The management of the multiply injured or polytrauma patient requires a

multidisciplinary approach integrating organ- and injury-specific treatment protocols. Multiple

Trauma injury to multiple organ systems can directly or indirectly trigger processes that may
injure specific organs, disrupt metabolic processes, interrupt normal endocrine function, create
hemodynamic and physiologic instability, and lead to highly lethal systemic diseases and
multiple organ failure. By definition, multiple trauma is a life-threatening disorder.
Successful management of the polytrauma patient requires a team approach and a broad
focus. Within a few days of injury, the polytrauma patient will be having or be at risk for a
myriad of potentially serious disorders in addition to their actual, initial injuries. A list of some of
these disorders is found in Table 1. The concept of a damage control approach to orthopaedic
injuries is discussed in the recent literature and should be observed to minimize the risk of
compounding
systemic injury through added surgical injury. A dedicated intensivist, skilled anesthesia staff,
trauma and orthopaedic trauma surgeons, nutritional support services, infectious disease
specialists, and plastic and reconstructive surgeons may all play a role in the care of a single
patient. It is imperative that all of these individuals buy into the principles of trauma
management and communicate well with the other members of the team.
The environment for patient care must support the level of care required. Access to
diagnostic studies, interventions, line care, and respiratory support must be immediate and
available around the clock. Nursing staff must understand the fragility of the patient and
recognize that changes in respiratory or circulatory parameters may require immediate attention
and response. Staff must also be familiar with protocols for mobilization, deep venous
thrombosis prophylaxis, and pulmonary and bowel care.
After the patients condition is stabilized, attention to nutrition, infection control,
pulmonary function, and skin care play an often underappreciated role in healing and
rehabilitation. Psychological support, occupational and physical therapy programs, and
multidisciplinary follow-up all contribute to full and timely recovery, and improve the likelihood
of a satisfactory return to function and community life.
These patients often face some likelihood of permanent impairment and long-term
disability. Advances have been made in all aspects of polytrauma care, ranging from improved
prehospital care to more aggressive resuscitation and surgical management to aggressive physical

therapy and spinal cord injury rehabilitation. The treating physician must be conversant in all of
these areas, and keep an eye on all aspects of the patients recovery if the best outcomes are to be
obtained and the worst complications avoided.
Assessment of the Polytrauma Patient
An orderly, structured assessment of the polytrauma patient has been shown to improve
care and reduce the likelihood of missed injuries. Patients with multiple injuries typically arrive
in the emergency department under the care of another health care provider, most often a trained
emergency medical technician, who will have assessed the patient in the field, established
intravenous access, and may have intubated the patient to restore or maintain the airway. They
will provide important information on the mechanism of injury, the patients condition at the
time of first contact, and evidence of neurologic function, respiratory status, and responsiveness
at the time of initial resuscitation. Their initial observations may provide important perspective
as to the patients improvement or deterioration when compared with the initial assessment in the
emergency department.
Once the patient arrives in the emergency department, resuscitation and a primary
assessment begin simultaneously. These two processes are interdependent in that the purpose of
the primary assessment is to find the causes of hemodynamic instability, respiratory impairment,
and circulatory collapse at the same time others on the team are trying to restore those functions
through volume replacement, ventilation, and pharmacologic support. Once the primary survey is
complete and the patients condition begins to stabilize, a secondary, more complete survey is
conducted, and the team can begin to formulate a plan for definitive care.
Primary Survey
Initial management of the polytrauma patient begins with an assessment of airway,
breathing, and circulation, along with neurologic status (disability) and environmental exposure.
Advanced Trauma Life Support guidelines set forth by the American College of Surgeons
advocate use of both the primary and secondary survey to provide an orderly, consistent
approach that will rapidly reveal life and limb threatening injuries.

