Time to think outside the box: 'Prompt-Individualised-Safe Management' (PR.I.S.M.) should prevail in patients with multiple injuries

Fracture fixation in polytraumatized patients-From an interdisciplinary early total/appropriate care to the safe definitive surgery concept

The strategies for the timing of fracture fixation in polytrauma patients have changed with improvements in resuscitation and patient assessment. Specifically, the criteria for damage control have been formulated, and more precise parameters have been found to determine those patients who can safely undergo primary definitive fixation of major fractures. Our current recommendations are supported by objective and data-based criteria and development groups. Those were validated and compared to existing scores. This review article introduces the concept of "safe definitive surgery" and provides an update on the parameters used to clear patients for timely fixation of major fractures.

Simultaneous ipsilateral floating hip and knee: the double floating extremity-a systematic review and proposal of a treatment algorithm

PURPOSE

To systematically review the currently available existing evidence related to the presentation and management of simultaneous floating hip and knee injuries to identify injury characteristics, treatment strategies, and complications.

METHODS

Data sources: Relevant articles were identified by searching Medline, PubMed, and Google Scholar databases with no language restrictions. Manual searches of other relevant databases (SciELO and grey literature databases) and reference lists of primary articles found from initial searches were also conducted.

STUDY SELECTION

All types of study designs published from January 1st, 2000 to October 1st, 2022 involving skeletally mature patients with simultaneous floating hip and knee injuries were included.

DATA EXTRACTION

Basic information and specific injury-related information were collected.

RESULTS

Eight case reports were included. No study adequately reported the case with sufficient detail to allow other investigators to make inferences, nor was the result properly calculated, nor was the follow-up considered adequate for adequate functional assessment to occur in 80% of the studies.

CONCLUSION

The exact treatment strategy and the follow-up time are not uniform across the included studies; therefore, they are not sufficient to adequately recommend surgical approach, timing of fixation, and fixation method. Our findings warrant the need for better documentation and reporting information about the mode of treatment of simultaneous floating hip and knee injuries.

Severe trauma with associated pelvic fractures: The impact of regional trauma networks on clinical outcome

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32  (95% CI 1.21 - 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care.

Temporary bridging trans-hip external fixation in damage control orthopaedics treatment after severe combat trauma: A clinical case series

The role of external fixation in Damage Control Orthopaedics has been well described. Temporary external fixation has been recommended to provide relative bone stability while the soft tissue heals, prior to formal open reduction and internal fixation. Temporary bridging external fixation, that spans the joint, is recommended as primary skeletal stabilization in complex intra-articular and peri-articular fractures, in extensive peri-articular soft-tissue damage around the knee, ankle, elbow and wrist joints. Works devoted to temporary trans-hip external fixation in treatment of complex high-energy injuries are relatively rare. The purpose of this article is to present our experience in using temporary hip spanning external fixation during primary treatment of six patients suffered from complex open intra-articular and peri-articular fractures of the proximal femoral bone with extensive soft tissue damage due to war blast or high-velocity gunshot trauma. Primary management was based on the concept of Advanced Trauma Life Support and Damage Control Orthopaedics. Conversion to definitive bone reconstruction was performed on the next stage of the treatment after general and local stabilization.

Risks in the Management of Polytrauma Patients: Clinical Insights

Polytrauma, a patient's condition with multiple injuries that involve multiple organs or systems, is the leading cause of mortality in young adults. Trauma-related injuries are a major public health concern due to their associated morbidity, high disability, associated death, and socioeconomic consequences. Management of polytrauma patients has evolved over the last few decades due to the development of trauma systems, improved pre-hospital assessment, transport and in-hospital care supported by complementary investigations. Recognising the mortality patterns in trauma has led to significant changes in the approach to managing these patients. A structured approach with application of advanced trauma life support (ATLS) algorithms and optimisation of care based on clinical and physiological parameters has led to the development of early appropriate care (EAC) guidelines to treat these patients, with subsequent improved outcomes in such patients. The journey of a polytrauma patient through the stages of pre-hospital care, emergency resuscitation, in-hospital stabilization and rehabilitation pathway can be associated with risks at any of these phases. We describe the various risks that can be anticipated during the management of polytrauma patients at different stages and provide clinical insights into early recognition and effective treatment of these to improve clinical outcomes.

Early intramedullary nailing of bilateral femur fractures: who might benefit most?

INTRODUCTION

Identifying which patients can receive immediate intramedullary nailing (IMN) after bilateral femoral shaft fracture may improve health-related quality of life outcomes and decrease healthcare costs. This retrospective study evaluated the perioperative factors that guided emergency department transfer of patients to the operating room (OR) where IMN or temporizing external fixation (TEF) was performed, to the intensive care unit (ICU), or to the orthopedic ward. The hypothesis was that patients referred initially to the OR or to the ICU had more serious co-morbidities, complications, or orthopedic polytrauma, increasing the likelihood that they would benefit from "damage control orthopedics" and TEF use.

