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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 pla

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 With Musculoskeletal Injuries

Clifford H Turen, MD, Michael A Dube, MD, and C Michael LeCroy, MD

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

protocols1has 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-col1(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)

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, nasotraorotra-cheal, 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

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 neac-cessary Once acac-cess 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/mm3)

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

Motor response

Purposeful movements in

Withdrawal in response

Flexion in response to pain 3

Extension in response to pain 2

Verbal response

* 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.)

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 al3,4more 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 comprescompres-sion (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

ture is the typical ÒrolloverÓ

frac-ture, in which one hemipelvis 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,5the 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 (2/3πr3) 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

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.

APC-III

VS

APC-II

LC-III

LC-II

releasing the reduction (Fig 2, B).

In patients with concurrent

intra-peritoneal and extraintra-peritoneal

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-dislocadisloca-tions

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.)

C

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*

Head

Face External carotid laceration (major) 3 (severe, not life-threatening)

Neck

Thorax

Abdomen and pelvic contents

Spine

Complete spinal cord injury at C4 or below 5

Upper extremity

Lower extremity Amputation

External

Second- or third-degree burns over

* 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 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 exterinter-nal 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 al10 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 al14retrospectively 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-ate reamed nailing To minimize the

potential for development of

pul-monary complications, Pape et al15

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 al16 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 al17

found no difference in pulmonary

hemodynamics between treatment

of femoral shaft fractures with

reamed nails, nonreamed nails, or

plate fixation Recently, Bosse et al18

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 Myllynen19compared 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 al10 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

al12found 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 al10found 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