Polytrauma Management

Clinical Imaging

Imaging Gallery

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Systematic approach to the multiply injured patient prioritizing life-saving interventions.

Critical warnings regarding the lethal triad and the balance between DCO and ETC.

Damage Control Orthopaedics

Goal: Rapidly stabilize fractures with minimal physiological insult. Buy time for resuscitation.

Techniques:

• External fixator for long bone fractures (femur, tibia)
• Pelvic binder or external fixator for pelvic fractures
• Splinting for other fractures

Benefits: Short surgery, minimal blood loss, avoids second hit.

Conversion: When patient stable (usually 5-10 days), convert external fixator to definitive fixation (IM nail, ORIF).

Early Total Care

Goal: Definitive fixation within 24 hours.

Patient: Stable, no evidence of physiological derangement.

Evidence: Reduces pulmonary complications, DVT, fat embolism in stable patients. Allows early mobilization.

Typical Scenario: Isolated femur fracture in otherwise healthy patient. Antegrade nailing within 24 hours.

Borderline patient is the challenge.

Factors favoring DCO:

• ISS greater than 40
• Hypothermia (less than 35°C)
• Initial systolic BP less than 90mmHg
• Coagulopathy
• Pulmonary injury (pulmonary contusion)
• Massive transfusion (greater than 10 units PRBC)
• Lactate greater than 2.5 mmol/L
• Head injury with intracranial pressure issues

If in doubt: DCO is safer. Can always convert to ETC later.

Injury Severity Scoring Systems

Injury Severity Score (ISS):

• Most widely used trauma scoring system
• Sum of squares of AIS (Abbreviated Injury Scale) for 3 most injured body regions
• Range 1-75 (AIS 6 in any region = ISS 75 automatically)
• ISS greater than 15 = major trauma (polytrauma)
• ISS greater than 25 = severe trauma
• ISS greater than 40 = critical, high mortality

New Injury Severity Score (NISS):

• Sum of squares of 3 highest AIS scores regardless of body region
• May better predict mortality in certain injury patterns
• Particularly useful when multiple injuries in same body region

Patient Physiological Categories:

Advanced Scoring Systems

AIS (Abbreviated Injury Scale):

• 1 = Minor, 2 = Moderate, 3 = Serious
• 4 = Severe, 5 = Critical, 6 = Unsurvivable

Body Regions for ISS:

• Head/Neck, Face, Chest, Abdomen, Extremities, External

Trauma and Injury Severity Score (TRISS):

• Combines anatomic (ISS) and physiologic (RTS) parameters
• Predicts probability of survival
• Used for trauma registry quality assessment

ATLS Primary Survey (ABCDE)

A - Airway with C-spine Protection:

• Chin lift/jaw thrust (avoid head tilt in trauma)
• Clear debris, suction, insert airway adjunct
• Definitive airway if GCS less than 8 or cannot protect airway
• Maintain in-line immobilization during intubation

B - Breathing and Ventilation:

• Expose chest, assess respiratory rate and effort
• Life-threatening chest injuries: tension pneumothorax, open pneumothorax, massive haemothorax, flail chest with pulmonary contusion
• Needle decompression or chest tube as indicated

C - Circulation with Haemorrhage Control:

• Assess pulse, BP, capillary refill, skin color
• IV access (2 large bore), initiate fluid resuscitation
• Apply direct pressure to external bleeding
• Pelvic binder if suspected pelvic ring injury
• Initiate massive transfusion protocol if indicated

D - Disability (Neurological):

• GCS assessment
• Pupillary response
• Gross motor function

E - Exposure with Environmental Control:

• Fully undress patient for complete examination
• Log roll for back and spine examination
• Actively prevent hypothermia (warm blankets, fluid warmers)

The primary survey must be completed and life-threatening injuries addressed before fracture care.

