Chapter 15
The Polytrauma Patient
Hargovind DeWal, MD
Robert McLain, MD
Introduction
The management of the multiply injured or polytrauma
patient requires a multidisciplinary approach integrating
organ- and injury-specific treatment protocols. Multiple
traumainjury to multiple organ systemscan directly
or indirectly trigger processes that may injure specific
organs, disrupt metabolic processes, interrupt normal
endocrine function, create hemodynamic and physio-
logic instability, and lead to highly lethal systemic dis-
eases 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 disor-
ders, 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 or-
thopaedic injuries is discussed in the recent literature
and should be observed to minimize the risk of com-
pounding 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 re-
constructive surgeons may all play a role in the care of a
single patient. It is imperative that all of these individu-
als 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, inter-
ventions, line care, and respiratory support must be im-
mediate and available around the clock. Nursing staff
must understand the fragility of the patient and recog-
nize that changes in respiratory or circulatory parame-
ters may require immediate attention and response.
Staff must also be familiar with protocols for mobiliza-
tion, deep venous thrombosis prophylaxis, and pulmo-
nary 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
American Academy of Orthopaedic Surgeons
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 func-
tion and community life.
These patients often face some likelihood of perma-
nent impairment and long-term disability. Advances
have been made in all aspects of polytrauma care, rang-
ing 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 re-
covery 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 pa-
tient has been shown to improve care and reduce the
likelihood of missed injuries. Patients with multiple inju-
ries typically arrive in the emergency department under
the care of another health care provider, most often a
trained emergency medical technician, who will have as-
sessed the patient in the field, established intravenous
access, and may have intubated the patient to restore or
maintain the airway. They will provide important infor-
mation on the mechanism of injury, the patients condi-
tion at the time of first contact, and evidence of neuro-
logic function, respiratory status, and responsiveness at
the time of initial resuscitation. Their initial observa-
tions may provide important perspective as to the pa-
tients improvement or deterioration when compared
with the initial assessment in the emergency depart-
ment.
Once the patient arrives in the emergency depart-
ment, resuscitation and a primary assessment begin si-
multaneously. These two processes are interdependent
in that the purpose of the primary assessment is to find
the causes of hemodynamic instability, respiratory im-
pairment, and circulatory collapse at the same time oth-
ers on the team are trying to restore those functions
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vomitus, and intubation performed as necessary. The ar-

Table 1 | Serious Disorders for Which the Polytrauma
Patient is at Risk terial blood gas will assess degree of oxygenation. If ox-
ygenation is inadequate, pulmonary function, including
Pulmonary contusions, aspiration, Cardiac ischemia, contusion, tam- tension pneumothorax, hemothorax, and flail chest,
pneumonia ponade should be reinvestigated.
Thromboembolic disease Hypothermia
Urosepsis Open, contaminated wounds, burns Breathing: Thoracic Injuries
Anemia Spinal cord injury Signs of major thoracic injury during the primary sur-
Systemic hypotension and hemor- Acute pulmonary embolism vey, including tension pneumothorax, open pneumotho-
rhagic shock Endocrine dysfunction rax, flail chest, massive hemothorax, and cardiac tam-
Renal insufficiency, acute tubular Hemothorax, pneumothorax, ponade (discussed in the following section) should be
necrosis pyothorax noted.
Immunosuppression Compartment syndrome Tension pneumothorax develops as air leaks into the
Malnutrition Multiple organ failure syndrome chest cavity either through the chest wall or from the
Pancreatitis Delirium lung. The air enters via a one-way valve mechanism
Myonecrosis, myoglobinemia Ischemic brain injury and does not exit the cavity. The affected lung collapses
Coagulopathy Septic shock and as air continues to build up, the mediastinum is dis-
Electrolyte disturbances Iatrogenic injury placed to the contralateral side, impeding venous return
Peptic ulcer disease Neurogenic shock and compressing the uninjured lung. The diagnosis is
Gastrointestinal disease made on the clinical findings of absent breath sounds
Decubitus ulcers and a hyperresonant percussion note. A chest radio-
graph is not required before treatment is initiated.
