Trauma*
section 1 Care of the Multiply Injured Patient
A Primary assessment—Assessment begins with the primary survey, which seeks to identify any life-threatening injuries. A rapid assessment of airway, breathing, and circulation (the ABCs) is performed.
1. The airway is often managed by intubation, especially in patients experiencing a great deal of pain or obtundation. The initial survey should include placement of intravenous lines and treatment of any life-threatening injuries that are encountered.
1. Aggressive fluid resuscitation should begin immediately in most cases with the placement of two large-bore intravenous cannulas.
2. Two liters of lactated Ringer solution or normal saline should be administered.
3. If the patient remains hemodynamically unstable after initial crystalloid infusion, begin infusion of blood products.
If a patient does not respond to 2 L of crystalloid, 2 units of packed red blood cells should be administered.
Patients become coagulopathic and, thus, require both fresh frozen plasma and platelets.
Increased citrate from packed red blood cells binds calcium directly and can cause hypocalcemia.
6. Hemodynamic instability may result from internal injury or fractures and is the most important consideration for the orthopaedic surgeon.
Once the airway and breathing are controlled, problems with circulation remain the biggest threat to life.
7. The end points of adequate resuscitation are not clear; use of hemodynamic parameters is inadequate.
Base deficit, as measured by lactate level, is a proxy for the amount of anaerobic metabolism by the body.
Lactate levels are frequently used in trauma to guide the adequacy of resuscitation.
Table 11-1
Classification and Treatment of Hemorrhagic Shock
From Browner BD, on behalf of the American College of Surgeons Committee on Trauma: Advanced trauma life support: skeletal trauma: basic science, management, and reconstruction, ed 8, Chicago, 2008, American College of Surgeons.
Due to a loss of sympathetic tone in setting of a spinal cord injury
Presents as low heart rate, low blood pressure, and warm skin
9. The systemic inflammatory response syndrome (SIRS) is a generalized response to trauma characterized by an increase in cytokines, complement, and many hormones. These changes are seen in varying degrees after trauma, and there is probably a genetic predisposition to an intense form of these changes. Patients are considered to have SIRS if they have two or more of the following criteria:
Heart rate greater than 90 beats per minute
White blood cell count (WBC) less than 4/mm3 or greater than 10/mm3
Respiration greater than 20 breaths per minute, with Paco2 less than 32 mm
10. SIRS is associated with disseminated intravascular coagulopathy, acute respiratory distress syndrome (ARDS), renal failure, shock, and multisystem organ failure.
1. A rapid radiologic workup that includes at a minimum anteroposterior (AP) chest, AP pelvis, and lateral cervical spine views is standard.
2. Availability and increased processing speed of computed tomographic (CT) scanners is leading to CT of cervical spine replacing lateral cervical spine radiography for trauma evaluation.
3. Care should be taken not to focus on obvious radiographic findings, such as an open-book pelvic injury, and miss other important findings, such as a widened mediastinum.
4. Pelvic fractures can be life threatening. The orthopaedic surgeon may be called on to stabilize pelvic fractures in the emergency department and should be prepared to place a pelvic binder or sheet.
5. Pelvic bleeding that does not respond rapidly to pelvic compression with a sheet or binder should be evaluated by angiography and embolization, if indicated.
D Trauma scoring systems—Numerous scoring systems seek to quantify the injury that a patient sustained (Tables 11-2 through 11-4). Although some may yield prognostic value, none is perfect. Therefore, a thorough workup is needed to identify all injuries and prioritize their management. Although it may be desirable to repair all fractures on the day of admission, it may be inherently dangerous to do so because of hemodynamic instability and the added trauma that surgery creates.