Secondary Survey and Monitoring

Secondary Survey:

• Complete head-to-toe examination once patient stabilized
• AMPLE history: Allergies, Medications, Past history, Last meal, Events
• Detailed neurological examination
• Complete musculoskeletal examination (all joints, spine)

Physiological Monitoring Parameters:

• Base excess: Target greater than -6 mmol/L
• Lactate: Target less than 2.5 mmol/L (tissue perfusion marker)
• Temperature: Prevent less than 35°C
• Coagulation: INR, fibrinogen, platelets
• Urine output: Target greater than 0.5 mL/kg/hr

Initial Trauma Investigations

Laboratory Studies:

• Blood gas: pH, base excess, lactate - assess tissue perfusion
• FBC: Haemoglobin (often normal initially despite blood loss)
• Coagulation: PT/INR, APTT, fibrinogen - guide transfusion
• Cross-match: Urgent type and screen, O-negative if exsanguinating
• TEG/ROTEM: Point-of-care coagulation assessment if available

Imaging - Primary Survey:

• CXR portable: Pneumothorax, haemothorax, widened mediastinum
• Pelvic XR: Pelvic ring disruption
• FAST scan: Free fluid in abdomen/pericardium

CT Imaging (once stable):

• CT Head: Intracranial haemorrhage, midline shift
• CT Chest/Abdomen/Pelvis: Solid organ injury, aortic injury, spine fractures
• Whole-body CT (pan-scan): Standard in major trauma centers for ISS greater than 15

Pan-scan is the gold standard for rapid injury assessment once hemodynamically stabilized.

Advanced Trauma Imaging

Orthopaedic-Specific Imaging:

• Long bone X-rays once patient stabilized
• CT spine (C-spine, thoracolumbar if indicated)
• CT pelvis 3D reconstruction for complex pelvic ring injuries
• CT angiography if vascular injury suspected

Physiological Markers for DCO Decision:

DCO Techniques by Fracture Location

Femoral Shaft:

• Spanning external fixator (hip to knee or knee-sparing)
• Pins: 2 proximal (subtrochanteric), 2 distal (supracondylar)
• Restore length and alignment
• Convert to antegrade IM nail when stable

Tibial Shaft:

• Spanning external fixator or immediate IM nailing (less physiological insult than femur nailing)
• Pins: 2 proximal (metaphyseal), 2 distal (metaphyseal)
• Tibial nailing can often proceed even in borderline patients

Pelvis:

• Pelvic binder first (at greater trochanters, NOT iliac crests)
• C-clamp for posterior ring if hemodynamically unstable
• Anterior external fixator (supra-acetabular pins or iliac crest pins)
• Angiography and embolization if ongoing arterial bleeding

Open Fractures:

• Debridement and washout
• Temporary external fixation
• Delayed soft tissue coverage and conversion to internal fixation

Temporary stabilization is critical in the early phase of open fracture management.

Specific DCO Constructs

Femoral External Fixator Construct:

• 5mm half-pins
• Proximal pins: Anterolateral approach, avoid femoral vessels
• Distal pins: Lateral supracondylar, avoid knee joint
• Frame configuration: Single bar or delta frame for stability
• Key: Restore length and alignment for easier conversion

Pelvic Fixation Options:

Nailing Considerations in Polytrauma:

• Unreamed nailing may reduce pulmonary insult (controversial)
• Femoral nailing causes more fat embolism than tibial nailing
• Vented nailing technique to reduce intramedullary pressure
• Consider damage control nailing (nail without final fixation)

Polytrauma Complications

Early Complications (0-72 hours):

• Haemorrhagic shock: Ongoing blood loss, coagulopathy
• ARDS: Pulmonary contusion, fat embolism, transfusion-related
• Compartment syndrome: High index of suspicion in unconscious patients
• Missed injuries: Up to 10% detected on tertiary survey
• Fat embolism syndrome: Triad of hypoxia, confusion, petechiae

Late Complications (Days to weeks):

• Multi-organ dysfunction syndrome (MODS): Inflammatory cascade
• Sepsis: Nosocomial infection, open fractures
• VTE: High risk in immobile polytrauma patients
• Nonunion/malunion: Inadequate initial stabilization
• Heterotopic ossification: Common in head injury + extremity fracture

Orthopaedic-Specific Complications:

• Pin site infection (5-10% with ex-fix)
• Deep infection after conversion (2-15% depending on pin status)
• Nonunion (higher in delayed treatment)
• Stiffness (prolonged immobilization)

Vigilant monitoring for metabolic and pulmonary complications is essential.

