comparison to sim ple pelv ic injuries . During the early phase, hemor rhage is the most c ommon cause of death. Later on, ARDS and multiple organ dy sfunction syndrome (MODS) are the sequelae of the blood loss and init ially p ersistent s hock determine the further course and eventual outcome of the patient. During acute the rapy, only imme dia te, priority-guid ed management c oncepts save the lives of these severely i njured patients and impr ove the prognosis. A v ariety of methods for hemorrhage control in pelvi c injuries are d iscussed in the literature. With these techniques several very complex therapeutic protocol s have been developed. Our own experience has resulted in a rather simple algorithm requiring three decisi ons within the first 30 min utes after admiss ion. The therapeutic goal i s based on a combi ned strategy of intensive shock treatment, early stabili zation of the pelvic ring, and potential operative hemorrhage control and packing rather than a sing le treatmen t option. After hemorrhage control is achi eved , th e associated urogenital and intes tinal i njuries should be treated to avoid septic complications. In urogenital inj uries, the primary goal is reliable urine drainage. During the first laparotomy, intraperi toneal ruptures of the bladde r are repaired. In in juries of the urethra, t he recommendations are to splint the urethra usin g a t ransurethral catheter, and the definit ive procedure is d one during the secondary period to reduce the rate of late strictures. If early realignme nt is not possibl e, then a suprapubic ca theter should b e inserted. In injuries to the rectum or anus (open pe lvic fractures), a temporary colostomy of the transverse colon g uarantees prope r excretion and mai ntains a low contamination. At the end of the proced ure, an extensiv e antegrade washout of the distal part is undertaken to reduce the mi crobia l load. Any potential muscular or skin necrosis is primarily radically de brided to minimize acti vation of the immune system. A highly active surgical management of planned revi sions, e xtensi ve lavage/ jet lavage and debr idement reduces the rate of pelvic sepsis to a minimum.
Unstable Injuries of the Spine

Generally , operative treatment of unstable spine injuries is mandatory, i f only for intensiv e care nursing purposes. Nonoperative treatment (e.g., jacket, Halo fixator) is unsuitabl e in multi ply injured patients, because the imm obilization of the patients carries a hi gh risk . Not only are the intensi ve care nursin g procedures much easier after internal stabilization, but the ti me of immobiliz ation and time of intensive care stay are also signi ficantly red uce d. Sp ine inj uri es with neurologic symptoms usually are stabilized in the same procedure as the spinal cord d ecompressi on. Howev er, in recent y ears, unstabl e injuries of the sp ine even without n eurologic sympt oms are much more often stabil ized during the acute period, because of t he reasons mentioned earlie r. In our expe rie nce, after d iagn osing an unstable in jury of the spine without ne urologi c symptoms , a closed reduction is advised in the following situations:
Fractures of the cervical sp ine Rotational inju ry of the lower thoracic or lumbar spine (AO class ification type C injury)
In any other in jury, t he reduction is pe rformed in the operating room just before the actual procedure. If there is but a slight P.80 suspi cion of a fracture fragment or a protruding intervertebral dis c narrowing the spinal canal after closed reduction, further imagi ng (e.g., CT, MRI) are required. I n multiply inju red patients in particular, closed reduction may be d iffi cult because of concomitant extremity injuries. In these cases, pr op er correction of rotation and axis can be only managed intraoperatively. In the case of interposition of a bone fragment or intervertebral disc, open reduction is always indicated following extraction of the impediment to avoid spinal cord compression. The ventral approach is our standard procedure for operative management of the upper (C1 to C3) and lowe r (C4 t o C7) cervic al spine. Therefore, the patient's head is fixed to a sp ecial reduction apparatus using the rim of
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the halo f ixator. In the case of thoracic or lumbar spine injuries , the associated injuries to the trunk (chest, abdomen) have to be consi dered. Nonetheless, in our expe rie nce, injuri es requir ing dorsal and ventral stabilization may usually be fixed using at least a dorsal internal fixator in the acute management period. Depending on the general status of the patient, the ventral stabil ization may be performed during the secondary period. Even intrathoracic or intra-abdominal injuries are not necessarily a c ontraindication for the required p rone position for dorsal ins trumentation. The prone position has been succes sfully used as a therapeutic strategy in severe lung injury. Other authors have found no contraindications to the prone position or thoracocentesis in mul tipl y injured patients (163).
Assessment of Fracture Severity

Closed Fractures
In our experience, there are many difficulties in properly diagnosing and asses sing the true soft tissue damage i n closed fractures. A s kin contusi on at an otherwise closed fracture site may raise more t herapeutic and p rognostic problems than an inside-out puncture wound in an open fractures . This type of blunt inj ury imp lies signi ficant weakening of the natural skin barri er. Skin necrosis secondary to contusi on is often the entry point for i nfecti ons, especially in the ICU environment. Thi s is sue has been addressed with the dev elopment of a classification system to allow the clinician to decide the appropriate therapeutic approach that would be beneficial to the patients' overall condition . Soft tissu e injuries therefore can be cl assified as follows (164):
Closed fracture C0: No injury or very minor soft tissu e injury. The C0 classifi cation covers simple fractures (i.e., fractures caused by indir ect mechanis ms of inju ry). Closed fracture C1: Superfici al abrasions or contusions from internal fragment pr essure a long with simp le to moderate fracture types are in cluded. Closed fracture C2: Deep, contaminated abrasions or local dermal and muscular contusions due to tang ential forces are included here. Al so, the threatening compartment syndrome is classified as G2. These injuries usually are caused by d irect forces, additional ly result ing in mod erate to severe f racture types. The closed bisegmental tibial fracture after a typical bumper impact is an illustrative example. Closed fracture C3: Extensive skin contusions or muscul ar destruction, su bcutaneous degloving and obvious compartment synd rome combined with any closed fracture are graded C3. In this subgroup of t he cla ssifica tion, there are severe fracture types and comminuted fractures. Closed fracture C4: The same injuries as in C3 closed fractures associated with a sig nifi cant vas cular damage requiring operative treatment form the C4 closed fractures group .
Open Fractures
Open fracture care i s an essential part of primary management. Primary care of open fractures consis ts of radical deb ride ment, extensive irriga tion, assessment of the damage to the soft tissues, and finally stable fracture fixation. A careful assessme nt of the in jury severity is the first step in the d evelopment of a treatment strategy. Here, time and mechanism of inj ury, the energy of the causative force, and the sev erity of the fracture should be considered. Additionall y, with respect to the preservation of an injured extremity, the extent of vascular and nerve dam age , an d the general condition of the patient are of gre at importance . In hi gh-energy trauma, sof t tiss ues may be severely damaged, requiring careful evaluation a nd extensive deb ride ment during the initial assessment. Open fractures from low-energy trauma are usu all y associa ted with le ss soft tis sue damage and may alm ost be treated like closed injuries. After the i nitial debridement, the fracture may be stabilized with the most sui table i mpla nt and method of fixation. Open fractures from high -energy trauma represent a unique problem that i s, a combin ation of conside rable soft tis sue damage and extensive bone destruction. Thi s injury requires a gr aded concept of care (Table 3-6). A sophisticated treatment plan should be established, adequately considering the important aspects of sufficient debridement, temporary stabilization wi th respect to the secondary definitive stabilization as well as the closure of the wound. Our e xperience wi th this type of inju ry shows an al most indiv idual personali ty of each fracture requiri ng personal treatment. In mul tipl y injured patients, the overall injury severity has to be considered as well as the extent of the shock and the initial bl ood l oss. Taking these factors into account, a clear therapeutic concept should be established for each patient indi vidually.
Classification of Soft Tissue Damage