Treatment consists of immediate decompression by in-
through volume replacement, ventilation, and pharma- sertion of a large bore needle into the second intercostal
cologic support. Once the primary survey is complete space in the midclavicular line of the affected side, fol-
and the patients condition begins to stabilize, a second- lowed by chest tube placement.
ary, more complete survey is conducted, and the team Open pneumothorax results from large defects in
can begin to formulate a plan for definitive care. the chest wall. Air will preferentially enter the chest
cavity through the defect rather than the trachea when
Primary Survey the diaphragm contracts. Initial management includes
Initial management of the polytrauma patient begins placement of an occlusive dressing covering the wound
with an assessment of airway, breathing, and circulation, edges, taped on three sides, allowing the dressing to oc-
along with neurologic status (disability) and environ- clude the wound with each inhalation and allowing for
mental exposure. Advanced Trauma Life Support guide- air to escape during exhalation. A chest tube should be
lines set forth by the American College of Surgeons ad- inserted at a site away from the wound as soon as possi-
vocate use of both the primary and secondary survey to ble.
provide an orderly, consistent approach that will rapidly Flail chest occurs in the presence of multiple rib
reveal life- and limb-threatening injuries. The secondary fractures and is usually associated with an underlying
survey consists of a head-to-toe evaluation and history. pulmonary contusion. The flail chest segment demon-
Both the primary and secondary survey should be re- strates paradoxical chest wall motion with inspiration
peated as needed to ascertain any change in the pa- and expiration, impairing ventilation. The paradoxical
tients status. Initial radiographs should include those of motion is not solely responsible for the associated hy-
the chest, pelvis, and cervical spine, all obtained immedi- poxia. Pain results in restricted chest wall motion, and
ately after the primary survey is complete. pulmonary contusion contributes significantly to devel-
opment of hypoxia. Intubation and ventilation may be
Airway necessary if hypoxia is progressive and unresponsive to
Assessment of the airway and breathing begins immedi- initial measures.
ately, in the field. The patient must be making an effort Massive hemothorax, the rapid accumulation of at
to breath, be successfully moving air, and be adequately least 1,500 mL of blood in the chest, may be the result
transferring oxygen to the circulating blood. Evaluation of blunt or penetrating trauma. The blood loss may con-
of effort, chest wall excursion, and breath sounds should tribute to hypoxia, and initial management includes
be done immediately on arrival. The physician should both restoration of blood volume and decompression of
look for cyanosis and obtain an arterial blood gas sam- the chest cavity by chest tube placement. Massive he-
ple. Mechanical obstruction should be addressed imme- mothorax often requires thoracotomy to control the
diately, looking for loose teeth, dentures, blood, food, or source of hemorrhage.

160 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8
Circulation
Evaluation of circulation involves physical examination
and an assessment of vital signs including blood pres-
sure and heart rate. Intravenous fluid infusion is recom-
mended in all patients, and is usually started before
reaching the hospital. Resuscitation should be moni-
tored by blood pressure, heart rate, perfusion, and urine
output. If the extremities are cold, clammy, and/or cyan-
otic, the patient should be treated for hypovolemia irre-
spective 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 gradi-
ent should be calculated to detect ventilation-perfusion
mismatches. Crystalloid infusion is used in the initial
management of these patients, through large bore intra-
venous access. If intravenous access is not readily avail-
able, cutdown on the saphenous, femoral, or cubital
veins may be necessary.
For patients who are experiencing exsanguination, im-
mediate 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 usu-
ally results from penetrating injuries. The diagnosis is of-
ten difficult, and it must be distinguished from tension
pneumothorax. The classic diagnostic finding of Becks
triad consists of (1) venous pressure elevation, (2) de-
cline in arterial pressure, and (3) muffled heart tones.
Kussmauls sign, a rise in venous pressure with sponta-
neous inspiration, may be present in cardiac tamponade.
An echocardiogram may aid in diagnosis, but a false-
negative result may be seen in about 5% of patients. Ex-
amination of the pericardial sac may also be performed
during a focused abdominal ultrasound. Prompt evacua-
tion of the pericardial blood (usually by pericardiocen-
tesis) is indicated for patients who do not respond to
usual resuscitative measures. A pericardial window, tho-
racotomy and pericardiotomy, may be necessary.
Head Injury
All trauma patients should receive a minineurologic ex-
amination consisting of a Glasgow Coma Scale (GCS)
score. This scoring system has prognostic value with re-
gard to future neurologic function. A decline in the
GCS score may indicate intracranial pathology. Reflexes
of the triceps, biceps, knee, and ankle should be evalu-
ated.