The secondary survey consists of a head-to-toe evaluation and history. Both the primary
and secondary survey should be repeated as needed to ascertain any change in the patients
status. Initial radiographs should include those of the chest, pelvis, and cervical spine, all
obtained immediately after the primary survey is complete.
Airway
Assessment of the airway and breathing begins immediately, in the field. The patient must be
making an effort to breath, be successfully moving air, and be adequately transferring oxygen to
the circulating blood. Evaluation of effort, chest wall excursion, and breath sounds should be
done immediately on arrival. The physician should look for cyanosis and obtain an arterial blood
gas sample. Mechanical obstruction should be addressed immediately, looking for loose teeth,
dentures, blood, food, or vomitus, and intubation performed as necessary. The arterial blood gas
will assess degree of oxygenation. If oxygenation is inadequate, pulmonary function, including
tension pneumothorax, hemothorax, and flail chest, should be reinvestigated.
Breathing: Thoracic Injuries
Signs of major thoracic injury during the primary survey, including tension
pneumothorax, open pneumothorax, flail chest, massive hemothorax, and cardiac tamponade
(discussed in the following section) should be noted. Tension pneumothorax develops as air leaks
into the chest cavity either through the chest wall or from the lung. The air enters via a one-way
valve mechanism and does not exit the cavity. The affected lung collapses and as air continues
to build up, the mediastinum is displaced to the contralateral side, impeding venous return and
compressing the uninjured lung. The diagnosis is made on the clinical findings of absent breath
sounds and a hyperresonant percussion note. A chest radiograph is not required before treatment
is initiated. Treatment consists of immediate decompression by insertion of a large bore needle
into the second intercostal space in the midclavicular line of the affected side, followed by chest
tube placement.
Open pneumothorax results from large defects in the chest wall. Air will preferentially
enter the chest cavity through the defect rather than the trachea when the diaphragm contracts.
Initial management includes placement of an occlusive dressing covering the wound edges, taped
on three sides, allowing the dressing to occlude the wound with each inhalation and allowing for

air to escape during exhalation. A chest tube should be inserted at a site away from the wound as
soon as possible.
Flail chest occurs in the presence of multiple rib fractures and is usually associated with
an underlying pulmonary contusion. The flail chest segment demonstrates paradoxical chest wall
motion with inspiration and expiration, impairing ventilation. The paradoxical motion is not
solely responsible for the associated hypoxia. Pain results in restricted chest wall motion, and
pulmonary contusion contributes significantly to development of hypoxia. Intubation and
ventilation may be
necessary if hypoxia is progressive and unresponsive to initial measures.
Massive hemothorax, the rapid accumulation of at least 1,500 mL of blood in the chest,
may be the result of blunt or penetrating trauma. The blood loss may contribute to hypoxia, and
initial management includes both restoration of blood volume and decompression of the chest
cavity by chest tube placement. Massive hemothorax often requires thoracotomy to control the
source of hemorrhage.
Circulation
Evaluation of circulation involves physical examination and an assessment of vital signs
including blood pressure and heart rate. Intravenous fluid infusion is recommended in all
patients, and is usually started before reaching the hospital. Resuscitation should be monitored
by blood pressure, heart rate, perfusion, and urine output. If the extremities are cold, clammy,
and/or cyanotic, the patient should be treated for hypovolemia irrespective of pulse or pressure.
If brisk bleeding from an extremity or penetrating wound is encountered, direct pressure should
be applied immediately.
Goals for urine output are 0.5 mL/kg/h in adults and 1.0 mL/kg/h in children. Central
venous pressure will provide information regarding atrial-filling pressures. Elderly patients with
severe thoracic trauma require a pulmonary artery catheter. The arterial-alveolar gradient should
be calculated to detect ventilation-perfusion mismatches. Crystalloid infusion is used in the
initial management of these patients, through large bore intravenous access. If intravenous access
is not readily available, cutdown on the saphenous, femoral, or cubital veins may be necessary.
For patients who are experiencing exsanguination, immediate use of universal donor blood group

(group O, Rh negative) is recommended. Thrombocytopenia is treated at levels below

50,000/mL.
Cardiac tamponade may result in circulatory failure in the face of normal blood volume.
This condition usually results from penetrating injuries. The diagnosis is often difficult, and it
must be distinguished from tension pneumothorax. The classic diagnostic finding of Becks triad
consists of (1) venous pressure elevation, (2) decline in arterial pressure, and (3) muffled heart
tones.
Kussmauls sign, a rise in venous pressure with spontaneous inspiration, may be
present in cardiac tamponade. An echocardiogram may aid in diagnosis, but a falsenegative
result may be seen in about 5% of patients. Examination of the pericardial sac may also be
performed during a focused abdominal ultrasound. Prompt evacuation of the pericardial blood
(usually by pericardiocentesis)
is indicated for patients who do not respond to usual resuscitative measures. A pericardial
window, thoracotomy and pericardiotomy, may be necessary.
Head Injury
All trauma patients should receive a minineurologic examination consisting of a Glasgow Coma
Scale (GCS) score. This scoring system has prognostic value with regard to future neurologic
function. A decline in the
GCS score may indicate intracranial pathology. Reflexes
of the triceps, biceps, knee, and ankle should be evaluated.
The minimum GCS score is 3 and is seen in flaccid
patients who are unable to open their eyes spontaneously
or speak. Patients who do open their eyes, obey
commands, and are oriented score the maximum of 15
points.A GCS score of 8 or less corresponds to the generally
accepted definition of coma.
Estimating Injury Severity
Grading the severity of multiple trauma is difficult. The
Injury Severity Score (ISS) was the first scoring system
to use anatomic criteria to assess the extent of injury.