Several classifications have bee n proposed over the years for the grading of open fractures but the standard system of classifyin g the soft tissue component of a fracture remains that of Gustilo et al (165). D espi te the d oubts that have been raise d over its reliabi lity, it seems likely to remain in common usa ge as it is fairly simp le to remember and to apply.
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A thorough as sess ment of t he soft ti ssue damage is even more P.81 crucial in multipl y injured patients. In this group, the prognosis of the soft tissue damage depends on a multitude of parameters potentially ending up in a vicious circle. Besides the overall tissue hypoxia and acidosis, there is a gen eral hypoperfusion of t he extremities due to the hemorrhagic shock. Al l these factors should be taken into account in the cl inical decision making and planning.
TABLE 3-6 Protocol of Management of Open Fractures
Emergency room
Clinical examination Class ify soft tissue damage Doppler examination Neurologic examination Antibiotics/ tetanus prophylaxis
Pri mary Ope ration
Ade quate debridement (Vascular recon struction) Fasciotomy > 6 h of isc hemia Fracture stabilization Transfixation if joint injury
Intens ive care unit
Continuous monitoring: Peripheral pe rfusion Compartment pressure Transcu taneous pO2
Secondary operati on
Ope rativ e revi sion (~48 h) Soft tissue (<72 h) reconstruction Joint reconstruction
Tertiary operation
Mesh gr aft transplantation Bone grafts
Reconstruction Versus Amputation

As a result of new microsurgical techniques, n ew methods of bone reconstruction and mor e skillf ul appli cation of the I lizarov technique, the preservation of a limb, especi ally in grade IIIb and IIIc fractures of the lower extremity, is more commonly attempted nowadays. Rec onstructive bone and soft ti ssue surgery us ually requires repeated op erations, long-term hospital stays, and prol onged periods of treatment impl icating considerable social and economic effects for the patie nt and his or her family that have to b e appreciated by the responsib le surgeon. Several authors therefore have looked into criteria to guide surgeons in their decision for preservation or amputation of a severely inju red extremity. From the surgical point of vie w, t he attempt to preserve the limb seems to be the best dec ision for the patient. But f rom a soci oeconomic p oint, the prolonged hospital stay may have severe eff ects for the pa tient: the financial loss for the patient from prolonged hospital stays and loss of time at work was proven to be higher than in a primary amputation. Even more, in patients with preserved l imbs, there is a low probability for these patients to get back to their jobs. Furthermore, many attempts at reconstruction leave the patients incapable of earning a living for more than 2 years (166). If a severely injured patient surviv es aft er primary amputation, the question is, whether the amp utation was unavoidable or the reconstruction was possibl e. If the patien t dies , the q uestion is, whether t he seve rity of the i njuries was underestimated initially and an early amputation would have saved the pati ent's l ife. Last, if the p atient survive s after primary reconstruction but s uffers from compl ications requiring prolonged treatment, the q uestion is, whether t he bad outcome justified the exp ended resources. In order therefore to de fin e a c lear, unmist akabl e and acceptable guideli ne for the treatment of severe injuries to the extremities, we are obliged to consider these problems and include them in our decision-making process.
Guiding Aid: Orientation at Primary Clinical Findings

In 1985, Gregory et al (167) analyzed 60 patients with open fractures and developed a scori ng system clas sifying severe injuries to the lower extremities. Seventeen patie nts were categori zed into the most severe group, the mangled extremity syndrome (MES). The pati ents were classified retrospectivel y by anal ysis of the extent of the soft tiss ue inju ry, the severity of the fracture, and injury of ma jor anatomic structures such as
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nerves and vessels. Addit ionally, age, preexist ing comorbi diti es, potential prolonged shock, and the time to treatment were in cluded in the asses sment. Ad dition ally, the overall injury severity was estimated using the ISS and included i n the scor ing system. The resulting score was published as the mangled extremity syndrome index (MESI). In this retrospec tive analysi s, a score of 20 points was found to be the cutoff point for amputation. In 7 out of the se 17 patients, t he preservation of the li mb was attempted. Each patient in this group scored below 20 points. In the remaining ten cases, amputation was performed. Each patient i n this second group scored above 20 points i n the MESI . The ass essment term extensive trauma of an anatomic structure was found to be a major proble m. Nerve injuries that are known to b e crucial for the prognosis of the extremity are supposed to be so categorized . But in doing so, some specialists argued, the effect of nerve damages was possibly underestimated (167). An othe r retrospective analysis was published by Howe et al in 1987 ( 168). A new scoring system was developed , the predicti ve salvage index. This score showed a high positi ve predictability (sensitivity 78%, specificity 100%) for the benefits of amputation. Timing and technique of vascular rec onstruction were considered as i ndependent parameters. The calculated score divided dermal, muscular, and bony damage into slig ht, moderate, or severe and counted one to three points, respect ive ly. For the score, the four s uitable parameters were sum marize d. When a total of more than eigh t poin ts was cal culated, pr imary amputati on was recommended. Using this c utoff, a P.82 high positive predictability for the functional outcome was found (78% sensiti vity, 100% specificity). A third retrospective study of 26 inj uries to the lower ext remities wi th vascul ar lesions included the extent of the soft tiss ue damage, the time of ischemia, t he duration of prolonged shock, and the age of the patient as predictive items for an amputation. Starting from here, the authors developed a score wit h the soft tiss ue damage showing the high est positive predict ability for the outcome. A cumulative analysis of variances showed this soft tiss ue damage to b e as predicti ve as the sum of all of the four parameters. U sing their population, Lange et al (169) also defined guiding parameters for the development of a therapeutic strategy i n extremi ty i njuries. They showed that in patients with similar local injuries, the age, comorbidities, and the social environment of the patients play an important r ole in the outcome. The authors stressed the crucial role of the posterior tibial nerve and suggested that intraoperative exploration with exclusion of a posterior tibial nerve l esion compul sory. I n multiply injured patients the di fficulties in assessi ng any kind of score and estimatin g the predictability are discussed (169). In 1990, Helfet et al (170) found Lange's absolute i ndications for amputation difficult to determine in certain patients. In an overview of the literature, Helfet et al found 59% of third-degree open tibial fractures (Gustilo grade IIIc) being amputated. Ha lf of t hese procedures wer e secondary amputations, at least 24 hours after the trauma. They conclu ded that obviously the valid criteria in dec ision making at that time were insuffici ent, resulting in delayed amputation. Consequently, from the retrospe cti ve analysi s of 26 se vere injuries to the lower extremity with vascular injuries (Gustilo grade IIIC) four parameters were si gnif icant: extent of the bone and soft tissue damage, ti me of ischemia, initial shock, and age of the patient. The resultin g score gave the cutoff for amputation as seven points (Table 3-7). In a prospective multice nter study, this score was verified. It was shown that in patients with a score of more than se ven points, there was a 100% probability of amputation. Most recently, McNamara et al (171) eval uated the MESS by retrospecti vely studyi ng 24 patients with grade IIIc i njuries. The results confirmed the hig h predictabili ty. To i mprove the predictive value, nerve damage and a detailed assessment of the bone and soft tiss ue damage were included. The newly formed score wad calle d the NISSSA s core and showed a sensitivity of 81.8% and a spe cificity of 92.3 % (171).
Comparison of Upper and Lower Extremities

