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Journal of the American Academy of Orthopaedic Surgeons 154 In a level I trauma center, it is usu- ally the trauma-trained general sur- geon who is the leader of the multi- disciplinary trauma team caring for the severely injured patient, and the orthopaedic surgeon functions as a member of that team. In many community hospitals, a general surgeon is often in charge of the overall management of the trauma patient, but the orthopaedic sur- geon plays an important role and may, at times, serve as the leader. Therefore, it is incumbent on the orthopaedic surgeon to be thor- oughly familiar with the evaluation and management of the trauma patient, from assessment through discharge and rehabilitation. 1 Injuries due to blunt trauma (the most common being motor- vehicle accidents), industrial acci- dents, and falls frequently affect more than one system. For exam- ple, flexion-distraction injuries to the lumbar spine are associated with a 50% incidence of intra- abdominal injuries. Therefore, poly- traumatized patients must be eval- uated with an awareness of the possibility of associated injuries and must be managed in time-relevant phases. The phases of trauma care can be designated as the prehospital phase, the hospital phase (which comprises the acute, primary, sec- ondary, and tertiary periods), and the rehabilitation phase. Each of these periods has its own priorities in resuscitation and injury manage- ment, as well as predictable pat- terns of morbidity and mortality. In the acute and primary periods, hemodynamic complications (e.g., blood loss) and lethal head injury are the most common causes of mortality. In the secondary period, the most common are early organ failure, particularly pulmonary fail- ure. In the tertiary period, sepsis, pulmonary failure, and delayed organ failure are the leading causes of death. This article focuses on the basic tenets of trauma care, the evalua- tion of the multiply injured pa- tient, and the benefits of early orthopaedic intervention in this setting. Dr. Turen is Attending Orthopaedic Surgeon, Section of Orthopaedic Traumatology, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore. Dr. Dube is Fellow, Section of Orthopaedic Traumatology, R Adams Cowley Shock Trauma Center. Dr. LeCroy is Fellow, Section of Orthopaedic Traumatology, R Adams Cowley Shock Trauma Center. Reprint requests: Dr. Turen, Section of Orthopaedics, R Adams Cowley Shock Trauma Center, #T3R64, 22 South Greene Street, Baltimore, MD 21201. Copyright 1999 by the American Academy of Orthopaedic Surgeons. Abstract The management of the multiply injured patient is a challenge for even experi- enced clinicians. Because many community hospitals lack a dedicated trauma team, it is often the orthopaedic surgeon who will direct treatment. Therefore, the orthopaedic surgeon must have an understanding of established guidelines for the evaluation, resuscitation, and care of the severely injured patient. Initial evaluation encompasses assessment and intervention for airway, breathing, cir- culation, disability (neurologic injury), and environmental and exposure con- siderations. Resuscitation requires not only administration of fluids, blood, and blood products but also emergent management of pelvic trauma and stabiliza- tion of long-bone fractures. Judicious early use of anterior pelvic external fixa- tion can be lifesaving in many cases. The secondary survey, which is often neglected, must incorporate a thorough physical evaluation. Although the method of fracture stabilization is still controversial, most clinicians agree that early fixation offers many benefits, including early mobilization, improved pul- monary toilet, decreased cardiovascular risk, and improved psychological well- being. Without an understanding of the complexities of the multiply injured patient, delays in the diagnosis and treatment of a patientÕs injuries are likely to adversely affect outcome. J Am Acad Orthop Surg 1999;7:154-165 Approach to the Polytraumatized Patient With Musculoskeletal Injuries Clifford H. Turen, MD, Michael A. Dube, MD, and C. Michael LeCroy, MD Clifford H. Turen, MD, et al Vol 7, No 3, May/June 1999 155 Prehospital Phase One of the goals of trauma care is to provide earlier evaluation and increasingly sophisticated prehos- pital care. Optimal transport, re- suscitation, stabilization, and defin- itive care of the multiply injured patient at the receiving facility depend on three key elements, all of which must be in place before the patient arrives: (1) paramedics who are familiar with recommended life support protocols; (2) open lines of communication between para- medics and hospital personnel regarding the patientÕs medical his- tory and the mechanism, time, and circumstances of the injury; and (3) dedicated space and equipment for the management of the patient. The number of paramedics trained in the American College of Surgeons Advanced Trauma Life Support protocols 1 has risen dramatically in the past decade. Often, this allows patients to arrive at the emergency room provisionally evaluated with resuscitation started. When indicated, the trauma patient should arrive at the hospi- tal with spine immobilization. This may include use of specialized equipment, such as a backboard that incorporates a preformed cer- vical spine stabilization device or the Kendrick extrication device, or classic sandbag immobilization. Open wounds should be covered with a sterile bandage. External hemorrhage should be controlled with direct pressure. A prefabri- cated splint should be used to immobilize long-bone injuries. Provisional splinting decreases pain and protects the soft