The ISS measures injury severity based on the abbreviated

injury scale (AIS), developed in 1971 and revised
in 1985. Injury severity in the AIS is graded on a scale
of 1 to 5 for each organ system. As currently applied,
the ISS is calculated by taking the AIS scores from the
three most severely injured anatomic areas, squaring
them, and adding the resultant figures. An ISS of 16 or
more has been shown to be associated with a mortality
of 10%, whereas a score greater than 40 predicts a 50%
mortality. The ISS score has not been shown to accurately
predict outcome for those individuals with a severe
injury to a single body area.
Secondary Survey
During the secondary survey, thoracic trauma can be
further defined. Injuries detected through the secondary
survey include simple pneumothorax or hemothorax,
pulmonary and cardiac contusion, tracheobronchial tree
injuries, and diaphragmatic rupture. In all of these injuries
hypoxia must be corrected before resuscitation is
successful.
Abdomen
During the primary survey, assessment of circulation, especially
in blunt trauma patients, includes a thorough
abdominal examination to rule out hemorrhage. Peritoneal
signs such as rigidity and rebound are useful to diagnose
a surgical abdomen, but may not always be apparent
in obtunded patients.
The Focused Assessment with Sonography for
Trauma examination is now widely used to further evaluate
the abdomen. This examination can be done
quickly and does not require the transport of a critically

injured patient. Ultrasound has a sensitivity, specificity,

and accuracy comparable to diagnostic peritoneal lavage
and CT scan, but the examination is operator dependent.
Its utility is limited in obese patients, in the
presence of subcutaneous air, and in patients who have
had previous abdominal operations. One recent study
found that the focused assessment with sonography for
trauma examination underdiagnosed significant intraabdominal
trauma in one group of 372 patients.
CT scan is used only in patients who are hemodynamically
stable and who have no immediate indication
for a laparotomy. CT can evaluate the extent of a specific
organ injury and can also help in the diagnosis of
retroperitoneal and pelvic organ injuries not readily ap
parent on clinical examination. CT may also be performed
serially to evaluate spleen, liver, and kidney injuries
not requiring immediate surgical intervention.
Spine
Injuries to the spinal column should always be sought in
polytrauma patients. Occult spinal injuries may be overlooked
in patients with an altered level of consciousness.
Inadequate immobilization and excessive manipulation
may cause additional damage in a patient with
spinal injury and may worsen the outcome. In hemodynamically
unstable patients or patients with respiratory
difficulty, exclusion of spine injury may be deferred as
long as the patients spine is safely immobilized and
protected during the primary survey and initial care.
Moreover, maintaining tissue perfusion and oxygenation
will help stop progression of any existing cord injury.

The secondary spinal assessment should be performed

once life-threatening issues have been dealt with.The goal
of the secondary assessment is to identify and initially
manage neurologically and mechanically unstable spinal
injuries.
Log rolling the patient is essential for an adequate
spinal examination. The soft tissues should be assessed
for swelling, ecchymosis, wounds, deformity, or bogginess.
Spinous processes should be palpated individually
with particular emphasis placed on areas of tenderness.
A complete motor, sensory, and reflex examination
should be performed, including tests for perianal sensation,
rectal sphincter tone, and bulbocavernosus reflex.
Serial examinations should be performed to document
any progression of neurologic deficits.A neurologic deficit
may be classified as complete, in which there is total
absence of motor or sensory function below the level of
injury, or incomplete. Identifying any distal motor or
sensory sparing (incomplete injury) is essential, as these
patients warrant treatment on a more urgent basis.
Spinal shock refers to the flaccidity and loss of reflexes,
specifically sacral reflexes, after spinal cord injury.
The return of these reflexes marks the end of spinal shock.
The diagnosis of a complete neurologic injury cannot be
made during spinal shock.
Neurogenic shock manifests itself through hypotension
and bradycardia, and must be distinguished from cardiogenic
shock, which is characterized by hypotension and
tachycardia. Neurogenic shock should be treated with judicious
use of fluid resuscitation and vasopressors. Atropine
may be useful to treat the bradycardia.

