Review Article

Timing of Fracture Fixation in

Multitrauma Patients: The Role of
Early Total Care and Damage
Control Surgery

Abstract
Hans-Christoph Pape, MD The optimal timing of surgical stabilization of fractures in the
Paul Tornetta III, MD multitrauma patient is controversial. There are advantages to early
definitive surgery for most patients. Early temporary fixation using
Ivan Tarkin, MD
external fixators, followed by definitive fixation (ie, the damage
Christopher Tzioupis, MD control approach), may increase the chance for survival in a subset
Vani Sabeson, MD of patients with severe multisystem injuries. Improved
Steven A. Olson, MD understanding of the pathophysiology of trauma has led to a
greater ability to identify patients who would benefit from damage
control surgery. A patient is classified as physiologically stable,
unstable, borderline, or in extremis. The stable patient can undergo
fracture surgery as necessary. An unstable patient should be
resuscitated and adequately stabilized before receiving definitive
orthopaedic care. The decision whether to perform initial temporary
Dr. Pape is W. Pauwels Professor or definitive fixation in the borderline patient is individualized based
and Chairman of Orthopaedic/
Trauma Surgery, University of
on the clinical condition. In patients presenting in extremis, life-
Aachen, Aachen, Germany, and saving measures are pivotal, followed by a damage control
Adjunct Professor, Division of approach to their injuries.
Orthopaedic Traumatology,
University of Pittsburgh Medical
Center, Pittsburgh, PA. Dr. Tornetta

T
is Chief, Trauma Surgery, Boston he timing of definitive fixation control approach. Recent clinical
Medical Center, Boston, MA.
Dr. Tarkin is Chief, Trauma Service, of major extremity fractures in data have yielded recommendations
and Assistant Professor, University the multitrauma patient has been the for optimal musculoskeletal care of
of Pittsburgh Medical Center. subject of debate for the past four the multitrauma patient. Historically,
Dr. Tzioupis is Research Fellow,
decades. Recommendations for early several eras can be differentiated.
University of Pittsburgh Medical
Center. Dr. Sabeson is Resident, total care versus a damage control
Division of Orthopaedic Surgery, approach are based on the physiol-
Duke University School of Medicine,
ogy of these critically ill patients, Rationale for Delayed
Durham, NC. Dr. Olson is Chief, Fixation: The 1960s
Division of Orthopaedic Surgery, with the benefits of early fracture
Duke University School of Medicine. stabilization balanced against the po- In the 1960s, immediate stabilization
Reprint requests: Dr. Pape, tential side effects of excessive surgi- of long-bone fracture in the patient
Department of Orthopaedic Surgery, cal burden. Advances in orthopaedic with multiple traumatic injuries was
University of Aachen Medical trauma surgery, along with pivotal
Center, 30 Pauwels Street, 52074
associated with an unacceptably high
Aachen, Germany. improvements in anesthesia and criti- mortality rate. The major concern of
cal care medicine, have increasingly surgeons treating multitrauma pa-
J Am Acad Orthop Surg 2009;17:
541-549 enabled orthopaedic surgeons to per- tients was the development of fat
form definitive operations on initial embolism syndrome and associated
Copyright 2009 by the American
Academy of Orthopaedic Surgeons. presentation. However, a subset of pulmonary dysfunction.1 Fat and in-
patients may benefit from a damage tramedullary contents liberated from