tissues. Acute Hospital Period (Initial 1 to 2 Hours) On patient arrival, it is important to follow a logical, systematic ap- proach for evaluation and manage- ment. This includes a primary sur- vey, with rapid assessment of vital signs and patient status with use of the ÒABCDEÓ management proto- col 1 (Table 1); acute resuscitation, which may include orthopaedic intervention; and a secondary sur- vey involving a complete head-to- toe evaluation of the patient. In a well-staffed trauma center, many components of the protocol may be performed concurrently, reducing the time for evaluation and resusci- tation. The primary survey should be accomplished rapidly. This survey may be altered on the basis of information received from the field, especially for patients with trauma resulting from certain mechanisms of injury. For exam- ple, side-impact motor-vehicle col- lisions are more likely to cause pelvic fractures due to lateral com- pression, solid-viscus injuries, and closed head injuries. During this survey, the patientÕs blood pres- sure, pulse, respiratory rate, uri- nary output, and arterial blood gas values should be monitored close- ly, as they are good indicators of the patientÕs response to resuscita- tion. Measurement of oxygen satu- ration by pulse oximetry may also provide a good reflection of the patientÕs airway, breathing, and circulatory status. Airway The first priority in the assess- ment of a trauma patient is to ascertain the status of the airway. The evaluation must be performed with constant care to protect the cervical spine until a concomitant injury has been ruled out. The up- per airway should be cleared of any foreign bodies, blood, or secre- tions, and the mandible, larynx, and trachea should be quickly eval- uated for fractures. The use of a chin lift or jaw thrust, as well as a nasopharyngeal or oropharyngeal airway in the unconscious patient, may help maintain a patent airway. A lateral radiograph of the cervi- cal spine, including the C7-T1 inter- space, should be obtained early in the assessment protocol. A normal study combined with a negative physical examination of a patient who is alert and is not intoxicated can be considered to rule out spine trauma. In the patient who is un- conscious or intoxicated or who has neck pain, a negative lateral cervi- cal spine radiograph does not nec- essarily clear the spine; other plain- radiographic views or radiologic studies may be needed for a com- plete evaluation. A computed to- mographic (CT) scan should be obtained in all cases in which the entire cervical spine is not visual- ized, as well as whenever it is indi- cated clinically or radiographically. Breathing and Ventilation As the airway is being assessed, the adequacy of ventilation is eval- uated by observing the patientÕs chest for the rise and fall of normal breathing, auscultating for normal breath sounds, percussing to evalu- Table 1 Mnemonic Device for Primary Evaluation of the Polytraumatized Patient A - Airway maintenance with cervical spine control B - Breathing and ventilation C - Circulation with hemorrhage control D - Disability evaluation (neurologic status) E - Exposure and environmental control (completely undress the patient but prevent hypothermia) The Polytraumatized Patient With Musculoskeletal Injuries Journal of the American Academy of Orthopaedic Surgeons 156 ate for pneumothorax or hemotho- rax, and palpating to determine whether there are chest wall abnor- malities or fractures. All trauma patients should receive supplemen- tal oxygen. Placement of an orotra- cheal, nasotracheal, or surgical air- way is mandatory if there are mechanical factors preventing nor- mal breathing (e.g., tension pneu- mothorax), if the airway cannot be maintained, or if the patient is unconscious. These procedures must be accomplished with ade- quate control of the cervical spine. If ventilation still cannot be estab- lished, the clinician should suspect pneumothorax or hemothorax and perform an immediate needle or tube thoracotomy. Occasionally, due to the emergent nature of the clinical scenario, these procedures may be performed before obtaining the initial chest radiograph. Circulation and Hemorrhage The third step is the assessment of circulation and blood volume. Loss of consciousness; pale, cool skin; and thready or absent pulses can indicate hypovolemia. In young patients, these signs may be the only indications of significant loss of circulating blood volume. Hypotension in the multiply in- jured patient may be due to diverse causes, including hemorrhage, brain injury (inability to regulate blood pressure), quadriplegia (loss of peripheral vascular resistance), hypothermia, myocardial infarc- tion, and mediastinal shock (aortic transection, pericardial tamponade, cardiac rupture). Hemorrhage is the most frequent cause of hypoten- sion, accounting for 95% of cases in blunt trauma patients. If bleeding has been excluded as the cause of hypotension, other causes should be sought. Signs indicating other causes of hypothermia include decreasing blood pressure with a decreasing heart rate, fixed and dilated pupils, and loss of gag reflex (terminal brain injury); core temperature of less than 95¡C (hypothermia); ST-segment eleva- tion on an electrocardiogram and poor ventricular wall motion and/or decreased ejection fraction on an echocardiogram (myocardial in- farction); widening pulse pressure; decreased or muffled heart sounds; and audible cardiac murmur (medi- astinal shock). If the patient is awake and alert, quadriplegia as a cause of hypotension can usually be diagnosed. However, in the unre- sponsive patient, the cause of hypo- tension can be difficult to identify, and