It is unlikely that an awake, alert, neurologically normal

patient without pain or tenderness along the spine
has any spinal injury. However, patients with an altered
level of consciousness (head injury, intoxication, hypoxia)
need to have their normal radiographs corroborated
via an adequate physical examination before neck
injury can be formally ruled out (Figure 1).
A full radiographic spinal survey, including cervical,
thoracic, and lumbosacral radiographs, is necessary in all
patients with a suspected spinal cord injury. Patients
with spinal cord injury at one level may have another
injury at a noncontiguous level 5% to 20% of the time.
Lateral cervical radiographs must show the cervicothoracic
junction, or a lateral swimmers view or CT should
be obtained through this area. An AP odontoid view
should also be obtained. Although patients with persistent
pain despite normal radiographs may eventually
benefit from flexion/extension views to identify ligamentous
injury, there is rarely a role for flexion/
extension radiographs in the initial evaluation of the
trauma patient.
CT is useful in delineating the extent of bony injuries
detected on plain radiographs. MRI is useful in patients
with abnormal neurologic findings. In patients

with specific lesions such as facet dislocations and who

are undergoing closed reduction, MRI should be done
to rule out extruded disks that may cause neurologic
damage during closed reduction. MRI is indicated in
any patient with a progressive neurologic deficit, or a
deficit that does not match the level of the recognized
spinal injury (C7 cord deficit in the face of a T10 burst
fracture).
Pelvis
The primary survey of the pelvis involves mechanical
assessment of stability and continuity: the physician
quickly checks for fractures or disruption by medially
compressing the iliac wings, applying an anteriorposterior
stress through the ASIS, and by checking stability
during hip range of motion. The secondary survey
involves a more thorough history, physical examination,
and analysis of an AP radiograph of the pelvis.
The history should determine the mechanism of injury.
Higher energy injuries are more likely to be associated
with an increased severity of fracture. Pelvic fractures
occur more frequently with lateral impact than
frontal impact. Patients on the side of impact are more
likely to have a severe injury.
Physical findings of pelvic injury may include scrotal/
labial swelling, open lacerations in the perineum and vagina
or rectum, associated urologic or neurologic injuries,
or excessive internal/external rotation of the lower
extremity. Provocative maneuvers test the stability of
the pelvis to internal and external rotation of the hip.
The pelvis should move as a single unit. If a hemipelvis

moves separately, the ring is disrupted and the pelvis is

mechanically unstable. Once a pelvic injury is determined
to be unstable, further manipulation that might
dislodge clots that have formed within the fracture
should be avoided.
Pelvic injuries can result in massive hemorrhage. In
polytrauma patients, intrathoracic and intra-abdominal
injuries are common, causing or contributing to hemorrhage
and hypotension. Open wounds and long bone
fractures such as femur fractures also contribute to
blood loss. Hypotension caused specifically by a pelvic
injury is invariably associated with a mechanically unstable
pelvis, and may prove difficult to control until the
pelvis is stabilized.
Early control of hemorrhage is crucial, in addition to
staying ahead of volume requirements. Resuscitation of
a hypotensive patient may result in hypothermia and acidosis.
These factors may contribute to coagulopathy,
complicating the existing problem and leading to further
bleeding. Persistent hypotension can aggravate pulmonary
and neurologic injury, and compromise renal, cerebral,
and cardiac function. In addition, the risk of sepsis,
adult respiratory distress syndrome (ARDS), and multiple
organ failure is increased in these patients.
Particular attention should be paid to open pelvic injuries
because they are associated with exceptional morbidity
and mortality and will require emergent dbridement.
Rectal and vaginal examinations must be
performed to rule out lacerations. Associated urologic
injuries should be sought. Clinical findings that may indicate
injury include blood at the urethral meatus, highriding

prostate, or inability to pass a Foley catheter.