METHODS

A Level I Trauma Center database (2010-2020) review identified the records of 23 patients that met study inclusion and exclusion criteria. Most sustained their injury in a motor vehicle accident (87%) and were not wearing a seatbelt.

RESULTS

Patients transferred to the operating room had a greater body mass index and shorter times between admission and surgery. Those transferred to the OR or ICU had higher injury severity scores (ISS), higher arterial blood O₂ partial pressure (paO₂) values on the first post-surgical day, and had more red blood cell unit (RBCU) transfusions during hospitalization. Patients transferred to the ICU more often underwent TEF and had shorter initial surgical procedure duration. Those with pneumothorax, rib fractures, or with other orthopedic comorbidities were more often transferred to the OR or ICU and those with acute complications requiring exploratory laparotomy were transferred to the OR.

CONCLUSIONS

Patients with higher BMI, ISS, greater RBCU transfusion needs, with pneumothorax, rib fractures, or acute complications requiring exploratory laparotomy were more likely to be initially transferred to the OR or ICU. Patients transferred to the orthopedic ward represented a more heterogenous group with greater possibility for benefitting from earlier definitive IMN.

[Subtrochanteric fractures]

Subtrochanteric fractures represent a distinct entity. They are different from proximal femoral fractures as well as femoral shaft fractures. Nowadays, these fractures are mainly found in the geriatric population. Fractures in younger patients are indicative of high-energy trauma. Comorbidities are important in the geriatric population whereas accompanying injuries are most important in younger patients. Early surgical stabilization of subtrochanteric fractures is the treatment of choice, which under certain circumstances should also be carried out within the framework of damage control orthopedics. Long cephalomedullary nails represent the standard procedure. In geriatric patients the primary aim is weight bearing stability. The risk of complications with subtrochanteric fractures in the literature is relatively high. Classical compression plates play a role in the management of complications.

Injury characteristics, initial clinical status, and severe injuries associated with spinal fractures in a retrospective cohort of 506 trauma patients

BACKGROUND

Our aim was to describe the characteristics of vertebral fractures, the presence of associated injuries, and clinical status within the first days in a severe trauma population.

METHODS

All patients with severe trauma admitted to our level 1 trauma center between January 2015 and December 2018 with a vertebral fracture were analyzed retrospectively. The fractures were determined by the AO Spine classification as stable (A0, A1, and A2 types) or unstable (A3, A4, B, and C types). Clinical status was defined as stable, intermediate, or unstable based on clinicobiological parameters and anatomic injuries. Severe extraspinal injuries and emergent procedures were studied. Three groups were compared: stable fracture, unstable fracture, and spinal cord injury (SCI) group.

RESULTS

A total of 425 patients were included (mean ± SD age, 43.8 ± 19.6 years; median Injury Severity Score, 22 [interquartile range, 17-34]; 72% male); 72 (17%) in the SCI group, 116 (27%) in the unstable fracture group, and 237 (56%) in the stable fracture group; 62% (95% confidence interval [CI], 57-67%) had not a stable clinical status on admission (unstable, 30%; intermediate, 32%), regardless of the group (p = 0.38). This decreased to 31% (95% CI, 27-35%) on day 3 and 23% (95% CI, 19-27%) on day 5, regardless of the group (p = 0.27 and p = 0.25). Progression toward stable clinical status between D1 and D5 was 63% (95% CI, 58-68%) overall but was statistically lower in the SCI group. Severe extraspinal injuries (85% [95% CI, 82-89%]) and extraspinal emergent procedures (56% [95% CI, 52-61%]) were comparable between the three groups. Only abdominal injuries and hemostatic procedures significantly differed significantly (p = 0.003 and p = 0.009).

CONCLUSION

More than the half of the patients with severe trauma had altered initial clinical status or severe extraspinal injuries that were not compatible with safe early surgical management for the vertebral fracture. These observations were independent of the stability of the fracture or the presence of an SCI.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Factors influencing management of bilateral femur fractures: A multicenter retrospective cohort of early versus delayed definitive Fixation

INTRODUCTION

The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries.

METHODS

Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit.

RESULTS

Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p<0.01), higher admission lactate (4.4 and 3.0; p<0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p<0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (X² statistic: institution: 45.6, ISS: 8.83, lactate: 6.77, GCS: 0.94).

CONCLUSION

In this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries.

LEVEL OF EVIDENCE

Level III.

Evolution of treatment of femoral shaft fracture in polytrauma: Did damage control orthopaedics improve the outcome? A retrospective study

BACKGROUND

Treatment of polytrauma patients with femoral shaft fracture has changed considerably during the past few decades. A transition from early total care (ETC) to "Damage Control" Orthopaedics (DCO) in selected patients was proposed in order to decrease mortality. The aim of the study was to investigate whether this policy change resulted in improved patient outcome.