The minimum GCS score is 3 and is seen in flaccid
patients who are unable to open their eyes spontane-
ously or speak. Patients who do open their eyes, obey
American Academy of Orthopaedic Surgeons
Chapter 15 The Polytrauma Patient
commands, and are oriented score the maximum of 15
points. A GCS score of 8 or less corresponds to the gen-
erally 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 abbrevi-
ated 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 accu-
rately predict outcome for those individuals with a se-
vere 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 inju-
ries hypoxia must be corrected before resuscitation is
successful.
Abdomen
During the primary survey, assessment of circulation, es-
pecially in blunt trauma patients, includes a thorough
abdominal examination to rule out hemorrhage. Perito-
neal signs such as rigidity and rebound are useful to di-
agnose a surgical abdomen, but may not always be ap-
parent in obtunded patients.
The Focused Assessment with Sonography for
Trauma examination is now widely used to further eval-
uate 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 lav-
age and CT scan, but the examination is operator de-
pendent. 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 intra-
abdominal trauma in one group of 372 patients.
CT scan is used only in patients who are hemody-
namically stable and who have no immediate indication
for a laparotomy. CT can evaluate the extent of a spe-
cific organ injury and can also help in the diagnosis of
retroperitoneal and pelvic organ injuries not readily ap-
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parent on clinical examination. CT may also be per-

formed serially to evaluate spleen, liver, and kidney in-
juries not requiring immediate surgical intervention.

Spine
Injuries to the spinal column should always be sought in
polytrauma patients. Occult spinal injuries may be over-
looked in patients with an altered level of conscious-
ness. Inadequate immobilization and excessive manipu-
lation may cause additional damage in a patient with
spinal injury and may worsen the outcome. In hemody-
namically 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 boggi-
ness. 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 sensa-
tion, rectal sphincter tone, and bulbocavernosus reflex.
Serial examinations should be performed to document Figure 1 Radiograph of a patient who sustained multiple injuries during a head-on
motor vehicle accident. Cognitively impaired because of head injury and intoxication,
any progression of neurologic deficits. A neurologic def- the patient was combative, denied neck or extremity pain, and demanded release from
icit may be classified as complete, in which there is total the cervical collar. Cervical precautions were maintained through resuscitation, emer-
absence of motor or sensory function below the level of gent laparotomy, and multiple emergent studies. Definitive cervical radiographs dem-
onstrated grossly unstable three-column cervical dissociation. The patient was treated
injury, or incomplete. Identifying any distal motor or definitively during the secondary stabilization period, with no neurologic injury or im-
sensory sparing (incomplete injury) is essential, as these pairment.
patients warrant treatment on a more urgent basis.
Spinal shock refers to the flaccidity and loss of re-
A full radiographic spinal survey, including cervical,
flexes, specifically sacral reflexes, after spinal cord injury.
thoracic, and lumbosacral radiographs, is necessary in all
The return of these reflexes marks the end of spinal shock.
The diagnosis of a complete neurologic injury cannot be patients with a suspected spinal cord injury. Patients
made during spinal shock. with spinal cord injury at one level may have another
Neurogenic shock manifests itself through hypoten- injury at a noncontiguous level 5% to 20% of the time.
sion and bradycardia, and must be distinguished from car- Lateral cervical radiographs must show the cervicotho-
diogenic shock, which is characterized by hypotension and racic junction, or a lateral swimmers view or CT should
tachycardia. Neurogenic shock should be treated with ju- be obtained through this area. An AP odontoid view
dicious use of fluid resuscitation and vasopressors. Atro- should also be obtained. Although patients with persis-
pine may be useful to treat the bradycardia. tent pain despite normal radiographs may eventually
It is unlikely that an awake, alert, neurologically nor- benefit from flexion/extension views to identify liga-
mal patient without pain or tenderness along the spine mentous injury, there is rarely a role for flexion/
has any spinal injury. However, patients with an altered extension radiographs in the initial evaluation of the
level of consciousness (head injury, intoxication, hy- trauma patient.
poxia) need to have their normal radiographs corrobo- CT is useful in delineating the extent of bony inju-
rated via an adequate physical examination before neck ries detected on plain radiographs. MRI is useful in pa-
injury can be formally ruled out (Figure 1). tients with abnormal neurologic findings. In patients

162 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8
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 anterior-
posterior stress through the ASIS, and by checking sta-
bility 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 in-
jury. Higher energy injuries are more likely to be associ-
ated with an increased severity of fracture. Pelvic frac-
tures 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 va-
gina or rectum, associated urologic or neurologic inju-
ries, 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 deter-
mined 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 hemor-
rhage 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 un-
stable 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 ac-
idosis. These factors may contribute to coagulopathy,
complicating the existing problem and leading to further
bleeding. Persistent hypotension can aggravate pulmo-
nary and neurologic injury, and compromise renal, cere-
bral, and cardiac function. In addition, the risk of sepsis,
adult respiratory distress syndrome (ARDS), and multi-
ple organ failure is increased in these patients.