In severe open fractures of the upper extremity different princ iples are appl ied to de velop the proper treatment strategy: The sensitiv ity of the foot, the continuity of all large nerves, maintenance of proper length, are of les s conseq uence in the tre atment plan f or the arm (172). However, the prosthetic care of the lower extremity is much more sophisticated than of the upper extremity, espec iall y in below k nee amputations. This is why the diffe rent sc oring systems should b e used with caution in injuries of the upper extremity.
TABLE 3-7 The Mangled Extremity Severity Score (MESS)
1.
Bone and soft tissue injuries
Ty pe-A fractures: 1 open or closed
Ty pe-B fractures: 1 open or closed
Ty pe-C fractures: 3 open or c losed
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Amputating injury
2.
Time of ischemia
Peripheral pulses palpable
Peripheral pulses not palpable but capillary pulse normal
1*
No pulse in Doppler, refil l >3 sec, paresis incomplete
2*
No pulse, cold extremity, paresis complete
3*
3.
Circulation
Sys tolic blood pressure al ways >90 mm Hg
Unstabl e ci rculation unt il admi ssion to ER
Unstabl e circulation until end of surgery
4.
Age
<30 years
3050 years
>50 years
TOTAL:
* D ouble points if time of isc hemia >6 h ours. Hel fet DL, Howey T, Sanders R, Johansen K. Limb salvage ve rsus amputation. Preliminary results of the Mangled Extremity Severi ty Score. Clin Orthop Relt Res 1990;256:8086.
Debridement
Af ter decid ing to salvage the limb, extensiv e and cri tical debrideme nt forms the first step in the operative treatment plan. Here all components of the soft tissues have to be regarded. Being too cautious with the debridement, especially wi th nonvital tiss ue in multiply injured patients has been demonstrated to lead to a deterioration of the patient's condition and even organ fail ure. Cle arly, an easy compromise shoul d be avoi ded. Sufficient surgical exposure of the injury is essential to assess and to treat the soft tissue damage. The possibility of extensive degloving has to be kept in mind. The mechanism of injury and a thorough clinical exam p rovide key information for the assess ment of suc h an injury. In multiply in jured patients, there is a high risk of increasing soft tissue necrosis due to impaired soft tissue p erfusi on (e.g., i n posttraumatic edema, i ncreased capi llary permeability, ma ssive volume resusci tation, unstable circula tion). Therefore, in many patie nts regu lar ope rativ e revisions need to be schedul ed. These second-look surgeries allow repeated assessment of the soft ti ssues. This strategy enables the surgeon t o do a timely redebri dement if required (e.g., with high-pressure irrigation). These operative P.83 revisions of soft tissue injures should be scheduled every 48 hours as long as there is an impaire d perfusion of the damage zone. Th e recent in troduction of vacuum therapy may save the patie nt some of the planned second-
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l ook surgeries but will not replace repeat explorati on. Following successful debride ment, vascular reconstruction, and stabili zation of the fracture, the soft tissu e repair should be planned meticulously.
Operative Strategy Depending on Overall Injury Severity