September 2009, Vol 17, No 9 541

Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery

the fracture were linked to pulmo- longer intensive care unit (ICU) stay, forts and others culminated in a
nary failure. Perioperative cardiovas- including more episodes of leukocy- change in orthopaedic practice. In
cular and pulmonary support was tosis and fever. light of the convincing results of
not well established, leading to mor- Frequently, musculoskeletal out- Bone et al,9 patients with femur frac-
tality rates of up to 50%.2 As a re- comes are compromised when frac- ture spent less time in traction and
sult, long-bone fractures were ini- ture surgery is delayed. Prolonged were stabilized more rapidly. Time
tially treated with splints, casts, or immobilization prevents initiation of in traction decreased from an aver-
traction until the systemic effects of comprehensive physiotherapy. Major age of 9 days to 2 days.10 However,
fat embolism syndrome resolved. De- joints cannot be exercised, which “early fracture fixation” was loosely
finitive surgical stabilization was of- sometimes leads to profound stiff- defined and could be interpreted as
ten delayed for 10 to 14 days until ness. Disuse muscle atrophy hampers several days after hospital admission.
the pulmonary, cardiovascular, and recovery in the long term.4-7
Along with a better understanding
neurologic systems and the coagula-
of pathophysiology after trauma,
tion profile had stabilized.3
Rationale for Early major improvements were made in
In 1967, Küntscher4 provided three
Fixation: The 1980s the general physiologic support of
recommendations for intramedullary
severely injured patients. Border10
stabilization of major fractures:
A radical shift in the treatment para- emphasized that optimizing nutri-
(1) “Do not nail as long as symp-
digm of the multitrauma patient with tion was correlated with decreased
toms of fat embolization are
major long-bone fracture occurred in mechanical ventilation requirements
present.” (2) “Take special precau-
the 1980s as a result of outcome and prolonged recumbency. Ventila-
tions for patients with multiple frac-
studies that focused on the timing of tion strategies improved and allowed
tures and extensive injuries to soft
orthopaedic fixation and the devel- orthopaedic surgery to be performed
tissues.” (3) “Do not nail immedi-
opment of acute respiratory distress earlier than previously.
ately, but wait a few days.”
syndrome (ARDS). Femur fracture in The principle of early fixation sur-
the multiply injured patient became gery sometimes was interpreted too
Negative Effects of the focus of and the study model for literally, however, resulting in an
Delayed Fixation intensive clinical research. Better out- overly aggressive treatment protocol
comes were achieved in the multi- in the multitrauma patient. Ortho-
Delayed fixation of major fractures trauma patient when intramedullary paedic operations for both major (ie,
is fraught with local and systemic nailing of femur fracture was per- immobilizing) and minor musculo-
implications. Without adequate fixa- formed within the first few days after skeletal injuries were being per-
tion, the patient cannot be mobilized admission.2,6-8 formed within 24 hours of admis-
and is often forced into supine re- Bone et al9 performed the first pro- sion, a practice that appeared to be
cumbency for prolonged periods. spective study that revealed the po- associated with an increased compli-
This can result in dysfunction of tential benefits of early fracture fixa- cation rate.11,12 The beneficial effects
multiple organ systems, leading to a tion. One hundred seventy-eight of fracture fixation were often ne-
variety of disorders, including pneu- patients with acute femoral fracture gated by the harm inflicted to the
monia, decubitus ulcers, vascular were randomized to receive early fix- overall physiology of the patient as a
abnormalities, psychological distur- ation or traction. Within the original result of lengthy operations associ-
bance, and gastrointestinal stasis, study population, 83 presented with ated with substantial blood loss.13
which is associated with a high risk multiple injuries. The cohort of pa- The lessons learned from this overly
of aspiration. Seibel et al5 were the tients treated with traction and late aggressive, comprehensive approach
first to describe an association be- femoral fixation had the highest inci- to managing orthopaedic injuries led
tween delayed stabilization and a dence of ARDS. These research ef- to further consideration of the timing

Dr. Tornetta or a member of his immediate family has received royalties from, has received research or institutional support from, and
serves as a paid consultant to or is an employee of Smith & Nephew, and has stock or stock options held in ExploraMed. Dr. Olson
or a member of his immediate family serves as a board member, owner, officer, or committee member of the Southeastern Fracture
Consortium Foundation, serves as a paid consultant to or is an employee of Synthes, and has received research or institutional
support from Synthes. None of the following authors or a member of their immediate families has received anything of value from or
holds stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Pape, Dr. Tarkin,
Dr. Tzioupis, and Dr. Sabeson.