American Academy of Orthopaedic Surgeons
Chapter 15 The Polytrauma Patient
Particular attention should be paid to open pelvic in-
juries because they are associated with exceptional mor-
bidity and mortality and will require emergent dbride-
ment. Rectal and vaginal examinations must be
performed to rule out lacerations. Associated urologic
injuries should be sought. Clinical findings that may in-
dicate injury include blood at the urethral meatus, high-
riding 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 correla-
tion with the physical examination to determine the sta-
bility of the pelvis. In a recent study, it was determined
that physical examination was accurate in identifying in-
juries of the posterior pelvic ring. Signs of instability in-
cluded 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 trans-
verse 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 radio-
graphs as well as CT scan can help further clarify the
degree of pelvic instability.
Classification of these injuries can help guide defini-
tive management. (1) The estimated blood loss for a se-
vere 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 inci-
dence 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 mor-
tality, 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 associ-
ated with severe soft-tissue and neurovascular trauma
that can render the extremity dysfunctional or even
nonviable.
Initial evaluation includes palpation of the entire ex-
tremity to the foot and a thorough neurovascular exam-
ination. 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
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Table 2 | Factors in Severely Injured Patients That May
Warrant a Damage Control Treatment Approach
Multiple injuries with an ISS > 20, and a thoracic trauma AIS >2
Multiple injuries with abdominal/pelvic trauma, and hemorrhagic shock
(systolic BP < 90 mm Hg)
ISS > 40
Chest radiograph or CT evidence of bilateral pulmonary contusion
Initial mean pulmonary arterial pressure > 24 mm Hg
Pulmonary artery pressure increase during intramedullary nailing
> 6 mm Hg
rule out an ipsilateral femoral neck fracture because this
can be missed on initial examination.
Tibial shaft fractures can be caused by direct or indi-
rect trauma. The limb should be inspected for evidence
of open fractures. Soft-tissue injury can be classified ac-
cording to the Tscherne classification: grade 0 has mini-
mal soft-tissue injury whereas grade III represents a
decompensated compartment syndrome requiring fas-
ciotomy. Once the lower extremities have been sur-
veyed, 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 op-
portunity.
Open fractures are classified according to Gustilo,
from type I (clean punctures) to type III (major disrup-
tion of the soft-tissue envelope). Type III injuries can be
further classified according to the extent of neurovascu-
lar 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 per-
fusion must be checked, and if a pulse deficit is present,
all correctable causes should be evaluated: fracture
alignment should be corrected, traction released and re-
stored, compartments checked, and hypotension cor-
rected 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 stan-
dard, however. In the polytrauma patient, formal an-
giography 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 mul-
tidisciplinary approach because of multiple injuries re-
quiring intervention from various disciplines including
general surgery, neurosurgery, and orthopaedic surgery.
The trauma surgery team is generally responsible for
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Orthopaedic Knowledge Update 8
coordinating these efforts and obtaining the appropriate
consultations. Most patients will benefit from rapid skel-
etal stabilization and mobilization, even when fixation
procedures have to follow abdominal or thoracic sur-
gery. Every patient must be assessed individually, how-
ever, 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 se-
vere hemodynamic shock (Table 2). The development of
these complications is thought to be linked to the proin-
flammatory 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 pa-
tients 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 sys-
temic inflammatory response syndrome. The inflamma-
tory mediators such as IL-6 that are liberated during
this cascade event may produce deleterious clinical ef-
fects, further impairing pulmonary function and precipi-
tating organ failure in other systems. Surgical treatment
of these severely injured patients may result in the re-
lease of additional inflammatory mediators, compound-
ing the injury.
An increased awareness of the role of these proin-
flammatory 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. De-
finitive surgery to provide rigid fracture fixation, articu-
lar 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 poly-
American Academy of Orthopaedic Surgeons
Orthopaedic Knowledge Update 8
trauma 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 dif-
ference 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 re-
covery of these severely injured patients. Finally, studies
of intramedullary fixation among severely injured pa-
tients have shown not only that the patients undergoing
nailing had no increased risk compared with patients
treated otherwise, but that, within these groups, the pa-
tients treated with immediate rodding had less pulmo-
nary compromise and a lower incidence of ARDS than
patients treated with intramedullary rodding on a de-
layed basis.