Th e question of the multip ly in jured patie nt needin g and tolerating reconstructive surgery is d ictated by the overall c ondit ion and the extent of the accompanyi ng injuries than by the local situation al one (Fig. 3-8). A l engthy reconstruction or replantation procedu re may harm the patient and p ut hi m in to a life-threatening situation. Addi tionally, attention has to be paid to the general l ong-term prognosis of an open injury in the multiply inj ured patient. To establish a therapeutic plan, all these parameters need to be considered. Patients of ISS Groups (115 points and 1625 points) and Grade IIIac Soft Tissue Injuries. In this subgroup of multiply injured patients, there is an indication for reconstruction. The surgery is largely standardi zed. Following extensive and radical deb ride ment, in the case of a vascul ar injury, the second step consists of vascular repair, sometimes requiring the interposi tion of a venous graft. Next, fractures shou ld usually be stabilized using intramedullary osteosynthesis. Thi s type of implants is much less damaging to the soft tis sues than any dir ect osteosynthesis . There is less soft ti ssue damage and only minimal i mpairment of the circulation of the bone (173). Th e covering and closure of any soft tissu e defect depends on the extent of the injury. In most cases, the wound wil l be covered temporarily using synthetic skin grafts or vacuum systems, before final cover by plastic reconstructive surgery. In general, the expected result of a reconstruction or limb saving strategy should outweigh the result of a n amputation and fitting of a good prosthesis . Patients of ISS Groups (115 points and 1625 points) With Complete and Incomplete Amp utations. In terms of the surgical management, these injuries are very similar. Replantation as an option has to be considered with r eferral to a specialized center. Before thi s, hemorrhage may be stoppe d by ele vation and appli cation of a pressure bandage. The conservation of the amputated limb foll ows clear emergency medi cine guidelines (174). Amputation injuries in children always have to be considered for replantation. Children, wi th t heir be tter tissue regenerative ability, show better functional outcome than similarly injured adults. Patients of ISS Groups (2650 points and >50 points). In recent years, l evel one trauma cen ters have i mprove d their critical care and osteosynthesis treatment and increasingly succeeded in saving the most severely traumatized extremities. P.84 Nevertheless, these li mbs often require secondary amputation (175).
FIGURE 3-8 Algorithm for reconstructi on/amputation in open fracture care depending on the overall injury severity. I SS grou p I: 15; ISS II : 1625; ISS II I: 2650; ISS IV: l50 points. (Modifi ed from Sudkamp N, Haas N, Flory PJ, et al. Criteria for amputation, reconstruction and replantation of extremities in multiple trauma patients. Chirurg 1989;60:774781.)
In this subgroup of most severely injured patients with extremity injuries the preservation of the extremity should not be attempted at all. The principle life before limb should absolutely hold true, and the i ndic ation f or a mputation may be wi dened. If the dec ision for amputation is made, it sh ould be performed by
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open or guillotine amputati on. Primary closure of the wou nds is associated with a high risk for c omplications, because the overall extent of the soft ti ssue damage and the posttraumatic edema is difficult to estimate.
Intra-Articular Open Fractures

Today, most surgeons prefer a two-step strategy in the management of open intra-articular fractures. First, the i njury is d ebrided, the join t surface i s reconstructed usi ng a mi nimal in vasive osteosynthetic (MIO) technique and the joi nt is immobilized by transarticula r external fixation. The minimally invasive osteosynthesis compri ses the r econstruction of the joint itself , temporary stabil ization wi th K-wires, and stabil ization wi th lag screws and adjusting or set screws. Plate osteosyntheses is contraindicated in these injuries, because of the extensive soft tissue damage (176). So, the definitive osteosynthesis is carried out secondarily followi ng consolidation of the soft tis sues. In this procedure, the initially reconstructed block of articular bone fragments is attached to the metaphysis. Sometimes, sh ortening of the fractured bone has to be accepted at least temporarily to close p otential b ony or soft tissu e defects. Th e Ilizarov fixator is widely appreciated as a good alternative to conventional transfixation technique (transarticul ar external fixation). The Iliz arov method all ows for stabiliz ation i n the damage zone by K-wires i nserted in the metaphyseal area and connected by ring fixators.
Timing of Soft Tissue Reconstruction

In many multiply inju red patients, primary wound closure is bad practice. The relative hypoxia of the tissues may lead to impa ired and delayed wound healing and a high er ris k of wound i nfection. In small soft tis sue i njuries, we recommend secondary closure of the wound after covering the wound with artificial skin until the swelling decreases. An absolute prerequisite for wound closure is to completely cover the implants with vital and well-perfused soft tissu es. I n these defects, artific ial skin replacements are used first and aft erwards the wound i s cl osed progressive ly over sev eral d ays. In some cases, continuous wound closure may be an option also. In medium-si zed soft tissu e defects, secondary closure is often achieved by local transposition after mobil ization of the surroundin g soft t issu es. In extensive soft tissu e defects associated wi th sign ifi cant periosteal damage, the soft tissue covers requ ire excell ent perfusion. The covering procedure should be done withi n 72 hours of the trauma. Otherwise, the comple te section of the extremi ty is i n danger of f urther damage. Large posttraumatic soft tissue defects are challe nging for the surgeon and require a well -defined therapeutic strategy . The overall concept of soft tissue coverage dep ends on the extent of uncovered bone, te ndons and nerves . To achiev e satisfactory results, ea rly communication and cooperation between t he trauma surgeon and the plastic surgeon is recommended. Soft Tis sue Re construction. To cover wound defects, there are numerous local and d istant f laps described in the literature. Local Flaps. Rotational flaps are us ed to cover small and medium-siz ed soft ti ssue defects. Th ese fl aps consis t of dif ferent combinations of muscle, fasci a, and skin . They allow closure of defects and should be applied without any tensi on at all. Nonetheless, there are also disadvantages associated with local flaps. On one hand, obtaining flaps from the local soft tissues may be diffic ult in multi ply i njured patients because of other injuries. On the other hand, t he fl ap proced ure is prevented by the preexi sti ng soft tis sue damage. Eve n more, the p erfusi on of musc ular or myocutaneous flaps must be considered. Often, the real extent of the requi red transpositi on is underestimated compared to the actual permitted options. Therefore, a meticu lous preoperative p lan is mandatory. For the most common defects on the anteromedial tibial surface, g astrocnemius or soleus flap s are useful. Distant Flaps. The indication for distant flaps is common in multiply injured patients. Microvascular flaps, such as the radial forearm or latissimus dorsi flap, are increasingly used. The indication for a distant flap has to be d iscussed , however. On one hand, the local situation requires urgen t treatment; on the other hand, a prolonge d surgical procedure represents a consid erable traumatic load for the severely in jured patient. Th erefore, careful timi ng of the operation is required. L ocal as we ll as systemic complications are common in this patient population.
INTENSIVE CARE UNIT ASPECTS OF MANAGEMENT