Prevention and Management

ARDS Prevention:

• Early stabilization of long bone fractures (reduces pulmonary emboli)
• Avoid fluid overload
• Lung-protective ventilation
• DCO in high-risk patients avoids second hit

Fat Embolism Syndrome:

• Incidence 1-10% in long bone fractures
• Mechanical theory: fat from medullary canal enters circulation
• Biochemical theory: inflammatory response to circulating fat
• Prevention: Early fracture stabilization, avoid hypoxia
• Treatment: Supportive (oxygen, ventilation), no specific therapy

VTE Prophylaxis:

• Mechanical: SCDs, IPC from admission
• Pharmacological: LMWH when bleeding risk acceptable (usually 24-48 hours post-injury)
• Duration: Until mobile, typically 2-4 weeks
• IVC filter considered if anticoagulation contraindicated

ICU Phase Management

Ongoing Resuscitation:

• Goal-directed therapy: lactate clearance, urine output
• Blood product replacement per MTP
• Temperature management (active warming to greater than 36°C)
• Nutrition: early enteral feeding when possible

Monitoring:

• Serial lactate and base excess
• Daily bloods: FBC, coagulation, renal function
• CRP and inflammatory markers for conversion timing
• Compartment checks in sedated patients

DVT Prophylaxis:

• Mechanical (SCDs/IPC) from admission

• Pharmacological once bleeding risk acceptable

• Enoxaparin 40mg daily or equivalent

• Plan for conversion to definitive fixation

Conversion criteria should be strictly followed to avoid complications.

Conversion Planning and Rehabilitation

Conversion Criteria (Ex-fix to Definitive):

• Hemodynamically stable, off vasopressors
• Lactate less than 2.5 mmol/L
• Temperature greater than 36°C
• No coagulopathy
• CRP decreasing
• No active infection
• Usually day 5-10 post-injury

Early Mobilization:

• Passive ROM when stable
• Chest physiotherapy critical
• Early weight bearing per fracture pattern
• Psychological support (PTSD screening)

Long-term Rehabilitation:

• Multidisciplinary team approach
• Physical therapy program
• Occupational therapy for ADL retraining
• Chronic pain management
• Return to work assessment

Polytrauma Survival Outcomes

Mortality Rates by ISS:

• ISS 16-24: 5-10% mortality
• ISS 25-40: 15-25% mortality
• ISS greater than 40: 30-50% mortality
• ISS 75: Near 100% mortality

Factors Affecting Mortality:

• Age (mortality increases significantly over 65)

• Injury pattern (head + chest worst prognosis)

• Time to definitive care

• Trauma center volume and resources

• Comorbidities

• Inappropriate ETC in unstable patient increases MODS risk

Proper patient selection is the most critical factor in survival outcomes.

Functional Outcomes

Return to Work:

• ISS 16-24: 70-80% return to previous occupation
• ISS 25-40: 50-60% return to work
• ISS greater than 40: Often permanent disability

Quality of Life:

• Physical function most affected
• Psychological sequelae common (PTSD 20-40%)
• Chronic pain in 30-50%
• Cognitive impairment if significant head injury

Orthopaedic-Specific Outcomes:

• Fracture healing: Generally good with appropriate treatment
• Nonunion rate: 5-10% for long bones (higher with open fractures)
• Functional outcomes: Dependent on associated injuries, not just fracture

Key Evidence for Polytrauma Management

Early Total Care (ETC) Evidence:

• Bone et al. (1989): Landmark study showing early femoral stabilization (less than 24h) reduces ARDS, fat embolism, and hospital stay in stable patients
• Multiple subsequent studies confirmed benefit of early long bone fixation in stable patients

Damage Control Orthopaedics (DCO) Evidence:

• Pape et al. (2002): Defined DCO concept - external fixation for unstable patients avoids second hit

• Scalea et al. (2000): Showed DCO reduces pulmonary complications in borderline patients

• Conversion timing: Days 5-10 optimal (Pape et al.)

• CRASH-2 Trial (2010): Tranexamic acid within 3 hours reduces mortality

Evidence-based protocols focus on physiological optimization and balanced resuscitation.

Advanced Evidence and Guidelines

Key Studies:

Current Guidelines:

• ATLS guidelines: Primary and secondary survey principles
• EAST guidelines: Early femur fixation when appropriate
• Orthopaedic Trauma Association: DCO vs ETC decision framework

Controversies:

• Exact thresholds for borderline patient remain debated
• Reamed vs unreamed nailing in polytrauma
• Role of early total care in modern trauma systems

Evidence supports the early administration of TXA in major trauma patients.