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Fracture Management

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Textbook of Polytrauma Management

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Abstract

Musculoskeletal injuries are common in polytraumatized patients. Over the last decades, the treatment strategies and management of fractures in critically injured have changed. The indication for early definitive treatment includes the assessment on the dynamic response to resuscitation and evaluation of the “Four Vicious Cycles” (hemorrhagic shock, hypothermia, coagulopathy, and soft tissues). Along with the goal of stabilizing major fractures as early as physiologically safe, “Safe Definitive Surgery” (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (Early Total Care (ETC) and Damage Control Orthopedics (DCO)). This concept does not rule out the use of ETC or DCO, but rather put it in perspective of the clinical situation considering the dynamics of the clinical course. Due to repeated reevaluation and assessment of the patients regarding their physiology, dynamic classification, and adaptation of the treatment strategy is possible. The following chapter elucidates the stages of treatment in polytrauma, management strategies in musculoskeletal injuries, and relevant assessment of soft tissues/concomitant injuries.

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References

  1. Pape HC, Tornetta P 3rd, 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(9):541–9.

    Article  PubMed  Google Scholar 

  2. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71(3):336–40.

    Article  CAS  PubMed  Google Scholar 

  3. Pape HC, Remmers D, Grotz M, Kotzerke J, von Glinski S, van Griensven M, et al. Reticuloendothelial system activity and organ failure in patients with multiple injuries. Arch Surg. 1999;134(4):421–7.

    Article  CAS  PubMed  Google Scholar 

  4. 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(8):551–62.

    Article  PubMed  Google Scholar 

  5. Xiao W, Mindrinos MN, Seok J, Cuschieri J, Cuenca AG, Gao H, et al. A genomic storm in critically injured humans. J Exp Med. 2011;208(13):2581–90.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Reinert M, Hoelper B, Doppenberg E, Zauner A, Bullock R. Substrate delivery and ionic balance disturbance after severe human head injury. Acta Neurochir Suppl. 2000;76:439–44.

    CAS  PubMed  Google Scholar 

  7. Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34(2):216–22.

    Article  CAS  PubMed  Google Scholar 

  8. Stellin G. Survival in trauma victims with pulmonary contusion. Am Surg. 1991;57(12):780–4.

    CAS  PubMed  Google Scholar 

  9. Regel G, Dwenger A, Seidel J, Nerlich ML, Sturm JA, Tscherne H. Significance of neutrophilic granulocytes in the development of post-traumatic lung failure. Unfallchirurg. 1987;90(3):99–106.

    CAS  PubMed  Google Scholar 

  10. Tate RM, Repine JE. Neutrophils and the adult respiratory distress syndrome. Am Rev Respir Dis. 1983;128(3):552–9.

    Article  CAS  PubMed  Google Scholar 

  11. 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. 1984;24(8):742–6.

    Article  CAS  PubMed  Google Scholar 

  12. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990;30(5):568–72. discussion 72–3

    Article  CAS  PubMed  Google Scholar 

  13. Rajasekaran S, Sabapathy SR, Dheenadhayalan J, Sundararajan SR, Venkatramani H, Devendra A, et al. Ganga hospital open injury score in management of open injuries. Eur J Trauma Emerg Surg. 2015;41(1):3–15.

    Article  CAS  PubMed  Google Scholar 

  14. Venkatramani H, Sabapathy SR, Dheenadayalan J, Devendra A, Rajasekaran S. Reconstruction of post-traumatic long segment bone defects of the lower end of the femur by free vascularized fibula combined with allograft (modified Capanna's technique). Eur J Trauma Emerg Surg. 2015;41(1):17–24.

    Article  CAS  PubMed  Google Scholar 

  15. Meara JG, Guo L, Smith JD, Pribaz JJ, Breuing KH, Orgill DP. Vacuum-assisted closure in the treatment of degloving injuries. Ann Plast Surg. 1999;42(6):589–94.

    Article  CAS  PubMed  Google Scholar 

  16. Mullner T, Mrkonjic L, Kwasny O, Vecsei V. The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique. Br J Plast Surg. 1997;50(3):194–9.