542 Journal of the American Academy of Orthopaedic Surgeons

 Hans-Christoph Pape, MD, et al

of fracture fixation in the multi- major sources of hemorrhage rather locking of the original implant after
trauma patient. than performing immediate, lengthy, resuscitation and stabilization.
definitive repair of the visceral or- Scalea et al12 used a DCO approach
gans. As part of the damage control on 43 critically ill patients with femo-
Role of the Immune philosophy, immediate life-saving ral fracture who underwent initial ex-
System interventions directed at stopping
ternal fixation followed by conversion
bleeding are applied, after which re-
Trauma causes sustained changes in to an intramedullary nail. They re-
suscitation and further stabilization
the immune response. A hyperin- are performed in the ICU. Only after ported minimal orthopaedic complica-
flammatory early phase may be fol- the overall physiology has improved tions and optimal survival rates. Indi-
lowed by a hypoinflammatory phase, is definitive intervention performed. cations for DCO in this study included
which often precedes the onset of or- This change in trauma practice re- head injury (46%) and hemodynamic
gan failure. The magnitude of the in- sulted in improved survival rates.17 instability (65%). Taeger et al7 re-
flammatory response depends on the Soon orthopaedic trauma surgeons ported a prospective cohort of pa-
used a similar temporizing approach tients treated according to DCO cri-
degree of trauma, and it can be influ-
for major fractures in multitrauma teria and described similar beneficial
enced by treatment. Surgery also in-
patients. Initial surgery was done effects. Pape et al20 reported a lower
cites an inflammatory response.14
with the goal of achieving rapid skel- incidence of pulmonary complica-
In a normal host, there is usually
etal stabilization of major ortho- tions in borderline patients with
no clinically significant consequence
paedic injuries to stop the cycle of femoral fractures (ie, those with in-
to the inflammatory response. How-
ongoing musculoskeletal injury and creased risk of systemic complica-
ever, in the multitrauma patient, ex-
to control hemorrhage. This ap- tions) treated with external fixation
posure to prolonged surgery with
proach was termed damage control initially. The largest study popula-
considerable blood loss and hypo-
orthopaedics (DCO).12 tion was examined by Morshed
thermia causes an exaggerated in-
The external fixator is the primary et al,21 who reviewed 3,069 patients
flammatory response.11,15 In these pa-
tool associated with DCO. This ap- with multisystem trauma. The data
tients, the beneficial effects of early pliance can be used in extremity frac- were housed in the National Trauma
definitive fracture stabilization may tures and in select pelvic fractures Data Bank. Definitive stabilization
not outweigh the associated risk of (Figure 1). A fixator can be applied done within 12 hours was associated
immune-related side effects, such as rapidly and with minimal blood loss. with a higher mortality rate than was
ARDS and multiple organ failure.12 Compared with a splint, access to delayed management. The authors
The surgical impact can act as a sec- the soft tissues is relatively easy, al- concluded that delaying repair of
ond hit (ie, second inflammatory in- lowing for wound management and
femoral shaft fracture beyond 12
sult after the initial trauma) when monitoring of compartment pres-
hours in the multisystem trauma
the timing and the duration are unfa- sure.18 In contrast to skeletal trac-
patient reduces mortality by approx-
vorable. Waiting several days before tion, treatment with initial external
imately 50%. Patients with life-
performing surgery in multitrauma fixation improves patient mobility,
threatening abdominal injury bene-
patients eradicates the danger of this which is beneficial for many aspects
fited most from delayed treatment.
detrimental immunologic response.16 of management, including pulmo-
nary toilet.11 Such fixation also facili-
tates nursing care. In some cases, es- Patient Assessment
Damage Control Surgery pecially those involving severe head
trauma, external fixation can serve The initial patient assessment usually
The term damage control was origi-
as a definitive treatment strategy un- is performed using standard scoring
nally used by the United States Navy
til fracture union. systems such as the Injury Severity
to describe tactics necessary to keep
afloat compromised vessels at sea. Damage control nailing has been Score or the New Injury Severity
General trauma surgeons came to advocated as an alternative to the Score. For life-threatening condi-
apply this term to a management spanning external fixator. In this ap- tions, which frequently are the result
strategy that involves reducing the proach, an unlocked retrograde nail of penetrating trauma, the triad of
impact of the initial operation and is used with limited or no reaming19 death (ie, blood loss, coagulopathy,
improving survival of critically ill pa- (Figure 2). For this treatment, the pa- loss of temperature) approach has
tients. Damage control in general tient is typically returned to the oper- been used. However, in patients with
trauma surgery includes packing the ating room for exchange nailing or blunt trauma, it is important to ac-

September 2009, Vol 17, No 9 543

Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery

Figure 1 Figure 2

Intraoperative photograph
demonstrating the use of an
unreamed, unlocked retrograde
intramedullary nail for rapid
stabilization of a femur fracture in a
multitrauma patient (ie, damage
control nailing).

Table 1
Clinical Parameters to Describe
Multitrauma Patients in
Borderline Condition

ISS >40
Multiple injuries (ISS >20) in associa-
Postoperative photograph demonstrating the use of spanning external tion with thoracic trauma (AIS >2)
fixators for temporary fracture stabilization in a multitrauma patient with Multiple injuries in association with se-
extremity fractures. vere abdominal or pelvic injury and
hemorrhagic shock at presentation
(systolic blood pressure <90 mm Hg)
count for soft-tissue injury, as well. tion are listed in Table 1. Three of the Bilateral femoral fractures
Parameters to assess adequate oxy- four criteria delineated in Table 2 Radiographic evidence of pulmonary
genation are useful for determining (shock, coagulation, temperature <35°C contusion
the clinical status of the patient. [95°F], soft-tissue injuries) should be Hypothermia (temperature <35°C
A patient can be classified as stable present to qualify a patient for a spe- [95°F])
(grade I, cleared for surgery), border- cific category.22 The current level of Additional moderate or severe head
line (grade II, uncertain condition with evidence is insufficient to definitively injuries (AIS ≥3)
episodes of cardiovascular instability stratify patients; thus, the proposed
AIS = Abbreviated Injury Score,
and hypoxemia), unstable (grade III, combination of these parameters is ISS = Injury Severity Score
cardiovascular instability [systolic blood only suggestive. Nevertheless, most
pressure <90 mm Hg]), or in extremis of these components are scores that
(grade IV, acutely life-threatening inju- have been routinely applied and are sponsive to therapy with >10 blood
ries). Although several parameters are widely accepted. units per 6 hours, and requirement
considered in classifying patients, clear For screening purposes, the follow- for vasopressors.20 Inflammatory pa-
numerical cutoffs have not been estab- ing threshold levels have been used: rameters have also been described to
lished; thus, judgment and experience pulmonary dysfunction (Pao2/Fio2 have predictive power for the devel-
are required. The parameters used to <250 mm Hg), platelet count opment of complications. However,
identify a patient in borderline condi- <95,000/mm3, hypotension unre- routine screening for inflammatory