These patients will require retrograde urethrogram or
cystogram, depending on the particular injury.
The AP radiograph of the pelvis is used in correlation
with the physical examination to determine the stability
of the pelvis. In a recent study, it was determined
that physical examination was accurate in identifying injuries
of the posterior pelvic ring. Signs of instability included
more than 5 mm of displacement of the posterior
sacroiliac joint, the presence of a posterior fracture gap,
and the presence of an avulsion fracture of the transverse
process of the fifth lumbar vertebrae. Pelvic ring
injuries can be classified based on anatomic location,
mechanism, or stability. The mechanistic classification
can help predict blood loss and guide management. This
classification as defined by Young and Burgess divides
pelvic injuries into four mechanisms of injury: lateral
compression, anteroposterior compression, vertical
shear, and combined mechanism. Inlet and outlet radiographs
as well as CT scan can help further clarify the
degree of pelvic instability.
Classification of these injuries can help guide definitive
management. (1) The estimated blood loss for a severe
lateral compression injury is approximately 3.6
units whereas blood loss from an AP compression injury
is 14.8 units. (2) AP compression injuries have a higher
mortality and a higher incidence of shock and ARDS
than lateral compression fractures. (3) Moderate lateral
compression injuries have a higher incidence of brain
injury, and vertical shear injuries also have a high incidence
of associated injuries as well as mortality.

Lower Extremity Injuries

Femoral shaft fractures are high-energy injuries, usually
occurring in the young patient population. Patients with
bilateral fractures typically have a high ISS, higher mortality,
and higher risk of ARDS. Early treatment of
these injuries is important to survival and morbidity.An
unsplinted closed femur fracture can lose up to four
units of blood into the thigh. Tibial fractures are associated
with severe soft-tissue and neurovascular trauma
that can render the extremity dysfunctional or even
nonviable.
Initial evaluation includes palpation of the entire extremity
to the foot and a thorough neurovascular examination.
Assessment of soft-tissue injury should be done
to rule out an open fracture.AP and lateral radiographs
should include the joints above and below the fracture.
Special attention should be paid to the ipsilateral hip to

rule out an ipsilateral femoral neck fracture because this

can be missed on initial examination.
Tibial shaft fractures can be caused by direct or indirect
trauma. The limb should be inspected for evidence
of open fractures. Soft-tissue injury can be classified according
to the Tscherne classification: grade 0 has minimal
soft-tissue injury whereas grade III represents a
decompensated compartment syndrome requiring fasciotomy.
Once the lower extremities have been surveyed,
the evaluation should be repeated for the upper
extremities. The physician should reduce dislocations as
soon as possible, dress open fractures and wounds with

saline-soaked gauze, and splint fractures at the first opportunity.

Open fractures are classified according to Gustilo,
from type I (clean punctures) to type III (major disruption
of the soft-tissue envelope). Type III injuries can be
further classified according to the extent of neurovascular
injury. Type IIIa injuries can be closed while type
IIIb injuries require flap coverage, and type IIIc injuries
require revascularization for limb salvage.
Vascular injury must be considered in any extremity
injury, especially with knee dislocations. Pulses and perfusion
must be checked, and if a pulse deficit is present,
all correctable causes should be evaluated: fracture
alignment should be corrected, traction released and restored,
compartments checked, and hypotension corrected
through resuscitation. Ankle-brachial index
(ABI) may provide information about the perfusion of
the limb. An ABI of 0.9 or higher will ordinarily rule
out arterial injury. Angiography remains the gold standard,
however. In the polytrauma patient, formal angiography
may not be possible and a limited study may
be performed in the operating room. Management of
life-threatening injury takes priority over limb salvage.
Trauma Management
Management of the polytrauma patient requires a multidisciplinary
approach because of multiple injuries requiring
intervention from various disciplines including
general surgery, neurosurgery, and orthopaedic surgery.
The trauma surgery team is generally responsible for
coordinating these efforts and obtaining the appropriate
consultations. Most patients will benefit from rapid skeletal
stabilization and mobilization, even when fixation

procedures have to follow abdominal or thoracic surgery.