the physician must rely on a process of exclusion. After blunt trauma, blood loss or accumulation may be external, intrathoracic, intraperitoneal, or extraperitoneal or may occur in the area of long-bone fractures. The location must be identified so that appropriate controls can be imple- mented. External hemorrhage is the easiest to diagnose and can usu- ally be controlled by application of pressure and a compressive dress- ing by paramedics or the resus- citation team. Less obvious sites of hemorrhage are the abdominal cav- ity (splenic and liver lacerations), the thorax (aortic tears), the ret- roperitoneum (pelvic fractures), and muscle and fascial planes (extremity fractures). Significant intrathoracic bleeding usually can be identified by decreased breath sounds on physical examination or will be visualized on an upright chest film. Free intraperitoneal blood can be evaluated by radiogra- phy, ultrasound, lavage, and physi- cal examination (shifting dullness to percussion and abdominal dis- tention). Long-bone fractures can be identified through physical examination (e.g., crepitus, ecchy- mosis, angulation, swelling, tender- ness) and radiography. Extraperi- toneal hemorrhage may be inferred from the presence of pelvic frac- tures. Pelvic fractures may cause life-threatening retroperitoneal hemorrhage and mandate immedi- ate intervention. If the history and physical exam- ination indicate the possibility of intra-abdominal injury, further studies are indicated. Historically, diagnostic peritoneal lavage (sensi- tivity, 100%; specificity, 84%) has been the standard in most trauma centers. In the United States, it may still be the diagnostic method of choice, especially for the unstable patient who cannot safely undergo CT scanning. However, for the sta- ble patient with suspected intra- abdominal injury, CT examination (sensitivity, 95%; specificity, 95%) has largely supplanted peritoneal lavage. 2 In Europe, ultrasonography (sensitivity, 90%; specificity, 95%) is the screening tool of choice. 2 The effectiveness of ultrasonography depends in great part on the experi- ence of the individual performing the examination. Continuous electrocardiograph- ic monitoring should be performed on all trauma patients. Cardiac electromechanical dissociation may be caused by cardiac tamponade, tension pneumothorax, or extreme hypovolemia. Disability/Neurologic Examination The primary survey should include a basic neurologic examina- tion. The ÒAVPUÓ mnemonic device (A = alert; V = responds to vocal stimuli; P = responds to pain; U = unresponsive) and the Glasgow Coma Scale (Table 2) are useful for a quick neurologic assessment. A more thorough examination can be made during the secondary survey. A decreasing level of conscious- ness dictates reevaluation of the patientÕs oxygenation and ventila- tion status. If hypoxia and hypo- volemia have been ruled out, al- tered consciousness may be related directly to central nervous system trauma, drugs, or alcohol. Clifford H. Turen, MD, et al Vol 7, No 3, May/June 1999 157 Environment and Exposure Adequate exposure of the pa- tient is a prerequisite for a thorough examination. The patient should be carefully logrolled to rule out poste- rior chest wall and flank abnormali- ties. The spine should be palpated in its entire length. However, a patient lying unclothed on the examination table is at increased risk for hypothermia, which can cause dysrhythmias. Warm blan- kets and heated intravenous fluids may be appropriate for selected high-risk patients. Resuscitation Concurrent with the primary assessment, the trauma team must begin the resuscitation of the pa- tient. A minimum of two large- caliber (16-gauge) intravenous cath- eters should be placed, preferably in the upper extremities, for adminis- tration of fluid therapy. If routine intravenous access is not possible, cutdowns and/or central venous ac- cess may be necessary. Once access has been established, blood should be drawn for a hemogram, blood chemistry and clotting factor evalu- ation, typing and cross-matching, pregnancy test, and toxicology screens. Crystalloid isotonic solutions, such as lactated RingerÕs solution, should be administered early in the resuscitation process. Two to three liters may be required to increase the mean arterial pressure to 60 mm Hg or more. As the blood pressure increases, the heart rate should decrease. If the crystalloid infusion provides only a transient response or no response at all, the use of Rh- negative type O or type-specific blood, respectively, may be indi- cated. The use of rapid-infusion de- vices may aid in the resuscitation effort. Cross-matched blood should be used to replace lost blood as indi- cated. Crystalloid isotonic solu- tions have no oxygen-carrying capability and, therefore, can be used only as an adjunct to blood replacement. Fresh-frozen plasma and platelets should be used in patients who are coagulopathic or thrombocytopenic (platelet count below 50,000/mm 3 ). In the acute setting, (e.g., imme- diately after fluid infusion), urinary output should be regarded with caution as an indicator of volume status and organ perfusion. How- ever, in the normotensive or stabi- lized patient, urinary output of 0.5 to 1.0 mL/kg per hour is a good indicator of renal perfusion. Before catheters are placed to monitor uri- nary output, the external genitalia and rectum should be inspected for injury. If a urethral injury is sus- pected, particularly in a male pa- tient, a retrograde urethrogram should precede catheter placement. Blood pressure and heart rate are also good indicators of the ade- quacy of resuscitation. A stable mean arterial pressure of 60 mm Hg or more and a