The manage men t of the pol ytrauma pat ient in the intens ive car e unit has been the cornerst one of t reating complications and i mprovi ng s urvival rates. This has be en attribu ted to tec hnological advanc es and a better understanding of MODS at the molecular level.
Ventilation Strategies
It is widely accepted that early ventilation leads to improvement of pulmonary function and reduces the i ncid ence of ARDS. Among the ventilation strategies, volume and pressure controlled methods have to be separated. Traditional ly, volume control led, low-frequency ventilation using high tidal volume and PEEP have b een preferred. However, high tidal vol umes may induce high airway pressures, thus causing overstretching of healthy areas of the lung. This may lead to secondary iatrogenic s tructural damage and forma tion of sc ar tissue (177). Currently, a pressure-controlle d ventilation mode, using low P.85
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tidal v olume, i s general ly preferred. Oxygenation can be additi onally improved by a prolonged inspiration time compared with expiratory time. Inversed ratio ventilation induces a higher me an ai rway flow, thereby impr oving oxy genation. With prol onged inspiration time, even multiple divided lung compartments that require a long time to be reached can take part i n the gas exchange. A shorter expirator y time leads to incompletely evacuated lung areas. In the regi onal compartments, intrinsic PEEP develops. Therefore, the i nversed ratio ventilation enlarges the area which takes part in the gas exc hange and reduces intrapulmonary shunt volu me. Pressure-controlled ventilation sh ould b e combi ned with PEEP, in creasing the functional residual capacity. Thus, the pulm onary areas taking part in the gas exchange could be improved. The optimal height of the PEEP level is still under discussion (178). Using increased PEEP, the pulmonary compliance improves until a cr itic al point is reached ( bes t PEEP b est compli ance ) (179) but cardiovascular side effects have to be considered. Modern ventilation strategies with low tidal volume (48 m L/kg) , best PEEP, l ow airway pressures (<35 cm H 2 O), and an insp irator y oxyge n concentration of 5 5% to 60% are often ideal. Al so, hypercapni a may be allowed up to a certain deg ree (p ermissiv e hypercapnia; PHC) (180). It is well tolerated in patients with ARDS and a PCO 2 of 60 to 120 mm Hg. Cli nical experience shows, t hat pressure-controlled ventilation with inversed ratio ventilation (I:E |1:1 to 4:1|), low tida l volumes (48 mL/kg), frequencies of 1015/min, permiss ive hypercapni a (PHC |PCO 2 ~70 mm Hg|b) and ind ividual PEEP (512 cm H 2 O), hig h oxyg en conce ntration (FiO 2 <0.5), and high airway pressure can prevent the lung from further ventilation damage (181). Early experiences using other ventilation strategies (e.g., bilevel positive airway pressure; BIPAP) demonstrated that they are also feasible , although there ma y be problems with BIPAP in cases in which long-term sedation is required. One of the most recent concepts developed for the prevention of pulmonary failure is the recruitment of alveoli by temporary incr ease in positiv e end expi ratory pressure (open lu ng concept) (182). It d oes not cause sustained cardiovascular side effects and also does not lead to the development of bronchople ural fistulae. Ye t, the cli nical rel evance of this new concept has to be proven in larger series (183).
Adult Respiratory Distress Syndrome

In pol ytrauma patients, a special situation occurs i n two ways: First, there is often a concomitant pulmonary parenchymal l esion, s uch as a lung contusion. This may lead to worsening of pu lmonary function within days after injury. Sec ond, there is a generali zed permeability defect due to the initial hemorrhagic shock. Th e lungs of a polytrauma patient therefore have a pathological water content and inflation by artificial ventilation is a challen ging task. The sum of the factor s discussed above (e.g., hemorrhagic shock, l ung contusions) induces a situation where pulmonary failure may occur. In the clinic al course, the lung is the first organ to fail and it also represents the most frequent organ system d evelop ing dysfunction (101). Among the reasons for lung failure during the course of MODS, the t heory of the first fil ter al so has to be taken into consideration. Ac tivated blood cells, cytokines, toxins and cell debris, often de riving from the areas of injury are di rectly transported into the lung via the blood stream. Histori call y, three phases of ARDS have been di fferentiated, t he t hird leading to a state of scarring of pu lmonary tiss ue and often irreversible loss of organ function. According to our cu rrent knowledge , the formation of scar tissue has often be en the result of high intraalveolar p ressures due to inadequ ate ventilation techniques. Be cause of the improved ventil ation strategies described above , the l ate form i s usually not seen now (184). Within days after the injury, changes in vascular permeability with albumin extravasation into the intersti tial room have been shown (185). Consequently, an increase in extravascular lung water has been observed, which may result in decompensation of lymph drainage pulmonary interstitial edema. These mechanism s are maintained by inflammatory reactions, s uch as activ ation of monocytes and polym orphonucle ar leukocytes, t hus i nducing a release of proteases and cytokines. All these mechanisms may also contribu te to the vi cious cycle l eading to organ failure during the late course after injury.
Multiple Organ Dysfunction Syndrome

The pathophysiology of MODS is defined as an excessive immunoinflammatory reaction (positive amplification of shock mediators) after traumatic hemorrhagic shock and tissue d amage, which is foll owed by systemic tissue damage and permeabili ty leadin g to specific organ disorder (186). Typically, after a latency period, sequential d ysfunction of several organ systems occur (187). The sequence of organ f ailures is variable, as described b elow.
Sequence of Organ Failure

This syndrome typical ly presents with sequential failure of various organ failures (188). Some combinations of i solated organs, su ch as lung and liver fai lure are associated with poor outcome (189). It can be diff icu lt to analyz e the normal seq uence of MODS in severe trauma patients, because of the defini tion of the isolated organ fail ure and the sensitivity and the sp ecification of the parameters used. Duri ng the course of MODS, 50% of patients develop lung failure followed by liver dysfunction (Table 3-8) (190). As previou sly described, two forms of the syndrome are described . A one-phase organ failu re as a r apid form and a two-p hase or gan failure as delayed form (101). A correlation between the numbe r of failing org ans and mortality during the course of MODS has been seen in ma ny cases. If more than three organ systems fail , the subsequent mortality rate is almost 100%. These resul ts illus trate yet again the importance of multiple organ fail ure as the most severe complication af ter seve re trauma.
TABLE 3-8 Sequence of Organ Failure
Page 32 of 50
Author (Ref.)
1. Organ
2. Organ
3. Organ
Baue 1975 (230)
Lung
Kidney
Liver
Border 1976 (231)
Lung
Heart
Kidney
Cerra 1987 (232)
Lung
Liver
Intestine
Deitch 1993 (190)
Lung
Liver
Intestine
Fry 1980 (100)
Lung
Liver
Intestine
Goris 1985 (102)
Lung
Liver
Intestine
McMe namy 1981 (233)
Lung
Liver
Heart
Regel 1995 (144)
Lung
Heart
Liver
P.86
Pulmonary Failure
While the early p hase of lung failu re may occur as desc ribe d above, a late phase has also been described. This occ urs in association wi th MODS, a nd the pathogenesi s of the late lu ng failure continues to be unclear. I t has been associated with im mune dysfunction. Also, infective complications have been claim ed to pla y a major role. Ty pically, late ARDS develops after about 2 to 3 weeks and is the hallm ark of organ f ailu re, often irreversi ble and leadin g to death. Thus, it mu st be viewed as part of late MODS.
Liver Failure
Th e liver is constantly described as the second orga n system with dys function (Table 3-8). The liver d emonstrates deteri oration of all three functions, synthesis, ex cretion, and the re tic ular endothel ial system. First there is a worsening in the reticuloendothelial sy stem. This le ads to a decrease in the cle arance function even though there is a compensatory increase in the measurable clearance (191). The clearance function of the l iver is bypassed and cell debris may be transported into the lung. Some clinical investigations show that the protein synthesis and the excretion of the liver are undergo early dysfunction but late total failure. The exact mechanisms that lead to this course are still bei ng discussed. Obviously, changes of the reticuloendot helial system in the li ver are associated with the integrity of the liver cells.
Cardiovascular Failure
Dysfunction of the cardi ovascular system occ urs a t a later stage. Once this complication develops, the mortality rate is very high. The function of the cardiovascular system is well known, with the blood pressure adapted heart rate (192). The heart i ndex refl ects the circul ating amount of blood p er unit tim e. Obviously, the failure of the cardiovascular system is the terminal variable, which will lead to death, independent of therapeutic i nterventions . The medications acting on the cardiovascular system usually do not show a clini cal response, which has been attributed to a pals y-like reaction of the arterial vascular sys tem.
Renal Failure
Isolated renal failure has become very rare today because early flu id repla cement i s usually undertaken (193). On e of the rare reasons for dys function is initial i schemia of the renal parenchymathat is, dir ect injury. On e of the general resp onses to trauma is disturbances in the a rea of the renal tubuli , which migh t lead to an i nterstitial edema and a transi ent dysfunction in excretion and resorption (187). Renal fai lure usually becomes rel evant only if it occurs late aft er t rauma and if it is associated with MODS. In this case, the pathogenesi s continues to be unexplained.
Treatment Options for MODS and ARDS

