Staged Surgical Management of Multiple Fractures in Polytrauma Patient (original) (raw)
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Basic principles of intensive care for patients with polytrauma at an early stage. Ways to optimize
ScienceRise, 2015
Aim of study: To describe the basic principles of polytrauma patients' care at the stages of traumatic disease. Materials and methods: An analysis of the treatment of fractures of 1285 patients with combined and multiple musculoskeletal injuries for the period from 2012 to 2017 was carried out. The studied population consisted of men-874 (68%) and women-411 (32%). The average age of patients was 42.7. The number of road accidents prevailed (53.6%) over catatrauma (32.5%). Results: In order to follow damage control low invasive osteosynthesis techniques have been preferred. Such methods provided reliable bony fragments stabilization with the possibility of avoiding additional external fixation. At the same time early range of motion exercises had been allowed. In order to prevent traumatic disease reposition and osteosynthesis had been performed as soon as it was possible. The osteosynthesis for the medial femoral neck fractures was rational only in the acute period of trauma. Conclusions: When correcting the lesions of bone structures in victims with polytrauma, operational benefits differ little from those in isolated trauma.
Romanian Journal of Orthopaedic Surgery and Traumatology
Purpose. Damage Control Orthopedics (DCO) is a surgical concept used in the recovery of seriously injured patients. Given that the leading cause of death among trauma patients remains uncontrolled hemorrhage, DCO emphasizes on preventing the "lethal triad” of acidosis, coagulopathy and hypothermia, rather than correcting the anatomy immediately. Thereby, we are presenting the crucial importance of using this technique in severe trauma cases. Methods. A 23-year-old female was admitted in the Emergency Room as a multi-trauma patient. Following the Advanced Trauma Life Support protocol, fully exposure examination showed bilateral forearm and femur deformities, with bilateral open femur fracture, left ankle deformity and pelvic ecchymosis. X-rays confirmed fractures of the ribs, bilateral pulmonary contusion, fracture of the left ankle fracture, bilateral superior and inferior pubic ramus, and bilateral femur fractures with both bone midshaft fracture on the right leg. DCO was proc...
Severely injured patients: modern management strategies
EFORT Open Reviews
Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors. The spectrum of injuries and their severity is quite extensive, which dictates a clear understanding of the existing nomenclature. What is defined nowadays as polytrauma or major trauma, together with other essential terms used in the orthopaedic trauma literature, is described in this instructional review. Furthermore, an analysis of contemporary management strategies (early total care (ETG), damage control orthopaedics (DCO), early appropriate care (EAC), safe definitive surgery (SDS), prompt individualised safe management (PRISM) and musculoskeletal temporary surgery (MuST)) advocated over the last two decades is presented. A focused description of new methods and techniques that have been introduced in clin...
The American Journal of Surgery, 2002
Information illustrating the benefits of fracture stabilization after multiple trauma has been gathering for almost a century. At the turn of the last century, the introduction of the Thomas splint clearly demonstrated the importance of skeletal stabilization in the management of these patients. The introduction of standardized surgical treatment for fractures in the early 1950s is considered today as the turning point in the care of the polytraumatized patient. With the knowledge acquired, the application of early operative fixation of fractures in severely injured patients in the 1980s has yielded to the concept of early total care of all fractures. Yet, in distinct patient subgroups with severe thoracic injuries and very high injury severity scores, this concept has been associated with adverse outcomes. Therefore, in a further era that began in the 1990s, a different approach has been favored for these subgroups. It recommends early (initial) temporary stabilization followed by secondary definitive osteosynthesis of major fractures in patients at high risk of developing systemic complications. In the last decade, attempts have been made to determine which patients benefit from early total care and which ones should undergo a secondary definitive approach. This manuscript provides a historical overview on the changing treatment of fractures and summarizes the evolution of "damage control orthopedic surgery."
Injury, 2019
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.
The Journal of the American Academy of Orthopaedic Surgeons, 2009
The optimal timing of surgical stabilization of fractures in the multitrauma patient is controversial. There are advantages to early definitive surgery for most patients. Early temporary fixation using external fixators, followed by definitive fixation (ie, the damage control approach), may increase the chance for survival in a subset of patients with severe multisystem injuries. Improved understanding of the pathophysiology of trauma has led to a greater ability to identify patients who would benefit from damage control surgery. A patient is classified as physiologically stable, unstable, borderline, or in extremis. The stable patient can undergo fracture surgery as necessary. An unstable patient should be resuscitated and adequately stabilized before receiving definitive orthopaedic care. The decision whether to perform initial temporary or definitive fixation in the borderline patient is individualized based on the clinical condition. In patients presenting in extremis, life-savi...
Management of a Polytrauma Case In a Resource-Constrained Hospital
2022
The management of polytrauma patient should be beforehand and always in keeping in mind the damage control. The surgical treatment is secondary to the stabilization of the patient. Clinical Case: We are reporting a 34 years old polytrauma patient from a motor vehicle accident. On physical examination, we noted : a severe brain injury, a closed articular fracture of right distal radius associated to a dislocation of distal radius and ulna distal joint, a closed bilateral fracture of both trochanters, an open communitive tibial fracture of proximal epiphysis methaphysis and diaphysis. The last one was classified as type III B of Gustilo and Anderson and associated to a closed fracture of the head and the neck of right fibula, a closed fracture of the right lateral malleolus. th After patient stabilization, the head injury improves to normal Glasgow score on 8 day of admission. Necrosis of soft tissus and exposition of the tibia was noted. The surgical treatment was done on 2 stages due to financial issues. A bone synthesis of the trochanteric fracture was done only on th nd the left and external frame as well as a muscle flap was done for the right tibial fracture on the 18 day. On the 42 day a PAPINEAU technic associated to a proximal inter tibiofibular graft was done. The functional outcome of the orthopaedic treatment of the wrist was bad (malunion). That last complication was managed by a SAUVE KAPANDJI surgery (at 6 months) and the contracture (pronation and supination) at 12 months post trauma. The outcome was fair good despite patient financial issue and local complications that compromise an optimal surgical management and a delay. He resumes normal professional activities at about 2 years. At 5 years follow up, functional and anatomical results were satisfactory. Conclusion: In a limited resources' setting, the management of lesions including a multiple fractures is a challenge for the practitioner and the injured patient. A management taking into account social and economic resources is mandatory to minimise sequelae.
Injury, 2009
The management of patients with multiple injuries continues to be a challenging process. A critical evaluation of treatment results is impeded by a heterogeneous patient population, low number of cases and different therapy regimens over the past years. Recently, in an attempt to address these problems, several multi-centre databases of multiple trauma patients have been established and contributed to improvements in trauma care. Only rarely have studies been published from a single institution to review the changes over time in outcome of multiple trauma/ intensive care patients. Back in 1995, our group reported on 3406 multiple trauma patients treated at a single institution comparing two 10-year treatment periods. Epidemiological and demographic characteristics were described in detail as well as changes of the patient population and the effect of new achievements. 29 This study showed a considerable reduction of mortality as well as success in volume and ventilator therapy. 29 It was then suggested that an effort should be made to decrease rescue and resuscitation time for fast and effective therapy of traumatic shock. We also recommended early definitive stabilisation of long bone fractures and radical debridement of necrotic tissues to allow early restoration of physiological functions. We concluded that a further reduction of Injury, Int.