544 Journal of the American Academy of Orthopaedic Surgeons

 Hans-Christoph Pape, MD, et al

Table 2
Criteria Used to Determine the Clinical Condition of Multitrauma Patients and Refer to Treatment Guidelines*
Patient Status

Criterion Parameter Stable Borderline Unstable In Extremis

Shock Blood pressure ≥100 80-100 <90 ≤70

(mm Hg)
Blood units given 0-2 2-8 5-15 >15
in a 2-hr period
Lactate levels Normal range ≈2.5 >2.5 Severe acidosis
(mg/dL) according to local
laboratory
Base deficit level Normal range No data No data >6-8
(mmol/L) according to local
laboratory
ATLS classifica- I (no shock) II-III (slight shock) III-IV (severe shock) IV (severe shock)
tion
Coagulation Platelet count >110,000/mm3 90,000-110,000/mm3 <70,000-90,000/mm3 <70,000/mm3
Factor II and V 90-100 70-89 50-70 <50
(%)
Fibrinogen (g/L) >1 ≈1 <1 Disseminated intra-
vascular coagulation
D-dimer (µg/mL) Normal range Abnormal Abnormal Disseminated intra-
according to local vascular coagulation
laboratory
Temperature °C (°F) <33 (<91.4) 33-35 (91.4-95.0) 30-32 (86.0-89.6) ≤30 (≤86.0)

Soft-tissue Lung function 350-400 300-350 200-300 <200

injuries (Pao2/Fio2
[mm Hg])
Chest trauma 1 or 2 (ie, abrasion) ≥2 (ie, 2-3 rib ≥3 (ie, serial rib ≥3 (ie, unstable chest)
scores (AIS) fractures) fractures >3)
Chest trauma 0 (concussion) I-II (slight thoracic II-III (moderate) IV (severe)
score (thoracic trauma)
trauma severity
score)
Abdominal trauma ≤II (none) ≤III (slight) III (moderate) ≥III (severe)
(Moore classifi-
cation)
Pelvic trauma (AO A (none) B or C (slight) C (moderate) C (crush, rollover,
classification) abdominal)
External AIS I-II (eg, abrasion) AIS II-III (eg, multiple AIS III-IV (eg, <30% Crush injury (>30%
tears >20 cm) burn) burn)

* Three of the four criteria must be met to classify for a certain grade. Note that the condition can change according to resuscitation or
additional hemorrhage.
AIS = Abbreviated Injury Score, ATLS = Advanced Trauma Life Support

markers is not available at many the limb, as well as to limit the time therapy plays an integral role in the
trauma centers.23 in the operating room to ≤2 hours.22 management of orthopaedic wounds.
Within this surgical window, open An initial guillotine amputation may
fractures should be débrided and sta- be lifesaving for the patient who is in
Surgical Priorities
bilized with an external fixator. A extremis because of an extremity
The first surgical priority is to save splint may be sufficient for upper ex- fracture or who has an open fracture
the patient’s life and, when feasible, tremity injuries. Negative pressure with vascular injury. It is not possi-

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Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery

Figure 3

Algorithm for management of femur fracture in borderline and unstable multitrauma patients. CHI = creatinine height
index, ICU = intensive care unit, IM = intramedullary, ISS = Injury Severity Score

ble to indicate specific criteria for ev- of fluids (should not exceed 3 L, or 5 hours following injury.26 Intraopera-
ery situation because each decision units of blood), and absence of sig- tive hypotension is an important risk
must take into account a number of nificant coagulopathy. Provided that factor for secondary brain injury.27
variables. However, some general the patient maintains these levels, the The primary goals of management of
recommendations can be made. surgeon may address the next major traumatic brain injury are mainte-
fracture; otherwise, a temporizing nance of adequate cerebral perfusion
In the patient in extremis, hemor-
approach should be selected.24 In the and avoidance of secondary insults.28
rhage control is paramount, followed
stable patient, all fractures can be de- Treatment of the multitrauma pa-
by stabilization of vital parameters in
finitively stabilized within the first tient with head injury requires a mul-
the ICU. Major fractures are considered
day. An algorithm for treatment of tidisciplinary approach that includes
to be a secondary priority. In the unsta-
borderline and unstable patients is the neurosurgical team, with treat-
ble patient, major lower extremity frac-
presented in Figure 3. ment tailored to the evolving status
tures should be stabilized with a tem-
porary method, such as external of the patient. The degree of cerebral
fixation. In the borderline patient who Head Injury swelling, imminent herniation, and
responds to resuscitation, definitive pro- Following significant head injury, increase in bleeding must be closely
cedures (eg, intramedullary nailing) can the brain loses the capacity for auto- monitored.
be performed but within an upper sur- regulation of blood flow in zones of Clinical studies have provided con-
gical time limit of <2 hours. The patient contusion. Furthermore, glucose uti- flicting results. In one study that
with several lower extremity fractures lization increases, adding to a flow- compared multitrauma patients who
should be continuously reassessed, with metabolism mismatch. Consequently, had closed head injury and femur
particular attention paid to the the injured brain is highly susceptible fracture with multitrauma patients
following parameters: lung function to ischemic injury.25 who had head injury but no femur
(Pao2/Fio2 should not drop below The individual with head trauma is fracture, McKee et al29 reported no
250 mm Hg), temperature (should at greatest risk for decreased cerebral significant difference in mortality, no
not be <32°C [89.6°F]), requirement blood flow during the first 12 to 24 difference in length of stay, and no

546 Journal of the American Academy of Orthopaedic Surgeons

 Hans-Christoph Pape, MD, et al

difference in neurologic outcome ac- action that affects the pulmonary en- complicated by the fracture and not
cording to the timing of stabilization. dothelium, similar to the response to timing of fixation.
However, in a study by Townsend described for general blood loss.33 van Os et al39 found no statistical
et al,30 patients with a Glasgow The progressive nature of a pulmo- difference in the incidence of ARDS
Coma Scale value of <9 on admis- nary contusion can cause problems in patients treated with early versus
sion who were operated on within 2 and is frequently underestimated.34 late fixation and concluded that se-
hours had an eightfold increased risk Early diagnostic studies may not vere thoracic trauma is not a con-
of hypotension. Thirty-six of 43 pa- adequately reveal the extent of the traindication for early osteosyn-
tients with poor neurologic out- evolving lung injury. Even when thesis. Bone et al40 compared three
comes had cerebral perfusion pres- blood gas parameters are within nor- groups of chest-injured patients:
mal limits and the chest radiograph
sures <70 mm Hg within the first 24 those whose femoral fracture was
is normal, pulmonary contusion may