heart rate of less than 100 beats per minute usually indicate hemodynamic stability. The central venous pressure or the pulmonary capillary wedge pressure may be a better indicator of hemodynamic stability than the blood pressure alone in the elderly and in patients with chest trauma. A near-normal value for either (adjusted for age) provides excel- lent information on the adequacy of resuscitation. Lactic acid levels are also useful measurements, because the lactate concentration rises with anaerobic metabolism. Increased levels may be an indicator that significant injury has gone unnoticed and resuscita- tion is incomplete. Most trauma patients receive large amounts of fluid and blood and often go from volume depletion to volume over- load in a short period of time. A nasogastric tube should be inserted early in the resuscitation to decompress the stomach. In pa- tients with facial trauma, the tube should be passed through the mouth, rather than the nasopharynx. Radiographs are a valuable ad- junct in evaluation of the trauma patient but should not interfere with resuscitation. Three radiographs should be obtained on all trauma patients concurrent with the primary survey and initial resuscitation: an anteroposterior (AP) chest film, an AP view of the pelvis, and a lateral view of the cervical spine. As indi- cated by physical examination or protocol, additional anatomy-specific radiographic studies can be obtained as part of the secondary survey. Pelvis A major concern for the trauma team is the presence of a pelvic frac- Table 2 Glasgow Coma Scale * Eye opening Spontaneous 4 In response to speech 3 In response to pain 2 None 1 Motor response Obeys commands 6 Purposeful movements in response to pain 5 Withdrawal in response to pain 4 Flexion in response to pain 3 Extension in response to pain 2 None 1 Verbal response Oriented 5 Confused 4 Inappropriate 3 Incomprehensible 2 None 1 * One score (the highest value) is recorded for each category. Thus, the possible combined scores range from 3 to 15. (Adapted with permission from Teasdale G, Jennett B: Assess- ment of coma and impaired con- sciousness: A practical scale. Lancet 1974;2:81-84.) The Polytraumatized Patient With Musculoskeletal Injuries Journal of the American Academy of Orthopaedic Surgeons 158 ture in a patient with continued hemodynamic deterioration. If hemorrhage from the chest, thorax, abdomen, and external sites or from the area of a long-bone fracture has been either excluded as the cause of hypotension or controlled, evalua- tion of an AP radiograph of the pelvis may reveal that a fractured pelvis is the site of hemorrhage. If the fracture pattern carries a high risk for instability, inlet (caudad) and outlet (cephalad) films of the pelvis should be obtained. These more clearly depict fracture dis- placement and are useful in identi- fying the direction of fracture. Obturator and iliac oblique views are helpful in assessing acetabular fractures. Although TileÕs pioneering ÒABCÓ classification of pelvic disruptions offers a simple description of these injuries and may be applicable for some pelvic fractures, we have found the classification devised by Young et al 3,4 more effective for guiding acute management of the multiply injured patient. In their system, pelvic fractures are divided into four groups: lateral compres- sion (LC), AP compression (APC), vertical shear, and combined me- chanical injury (Fig. 1). The first two groups are further categorized according to the severity of injury due to the energy imparted to the pelvis. In a review of 210 pelvic fractures, the authors found that the plane of the anterior ring disruption indicated the direction of the force imparted to the pelvis, suggested the nature of the posterior-ring lesion, and could be used to estab- lish the risk of hemorrhage. 4 Lateral compression injuries are characterized by an oblique anterior ring fracture and are associated with decreasing pelvic volume, intraperitoneal or intrathoracic hemorrhage, and a high incidence of head injury, which may cause hypotension. The type LC-III frac- ture is the typical ÒrolloverÓ frac- ture, in which one hemipelvis sus- tains an LC injury and the other sus- tains an AP injury, the latter most often associated with high blood loss. However, the high mortality rates associated with type LC-III injuries usually are secondary to associated injuries rather than the pelvic fracture. Anteroposterior compression injuries are characterized by vertical pubic ramus fractures and are asso- ciated with the greatest incidence of hemorrhage because of the sequen- tial disruption of the sacrotuberous and sacrospinous ligaments (type APC-I), the anterior sacroiliac liga- ment (type APC-II), and the poste- rior sacroiliac ligament (type APC- III), as well as the neurovascular structures adjacent to those liga- ments. The mechanism of type APC-I and APC-II injuries can be likened to opening a book. The APC-III fracture (an innominosacral dissociation, or internal hemipel- vectomy) can be likened to breaking the binding of a book. This injury pattern has been associated with blood requirements in excess of 20 units, 5 the highest blood loss for all pelvic fracture types. Vertical shear injuries, often associated with massive blood loss, show an initial cephalad displace- ment that is not seen in APC in- juries until later in the postinjury course. Combined mechanical injuries may incorporate two or more of these injury patterns, but it is the APC portion that is most at risk for hemorrhage. During injury, the forces that disrupt the pelvic ligaments con- straining the ring (the anterior sacroiliac, sacrospinous, sacrotuber- ous, and posterior sacroiliac