Every patient must be assessed individually, however,
to avoid serious complications.
The Concept of Damage Control
Although early stabilization of long bone fractures has
been shown to reduce morbidity and length of hospital
stay, there is a subset of patients who may deteriorate in
the face of early, prolonged surgical intervention. The
cause of this decompensation is always difficult to prove
in patients with so many confounding issues, but several
investigators have suggested that the trauma of surgery,
with its systemic effects, superimposed on the initial
trauma of injury, leads to an increased incidence of
ARDS, multiple organ failure, and death. Patients at
risk for these complications are more seriously injured
and include patients with severe chest injuries and severe
hemodynamic shock (Table 2). The development of
these complications is thought to be linked to the proinflammatory
cascades that develop as a result of injury,
resuscitation efforts, and surgical interventions.
Although all polytrauma patients develop a systemic
inflammatory response, the more seriously injured patients
suffer from an increased inflammatory response
and higher levels of cytokine release (interleukin [IL]-1,
tumor necrosis factor) for longer periods of time. This
prolonged inflammatory response is referred to as systemic
inflammatory response syndrome. The inflammatory
mediators such as IL-6 that are liberated during
this cascade event may produce deleterious clinical effects,
further impairing pulmonary function and precipitating
organ failure in other systems. Surgical treatment

of these severely injured patients may result in the release

of additional inflammatory mediators, compounding
the injury.
An increased awareness of the role of these proinflammatory
cascades during surgery has led to the belief
that the second hit or surgical intervention, taking
place after the initial trauma (first hit), should be kept
to a minimum in these severely compromised patients.
This damage control concept was originally developed
as an approach to managing severe abdominal trauma.
As in the original concept, damage control orthopaedic
care is delivered in three stages. The first stage involves
immediate surgery to control bleeding, visceral injury,
gross instability, and contamination. The second stage
focuses on resuscitation and medical optimization. Definitive
surgery to provide rigid fracture fixation, articular
continuity, and soft-tissue coverage is reserved for
the third stage.
The benefits of early skeletal stabilization are well
recognized, and the impact of surgical trauma on polytrauma patients is far from proven. Several studies are
available that suggest that other factors may be to
blame for the increase in complications seen among
these more seriously injured patients. Although many
authors suggest that reamed intramedullary nailing is
the culprit, particularly in the face of pulmonary trauma
and contusion, comparative studies have shown no difference
in the incidence of ARDS or mortality relative
to that treatment. Similarly, the adequacy of early fluid
resuscitation has long been believed to influence the recovery

of these severely injured patients. Finally, studies

of intramedullary fixation among severely injured patients
have shown not only that the patients undergoing
nailing had no increased risk compared with patients
treated otherwise, but that, within these groups, the patients
treated with immediate rodding had less pulmonary
compromise and a lower incidence of ARDS than
patients treated with intramedullary rodding on a delayed
basis.
However, it may be inappropriate to attempt definitive
procedures in some patients with severe chest
trauma or hemodynamic instability. Damage control
principles are well applied in these circumstances.
The first stage care of orthopaedic injuries consists
of fracture and joint reduction, rapid skeletal stabilization,
and control of hemorrhage. Wounds can generally
be washed and superficially dbrided as the patient is
being resuscitated and ventilated, but procedures that
generate more blood loss or tissue damage are avoided.
The second stage of damage control care focuses on
resuscitation and optimization of the patients medical
status. This may require several days in an intensive care
setting, but may also be accomplished over the course of
a few hours without the patient ever leaving the resuscitation
area or operating theater. The patients condition
may be considered stable for definitive care whenever
specific parameters are met (Table 3). The trauma team
may find circumstances under which it is believed
worthwhile to push harder for stabilization of specific
injuries to mobilize the patient and obtain a vertical
chest for improved ventilation and pulmonary toilet.

Spinal and pelvic stabilization are sometimes afforded

priority to allow the patient to be safely moved and positioned.
Similarly, rapid revascularization of a compromised
extremity warrants additional consideration, and
can be accomplished with a temporary shunt and external
fixation.
It is in the third and final stage that delayed definitive
care of individual fractures is performed. Two methods
by which rapid, temporary fracture stabilization can
be performed on the pelvis or long bones are external
fixation and unreamed intramedullary fixation. External
fixation can be accomplished rapidly, with minimal
blood loss, and can be used to span simple, complex, and
segmental fractures as well as traumatized joints. Conversion
to an intramedullary nail or fixation plate is usually
straightforward and carries a low risk of infection
within the first week of treatment. These methods of definitive
fixation may be performed after the patient has
achieved optimal medical status.
Prioritizing Orthopaedic Care
Early and stable fracture fixation is of utmost importance
in the orthopaedic management of most polytrauma
patients. If initial long bone stabilization is delayed
the patient could be at risk for greater morbidity
and mortality. It is useful to prioritize the orthopaedic
problems of polytrauma patients with respect to four
relative periods for intervention, as described by
Tscherne: (1) acute care (first 3 hours after injury);
(2) primary stabilization period (1 to 72 hours); (3) secondary
stabilization period (3 to 8 days after injury);
and (4) tertiary stabilization or rehabilitation period (after