hours. Jaicks et al31 reported that treated with a nail, those whose frac-
occur as a result of the immune re-
fracture fixation in the presence of ture was treated with a plate, and
sponse, resulting in an increased risk
severe head injury has negative ef- those without a femur fracture. The
of ARDS.35,36
fects; however, the authors did not authors concluded that the chest in-
Patient evaluation should be fo-
include in their analysis patients who jury, not the method of femoral frac-
cused on the following clinical crite-
died before discharge. These conflict- ria: presence of a lung contusion on ture fixation, was responsible for
ing results are noteworthy and may the initial chest radiograph or CT ARDS.
be attributable to different inclusion scan, worsening oxygenation (re- Pryor and Reilly41 noted that inclu-
criteria in these respective studies. quirement of increased Fio2 >40% or sion criteria may be responsible for
In the multitrauma patient with Pao2/Fio2 <250 mm Hg), and in- the conflicting results in the litera-
head injury, acceptable thresholds creased airway pressures (eg, >25 to ture. Most publications have relied
for operating room time, blood loss, 30 cm H2O). Pulmonary function on the Abbreviated Injury Scale for
and temperature loss must be deter- can change within hours after the in- assessment,42 but use of a more so-
mined on an individual basis. In jury, and repeat blood gas analyses phisticated scoring system may be
equivocal cases, monitoring of the should be obtained. appropriate to precisely grade pul-
intracranial pressure is prudent. Dur- The timing of fracture management monary injury. Because all authors
ing fracture fixation, the goals of in patients with thoracic injuries re- agree that severe chest trauma repre-
management should include mainte- mains controversial, with conflicting sents a risk factor for ARDS, ruling
nance of adequate cerebral perfusion studies and recommendations. Fakhry out severe lung contusions by early
and avoidance of secondary insults. et al37 examined a statewide database CT scan is advisable; the decision re-
and discovered a 4.6% mortality rate garding how to proceed should be
Chest Injury in patients with severe chest injuries made on an individualized basis us-
Chest injury in the multitrauma pa- who underwent surgery on day 1, ing a multidisciplinary approach.
tient typically consists of either chest compared with a 0% mortality rate
wall fracture or lung contusion, or in patients who were definitively sta- Pelvic Ring Injury
both. In the patient with isolated rib bilized >1 day after admission to the Pelvic fracture is an indicator of
fractures, the act of breathing is hospital. The authors concluded that high-energy trauma. The systemic ef-
painful, causing hypoxemia that can “the presence of severe chest injury fects of severe pelvic injuries are de-
be addressed with either local pain may be an indication to delay the termined by the degree of hemor-
blocks or artificial ventilation. femoral repair for 24 to 48 hours un- rhage and soft-tissue injury. Unlike
Lung contusion is of utmost con- til these injuries have been stabi- other injuries, autotamponade does
cern because it is closely associated lized.” In a study by Pelias et al,38 not occur, and retroperitoneal bleed-
with ARDS.32 In the patient with the comparison between early and ing may mimic intra-abdominal in-
lung contusion, the disturbance of late fixation of long-bone fractures jury. Soft-tissue disruption can cause
oxygenation can increase despite ad- revealed no appreciable difference more severe side effects in pelvic
equate efforts at mechanical ventila- in pulmonary complications (early fracture than in extremity fracture
tion, because of the formation of operation, 27.6%; late operation, because, in the former, a higher de-
pulmonary edema. This pulmonary 29.4%). The authors concluded that gree of kinetic energy is required
edema is mediated by inflammatory the incidence of ARDS in these pa- to cause substantial displacement.
cells, causing a local immunologic re- tients is attributable to chest trauma Open injuries are common. Gas-