However, it may be inappropriate to attempt defini-
tive 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 stabiliza-
tion, 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 resusci-
tation 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 po-
sitioned. Similarly, rapid revascularization of a compro-
mised extremity warrants additional consideration, and
can be accomplished with a temporary shunt and exter-
nal fixation.
It is in the third and final stage that delayed defini-
tive care of individual fractures is performed. Two meth-
ods 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. Con-
version to an intramedullary nail or fixation plate is usu-
American Academy of Orthopaedic Surgeons
Chapter 15 The Polytrauma Patient
Table 3 | Criteria for Adequate Resuscitation
Hemodynamically stablewarm and well perfused
Stable oxygen saturation
Lactate level < 2 mmol/L
No coagulopathy, INR < 1.25
Normal body temperature
Urine output > 1 mL/kg/h
Not requiring inotropic support
INR= International Normalized Ratio
ally straightforward and carries a low risk of infection
within the first week of treatment. These methods of de-
finitive fixation may be performed after the patient has
achieved optimal medical status.
Prioritizing Orthopaedic Care
Early and stable fracture fixation is of utmost impor-
tance in the orthopaedic management of most poly-
trauma patients. If initial long bone stabilization is de-
layed 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) sec-
ondary stabilization period (3 to 8 days after injury);
and (4) tertiary stabilization or rehabilitation period (af-
ter 6 to 8 days).
Acute Care
In the acute period, the primary survey and secondary
assessment and hemodynamic resuscitation are accom-
plished. Head, chest, abdomen, and pelvic injury are all
recognized and life-saving/limb-saving interventions are
initiated. Significant epidural and subdural bleeding re-
quires immediate evacuation. Once a hemothorax is di-
agnosed, 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 hemodynam-
ically unstable patient requires emergent laparotomy.
Bleeding from the pelvic region must be ruled out be-
fore 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, bean-
bags, or military antishock trousers. The use of military
antishock trousers, however, has been associated with
compartment syndrome and decreased respiratory abil-
ity. In the emergency department, external immobiliza-
tion has been shown to decrease blood loss and to lower
165
The Polytrauma Patient
ISS dependent mortality. Moreover, transfusion require-
ments 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 emer-
gent 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. Ur-
gent care then focuses on methods of preventing further
damage and rapid realignment of the spine to decom-
press neurologic structures. High-dose methylpredniso-
lone 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 repre-
sents a treatment option, and a controversial one at
that. There is scant evidence that this intervention pro-
vides consistent or functionally significant improvement
in neurologic outcomes. H2 blockers or proton pump in-
hibitors 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 respi-
ratory stability has been achieved. Although a contro-
versial issue, the use of MRI before reduction of dislo-
cations 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 spi-
nal cord compression or the presence of hematoma.
The issue of when to surgically stabilize patients
with spinal injury and neurologic deficit remains contro-
versial. Emergency surgery for spinal cord injury has not
been clinically proven to be beneficial. However, some
studies indicate that patients with incomplete lesions
166
Orthopaedic Knowledge Update 8
probably benefit from early intervention to relieve per-
sistent neurologic compression.
On the other hand, urgent surgical treatment (< 24
hours after injury) does not increase the risk to the spi-
nal cord injured patient, compared with early care (1 to
3 days after injury), and can improve the overall out-
come 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 re-
duced 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 sur-
gery, it does suggest that it is safe to proceed on an ur-
gent 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 in-
tramedullary nailing in patients with severe pulmonary
injury. Marrow contents and bone fragments may embo-
lize during reaming, and it has been proposed that em-
bolization 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 pulmo-
nary morbidity. As noted earlier, a study examining in-
tramedullary fixation versus plating of femur fractures
demonstrated no difference in pulmonary complica-
tions.
Vascular injury must be recognized immediately in
injured extremities. Timely diagnosis and treatment can
minimize ischemic injury. Although arterial reconstruc-
tion 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. Com-
partment syndrome should be anticipated and treated
immediately with fasciotomy. In obtunded polytrauma
patients clinical examination may not prove to be reli-
able. Compartment pressures within 30 mm Hg of dias-
tolic pressure are consistent with compartment syn-
drome 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, exten-
sive soft-tissue injuries and associated tibia and femur
fractures (grade III) are safely treated with intramedul-
American Academy of Orthopaedic Surgeons
Orthopaedic Knowledge Update 8
lary nailing whereas in the past these injuries were
treated with external fixation.