    Article  CAS  PubMed  Google Scholar 

  17. Banwell P, Withey S, Holten I. The use of negative pressure to promote healing. Br J Plast Surg. 1998;51(1):79.

    Article  CAS  PubMed  Google Scholar 

  18. Fleischmann W, Lang E, Russ M. Treatment of infection by vacuum sealing. Unfallchirurg. 1997;100(4):301–4.

    Article  CAS  PubMed  Google Scholar 

  19. Pfeifer R, Kalbas Y, Coimbra R, Leenen L, Komadina R, Hildebrand F, et al. Indications and interventions of damage control orthopedic surgeries: an expert opinion survey. Eur J Trauma Emerg Surg. 2020;

    Google Scholar 

  20. Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6):781–8.

    Article  CAS  PubMed  Google Scholar 

  21. Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, et al. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma. 2002;53(3):452–61. discussion 61-2

    Article  PubMed  Google Scholar 

  22. Probst C, Probst T, Gaensslen A, Krettek C, Pape HC. Timing and duration of the initial pelvic stabilization after multiple trauma in patients from the German trauma registry: is there an influence on outcome? J Trauma. 2007;62(2):370–7. discussion 6-7

    PubMed  Google Scholar 

  23. Tjardes T, Paffrath T, Baethis H, Shafizadeh S, Steinhausen E, Steinbuechel T, et al. Computer assisted percutaneous placement of augmented iliosacral screws: a reasonable alternative to sacroplasty. Spine. 2008;33(13):1497–500.

    Article  PubMed  Google Scholar 

  24. Bono CM. The halo fixator. J Am Acad Orthop Surg. 2007;15(12):728–37.

    Article  PubMed  Google Scholar 

  25. Giorgi H, Blondel B, Adetchessi T, Dufour H, Tropiano P, Fuentes S. Early percutaneous fixation of spinal thoracolumbar fractures in polytrauma patients. Orthop Traumatol Surg Res. 2014;100(5):449–54.

    Article  CAS  PubMed  Google Scholar 

  26. Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Stahel PF, Mauffrey C, Smith WR, McKean J, Hao J, Burlew CC, et al. External fixation for acute pelvic ring injuries: decision making and technical options. J Trauma Acute Care Surg. 2013;75(5):882–7.

    Article  PubMed  Google Scholar 

  28. Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients—an update on principles, parameters and strategies for 2020. Injury. 2019;50(10):1656–70.

    Article  PubMed  Google Scholar 

  29. Dezman ZD, Comer AC, Smith GS, Narayan M, Scalea TM, Hirshon JM. Failure to clear elevated lactate predicts 24-hour mortality in trauma patients. J Trauma Acute Care Surg. 2015;79(4):580–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Hatton GE, McNutt MK, Cotton BA, Hudson JA, Wade CE, Kao LS. Age-dependent association of occult hypoperfusion and outcomes in trauma. J Am Coll Surg. 2020;230(4):417–25.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Kobbe P, Lichte P, Wellmann M, Hildebrand F, Nast-Kolb D, Waydhas C, et al. Impact of hypothermia on the severely injured patient. Unfallchirurg. 2009;112(12):1055–61.

    Article  CAS  PubMed  Google Scholar 

  32. Nuytinck JK, Goris JA, Redl H, Schlag G, van Munster PJ. Posttraumatic complications and inflammatory mediators. Arch Surg. 1986;121(8):886–90.

    Article  CAS  PubMed  Google Scholar 

  33. Keel M, Trentz O. Pathophysiology of polytrauma. Injury. 2005;36(6):691–709.

    Article  PubMed  Google Scholar 

  34. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care (London, England). 2019;23(1):98.

    Article  Google Scholar 

  35. Kutcher ME, Howard BM, Sperry JL, Hubbard AE, Decker AL, Cuschieri J, et al. Evolving beyond the vicious triad: differential mediation of traumatic coagulopathy by injury, shock, and resuscitation. J Trauma Acute Care Surg. 2015;78(3):516–23.

    Article  CAS  PubMed  Google Scholar 

  36. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for use of damage control surgery and damage control interventions in civilian trauma patients: a scoping review. J Trauma Acute Care Surg. 2015;78(6):1187–96.