September 2009, Vol 17, No 9 547

Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery

trointestinal contamination is partic- 4. Küntscher G: Practice of Intramedullary

ularly worrisome because of the sub- Summary Nailing. Springfield, IL, Charles Thomas,
1967, pp 36-51.
stantially increased risk of infection
The patient with multiple traumatic in- 5. Seibel R, LaDuca J, Hassett JM, et al:
and late sepsis.43 Blunt multiple trauma (ISS 36), femur
juries may be classified as stable, bor-
Evaluation of the patient with pel- traction, and the pulmonary failure-
derline, unstable, or in extremis. Early septic state. Ann Surg 1985;202:283-
vic fracture is similar to that for any 295.
definitive fracture fixation is recom-
patient with an injury associated
mended for the stable multitrauma pa- 6. Goris RJ, Gimbrère JS, van Niekerk JL,
with sustained hemorrhage. Timing Schoots FJ, Booy LH: Early
tient and in the borderline or unstable osteosynthesis and prophylactic
of pelvic fixation is based on hemo-
patient who responds well to resusci- mechanical ventilation in the
dynamic status and the presence of multitrauma patient. J Trauma 1982;22:
tation. However, in the patient who pre- 895-903.
associated abdominal injuries. The
sents with severe hemorrhagic shock or
decision to attempt definitive fixa- 7. Taeger G, Ruchholtz S, Waydhas C,
any other life-threatening condition, Lewan U, Schmidt B, Nast-Kolb D:
tion within 24 to 48 hours appears Damage control orthopedics in patients
prolonged surgical procedures should
to be dependent on the pelvic ring with multiple injuries is effective, time
be avoided, and staged fracture fixation saving, and safe. J Trauma 2005;59:409-
fracture pattern.44 Fixation can be at-
should be done. The damage control 416.
tempted in stable and borderline pa-
approach, which uses external fixation 8. Johnson KD, Cadambi A, Seibert GB:
tients. In unstable patients, the use of Incidence of adult respiratory distress
as a primary tool, may be applied in
sheets wrapped about the pelvis or a syndrome in patients with multiple
such cases. For the patient who presents musculoskeletal injuries: Effect of early
pelvic binder, optimally placed at the operative stabilization of fractures.
as borderline or in poorer condition, a
level of the greater trochanters, al- J Trauma 1985;25:375-384.
multidisciplinary approach is required
lows for rapid circumferential splint- 9. Bone LB, Johnson KD, Weigelt J,
to determine the best timing of muscu- Scheinberg R: Early versus delayed
ing of the pelvic ring.45
loskeletal care. stabilization of femoral fractures: A
There is a paucity of literature on the prospective randomized study. J Bone
Joint Surg Am 1989;71:336-340.
optimal timing of definitive pelvic sta-
bilization. Favorable patterns may be References 10. Border JR: Death from severe trauma:
Open fractures to multiple organ
treated with percutaneous fixation dysfunction syndrome. J Trauma 1995;
when certain criteria are met: a closed Evidence-based Medicine: Levels of ev- 39:12-22.
reduction is possible, the injury pattern idence are described in the table of con- 11. Giannoudis PV, Abbott C, Stone M,
is amenable to screw fixation alone, and tents. In this article, references 9, 14, Bellamy MC, Smith RM: Fatal systemic
inflammatory response syndrome
the surgeon and operating team are and 18 are level I studies. References following early bilateral femoral nailing.
available and experienced.46 In ex- 7, 8, 30, 33, and 34 are level II stud- Intensive Care Med 1998;24:641-642.
treme cases of exsanguination result- ies. References 2, 3, 5, 6, 13, 15, 17, 12. Scalea TM, Boswell SA, Scott JD,
ing from pelvic ring injury, direct 21, 25-29, 35, and 36 are level III Mitchell KA, Kramer ME, Pollak AN:
External fixation as a bridge to
packing of the true pelvic space has studies. References 1, 4, 10, 12, 16, intramedullary nailing for patients with
been described.47 However, this tech- 20, 22-24, 31, 32, 37-39, 44, and 45 multiple injuries and with femur
fractures: Damage control orthopedics.
nique must be performed with ad- are level IV studies. References 40-43
J Trauma 2000;48:613-621.
junctive pelvic ring stabilization, are level V expert opinion.
13. Pape HC, van Griensven M, Rice J, et al:
which may include a binder, external Citation numbers printed in bold Major secondary surgery in blunt trauma
fixation, or internal fixation. type indicate references published patients and perioperative cytokine
liberation: Determination of the clinical
Currently it is recommended that within the past 5 years. relevance of biochemical markers.
the surgeon identify the source of J Trauma 2001;50:989-1000.
1. Tscherne H, Schreyer H, Magerl F:
pelvic hemorrhage and stop bleeding Pulmonary and cardiac x-ray findings in 14. Pape HC, Schmidt RE, Rice J, et al:
emergently, then stabilize the pelvic traumatic fat embolism [German]. Biochemical changes after trauma and
Fortschr Geb Rontgenstr Nuklearmed skeletal surgery of the lower extremity:
ring. The use of a binder is often suc- 1967;106:703-710. Quantification of the operative burden.
cessful in achieving a physiologic Crit Care Med 2000;28:3441-3448.
2. Beck JP, Collins JA: Theoretical and
state that allows surgery. A single clinical aspects of posttraumatic fat 15. Porter JM, Ivatury RR, Nassoura ZE:
damaged artery may be treated by embolism syndrome. Instr Course Lect Extending the horizons of “damage
1973;22:38-87. control” in unstable trauma patients
coil embolization instead. The local
beyond the abdomen and gastrointestinal
conditions in a given trauma center 3. Smith JE: The results of early and tract. J Trauma 1997;42:559-561.
delayed internal fixation of fractures of
often determine the specific tech- the shaft of the femur. J Bone Joint Surg 16. Pape HC, Grimme K, Van Griensven M,
nique for stabilizing the pelvic ring. Br 1964;46:28-31. et al: Impact of intramedullary

