Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes

Lewis, Richard H.; Perkins, Meredith; Fischer, Peter; Beebe, Michael J.; Magnotti, Louis J.

doi:10.1097/ta.0000000000003430

Cited by 3 publications

(3 citation statements)

References 23 publications

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“…26 The injured extremity is assessed for external bleeding and changes in pulse quality and capillary refill. 27,28 Doppler examination with ankle/brachial or ankle/ankle index provides a sensitive tool to raise awareness about the likelihood of a significant vascular injury. 28 The index is calculated as the systolic blood pressure measured on the injured extremity divided by the blood pressure of the contralateral uninjured (upper or lower) extremity.…”

Section: Initial Assessment and Management Prehospital And Emergency ...mentioning

confidence: 99%

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Contemporary management of open extremity fractures: What you need to know

Stahel,

Kaufman

2024

J Trauma Acute Care Surg

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Open extremity fractures are high-risk injuries prone to significant complications, including soft tissue loss, bone defects, infection, infected nonunion, and the necessity for limb amputation. Large-scale multicenter prospective studies from the “Lower Extremity Assessment Project” (LEAP) and the “Major Extremity Trauma Consortium” (METRC) have provided novel scientific insights pertinent to the timeliness and appropriateness of specific treatment modalities aimed at improving outcomes of patients with open extremity injuries. These include the imperative for early administration of intravenous antibiotics within three hours of injury, preferably within one hour of hospital admission. Unlike the proven value of early antibiotics, the time to initial surgical débridement does not appear to affect infection rates and patient outcomes. Recent evidence-based consensus guidelines from the American Academy of Orthopaedic Surgeons (AAOS) provide scientific guidance for preventing surgical site infections in patients with open extremity fractures and support the decision-making of limb salvage versus amputation in critical open extremity injuries. Patient survival represents the overarching priority in the management of any trauma patient with associated orthopaedic injuries. Therefore, the timing and modality of managing open fractures must take into account the patient’s physiology, response to resuscitation, and overall injury burden. The present review was designed to provide a state-of-the-art overview on the recommended diagnostic workup and management strategies for patients with open extremity fractures, based on the current scientific evidence.

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Section: Initial Assessment and Management Prehospital And Emergency ...mentioning

confidence: 99%

“…The injured extremity is assessed for external bleeding and changes in pulse quality and capillary refill 27,28 . Doppler examination with ankle/brachial or ankle/ankle index provides a sensitive tool to raise awareness about the likelihood of a significant vascular injury 28 .…”

Section: Initial Assessment and Managementmentioning

confidence: 99%

Contemporary management of open extremity fractures: What you need to know

Stahel,

Kaufman

2024

J Trauma Acute Care Surg

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“…11 In cases of combined vascular and orthopaedic skeletal injury, debate continues regarding the best timing and order of revascularization and skeletal stabilization. 12,13 It may be beneficial to consider initial temporary shunting before provisional fracture stabilization in certain situations to minimize ischemia time and reperfusion injury and increase distal tissue viability. 14,15 Aggressive debridement should precede skeletal stabilization so that maximum access to the wound facilitates removal of contaminated and devitalized tissues.…”

Section: Performing the First Debridementmentioning

confidence: 99%

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

Lansford

McCarthy

Souza

et al. 2023

OTA International: The Open Access Journal of Orthopaedic Trauma

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Severe open lower extremity trauma requires debridement to remove contamination and devitalized tissues. Aggressive debridement should be balanced with preservation of viable tissue. These often damaged but preserved viable tissues are “spare parts” that augment the options available for reconstruction. The long-term goal of reconstruction should be functional limb restoration and optimization. Injury patterns, levels, and patient factors will determine whether this endeavor is better accomplished with limb salvage or amputation. This article reviews the rationale and strategies for preserving spare parts throughout debridement and then incorporating them as opportunistic grafts in the ultimate reconstruction to facilitate healing and maximize extremity function. Level of Evidence: 5.

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Early major fracture care in polytrauma—priorities in the context of concomitant injuries: A Delphi consensus process and systematic review

Pfeifer,

Klingebiel,

Balogh

et al. 2024

J Trauma Acute Care Surg

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BACKGROUND The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures. METHODS This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach. RESULTS A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2). CONCLUSION A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room. LEVEL OF EVIDENCE Delphi-Consensus/Systematic Review; Level IV

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Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes

Cited by 3 publications

References 23 publications

Contemporary management of open extremity fractures: What you need to know

Contemporary management of open extremity fractures: What you need to know

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

Early major fracture care in polytrauma—priorities in the context of concomitant injuries: A Delphi consensus process and systematic review

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