Visual Element: A diagram of the "Lethal Triad" (Hypothermia, Acidosis, Coagulopathy) with an added fourth arm for "Soft Tissue Injury," illustrating the "Lethal Diamond" concept.

The Ultimate Test of Surgery

The polytrauma patient is the ultimate test of an orthopaedic surgeon's judgment. Unlike elective surgery, where the primary risk is technical failure, in polytrauma, the risk is death. The decisions you make in the first 6 hours—regarding resuscitation, surgical timing, and stabilization methods—determine whether the patient survives to rehabilitation.

This guide provides a comprehensive framework for managing the polytrauma patient, aligned with the FRACS curriculum and modern trauma principles.

Defining the "Polytrauma" Patient

Not every patient with multiple fractures is a "polytrauma" patient. The term has a specific physiological definition.

• Anatomical Definition: Injury Severity Score (ISS) ≥ 16 (or ≥18 in some papers) with injuries in at least two body regions (e.g., Head + Femur).
• Physiological Definition: A patient with multiple injuries who presents with physiological derangement (Systemic Inflammatory Response Syndrome - SIRS).

Clinical Pearl: A patient with bilateral femur fractures and a stable pelvis is "multiple injuries." A patient with a femur fracture, a lactate of 6, and a base deficit of -8 is "polytrauma." The physiology dictates the management, not the X-ray.

The Primary Survey: Orthopaedic Relevance

While the General Surgeons/ED physicians run the ATLS (EMST) protocol, the orthopod has specific roles in the primary survey.

C - Circulation (The Orthopaedic Haemostasis)

Orthopaedic injuries are major sources of occult blood loss.

• Pelvis: Can hold 4L+ of blood. Management: Binder.
• Femur: 1-1.5L per femur. Management: Traction splint.
• Open Wounds: "Blood on the floor." Management: Direct pressure/Tourniquet.

Massive Transfusion Protocol (MTP) Modern resuscitation has moved away from crystalloids ("salt water") which dilute clotting factors and cause acidosis. The standard is Haemostatic Resuscitation.

• Ratio: 1:1:1 (Packed Red Cells : FFP : Platelets).
• Goal: Mimic whole blood.
• Permissive Hypotension: Aim for SBP ~90mmHg (or palpable radial pulse) until bleeding is controlled. Pushing BP higher just "pops the clot."

Trap: "The patient responded to 2L of saline." This is the "Transient Responder." They have refilled their tank with water, but they are still bleeding red cells. They will crash again.

The "Second Hit" Phenomenon

To understand when to operate, you must understand the immunology of trauma.

1. First Hit (The Injury): The trauma itself releases cytokines (IL-1, IL-6, TNF-alpha) causing a systemic inflammatory response (SIRS). The immune system is primed.
2. The Window: There is a brief period (early) where the patient is resuscitable.
3. Second Hit (The Surgery): Surgery is trauma. Reaming a femoral canal, losing blood, and prolonged anaesthesia acts as a "Second Hit."
4. Result: If the Second Hit is too big (long surgery) on a patient who is already inflamed ("First Hit"), it pushes them into Multi-Organ Failure (MOF) and ARDS.

DCO vs. ETC: The Decision Matrix

The fundamental question is: "Fix it all now (ETC) or temporize (DCO)?"

Early Total Care (ETC)

• Definition: Definitive fixation of all long bone fractures within 24 hours.
• Pros: Early mobilization, better pulmonary toilet, psychological benefit.
• Candidate: Stable hemodynamics (Lactate < 2), no chest injury, no head injury.

Damage Control Orthopaedics (DCO)

• Definition: Rapid, temporary stabilization (Ex-Fix) to control biology, followed by definitive fixation days later when the patient recovers.
• Pros: Minimizes the "Second Hit." Short operative time (<1 hour).
• Candidate: The "Borderline" or "Unstable" patient.

The "Borderline" Patient Parameters

How do you spot the patient who needs DCO? Look for these signs:

• ISS > 40
• Hypothermia < 35°C
• Acidosis (pH < 7.24)
• Coagulopathy (INR > 1.5)
• Lactate > 2.5-4.0 mmol/L (and not clearing)
• Chest Injury: Bilateral lung contusions or PaO2/FiO2 < 200.
• Head Injury: GCS < 8 (Intracranial pressure concerns).

Evidence Corner: The Pape et al. studies defined the "Borderline" patient. They showed that in patients with severe chest trauma, reaming the femur (ETC) significantly increased the rate of ARDS compared to Ex-Fix (DCO).

Timing of Surgery: The Four Phases

If you choose DCO, when do you go back to fix the femur?

1. Acute Phase (Hours 0-24): Life-saving surgery / DCO.
2. Hyper-Inflammatory Phase (Days 2-4): DANGER ZONE. The immune system is peaking. Major surgery here causes MOF. Do not convert Ex-Fix to Nail here.
3. Window of Opportunity (Days 5-10): Inflammation subsides. Edema resolves. This is the time for definitive fixation.
4. Recovery Phase (> weeks): Long term reconstruction.

Specific Injury Management

The Floating Knee

Ipsilateral fracture of the femur and tibia.

• Pathology: High energy. The knee is disconnected from the body.
• Risk: High rate of vascular injury and compartment syndrome.
• Management: Usually IM nail both. Retrograde femur + Antegrade tibia is a common combo.

The "Mangled" Extremity

Severe injury with bone, soft tissue, nerve, and vascular compromise.

• The Decision: Salvage vs. Amputation.
• MESS Score: (Mangled Extremity Severity Score). Useful guide, but not absolute.
  • Age, Shock, Ischaemia, Injury mechanism.
  • Score ≥ 7 historically predicted amputation.
• Modern View: "Function is the goal." A prosthesis is often better than a painful, insensate, stiff salvaged leg. The LEAP Study showed that functional outcomes are similar between salvage and amputation at 2 years, but salvage has more complications and hospital time.

Fat Embolism Syndrome (FES)

A dreaded complication of long bone fractures.

• Pathophysiology: Marrow fat enters the venous system -> lungs -> systemic circulation.
• Gurd's Criteria:
  • Major: Petechial rash (axilla/conjunctiva), Respiratory insufficiency, Cerebral involvement (confusion).
  • Minor: Tachycardia, Pyrexia, Retinal changes, Jaundice, Renal changes.
• Prevention: Early stabilization (fix the fracture!). Reaming vs. unreamed nails has shown mixed evidence, but venting the femur during reaming is wise in high-risk chest patients.

Conclusion

Polytrauma management is a dynamic chess game. The surgeon must constantly reassess the patient's physiology.

• Be aggressive in the primary survey.
• Be conservative in your surgical ambition for the unstable patient.
• Respect the Second Hit.

Your Mantra: "Life before Limb. Limb before Function. Function before Aesthetics."

References

1. Pape HC, et al. "Damage control orthopedics: evolution and practical applications." Tech Orthop. 2013.
2. Bose D, et al. "Extended release of immunostimulatory cytokines... after intramedullary nailing." J Bone Joint Surg Am. 2008.
3. Vallier HA, et al. "Timing of orthopaedic surgery in multiple trauma patients: development of a protocol." J Orthop Trauma. 2009.