liga- ments) also disrupt the associated vessels, causing hemorrhage. Even a small increase in pelvic diameter exponentially increases the pelvic volume (2/3πr 3 ). A patient who has sustained blunt trauma and has an unstable pelvic fracture is at risk for fatal exsanguinating hemor- rhage because of (1) the administra- tion of fluids to raise the blood pressure, which impairs the bodyÕs natural compensatory hypotension (i.e., decreased blood pressure causes decreased blood flow, which in- creases clotting and thereby de- creases hemorrhage); (2) the admin- istration of nonclotting, often cold, resuscitation fluids, which can limit clotting ability; and (3) movement for diagnostic and examination pro- cedures. Hemorrhage following pelvic fractures can be managed with angiography and embolization, exploration and vascular ligation, open reduction and internal fixa- tion (ORIF), a pneumatic antishock garment, or external fixation. The choice of treatment depends not only on the resources of the institu- tion but also on the experience and availability of required personnel. In institutions with skilled radi- ology personnel and trauma teams, patients with hemodynamic insta- bility secondary to pelvic fracture may be managed with angiography and embolization. Although this technique can be used to diagnose and treat arterial hemorrhage, it is less than optimal for the patient in extremis because the bleeding is most frequently venous and be- cause the procedure requires the immediate availability of special- ized personnel. Open reduction and internal fix- ation is mechanically the most sta- ble form of fixation and may be per- formed at the same time as other emergent surgery (e.g., laparotomy for intraperitoneal injury). How- ever, ORIF requires a substantial amount of surgical experience, and special care is necessary to avoid violating the retroperitoneal space, thus decompressing any existing tamponade. Recently, the use of percutaneous iliosacral screw fixa- tion has gained acceptance. 6 Al- though this modality can provide Clifford H. Turen, MD, et al Vol 7, No 3, May/June 1999 159 stability to the posterior pelvis and control pelvic volume, the tech- nique is exacting, and incorrect placement of the screw can violate the neural canal posteriorly or the vessels and/or nerve roots anteri- orly as the screw traverses the sacral ala. Certain injuries, such as hollow-viscus perforation with contamination of the wound, are relative contraindications to ORIF. Pneumatic antishock garments are effective as a temporary splint for the pelvis and lower extremi- ties, but prolonged use limits eval- uation of, and access to, lower- extremity trauma. Their use is contraindicated in the treatment of open fractures and may potentiate a compartment syndrome. 7 Recent reports questioning the use of pneumatic antishock garments have focused on penetrating, not blunt, injuries. 8 In many instances, use of an external fixator is the method of choice for controlling hemorrhage in a blunt trauma victim with hypotension secondary to pelvic disruption. The fixator can be applied in the emergency room, but it is most often applied in the operating room if a patient remains hypotensive after resuscitation. Early external fixation stabilizes the pelvic ring, controls pelvic volume, minimizes dislodgment of clots formed during the bodyÕs initial attempt to control the hemorrhage, aids in controlling cancellous bleeding, and facilitates early pa- tient mobilization, promoting good pulmonary toilet through an up- right chest. To apply an external fixator, pins are inserted between the cor- tices of the ilium through separate stab incisions (Fig. 2, A). Pelvic clamps are used to attach the pins in groups. Connecting rods are loosely attached to the clamps to form a frame. The pelvis is re- duced by posterior manual com- pression on the pelvis (not the pins) at the level of the sacroiliac joint and by longitudinal traction, and the frame is locked. The frame construct should allow further abdominal and chest diagnostic studies or intervention without Fig. 1 Classification system for pelvic frac- tures devised by Young et al. 3,4 Lateral compression (LC) fractures: type LC-I is a stable injury with ipsilateral sacral crush; type LC-II is an injury with ipsilateral hori- zontal pubic ramus fractures, anterior sacral crush, and crescent fractures through the iliac wing; type LC-III is a type I or II fracture with ipsilateral opening of the sacroiliac joint posteriorly and disruption of the sacrotuberous and spinous ligaments. Anteroposterior compression (APC) frac- tures: type APC-I is a stable injury that opens the pelvis but leaves the posterior ligamentous structures intact; type APC-II is a rotationally unstable fracture with dis- ruption of the sacrospinous and sacrotuber- ous ligaments and anterior sacroiliac joint opening; type APC-III is an unstable injury with complete disruption of all ligamentous supporting structures. A vertical shear (VS) fracture is an unstable fracture involving vertical ramus fractures and disruption of all ligamentous structures. LC-I APC-I APC-III VS APC-II LC-III LC-II The Polytraumatized Patient With Musculoskeletal Injuries Journal of the American Academy of Orthopaedic Surgeons 160 releasing the reduction (Fig. 2, B). In patients with concurrent intra- peritoneal and extraperitoneal in- jury and hemorrhage, immediate application of the fixator followed by laparotomy can be lifesaving (Fig. 2, C). Reduction of major joint disloca- tions and fracture-dislocations should also be addressed in the acute period. Although this should not be the first priority in the hemo- dynamically unstable patient, the