6 to 8 days).
Acute Care
In the acute period, the primary survey and secondary
assessment and hemodynamic resuscitation are accomplished.
Head, chest, abdomen, and pelvic injury are all
recognized and life-saving/limb-saving interventions are
initiated. Significant epidural and subdural bleeding requires
immediate evacuation. Once a hemothorax is diagnosed,
a chest tube drainage should be placed. If
more than 1,500 mL of blood is obtained through the
chest tube or if drainage of more than 200 mL/h for 2 to
4 hours occurs, surgery should be considered. Continued
hemorrhage into the peritoneal cavity of a hemodynamically
unstable patient requires emergent laparotomy.
Bleeding from the pelvic region must be ruled out before
laparotomy is done.
External immobilization must be performed if the
pelvic ring is determined to be unstable. Initial external
immobilization consists of sandbags and straps, beanbags,
or military antishock trousers. The use of military
antishock trousers, however, has been associated with
compartment syndrome and decreased respiratory ability.
In the emergency department, external immobilization
has been shown to decrease blood loss and to lower

ISS dependent mortality. Moreover, transfusion requirements

are decreased in patients treated with external
immobilization. External fixation can be applied in the

emergency department or operating room in concert

with other trauma surgery procedures.
Open fractures and joint injuries will require emergent
dbridement and stabilization. These wounds
should not be closed primarily, and may require deep
dbridement and repeated irrigation when the patient is
more stable. Open pelvic injuries require emergent
dbridement, and perineal wounds that communicate
with the rectum or colon require diverting colostomy.
Vaginal injuries associated with pelvic ring disruptions
should be repaired to stop hemorrhage and to prevent
the development of abscesses. Degloving injuries of the
skin should be dbrided.
Established or incipient compartment syndromes
should be treated with adequate fasciotomy at the first
opportunity. Although fully developed compartment
syndrome is rarely seen at initial presentation, patients
with severe crushing injuries or prolonged ischemia of
the limb should undergo prophylactic fasciotomy under
their first anesthetic, if at all possible.
Primary Stabilization Period
Maintaining adequate perfusion of the spinal cord helps
to minimize secondary injury to the neural elements. Urgent
care then focuses on methods of preventing further
damage and rapid realignment of the spine to decompress
neurologic structures. High-dose methylprednisolone
is commonly used to treat patients presenting with
a spinal cord injury with no contraindications to use.
Despite widespread use and a perception that steroid
therapy represents the standard of care for spinal cord
injured patients, in reality steroid therapy simply represents

a treatment option, and a controversial one at

that. There is scant evidence that this intervention provides
consistent or functionally significant improvement
in neurologic outcomes. H2 blockers or proton pump inhibitors
should be considered to prevent formation of
gastric stress ulcers.
Compression of the neural elements from spinal
malalignment such as a cervical spine facet dislocation
should be addressed as soon as hemodynamic and respiratory
stability has been achieved. Although a controversial
issue, the use of MRI before reduction of dislocations
to rule out disk extrusion that could compress
the cord after reduction has been advocated. MRI also
provides details of bone or disk fragments causing spinal
cord compression or the presence of hematoma.
The issue of when to surgically stabilize patients
with spinal injury and neurologic deficit remains controversial.
Emergency surgery for spinal cord injury has not
been clinically proven to be beneficial. However, some
studies indicate that patients with incomplete lesions
probably benefit from early intervention to relieve persistent
neurologic compression.
On the other hand, urgent surgical treatment (< 24
hours after injury) does not increase the risk to the spinal
cord injured patient, compared with early care (1 to
3 days after injury), and can improve the overall outcome
of the polytrauma patient. Urgent stabilization of
the fractured spine allows immediate mobilization of
the patient, reducing risks of prolonged recumbency
(thrombophlebitis, pulmonary embolism, pneumonia,
urosepsis, and ARDS). This appears to hold true for