Numerous attempts have been made in the past few de cades to develop an effective treatment f or both ARDS and MODS. Some workers have tried to reduce the degree of the endothelial leakage by using steroid hormones. However, immunologic side effects have been claimed to prevent this strategy from providing any clinically
Page 33 of 50
rel evant positive effects (194). Others have tried to lower the pathol ogi call y increased pulmonary arteri al p ressure associ ated with the syndrome. For this, prostaglandins have been use d (195). These did lower the pulmonary arterial pressure in some studies , but were either not associated with a reduction in ARDS or were associated with side ef fects (e.g., decrease in systemic arterial pressure). In cases of acute worsening of pulmonary failure, nit ric oxide was used. It has been shown to exert positive effects in patients with i sche mia /reperfusion i njury (lung transplant), and there are some reports about its effectiveness in lu ng contusion. I ts use usually has been limited to a few days after t rauma only , however, and the effects have to be weighe d against possible s ide effects in every case (195). Li kewise , some authors have claimed that the treatment of intestinal failure associated with the development of MODS would p rovide a causative treatment for MODS. Selective intestinal decontamination by antibiotics was used but fail ed to provide an improvement of the clinical status. E arly enteral feeding has been shown to have positive effects on intestinal function (196). Yet, i ts use for t he dev elopment of organ failure has not been proven to da te. L-select in has been used as a single agent to reduce the degree of adhesi on to the endotheli al layer. However, a clinical study documenting the effectiveness of L-sel ectin has not become available (197). Some authors have recently argued that a combination of several immunologically active substances may pr ovide b enefici al effects. However, there is a known sustained heterogeneity of pathogenetic pathways, which may not allow a clinical b reakthrough in the near future. Once MODS has de veloped , sympt omatic treatme nt is the P.87 only treatmen t option. It consists of adequ ate ventilati on strategies as de scri bed above . In cas es of se ver e lung contusions, some authors have favored bronchoalveolar lavage to d iagnose the degree of inflammatory c hange and to assess possible worsening . However, bronchoalveol ar la vage does not represent a routine measure for the determination of these pulmonary changes. In addition, there may be temporary worsening of pu lmonary functi on after a lavage has been performed. This is due to the alveolar collapse after suction has been p erformed. Among the other symptomatic measures, cardiovascular support with i notrop ic substances is the rule. The support of liver and intestin al dysfunction is usually unable to improve the clinical condition and to reverse the organ failure. Most authors agree that it merely prol ongs the time until a lethal outcome is reached (198).
Crush Syndrome
Th e crush syn drome develops in cases of severe soft tissu e trauma and is associ ated with earthquakes or other condit ions in which patients are buried under solid material (199). The destruction of soft tiss ues represents the major problem, le ading to an often devastating intravasation of debri s from muscle and fatty tissue (200). Rhabdomyolysis is one of the most feared compl ications of this syndrome (2 01). The subsequent clinical presentation is a state of latent shock and subsequent renal failure secondary to direct obstruction of renal tubules (202). Tim ely dial ysis is crucial in these cases. Unl ess this can be provid ed, patients succumb withi n 2 or 3 days after t he inju ry. Eve n if dialy sis i s performed early, the patient i s at high risk for further complications, mai nly due to seps is deriving from sec ondary infection of necrotic tissue (203). From the surgical standpoint, d ebrideme nt is the crucial treatment to avoid secondary complications. Whenever positiv e swabs are cultured from the i njured tissue, antibiotic treatment sh ould be initiated. Some authors have advocated the us e of hyperbaric oxygen therapy for these cases. This has been su pported by several reports. Although larger or randomize d studies are not available, the use of this method appears to be justified in vie w of the high mortality (204). More importantly, repeated revisions and debrid ements are re quired to mi nimiz e the area of necrosis and the risk of secondary infection (205).
REHABILITATION
Aftercare in polytrauma pati ents has to start duri ng the immediate postoperati ve period. This implies mobilization of the extremities during the course of the intensive care treatment. Among the measures to be undertaken is passive continuous motion. Moreover, mobiliz ation of all major joints may be performed and should be part of a standardiz ed rehabil itation prog ram. During treatment on the regular ward, these mea sur es are maintained and may be acc omp ani ed b y acti ve exercises by the patient. Thes e should be performed under the supervision of a t raine d physiotherapist. Al so, the modes of mobi lization and the degree of weightbearing shoul d be carefull y discussed between the treating surgeon and the physical therapist. From the point of view of the patients, a tendency exist s to pe rfor m mobilization in a cautious way. Most often, there is a fear of undertaking too much weig htbearing. This can often be explained by the severe psy chological im pact induced by the traumatic ins ult. Reassurance of the patient rep res ents an important add itional fac tor to ascertain adequ ate mob ilization. Thes e factors are relevant not only i n regard to the maintenance of the joint mobili ty but also in preventing osteopor osis induced by immobility. Careful explanation is crucial so that patients real ize the importance of muscul ar activities, joint mobility and we ightbearing. Onl y then can a joint effort towa rd rapid mobi lization be achieved.
Patients With Head Trauma