orthopaedic surgeon must be ag- gressive in managing these injuries, particularly hip and knee disloca- tions. Reduction can usually be accomplished without impeding the resuscitation team. Frequently, the patient is intubated and has been given muscle relaxants, which helps make the reduction atraumatic. If there is neurovascular compro- mise, early realignment of the joint may help restore blood flow to the distal extremity, avoiding ischemia and compartment syndrome. Primary Hospital Period (Hours 3 to 12) Reevaluation During this period, the existing history is expanded, when possible, detailing not only allergies, medica- tions, past and present illnesses, and recent food intake but also the mechanism of injury, the duration of exposure to the elements, the area surrounding the scene, and other information obtained from the patient, paramedics, and family members. After obtaining a de- tailed history, the physician per- forms the secondary survey, a head-to-toe evaluation undertaken only after completion of the prima- ry survey. Each area of the bodyÑ maxillofacial, cervical, thoracic, abdominal, perineal (including rec- tum and vagina), musculoskeletal, and neurologicÑis fully examined. Because the patient is often uncon- scious, and thus unable to help the examiner localize injuries, a great deal of care must be used during this evaluation. The Glasgow Coma Scale score (Table 2) is determined at this time. Fig. 2 External fixation of a pelvic fracture. A, Pins are inserted between the inner and outer tables of the ilium into the thick can- cellous bone above the acetabulum for maximum pin-to-bone con- tact. B, The resuscitative pelvic fixator allows manipulation of the frame without loss of reduction. One portion of the frame remains locked while the other is rotated to allow access to the abdomen and to facilitate patient positioning for CT scanning. C, The pelvic fixator is adjusted to allow access to the abdomen for laparotomy. (Part C reproduced with permission from Burgess AR: The man- agement of haemorrhage associated with pelvic fractures. Int J Orthop Trauma 1992;2:101-111.) A B C Clifford H. Turen, MD, et al Vol 7, No 3, May/June 1999 161 One of the most important man- agement principles, and one that is often overlooked, is continual re- evaluation of the patient. A pa- tientÕs overt, overwhelming injuries frequently mask other serious in- juries that, if unrecognized and untreated, may cause future dis- ability. During the primary period of patient care, decisions related to limb salvage must be considered. Extremities with massive injuries must be carefully evaluated for the degree of soft-tissue damage, per- fusion of the limb distal to the in- jury, neurologic function in the dis- tal limb, and the number of levels of injury within the limb. Unfortunately, attempts to quan- tify the injury and outcome have not proved uniformly successful. However, the Mangled Extremity Salvage Score, 9 the Abbreviated Injury Scale (Table 3), and other scoring systems direct attention to the important factors, such as ischemic time, hypotension, and neurologic function, that must be considered when evaluating the feasibility of limb salvage. Physi- cian experience may be the most reliable determinant of whether to salvage or amputate the limb. Severe open fractures have the highest treatment priority once the patient is hemodynamically stable. However, one must not allow the salvage of a limb to compromise the well-being of the patient. The mangled limb may place too great a metabolic load on a critically ill patient, and amputation may there- fore be required to ensure patient survival. For patients with less extensive injuries, management of open frac- tures should be no less aggressive. Wounds should be examined only once in the emergency department, in the presence of the orthopaedic surgeon. Drawings or Polaroid pho- tographs of the wounds can be help- ful in avoiding repeated inspections. Table 3 Examples of Scores on the Abbreviated Injury Scale* Examples Score (Description) Head Crush of head/brain 6 (lethal) Brainstem contusion 5 (critical, survival uncertain) Epidural hematoma (small) 4 (severe, life-threatening) Face External carotid laceration (major) 3 (severe, not life-threatening) Le Fort III fracture 3 Optic nerve laceration 2 (moderate) Neck Crushed larynx 5 Pharyngeal hematoma 3 Thyroid gland contusion 1 (minor) Thorax Open chest wound 4 Aorta, intimal tear 4 Esophageal contusion 2 Myocardial contusion 3 Pulmonary contusion (bilateral) 4 Two or three rib fractures 2 Abdomen and pelvic contents Bladder perforation 4 Colon transection 4 Liver laceration >20% blood loss 3 Retroperitoneal hematoma 3 Splenic laceration, major 4 Spine Incomplete brachial plexus 2 Complete spinal cord injury at C4 or below 5 Herniated disk with radiculopathy 3 Vertebral body compression >20% 3 Upper extremity Amputation 3 Elbow crush 3 Shoulder dislocation 2 Open forearm fracture 3 Lower extremity Amputation Below knee 3 Above knee 4 Hip dislocation 2 Knee dislocation 2 Femoral shaft fracture 3 Open pelvic fracture 3 External Hypothermia 31¡C to 30¡C 3 Electrical injury with myonecrosis 3 Second- or third-degree burns over 20% to 29% of body surface area 3 * Adapted with permission from Kellam JF, Bosse MJ: Orthopaedic management decisions in the multiple trauma patient, in Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries, 2nd ed. Philadelphia: WB Saunders, 1998, p 153. The Polytraumatized Patient With Musculoskeletal Injuries Journal of the American Academy of Orthopaedic Surgeons 162 The patient should then be taken urgently to the operating room for aggressive surgical debridement of wounds, removing all