METHODS

We present a retrospective, comparative study, held in a Level I trauma center in Jerusalem, Israel. Polytrauma patients with Injury Severity Score higher than 16 with femoral shaft fracture were included. Data was extracted from our institute's electronic trauma registry. The study examines two time periods: Between the years 1996 and 2006 patients were treated according to the ETC protocol, with immediate intramedullary nailing (IMN) within 12 h. From 2007 until 2019 a DCO policy was adopted, implementing temporary external fixator for high risk patients, according to the "Hannover" criteria. Following resolution of the acute phase, these were converted to IMN. Patients eligible for DCO were matched to controls who received ETC during the earlier period.

RESULTS

A total of ninety-six patients were included (DCO n = 44, ETC n = 52). The groups were comparable in terms of age, gender, mechanism of injury, injury to surgery time and Injury severity score (DCO median 31.5, ETC median 29). No statistical difference was found between the groups in terms of mortality (P = 0.757), acute respiratory distress syndrome (P = 0.534), sepsis (P = 0.519) and hospital stay (DCO median 24 days, ETC median 21.5 days) or ICU stay (Median 7 days in both groups).

CONCLUSIONS

This pilot study did not demonstrate better outcome by implementing DCO concepts in the polytrauma patient.

LEVEL OF EVIDENCE

III prognostic.

Surgical strategy for femoral shaft fractures in severely injured patients: A 13-year experience from a tertiary trauma centre

BACKGROUND

The treatment strategy of femoral shaft fractures in polytraumatised patients has evolved over the years and led to improved outcomes for these patients. However, there is still controversy regarding the optimal treatment strategy and surgical care can differ markedly from one country to another. We investigate the surgical treatment strategy (Early Definitive Care (EDC) or Damage Control Orthopaedics (DCO)) implemented in the care of severely injured patients with femoral shaft fractures treated at a single tertiary trauma centre in southern Finland and factors affecting decision making.

METHODS

The Helsinki Trauma Registry (HTR) was used retrospectively to identify severely injured patients (New Injury Severity Score [NISS] ≥ 16) treated from 2006 through to 2018 with concomitant femoral shaft fractures. Patients <16 years old, with isolated head injuries, dead on arrival and those admitted >24 h following the injury were excluded. Based on their initial surgical management strategy, femoral fracture patients were divided into EDC and DCO groups and compared.

RESULTS

Compared to other trauma-registry patients, those with femoral shaft fractures are younger (30.9 ± 15.9 vs. 47.0 ± 19.7, p<0.001) and more often injured in road traffic accidents (64.1% vs. 34.4%, p<0.001). The majority (78%) of included patients underwent EDC. Patients who underwent DCO were significantly more severely injured (NISS: 40.1 ± 11.5 vs. 27.8 ± 10.1, p<0.001) with longer lengths of stay in ICU (15.4 ± 9.8 vs. 7.5 ± 6.1 days, p<0.001) and in hospital (29.9 ± 29.6 vs. 13.7 ± 11.4 days, p<0.001) than patients treated with EDC. Decision making was based primarily on injury related factors, while non-injury related factors may have contributed to choosing a DCO approach in a small number of cases.

CONCLUSION

Early definitive care is the prevailing treatment strategy in severely injured femoral shaft fracture patients treated at a tertiary trauma centre. Patients treated with DCO strategy are more severely injured particularly having sustained worse intracranial and thoracic injuries. In addition to injury related factors, treatment strategy decision making was influenced by non-injury related factors in only a minority of cases.

Polytrauma: update on basic science and clinical evidence

The management of multiply injured or severely injured patients is a complex and dynamic process. Timely and safe fracture fixation is a critical component of the multidisciplinary care that these patients require. Effective management of these patients, and their orthopaedic injuries, requires a strong understanding of the pathophysiology of the response to trauma and indicators of patient status, as well as an appreciation for the dynamic nature of these parameters. Substantial progress in both clinical and basic science research in this area has advanced our understanding of these concepts and our approach to management of the polytraumatized patient. This article summarizes a symposium on this topic that was presented by an international panel of experts at the 2020 Virtual Annual Meeting of the Orthopaedic Trauma Association.

Current challenges and controversies in the management of scapular fractures: a review

Fractures of the scapula are rare and usually associated with high-energy trauma. The unfavorable scapular anatomy, combined with the complexity of the approaches for fracture fixation, make the treatment challenging, even for experienced surgeons. Furthermore, the literature is controversial regarding surgical indications and rationale for treatment. The present review article was designed to address and discuss critical aspects of decision-making for the management of scapular fractures, including surgical indications and patient safety considerations.

Evolving concepts and strategies in the management of polytrauma patients

Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.

Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020

OBJECTIVES

Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient.

METHODS

I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome.

INCLUSION CRITERIA

adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure).

RESULTS

I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation.

CONCLUSIONS

Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.

Innate immune responses to trauma

Trauma can affect any individual at any location and at any time over a lifespan. The disruption of macrobarriers and microbarriers induces instant activation of innate immunity. The subsequent complex response, designed to limit further damage and induce healing, also represents a major driver of complications and fatal outcome after injury. This Review aims to provide basic concepts about the posttraumatic response and is focused on the interactive events of innate immunity at frequent sites of injury: the endothelium at large, and sites within the lungs, inside and outside the brain and at the gut barrier.