Table 11-2
| Response to Assessment | Score |
| Best Motor Response | |
| Obeys commands | 6 |
| Localizes pain | 5 |
| Normal withdrawal (flexion) | 4 |
| Abnormal withdrawal (flexion)—decorticate | 3 |
| Extension—decerebrate | 2 |
| None (flaccid) | 1 |
| Verbal Response | |
| Oriented | 5 |
| Confused conversation | 4 |
| Inappropriate words | 3 |
| Incomprehensible sounds | 2 |
| None | 1 |
| Eye Opening | |
| Spontaneous | 4 |
| To speech | 3 |
| To pain | 2 |
| None | 1 |
Table 11-3
| Examples of Abbreviated Injury Score | Score |
| Head | |
| Crush of head or brain | 6 |
| Brainstem contusion | 5 |
| Epidural hematoma (small) | 4 |
| Face | |
| Optic nerve laceration | 2 |
| External carotid laceration (major) | 3 |
| Le Fort III fracture | 3 |
| Neck | |
| Crushed larynx | 5 |
| Pharynx hematoma | 3 |
| Thyroid gland contusion | 1 |
| 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 |
| Abdominal and Pelvic Contents | |
| Bladder perforation | 4 |
| Colon transaction | 4 |
| Liver laceration with >20% blood loss | 3 |
| Retroperitoneal hematoma | 3 |
| Splenic laceration—major | 4 |
| Spine | |
| Incomplete brachial plexus | 2 |
| Complete spinal cord, C4 or below | 5 |
| Herniated disc 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° to 30° C | 3 |
| Electrical injury with myonecrosis | 3 |
| Second- to third-degree burns—20%-29% of body surface area | 3 |
From Browner BD, et al, editors: Skeletal trauma, ed 3, Philadelphia, 2003, WB Saunders, p 135.
Table 11-4
Variables for the Mangled Extremity Severity Score
| Component | Points |
| Skeletal and Soft Tissue Injury | |
| Low energy (stab, simple fracture, “civilian” gunshot wound) | 1 |
| Medium energy (open or multiplex fractures, dislocation) | 2 |
| High energy (close-range shotgun or “military” gunshot wound, crush injury) | 3 |
| Very high energy (same as above, plus gross contamination, soft tissue avulsion) | 4 |
| Limb Ischemia (score is doubled for ischemia >6 hr) | |
| Pulse reduced or absent but perfusion normal | 1 |
| Pulseless, paresthesias, diminished capillary refill | 2 |
| Cool, paralyzed, insensate (numb) | 3 |
| Shock | |
| Systolic blood pressure always >90 mm Hg | 0 |
| Transient hypotension | 1 |
| Persistent hypotension | 2 |
| Age (yr) | |
| <30 | 0 |
| 30-50 | 1 |
| >50 | 2 |
From Johansen K, et al: Objective criteria accurately predict amputation following lower extremity trauma, J Trauma 30:568, 1990.
E Damage-control orthopaedics—Principles of damage control have been applied to orthopaedic surgery and are now widely accepted. Damage-control orthopaedics involves staging the definitive care of the patient to avoid adding to the overall trauma that the patient has undergone.
1. Trauma is associated with a surge in inflammatory mediators, which peak 2 to 5 days after trauma.
2. After the initial burst of cytokines and other mediators, leukocytes are “primed” and can be activated easily with further trauma, such as surgery. This may lead to multisystem organ failure or ARDS.
3. To minimize the additional trauma that is added with surgery, traumatologists will often treat only potentially life-threatening injuries during this acute inflammatory window.
4. In the severely injured polytrauma patient or one with significant chest trauma, only emergent and urgent conditions should be treated.
Compartment syndrome, fractures associated with vascular injury, unreduced dislocations, long bone fractures, open fractures, or unstable spine fractures should be stabilized acutely.
5. Acute stabilization is achieved primarily via external fixation.
Femur fractures may be converted from an external fixator to an intramedullary (IM) nail within 3 weeks.
6. The definitive treatment of pelvic and acetabular fractures is usually delayed for 7 to 10 days in polytrauma patients to allow consolidation of the pelvic hematoma and resolution of the acute inflammatory response.
II CARE OF INJURIES TO SPECIFIC TISSUES
1. Vascular injury—may be due to penetrating or blunt trauma
Diagnosis—The orthopaedic surgeon should recognize the injury and refer the patient to a vascular surgery specialist or a microsurgeon, as indicated.
Vascular injury can be present when pulses are palpable, and a change in pulse or a difference from the contralateral side may be the only harbinger of a serious vascular injury.
If pulses are not equal to the uninjured side, a workup is indicated.
Treatment—Reduction of fractures will often restore vascularity in the case of long bone fractures.
Diagnosis—One of the most frequently missed complications of trauma, this results when intracompartmental pressure exceeds capillary pressure, thus preventing exchange of waste and nutrients across vessel walls.