devitalized skin, muscle fascia, and bone. Irrigation should be performed with copious amounts of crystalloid solu- tion, preferably via pulsatile lavage. Wounds should be reinspected at the conclusion of the initial debride- ment and irrigation for any nonvi- able tissue that was missed. Bone fragments should be stabilized under a different surgical setup (new drapes and surgical instru- ments). Whenever possible, frac- tures should be stabilized with inter- nal or external fixation. Repeat inspection and debridement should occur within the next 48 hours. Early soft-tissue coverage is neces- sary for optimal functional outcome. Prophylactic antibiotic therapy with a first-generation cephalo- sporin should be given in the emer- gency department and continued for up to 48 hours after debridement. The addition of a second antibiotic is infrequently necessary but is appro- priate in special circumstances, such as after exposure to barnyard con- taminants and brackish water. With each additional debridement, the patient should again receive a pro- phylactic course of antibiotics. Benefits of Early Fracture Stabilization It is generally recognized that proper management of the multiply injured patient requires a multidis- ciplinary, team-oriented approach. Standardized trauma protocols have resulted in improved patient outcomes. 1 A critical component of modern trauma care is early stabi- lization of major pelvic and long- bone fractures. Unfortunately, this does not always translate into clini- cal practice. Orthopaedic injuries are frequently overlooked initially in the interest of acute resuscitation of the multiply injured patient. However, many studies have shown that aggressive early management of these injuries increases long-term survival and decreases morbidity. Fixation of unstable fractures of the pelvis, femur, and tibia should be performed within the first 24 hours after injury if medically fea- sible. The goal is stable skeletal fix- ation with the use of internal and/or external orthopaedic im- plants that will allow early mobi- lization of the patient. Early frac- ture stabilization has been shown to have many beneficial effects on the clinical course of the multiply injured patient, decreasing compli- cations and improving outcome. Decreased Musculoskeletal Morbidity Musculoskeletal morbidity is the primary source of long-term disabili- ty for survivors of multisystem trau- ma, particularly those with spinal cord injury. Early fracture stabiliza- tion minimizes morbidity secondary to the loss of musculoskeletal func- tion. Early patient mobilization, facilitated by early fracture stabiliza- tion, allows early range-of-motion and muscle-strengthening exercises, thereby decreasing rehabilitation time and long-term disability. 10,11 Decreased Hospital Stay Early fracture stabilization re- duces the length of time in the intensive care unit and the overall hospital stay, which translates into a substantial reduction in the cost of hospital care for the multiply injured patient. 10,12,13 Bone et al 10 found that multiply injured pa- tients managed with early stabi- lization averaged 2.8 intensive care unit days and 17.3 hospital days, compared with 7.6 and 26.6 days, respectively, for those treated with delayed stabilization. The average total hospital cost was 66% higher for the delayed-stabilization group. Other Benefits Other benefits of early skeletal stabilization are more subjective but nevertheless clinically significant in the management of the multiply injured patient. Early fracture fixa- tion allows rapid patient mobili- zation, improved nursing care, and a decreased incidence of decubitus ulcers. Early fracture stabilization also improves patient comfort, there- by reducing the need for narcotic analgesics, with their associated res- piratory depressant side effects. It has also been argued that early fracture stabilization increases the risk of complications from skeletal fixation in the already stressed mul- tiply injured patient. However, no prospective study to date has shown increased rates of infection or nonunion in patients managed with early fracture stabilization. Therefore, it is now accepted that surgical intervention should be undertaken as soon as possible after injury, when the nutritional status is optimal and the probability of colo- nization by drug-resistant nosoco- mial organisms is lowest. The Role of Reaming of Femoral Fractures Although the benefits of early long-bone fracture stabilization are now well recognized, some clini- cians have voiced concerns about the potentially harmful effects of intramedullary reaming of femoral fractures in the multiply injured patient. Intramedullary reaming has been shown to result in embo- lization of fat and marrow contents, but the clinical significance of this with respect to pulmonary function in the polytraumatized patient remains controversial. Pape et al 14 retrospectively stud- ied the relationship between reamed intramedullary nailing of femoral shaft fractures and posttraumatic pulmonary complications. Their data suggest that patients with asso- ciated pulmonary injury have a higher incidence of posttraumatic adult respiratory distress syndrome (ARDS) when treated with immedi- Clifford H. Turen, MD, et al Vol 7, No 3, May/June 1999 163 ate reamed nailing. To minimize the potential for development of pul- monary complications, Pape et al 15 recommend nonreamed intramedul- lary nailing for the treatment of femoral shaft fractures in the multi- ply injured patient. Other researchers have found the harmful effects of reaming to be negligible in both animal models and retrospective clinical studies. Duwelius et al 16 utilized a