Soft-tissue injuries may require extensive dbride-
ment 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 dbride-
ment or second look, which is usually performed at
48 hours. Coverage with either a local or free vascular-
ized 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 insta-
bility, 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 treat-
ing the lower extremity fractures, in most cases, but un-
stable 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 per-
formed on a semielective basis. It is at this time that
dbridement of any areas of soft-tissue necrosis is per-
formed. Secondary wound closure and some soft-tissue
reconstructions may be achieved. Intra-articular recon-
struction, hand, foot, and upper extremity fracture fixa-
tion, and complex spinal and pelvic and acetabular re-
construction may be performed at this time.
Tertiary Stabilization Period
Late reconstructive procedures may be performed in
the tertiary stabilization period, including definitive clo-
sure 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, rehabilita-
tion may begin. This process should be started on an in-
patient basis and should be taken through the outpa-
tient phase if necessary.
Long-Term Outcome
Advanced age and increased severity of injury is associ-
ated with increased mortality in the short term. Long-
term outcomes of polytrauma patients vary with the se-
verity of injury initially sustained. Severity of injury is
associated with greater disability, higher rate of unem-
ployment after injury, and lower quality of life. Studies
examining both subjective and objective outcomes data
American Academy of Orthopaedic Surgeons
Chapter 15 The Polytrauma Patient
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 in-
jury at the time of spinal fracture have poorer func-
tional outcomes and poorer return to work, even among
those with good neurologic recovery.
Annotated Bibliography
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The authors compared femoral plating versus intramedul-
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head-injured patients. The study group included 119 patients
with severe head injuries and lower extremity fractures. There
was no significant difference in mortality rates between pa-
tients treated with intramedullary nailing or plating. The stron-
gest predictor of mortality was the severity of the initial head
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Cook RE, Keating JF, Gillespie I: The role of angiogra-
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tures of the pelvis. J Bone Joint Surg Br 2002;84:178-182.
This study examined 150 patients with unstable pelvic frac-
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going angiography prior to external fixation or laparotomy,
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Giannoudis PV: Surgical priorities in damage control in
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The authors report their experience with blunt abdominal
aortic disruption at regional trauma centers. Eight cases were
identified, six of which were associated with thoracolumbar
fractures, with a mean ISS of 42. All spinal fractures were as-
sociated with a distractive force pattern. The authors con-
cluded that with all distractive thoracolumbar injuries, aortic
disruption must be considered as this injury may occur as a re-
sult of similar distractive forces.
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The Polytrauma Patient
McCormick JP, Morgan SJ, Smith WR: Clinical effective-
ness of the physical examination in diagnosis of poste-
rior pelvic injuries. J Orthop Trauma 2003;17:257-261.
This article presents a prospective study evaluating the
correlation of physical examination to radiographic studies in
the diagnosis of posterior pelvic ring disruptions. Of those pa-
tients found to have posterior pelvic ring disruptions as shown
on CT scan, 98% had posterior pelvic pain on examination.
The authors concluded that physical examination was accurate
in detecting injuries of the posterior pelvic ring.
Miller MT, Pasquale MD, Bromberg WJ, Wasser TE,
Cox J: Not so FAST. J Trauma 2003;54:52-59.
The authors performed a study comparing a Focused As-
sessment with Sonography for Trauma with CT scan to com-
pare accuracy in diagnosis of injury in patients sustaining
blunt abdominal trauma. A total of 372 patients were studied
and it was noted that the Focused Assessment with Sonogra-
phy for Trauma examination underdiagnosed significant intra-
abdominal trauma. The authors concluded that patients who
are hemodynamically stable who sustain blunt abdominal
trauma should undergo CT scan for further evaluation for
more accurate diagnosis of intra-abdominal injuries.
Zalavras CG, Patzakis MJ: Open fractures: Evaluation
and management. J Am Acad Orthop Surg 2003;11:212-
219.
This article is a review of the literature regarding manage-
ment of open fractures. The authors discuss the controversies
regarding wound closure. Soft-tissue coverage of large and
contaminated wounds is also discussed.
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Orthopaedic Knowledge Update 8
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Chapman MW: The role of intramedullary fixation in
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American Academy of Orthopaedic Surgeons