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

Abstract

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.

Surgical Stabilization of Clavicle Fractures Reduces Organ Failure Rates in Multiply-injured Patients with Thoracic Trauma: An Analysis Based on the TraumaRegister DGU®.

“…Yet, these positive results come with the cost of an operative intervention. As shown in other studies surgical timing and early operative treatment may result in positive implications for the intensive care unit stay and clinical outcome [45,46]. In line with studies showing bene ts in organ failure reduction and shortening of intubation periods after early operative treatment of fractures in different body regions we are the rst to describe this effect in early stabilization of clavicle fractures in thoracic trauma patients.…”

“…There is an ongoing discussion on the management of multiply-injured patients and timing of osteosynthesis [45]. For small bone fractures no recommendations or studies exist on when to surgically stabilize these injuries in multiply injured patients.…”

“…For small bone fractures no recommendations or studies exist on when to surgically stabilize these injuries in multiply injured patients. For long bone and spinal fractures research exists and some favor stabilization within 72 hours after hospital admission [45,46]. Since long bone and spinal fractures are more relevant to patient management on the ICU and are preferably stabilized before small bone fractures, we concluded to examine the time for early clavicular stabilization until 5 days after hospital admission.…”

Staphylococcus aureus Osteomyelitis: Bone, Bugs, and Surgery

“…In orthopedic trauma, a main principle in the management of open fractures, which have a high risk of developing infection, is urgent irrigation and debridement to prevent infection and promote healing (5,(90)(91)(92). Early surgical intervention, antibiotics, and stabilization of the fracture are tenets of what has been termed "damage control orthopedics" in a trauma setting (93,94). In osteomyelitis associated with implant infections such as periprosthetic joint infection, surgery serves an equally important role, where both surgery and antibiotics are critical to successful treatment of the infection (9,19,77,79,80,95).…”

Reaming of femoral fractures with different reaming irrigator aspirator systems shows distinct effects on cardiac function after experimental polytrauma

“…The adequate stabilization of fractures after multiple trauma is crucial for early management and improves the overall outcome of critically injured patients 9 . Intramedullary nailing is considered as the gold standard for stabilization of femoral shaft fractures 10 .…”