Unless it is treated within 4 to 6 hours, permanent injury will ensue. The diagnosis is clinical or made using a pressure monitor.
Treatment—Treatment is emergent decompression via fasciotomy.
Sequelae—Sequelae are common and include claw toes and contractures in the hand.
Tend to occur in certain regions of the United States. Envenomation occurs in only 25% of cases. Venom may be neurotoxic (coral snakes) or hemotoxic (rattlesnake, cottonmouth).
6. Electrical injury—may cause bone necrosis and massive soft tissue necrosis. The extent of tissue injury may not be apparent for days after injury because the skin may not be broken despite significant injury underneath.
Treatment is similar to that of burns; débridement followed by reconstruction with amputation, a flap, or a skin graft is required.
7. Chemical burns—The first rule is to avoid contamination from other people and further damage to the victim.
Dilution with copious irrigation is the initial treatment. After initial irrigation, the degree of necrosis is assessed, with débridement of necrotic tissue. Hydrofluoric acid is extremely toxic, causing profound hypocalcemia and cardiac death with little exposure; calcium gluconate may be used to treat skin exposure.
8. High-pressure injury (water, paint, grease)—Hand injuries are the most common. There may be extensive damage to underlying soft tissues despite a small entrance wound. Wide débridement of necrotic tissue and foreign material is required.
B Joint injuries—Joint injuries may be caused by penetrating or blunt trauma.
1. Dislocations—These orthopaedic emergencies should be reduced as soon as possible to avoid injury to the nerve and vessels and the articular cartilage; general anesthesia may be needed. Neurovascular status should be assessed and documented both before and after reduction.
Antibiotics—Penetrating trauma such as gunshot wounds may be treated with oral antibiotics if there is no debris in the joint; however, foreign matter is often carried into the joint as it is penetrated, even in “clean” gunshot wounds.
3. Fractures involving the joints—must be reduced as anatomically as possible to reduce unequal wear
Classification—The Gustillo and Anderson grading system is widely used (Table 11-5). There is considerable interobserver variability, and the type may change with time.
Table 11-5
Classification of Open Fractures
| Fracture Type | Description |
| I | Skin opening of ≤1 cm, quite clean; most likely from inside to outside; minimum muscle contusion; simple transverse or short oblique fractures |
| II | Laceration >1 cm long, with extensive soft tissue damage, flaps, or avulsion; minimum to moderate crushing component; simple transverse or short oblique fractures with minimum comminution |
| III | Extensive soft tissue damage, including muscles, skin, and neurovascular structures; often a high-velocity injury with severe crushing component |
| IIIA | Extensive soft tissue laceration, adequate bone coverage; segmental fractures, gunshot injuries |
| IIIB | Extensive soft tissue injury, with periosteal stripping and bone exposure; usually associated with massive contamination; requires soft tissue coverage |
| IIIC | Vascular injury requiring repair |
From Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures, J Trauma 24:742, 1984.
Type I—no periosteal stripping, minimum soft tissue damage, small skin wound (1 cm)
Type II—little periosteal stripping, moderate muscle damage, skin wound (1-10 cm)
Type IIIB—same as IIIA but will require flap coverage
Type IIIC—same as IIIA but with vascular injury that requires repair
Débridement—Initial treatment should consist of local wound débridement that is adequate to clean the wound and débridement of all necrotic tissue.
Types I and II—first-generation cephalosporin (cefazolin) for 24 hours
Type III—cephalosporin and aminoglycoside for 72 hours after last incision and drainage
Heavily contaminated wounds and farm wounds—cephalosporin, aminoglycosides, and high-dose penicillin
Salt water wounds—doxycycline and ceftazidime or a fluoroquinolone
Stabilization of bony injuries—will decrease further damage to soft tissue
Early coverage (<5 days is the goal). However, zone of injury must be well defined before coverage.
2. Stabilization with external fixation
Immediate treatment—Most fractures should be reduced and splinted promptly to avoid further soft tissue damage. External fixation may be used to treat grossly contaminated wounds and fractures that will require time for the soft tissues to heal before definitive fixation.
