Multiply injured patients have to be treated according to an individual therapy regime. This regime has to include the urgent treatment of life-threatening injuries as well as extremity fracture care and reconstruction of soft tissue injuries.
The classification of patients into the four subgroups “stable,” “borderline,” “unstable,” and “in extremis” is helpful for the determination of an adapted treatment strategy. These categories are based on the patient’s physiological status, the ISS, and specific injury combinations.
Fractures of stable patients should be treated by initial definitive osteosynthesis.
The treatment regime of borderline patients should be a staged approach with periodically reassessment of the patient’s physiological state. In case of deterioration, the surgical regime should be changed into a damage control strategy.
In unstable patients damage control procedures are favored to stop the bleeding. Definitive fracture care can be performed after stabilization.
The treatment of patients “in extremis” should be strictly limited to lifesaving procedures.
The difficult decision between amputation and salvage of severely injured extremities should be based on the injury itself but as well on the physical state of the patient. The basic rule “life before limb” should absolutely hold true.
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This is a preview of subscription content, log in to check access.
Bederman SS, Murnaghan O, Malempati H, Lansang E, Wilkinson M, Johnston E, Bronstein Y, Finkelstein JA, Yee AJ. In-hospital mortality and surgical utilization in severely polytraumatized patients with and without spinal injury. J Trauma. 2011;71:E71–8.PubMedCrossRefGoogle Scholar
Trunkey DD. Trimodal distribution of death. Trauma Sci Am. 1983;249(2):20–7.Google Scholar
Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ. Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg. 2010;34:158–63.PubMedCrossRefGoogle Scholar
Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma. 2005;19:551–62.PubMedCrossRefGoogle Scholar
Canadian Orthopaedic Society. Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma. 2006;20:384–7.CrossRefGoogle Scholar
Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, Gruner A, Oestern HJ, Bayeff-Filoff M, Garving C, Pardini D, van Griensven M, Krettek C, Giannoudis P. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246:491–9.PubMedCrossRefGoogle Scholar
Pape HC, Tornetta III P, Tarkin I, Tzioupis C, Sabeson V, Olson SA. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009;17:541–9.PubMedGoogle Scholar
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48:613–21.PubMedCrossRefGoogle Scholar
Morshed S, Miclau III T, Bembom O, Cohen M, Knudson MM, Colford Jr JM. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am. 2009;91:3–13.PubMedCrossRefGoogle Scholar
Lasanianos NG, Kanakaris NK, Dimitriou R, Pape HC, Giannoudis PV. Second hit phenomenon: existing evidence of clinical implications. Injury. 2011;42(7):617–29.PubMedCrossRefGoogle Scholar
Lefaivre KA, Starr AJ, Stahel PF, Elliott AC, Smith WR. Prediction of pulmonary morbidity and mortality in patients with femur fracture. J Trauma. 2010;69:1527–35.PubMedCrossRefGoogle Scholar
Taeger G, Ruchholtz S, Waydhas C, Lewan U, Schmidt B, Nast-Kolb D. Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma. 2005;59:409–16.PubMedCrossRefGoogle Scholar
Kashuk JL, Moore EE, Pinski S, Johnson JL, Moore JB, Morgan S, Cothren CC, Smith W. Lower extremity compartment syndrome in the acute care surgery paradigm: safety lessons learned. Patient Saf Surg. 2009;3(1):11.PubMedCrossRefGoogle Scholar
Nork SE, Agel J, Russell GV, Mills WJ, Holt S, Routt Jr ML. Mortality after reamed intramedullary nailing of bilateral femur fractures. Clin Orthop Relat Res. 2003;272–8.Google Scholar
Copeland CE, Mitchell KA, Brumback RJ, Gens DR, Burgess AR. Mortality in patients with bilateral femoral fractures. J Orthop Trauma. 1998;12:315–9.PubMedCrossRefGoogle Scholar
Fu CY, Hsieh CH, Wu SC, Chen RJ, Wang YC, Shih CH, Huang HC, Huang JC, Tsuo HC, Tung HJ. Anterior-posterior compression pelvic fracture increases the probability of requirement of bilateral embolization. Am J Emerg Med. 2013;31(1):42–9 [Epub ahead of print].PubMedCrossRefGoogle Scholar
Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma. 2001;15(7):468–74.PubMedCrossRefGoogle Scholar
Enninghorst N, Toth L, King KL, McDougall D, Mackenzie S, Balogh ZJ. Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option. J Trauma. 2010;68:935–41.PubMedCrossRefGoogle Scholar
Vallier HA, Cureton BA, Ekstein C, Oldenburg FP, Wilber JH. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. J Trauma. 2010;69:677–84.PubMedCrossRefGoogle Scholar
Shuler TE, Boone DC, Gruen GS, Peitzman AB. Percutaneous iliosacral screw fixation: early treatment for unstable posterior pelvic ring disruptions. J Trauma. 1995;38(3):453–8.PubMedCrossRefGoogle Scholar
Rajasekaran S. Thoracolumbar burst fractures without neurological deficit: the role for conservative treatment. Eur Spine J. 2010;19 Suppl 1:S40–7.PubMedCrossRefGoogle Scholar
Fakler JK, Hogan C, Heyde CE, John T. Current concepts in the treatment of proximal humeral fractures. Orthopedics. 2008;31(1):42–51.PubMedCrossRefGoogle Scholar
Kind GM, Dickinson JA, Buncke GM, Buntic RF, Chin B, Buncke Jr HJ. Salvage of the severely traumatized lower extremity. Surg Technol Int. 1997;6:337–45.PubMedGoogle Scholar
Tintle SM, Keeling JJ, Shawen SB, Forsberg JA, Potter BK. Traumatic and trauma-related amputations: part I: general principles and lower-extremity amputations. J Bone Joint Surg Am. 2010;92(17):2852–68.PubMedCrossRefGoogle Scholar
Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347:1924–31.PubMedCrossRefGoogle Scholar
Pfeifer R, Zelle BA, Kobbe P, Knobe M, Garrison RL, Ohm S, Sittaro NA, Probst C, Pape HC. Impact of isolated acetabular and lower extremity fractures on long-term outcome. J Trauma Acute Care Surg. 2012;72(2):467–72.PubMedGoogle Scholar