    Article  PubMed  Google Scholar 

  37. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for use of damage control surgery in civilian trauma patients: a content analysis and expert appropriateness rating study. Ann Surg. 2016;263(5):1018–27.

    Article  PubMed  Google Scholar 

  38. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: a content analysis and expert appropriateness rating study. J Trauma Acute Care Surg. 2015;79(4):568–79.

    Article  PubMed  Google Scholar 

  39. Pape HC, Schmidt RE, Rice J, van Griensven M, das Gupta R, Krettek C, et al. Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden. Crit Care Med. 2000;28(10):3441–8.

    Article  CAS  PubMed  Google Scholar 

  40. Schemitsch EH, Jain R, Turchin DC, Mullen JB, Byrick RJ, Anderson GI, et al. Pulmonary effects of fixation of a fracture with a plate compared with intramedullary nailing. A canine model of fat embolism and fracture fixation. J Bone Joint Surg Am. 1997;79(7):984–96.

    Article  CAS  PubMed  Google Scholar 

  41. Duwelius PJ, Huckfeldt R, Mullins RJ, Shiota T, Woll TS, Lindsey KH, et al. The effects of femoral intramedullary reaming on pulmonary function in a sheep lung model. J Bone Joint Surg Am. 1997;79(2):194–202.

    Article  CAS  PubMed  Google Scholar 

  42. Olson SA, Burgess A. Classification and initial management of patients with unstable pelvic ring injuries. Instr Course Lect. 2005;54:383–93.

    PubMed  Google Scholar 

  43. Bottlang M, Simpson T, Sigg J, Krieg JC, Madey SM, Long WB. Noninvasive reduction of open-book pelvic fractures by circumferential compression. J Orthop Trauma. 2002;16(6):367–73.

    Article  PubMed  Google Scholar 

  44. Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma. 2006;20(Suppl. 1):S3–6.

    Article  PubMed  Google Scholar 

  45. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007;62(4):834–9. discussion 9–42

    PubMed  Google Scholar 

  46. Salcedo ES, Brown IE, Corwin MT, Galante JM. Pelvic angioembolization in trauma—indications and outcomes. Int J Surg. 2016;33(Pt B):231–6.

    Article  PubMed  Google Scholar 

  47. Salcedo ES, Brown IE, Corwin MT, Galante JM. Angioembolization for solid organ injury: a brief review. Int J Surg. 2016;33(Pt B):225–30.

    Article  PubMed  Google Scholar 

  48. Kobbe P, Lichte P, Pape HC. Complex extremity fractures following high energy injuries: the limited value of existing classifications and a proposal for a treatment-guide. Injury. 2009;40(Suppl. 4):S69–74.

    Article  PubMed  Google Scholar 

  49. Pape HC, Pfeifer R. Safe definitive orthopaedic surgery (SDS): repeated assessment for tapered application of early definitive care and damage control? An inclusive view of recent advances in polytrauma management. Injury. 2015;46(1):1–3.

    Article  CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Trauma, University Hospital Zurich, Zurich, Switzerland

    Roman Pfeifer & Hans-Christoph Pape

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  1. Roman Pfeifer
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  2. Hans-Christoph Pape
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Correspondence to Roman Pfeifer .

Editor information

Editors and Affiliations

  1. Department of Trauma Surgery, University Hospital Zürich, Zürich, Switzerland

    Hans-Christoph Pape

  2. Department of Orthopaedic Surgery & Sports Medicine, The University of South Florida Morsani College of Medicine, Tampa, FL, USA

    Joseph Borrelli Jr.

  3. Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA

    Ernest E. Moore

  4. Klinik für Traumatologie, University Hospital of Zürich, Zürich, Switzerland

    Roman Pfeifer

  5. Rocky Vista University, College of Osteopathic Medicine, Parker, CO, USA

    Philip F. Stahel

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Pfeifer, R., Pape, HC. (2022). Fracture Management. In: Pape, HC., Borrelli Jr., J., Moore, E.E., Pfeifer, R., Stahel, P.F. (eds) Textbook of Polytrauma Management . Springer, Cham. https://doi.org/10.1007/978-3-030-95906-7_27

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  • DOI: https://doi.org/10.1007/978-3-030-95906-7_27

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