During the treatment of patients who have significant head trauma, special care must be taken to avoid the development of sec ondary brain damage. Th ese patients profit from early rehabil itation measures. Thus, a timely tr ansfer to a rehabilitation center is advisable to facilitate a stimulation of the cognitive functions. Al though it may be consid ered to commence treatment in the primary center, the patients are often still under the influence of sed ative drugs or withdrawal symp toms from these drugs. I n this si tuation, a thorough work-up cannot be performed and cognitive trai ning is useless. In an ideal situation, tr ansfer to a speciali zed facility may
Page 34 of 50
overlap with the normalization of the withdrawal symp toms and thus forms the basis of a timely begi nning of the rehabi litati on pr ogram.
OUTCOME STUDIES General Outcome

Ov er the past f ew decades, improved preclinical and clinical emergency care has led to a sustained improvement i n the survival rate of multiply injured patients. Therefore, t he major treatment goals have changed toward achieving optimal results in terms of rehabil itation and return of the patient to a productive lifestyle (206,207,208). In order to judge the true clinic al outcome, follow-up studies are required that provide data ind ependent from the subjec tive view of the tre ating physician, who may not be abl e to jud ge the true outcome. Several factors may be responsibl e for this fact:
1. 2.
The mobility of modern Western societies prevents patients' availability for follow-up. Patients may have a different view on which criteria are important to judge the outcome in comparis on with doctors (e.g., range of motion versus subject ive ability to ma intain certain motor sk ills) . Social and ps ychologic al aspects may cause a more sustained impa irment of the subje ctiv e ou tcome than assessed by the clin ical examination performed by an orthopedic surgeon.
3.
P.88 Th e measurement of outcome largel y depends on measurements such a s the quality of life, empl oyment s tatus, or r esidual subjective complaints. These va riables have to be investigated carefully for several reasons:
1.
A de tailed analysis of the long-term results followin g polytrauma provides important information for the dev elopment or i mprovement of t reatment g uide lines and the allocation of r esources . A broad knowledge about long-term ou tcomes following polytrauma will help trauma surgeons to better manage and advise their patients regarding discharge planning, rehabilitation plans, or career planning. Therefore, patients certainly benefit from a thorough consultation. The length of rehabilitation, physical disability, and employment status following polytrauma are of ec onomi c interest.
2.
3.
Tr auma patients continue to i mprove after discharge. R ecovery is often prolonged, however, and up to now, the completeness of this recovery has remained uncertain. The outcome following polytrauma has been investiga ted i n p revious studies and the following demographic variables were r eported to be associated with a poor outcome:
Female gender (209) Old age (210,211,212) ISS (211) MAIS (213) Head injuries (209,211,214) Workers' compens ation (215) Lower educational level (216)
A long-term study from Ger many aime d to evaluate t he long-term subje ctive and objec tive outcome of pa tients with multiple blu nt injuries (217). In that study, an adequate follow-up period and a combination of subje ctive evaluation, and an e xami nation performed by a phy sician were presented. Th e overall outcome in this pa tient population was favorabl e. More than three fourths of the patients graded their overall outcome as sati sfactory, good, or very good. The younger patient population trended toward superior results. The most limi ting factors for a su cce ssfu l rehabil itation were injuries to the head and the lower extremities (Figs. 3-9 a nd 3-10). These results were consistent with previous studies, reporting superi or results in young patients (210,211,212). A very important outcome measurement f or polytrauma patients is the economic status and the return to work followin g the in jury. The se result s have to be vie wed in the context of speci fics of the German healthcare system. German reside nts have universal insurance to health care and can receive signifi cant social welfare payments. Despite this apparently favorable situation, signific ant financi al losses due to injury were indicated by 36.9 % of the patients and retirement or permanent disability due to physic al disability was found in 26.9% of the pati ents (217).
Page 35 of 50
MacKenzie et a l (216) found that 56% of those working full-time before multiple trauma h ad returned to work 1 year after in jury. The group that returned to work was more likel y to have had lower severity inj ury, hig her educ ational lev el, whi te collar occu pation, a nd hig her prein jury income. Rhodes et al (214) documented a 75% rate of return to preinjury work status in trauma patients. Morris et al (218) reported that 55% of trauma patients had returned to p roductivity during an average follow-up interval of 2.6 years.
FIGURE 3-9 Injuries responsibl e for physic al disability determined at a 10-year mi nimum time point after trauma.
It app ears from the li terature that head in juries and injuries to the lower ex tremities have been reported to be a l imiting factor for a success ful rehabilitation process (214,219). Th erefore, the outcome of lowe r extremity i njuries requires close attention and is discussed below.
Outcome After Lower Extremity Injuries