even the most severely injured patients. Urgent surgical

stabilization among patients with a mean ISS of 40 or
greater reduced overall mortality from expected, and reduced
or eliminated pulmonary complications such as
pneumonia, pulmonary embolus, and ARDS. Although
this does not suggest that all spine fracture patients
should be rushed to the operating room for urgent surgery,
it does suggest that it is safe to proceed on an urgent
basis when compelled to do so.
The benefits of early long bone stabilization have
been well established. It has been shown that patients
with femoral shaft fractures with an ISS greater than 18
who had early stabilization experienced a decrease in
the incidence of ARDS, pulmonary complications, and
length of intensive care unit stay.
Controversy exists regarding reaming during intramedullary
nailing in patients with severe pulmonary
injury. Marrow contents and bone fragments may embolize
during reaming, and it has been proposed that embolization
of such contents may lead to an inflammatory
response as well as mechanical blockage, exacerbating
the existing pulmonary injury. However, several recent
studies have suggested that the extent of the primary
pulmonary injury is the major determinant of pulmonary
morbidity. As noted earlier, a study examining intramedullary
fixation versus plating of femur fractures
demonstrated no difference in pulmonary complications.
Vascular injury must be recognized immediately in
injured extremities. Timely diagnosis and treatment can
minimize ischemic injury. Although arterial reconstruction
has high priority, bony stability may need to be

achieved before vascular repair. If immediate repair is

not possible, a temporary shunt may be placed. Compartment
syndrome should be anticipated and treated
immediately with fasciotomy. In obtunded polytrauma
patients clinical examination may not prove to be reliable.
Compartment pressures within 30 mm Hg of diastolic
pressure are consistent with compartment syndrome
and thus a fasciotomy should be performed.
Treatment of open fractures involves administration
of antibiotics and extensive surgical dbridement. Stable
fixation of the fracture is advocated. Currently, extensive
soft-tissue injuries and associated tibia and femur
fractures (grade III) are safely treated with intramedul-

lary nailing whereas in the past these injuries were

treated with external fixation.
Soft-tissue injuries may require extensive dbridement
and reconstruction to ensure adequate coverage of
bone, tendons, vessels, nerves, and implants. If a large
soft-tissue defect is present, the decision on the type of
reconstruction should be made at the second dbridement
or second look, which is usually performed at
48 hours. Coverage with either a local or free vascularized
flap should be performed within 72 hours of injury.
In the setting of multiple closed fractures, long bone
fractures of the lower extremity should be stabilized
first. Because of the extensive soft-tissue damage and
blood loss associated with uncontrolled spasm and instability,
femur and tibia fractures should be reduced and
stabilized first, whereas fractures of the upper extremity

can be splinted initially, with good results. Pelvic and

spinal fractures may be definitively treated after treating
the lower extremity fractures, in most cases, but unstable
cervical injuries may warrant earlier treatment,
maintaining the long bone fractures in traction until the
spinal segment is adequately fixed. Upper extremity
fractures may be definitively managed after addressing
the above injuries.
Secondary Stabilization Period
During the secondary stabilization period, the patient is
hemodynamically stable and surgical intervention is performed
on a semielective basis. It is at this time that
dbridement of any areas of soft-tissue necrosis is performed.
Secondary wound closure and some soft-tissue
reconstructions may be achieved. Intra-articular reconstruction,
hand, foot, and upper extremity fracture fixation,
and complex spinal and pelvic and acetabular reconstruction
may be performed at this time.
Tertiary Stabilization Period
Late reconstructive procedures may be performed in
the tertiary stabilization period, including definitive closure
of amputation sites or any procedure that may
have been postponed during the secondary stabilization
period. The prognosis of the patient is usually known.
If the patient is stable and is extubated, rehabilitation
may begin. This process should be started on an inpatient
basis and should be taken through the outpatient
phase if necessary.
Long-Term Outcome
Advanced age and increased severity of injury is associated
with increased mortality in the short term. Longterm

outcomes of polytrauma patients vary with the severity

of injury initially sustained. Severity of injury is
associated with greater disability, higher rate of unemployment
after injury, and lower quality of life. Studies
examining both subjective and objective outcomes data
among patients with multiple extremity fractures have
demonstrated that functional disabilities are greatest for
injuries below the knee. Intra-articular injuries to the
foot and ankle, in particular, tend to impair patients who
have had an otherwise satisfactory recovery from
trauma. Additionally, recent evidence indicates that
polytrauma patients sustaining cord or cauda equina injury
at the time of spinal fracture have poorer functional
outcomes and poorer return to work, even among
those with good neurologic recovery.