Developments in the understanding of staging a “major fracture” in polytrauma: results from an initiative by the polytrauma section of ESTES

Abstract

Purpose Although the term “major fracture” is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of “major fractures” has changed and is modified by a better understanding of patient physiology. Methods A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades. Results 4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000. Conclusion Over time, the way “major fractures” influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.

The sequence of the treatment of combined fractures of the pelvis, spine, and extremities in polytraumatized patients

“…Basically, the extended recommendation of the ‘treat first what kills first’ principle applies here, ‘treat first what compromises most’. The aim is to get the severely injured person stabilized and mobile as quickly as possible to prevent complications and improve the outcome ( 39 ). Therefore, our recommendation is to perform pelvic and vertebral treatments as soon as possible to minimize complications while the patient's condition is acceptable.…”

Traumogenesis of the Floating Hip in Patients With Polytrauma

“…Нашу думку не розділяє Y. Kalbas et al (2023), які вказують, що серед пацієнтів молодших вікових груп високоенергетичні механізми травми були виявлені у 81,5% випадків. Автори відзначають наявність двох піків у розподілі переломів вертлюгової западини та стегна: перший пік припадав на вікову категорію 20-40 років і був результатом високоенергетичної травми, а другий пік спостерігався серед пацієнтів вікової категорії більше 60 років і був результатом низькоенергетичних ушкоджень [6].…”

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

“…In view of these considerations, the polytrauma section of the European Society for Trauma and Emergency Surgery (ESTES) has led an initiative to introduce a definition for "major fracture(s)" in the multiply injured patient (28,29). A recent systematic review showed that, over the last decades, the timing of fixation of pelvic and spinal fractures gained importance in the treatment of polytrauma patients, which is likely due to improved diagnostic tools and less invasive operative techniques.…”