sheep model without thoracic trauma and found that reaming produced only a modest and transient effect on pul- monary vascular resistance. Simi- larly, in a sheep model with coexis- tent thoracic trauma, Neudeck et al 17 found no difference in pulmonary hemodynamics between treatment of femoral shaft fractures with reamed nails, nonreamed nails, or plate fixation. Recently, Bosse et al 18 reviewed the data on two groups of multiply injured patients with femoral shaft fractures and pul- monary injuries who had been treat- ed at two different trauma centers with either plate fixation or reamed intramedullary nailing. They found no difference in the incidence of pul- monary complications in the two groups of patients, suggesting that reamed nailing does not potentiate the development of ARDS. Pulmonary Complications After Trauma Although fat embolism syn- drome may be a component of ARDS, the latter may occur in the absence of fat embolism syndrome, as occurs with pulmonary contu- sion. Therefore, these two concepts will be discussed separately. Fat Embolism Syndrome After musculoskeletal trauma, marrow fat from the fracture site or sites can embolize and become con- centrated in the pulmonary vascu- lar bed. This embolization activates a complex series of interactions, including the coagulation cascade, increased platelet function, and release of vasoactive substances. Clinically, fat embolism syndrome is characterized by acute hypox- emia, mental status alteration, and interstitial infiltration evidenced on chest radiographs. In patients with isolated long-bone fractures, the incidence is 0.5% to 2.0%; that in multiply injured patients with pelvic and/or lower-extremity frac- tures approaches 10% to 15%. 19 Studies have demonstrated that early fracture stabilization results in a decreased incidence of fat embolism syndrome. Riska and Myllynen 19 compared two groups of multiply injured patients and found that the incidence of fat embolism syndrome was 1.4% in those treated with early fracture stabilization and 22% in those treat- ed without it. Similarly, in a pro- spective randomized series of early versus delayed stabilization of femoral shaft fractures, Bone et al 10 found no cases of fat embolism syndrome in the early-stabilization group. Adult Respiratory Distress Syndrome Adult respiratory distress syn- drome, a particularly devastating complication of trauma, is charac- terized by refractory hypoxemia and diffuse infiltrative changes on the chest radiograph. Prolonged intubation and mechanical ventila- tion are usually necessary, with the attendant risks to the patient. The condition is known to be associated with late septic complications, multi- system organ failure, 12,20 and high mortality rates. 20 A growing body of evidence has shown that early fracture stabiliza- tion can substantially decrease the incidence of ARDS. 10,12,13 In a large retrospective review, Johnson et al 12 found that delaying fracture stabilization for more than 24 hours was associated with a fivefold in- crease in the incidence of ARDS, particularly in more severely in- jured patients. When such patients were treated with delayed stabi- lization, the incidence of ARDS was 75%; when managed with early sta- bilization, it was 17%. Thromboembolic Complications Thromboembolic complications (deep venous thrombosis and pul- monary embolism) can adversely affect patient outcome and have been reported to occur more fre- quently in multiply injured patients than in patients with isolated in- juries. 10 Early fracture stabilization facilitates early patient mobilization and may decrease the incidence of thromboembolic complications. In a prospective study, Bone et al 10 found only one thromboembolic complica- tion in a group of 178 multiply injured patients managed with early stabilization. Mechanical devices, such as the sequential compression device, and chemical agents, such as low- molecular-weight heparin, are indicated for prophylaxis of deep venous thrombosis. The use of anticoagulants may be contraindi- cated in multiply injured patients. Patients with documented deep venous thrombosis and those undergoing pelvic surgery may benefit from placement of a vena cava filter. However, the use of a vena cava filter is not without potential complications, such as severe lower extremity edema. Secondary Period (Hours 13 to 72) At the conclusion of the primary period, a plan for fixation of the remaining fractures must be for- mulated, taking into consideration the patientÕs overall status and always subject to alteration because of changes in that status. It is essential that this plan be commu- nicated to the other members of the treatment team. [...]... fracture does not necessarily decompress the limb compartments Soft-tissue injury, increased membrane permeability, infusion of large volumes of crystalloid isotonic solutions, and the presence of hypotension potentiate the risk of compartment syndrome Pain out of proportion to the apparent injury, pain with passive stretching of a compartment, compartment rigidity on palpation, and increased two-point . resistance), hypothermia, myocardial infarc- tion, and mediastinal shock (aortic transection, pericardial tamponade, cardiac rupture). Hemorrhage is the most frequent cause of hypoten- sion, accounting. patients. If bleeding has been excluded as the cause of hypotension, other causes should be sought. Signs indicating other causes of hypothermia include decreasing blood pressure with a decreasing. victim with hypotension secondary to pelvic disruption. The fixator can be applied in the emergency room, but it is most often applied in the operating room if a patient remains hypotensive after