3. Perioperative complications
Thromboembolic disease—The incidence is very high in pelvic, spine, hip, and lower extremity fractures. Pulmonary embolus develops in as many as 5% of those who have deep venous thrombosis (DVT).
Delayed union—defined as no progression of healing over serial radiographs. Treatment may include bone grafting and external bone stimulation.
Biologic treatments—many new treatments, but scanty literature to support any one over the others
Identify infection and treat appropriately.
Bone stimulator—no strong evidence for effectiveness of one method over the other
Diagnosis—common in head-injured patients and in hip, elbow, and shoulder fractures. Any fracture associated with extensive muscle damage is at risk.
Fractures caused by gunshot wounds
High-energy gunshot and shotgun wounds—These are considered grade III open fractures because they are often associated with considerable soft tissue injury (Table 11-6). They require extensive surgical débridement of necrotic tissue and require surgical stabilization of the fracture.
Table 11-6
Classification of Closed Fractures with Soft Tissue Damage
| Fracture Type | Description |
| 0 | Minimum soft tissue damage; indirect violence; simple fracture patterns Example: torsion fracture of the tibia in skiers |
| I | Superficial abrasion or contusion caused by pressure from within; mild to moderately severe fracture configuration Example: pronation fracture-dislocation of the ankle joint with soft tissue lesion over the medial malleolus |
| II | Deep, contaminated abrasion associated with localized skin or muscle contusion; impending compartment syndrome; severe fracture configuration Example: segmental “bumper” fracture of the tibia |
| III | Extensive skin contusion or crush injury; underlying muscle damage may be severe; subcutaneous avulsion; decompensated compartment syndrome; associated major vascular injury; severe or comminuted fracture configuration |
From Tscherne H, Oestern HJ: Die Klassifizierung des Weichteilschadens bei offenen und geschlossenen Frakturen, Unfallheilkunde 85:111-115, 1982. © Springer-Verlag.
III BIOMECHANICS OF FRACTURE HEALING
Also see Chapter 1, Biomechanics
A Stability and fracture healing
1. Micromotion at fracture site under physiologic load leads to callus formation.
2. Strain decreases as callus matures, leading to increased stability.
3. If there is too much motion, callus becomes hypertrophic as it tries to spread out force and hypertrophic nonunion can result.
4. Examples: casts, external fixators, IM nails, bridge plates
1. No motion at fracture site under physiologic load
2. Bone heals through direct healing (no callus).
2. Healing times are longer and more difficult to confirm on by radiography.
5. Implants must have longer fatigue life.
6. Examples: lag screws, compression plating, rigid locked plating (in nonbridging mode)
Also see Chapter 1, Biomechanics
1. Provide rigid interfragmentary compression (absolute stability)
2. Force is concentrated over a small area (around the screw) so typically a plate is needed to protect/neutralize the deforming forces.
1. Compress plate to bone but will not provide interfragmentary compression
2. Friction between screw, plate, and bone resists pullout or bending.
1. Plate length matters more for bending stability than number of screws in plate.
2. Torsional stability is more affected by position of screws (need end hole filled).
3. Longer plates spread the strain over more area (working length).
4. Plates are load bearing—will stress shield area covered by plate; important to protect area temporarily if plate removed after healing
1. Plate design (oval holes) or use of compression device allows plate to apply compressive forces across fracture.
2. Provides absolute stability when properly applied
3. Relies on friction between plate and bone (needs at least some nonlocking screws)
4. May need pre-bend to eliminate gapping opposite plate
5. Insertion order is neutral position, then compression on opposite side of fracture, then lag screw (if placing through plate).
6. Tight contact of plate to bone when initially applied causes decreased periosteal blood flow and temporary osteopenia.
1. Primarily for comminuted fracture patterns
2. Plate “bridges” area of comminution with fixation above and below fracture.
3. Allows some elastic deformation (relative stability)
4. Avoid use of screws too close to fracture.
5. Number and types of screws to insert are fracture dependent—no clear, widely accepted guidelines.
6. Nonlocking screws compress plate to bone and can be used to lag in fragments; locking screws provide angular stability in short metaphyseal segments or in osteoporotic bone.
1. Provides support at 90-degree angle to fracture—typically in depressed metaphyseal/articular fractures that have been reduced
G Submuscular/percutaneous plating