Lower extremity injuries are a well-known limiting factor f or successful rehabilitation (220,221). In addition, some authors P.89 have suggested that distal lower extremity injuries represent a particular problem for the functional recovery after polytrauma (222,223). These previous studies have mainly focused on the outcome within the first 2 years p ostinjury. The recovery in this s ubse t of patients, however, is often prolonged and requires long- term data for evaluation. Social variabl es such as return to work must be considered in the long-term. Although some p olytrauma patien ts achie ve maxi mum phy sical restoration withi n the fi rst few months postinjury, in most cases a longer follow-up is necessary to develop a bet ter understandi ng of the permanent conseq uences of the in jury. Bu tcher e t al (221) were able to s how that in patients with lower extremity trauma the cumulative percentage of fir st return to work continuously in creased until the study end poin t at 30 months postinjury. Therefore, their study i ndicates that the posttraumati c recovery in this patient population is continuous. Most previous reports b ased their hypotheses mainly on su bjective outcome measurements.
Page 36 of 50
FIGURE 3-10 Overall rehabil itati on status as gr ade d by the pat ients.
In a study investi gating polytrauma patients at a minim um of 10 years after trauma, combin ed inju ries had p oorer outcomes than the two other groups (217). However, the comparison between combined injuries and above-knee injuries demonstrated that all but one t ested item showed sig nificantly worse outcomes for combined injuries, whereas the comparison between combined injurie s and below-knee inj uries showed no signi ficant dif ference regarding range of motion, l impin g gait, and weightbearing status. I t was b elie ved that thi s finding further proves the signif icant impact of below-knee injuries for the functional outcome of the p oly trauma pat ient. It was speculated that various factors played a role in these findings. Firs t, it was argu ed that the life-threatening inju ries are frequently the focus of treatment on t heir admi ssion to t he hospi tal, and therefore in some cases, t he dia gnosis and treatment of r elatively subtle distal lower extremity injuries may be delayed, resulting in inferi or outcomes in this subset of patients. Second, the thin soft tissue envelope below the knee joint may limit the heali ng potential of inj uries below the knee j oint as compared with injuries above the j oint (217). Th ese assumptions are in as sociation with the results of Stie gelmar et al, who spe culated that in polytrauma patients, f oot and ankle inju ries are more likely to be a consequence of dire ct impa ct and high -energy trauma; and therefor e these injuries may be associated with increased soft tissu e damage and neurovascular compromise (223). Moreove r, in polytrauma patients, s everal conditions such as hypotension or hypothermia may resul t i n decreased periphe ral blood supply ; therefore, the soft tiss ues of the dis tal lower extremities are more likely to be compromised by these general ins ults than proxim al inju ries. The increased incidence of complex foot and ankle injuries such as pilon, talus, and calcaneus fractures or Lisfranc lesions when compared wi th isolated i njuries may also be relevant. I n addition, the rehabilitation process of patients with combi ned inj uries to the extremiti es may be less favorable than the rehabilitation for an i sol ated injury (213,215). Another que sti on t hat may not be able to be ans wered is the indication for a mputation. The mos t extens ive and demandin g study has been performed as a mul tic enter study among several centers in North Ame rica (LEAP study) (206). In this study, p atients were investiga te specifi call y in regard to their long-term outcomes after l imb reconstruction or amputation. I n an observational setup, fu nctional outcomes of 569 pa tients with severe l eg injurie s resulti ng in reconstruction or ampu tation were evaluated. Th e authors found no sig nifi cant difference i n scores for the Si ckness Impact Profile betwee n the amputation and reconstruction groups at 2 years. The authors conclude d that the characteris tics of the patients and their injuries should b e adjus ted and patients who underwent amp utation had functional outcomes similar to those of patien ts who underwent r econstruction. I n general, a les s favorable outcome was measured in cases of lower educational leve l, nonwh ite race, poverty, l ack of private health in surance, poor social support network, low self-efficacy (the patient's confidence i n b eing able to resume lif e activities), smoking, and involvement i n disability compensation litigation. Reconstruction was associated with a higher rate of rehospitalization than primary amputation. Although these results are expected for the population of i solated extremity injuries, they may not be transferable to the more comple x situation seen in patients with multiple injuries (206). Similarly, the LEAP study demonstrated a simi lar return to work by 2 years i n patients who underwent amputation and patients who underwent reconstruction (224). Th us, the decision making in polytrauma pa tients may have to be adjusted to the individ ual situation. In these p atients, a mputation of a lim b may represent a lifesavin g procedure in the early stage after injury. Th erefore, factors other than the mere feasibil ity of li mb reconstruction and the local tissue situation have to be considered.

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Ovid: Rockwood & Green's Fractures in Adults

Chapter 3 Management of the Multiply Injured Patient

DEFINITIONS OF POLYTRAUMA: INCIDENCE, INJURY DISTRIBUTION, AND MORTALITY

Ovid: Rockwood & Green's Fractures in Adults

STAGED APPROACH TO CARE

Acute Reanimation Period

Primary Stabilization Period

Secondary Regeneration Period

Tertiary Reconstruction and Rehabilitation Period

Ovid: Rockwood & Green's Fractures in Adults

IMPACT OF RESCUE CONDITIONS ON THE CLINICAL COURSE

INITIAL ASSESSMENT AND EARLY MANAGEMENT

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Cardiac tamponade Tension pneumothorax Myocardial infarction Cardiac contusion

Ovid: Rockwood & Green's Fractures in Adults

Management of Hemorrhagic Shock

Ovid: Rockwood & Green's Fractures in Adults

Monitoring Response to Fluid Replacement Therapy

Ovid: Rockwood & Green's Fractures in Adults

DEFINITION OF THE PATIENT'S CONDITION

Ovid: Rockwood & Green's Fractures in Adults

SURGICAL PRIORITIES IN POLYTRAUMA: WHAT COMES FIRST?

Urgent Lifesaving Surgery

Ovid: Rockwood & Green's Fractures in Adults

Mediastinal Hemorrhage and Thoracic Aortic Injury

Severe Pelvic Trauma and Packing

Ovid: Rockwood & Green's Fractures in Adults

FIGURE 3-1 Application of pelvic packing in a patient with hemodynamic instability.

Treat Exsanguinating Abdominal Hemorrhage or Expanding Intracranial Hematoma First?

Ovid: Rockwood & Green's Fractures in Adults

FIGURE 3-2 Algorithm of management of pelvic fractures.

MOLECULAR ASPECTS OF TRAUMA

Ovid: Rockwood & Green's Fractures in Adults

FIGURE 3-3 One and two hit inflammatory models.

Systemic Impact of Trauma ( First Hit )

Ovid: Rockwood & Green's Fractures in Adults

TABLE 3-1 Variety of Defined Cytokines

Tu mor necrosis factors (TNF)

IFN-, INF- , INF-

Colony stimulating factors (CSF)

G-CSF, M-CSF, GM-CSF

Systemic Impact of Operative Procedures ( Second Hit )

Ovid: Rockwood & Green's Fractures in Adults

Pro-i nflammator y release

Promotes muscl e metabolism, cachexia, apoptosis, and ICAM

Cardio dep res sant

Expressi on of COX-2, iNOS, ICAM-1

Synergizes with TNF-

Mediates acute hepatic phase response

Ovid: Rockwood & Green's Fractures in Adults

Activates HPA axis

Recruits neutrophils, releases superoxides and proteases

Associated with IL-6

Promotes neutrop hil and coag ulation activation

Synergistic with IL-18

Syn ergize s with IL-1 and IL-12

Down regulates Fas ligand and TNF-

Promotes IL-2, IL -12, IL- 18

Activates macrophage-acute lun g in jur y

Induces apopt osis, tumor surveillance

Growth factor for T cells, NK cel ls

Downregulates IL-1, TNF, IL -6, I L-8

Increases effects of glucocorticoids