548 Journal of the American Academy of Orthopaedic Surgeons

 Hans-Christoph Pape, MD, et al

instrumentation versus damage control ischaemia: Implications for therapy. Br J statewide population-based analysis of
for femoral fractures on Anaesth 1985;57:120-130. 2805 adult patients in a rural state.
immunoinflammatory parameters: J Trauma 1994;37:255-260.
27. Chesnut RM, Marshall LF, Klauber MR,
Prospective randomized analysis by the
et al: The role of secondary brain injury 38. Pelias ME, Townsend MC, Flancbaum L:
EPOFF Study Group. J Trauma 2003;55:
in determining outcome from severe Long bone fractures predispose to
7-13. head injury. J Trauma 1993;34:216-222. pulmonary dysfunction in blunt chest
17. Rotondo MF, Schwab CW, McGonigal 28. Siegel JH, Gens DR, Mamantov T, trauma despite early operative fixation.
MD, et al: ‘Damage control’: An Geisler FH, Goodarzi S, MacKenzie EJ: Surgery 1992;111:576-579.
approach for improved survival in Effect of associated injuries and blood
exsanguinating penetrating abdominal 39. van Os JP, Roumen RM, Schoots FJ,
volume replacement on death,
injury. J Trauma 1993;35:375-382. Heystraten FM, Goris RJ: Is early
rehabilitation needs, and disability in
osteosynthesis safe in multiple trauma
blunt traumatic brain injury. Crit Care
18. Pryor JP, Reilly PM: Initial care of the Med 1991;19:1252-1265. patients with severe thoracic trauma and
patient with blunt polytrauma. Clin pulmonary contusion? J Trauma 1994;
Orthop Relat Res 2004;422:30-36. 29. McKee MD, Schemitsch EH, Vincent 36:495-498.
LO, Sullivan I, Yoo D: The effect of a
19. Higgins TF, Horwitz DS: Damage femoral fracture on concomitant closed 40. Bone LB, Anders MJ, Rohrbacher BJ:
control nailing. J Orthop Trauma 2007; head injury in patients with multiple Treatment of femoral fractures in the
21:477-481. injuries. J Trauma 1997;42:1041-1045. multiply injured patient with thoracic
20. Pape HC, Rixen D, Morley J, et al: injury. Clin Orthop Relat Res 1998;347:
30. Townsend RN, Lheureau T, Protech J, 57-61.
Impact of the method of initial Riemer B, Simon D: Timing fracture
stabilization for femoral shaft fractures repair in patients with severe brain injury 41. Pryor JP, Reilly PM: Initial care of the
in patients with multiple injuries at risk (Glasgow Coma Scale score <9). patient with blunt polytrauma. Clin
for complications (borderline patients). J Trauma 1998;44:977-982. Orthop Relat Res 2004;422:30-36.
Ann Surg 2007;246:491-499.
31. Jaicks RR, Cohn SM, Moller BA: Early 42. Baker SP, O’Neill B, Haddon W Jr, Long
21. Morshed S, Miclau T III, Bembom O, fracture fixation may be deleterious after
Cohen M, Knudson MM, Colford JM Jr: WB: The injury severity score: A method
head injury. J Trauma 1997;42:1-5. for describing patients with multiple
Delayed internal fixation of femoral
shaft fracture reduces mortality among 32. Stellin G: Survival in trauma victims with injuries and evaluating emergency care.
patients with multisystem trauma. pulmonary contusion. Am Surg 1991;57: J Trauma 1974;14:187-196.
J Bone Joint Surg Am 2009;91:3-13. 780-784.
43. Keel M, Trentz O: Pathophysiology of
22. Pape HC, Giannoudis PV, Krettek C, 33. Regel G, Dwenger A, Seidel J, Nerlich polytrauma. Injury 2005;36:691-709.
Trentz O: Timing of fixation of major ML, Sturm JA, Tscherne H: Significance
fractures in blunt polytrauma: Role of of neutrophilic granulocytes in the 44. Olson SA, Burgess A: Classification and
conventional indicators in clinical development of post-traumatic lung initial management of patients with
decision making. J Orthop Trauma failure [German]. Unfallchirurg 1987;90: unstable pelvic ring injuries. Instr Course
2005;19:551-562. 99-106. Lect 2005;54:383-393.

23. Pape HC, Remmers D, Grotz M, et al: 34. Fulton RL, Peter ET: The progressive 45. Bottlang M, Simpson T, Sigg J, Krieg JC,
Reticuloendothelial system activity and nature of pulmonary contusion. Surgery Madey SM, Long WB: Noninvasive
organ failure in patients with multiple 1970;67:499-506. reduction of open-book pelvic fractures
injuries. Arch Surg 1999;134:421-427. by circumferential compression.
35. Tate RM, Repine JE: Neutrophils and J Orthop Trauma 2002;16:367-373.
24. Pape HC, Regel G, Tscherne H: Local the adult respiratory distress syndrome.
and systemic effects of fat embolization Am Rev Respir Dis 1983;128:552-559. 46. Routt ML Jr, Falicov A, Woodhouse E,
after intramedullary reaming and its Schildhauer TA: Circumferential pelvic
influence by cofactors. Techniques in 36. Weiland JE, Davis WB, Holter JF, antishock sheeting: A temporary
Orthopaedics 1996;11:2-13. Mohammed JR, Dorinsky PM, Gadek resuscitation aid. J Orthop Trauma
JE: Lung neutrophils in the adult 2006;20(1 suppl):S3-S6.
25. Reinert M, Hoelper B, Doppenberg E, respiratory distress syndrome: Clinical
Zauner A, Bullock R: Substrate delivery and pathophysiologic significance. Am 47. Cothren CC, Osborn PM, Moore EE,
and ionic balance disturbance after Rev Respir Dis 1986;133:218-225. Morgan SJ, Johnson JL, Smith WR:
severe human head injury. Acta Preperitonal pelvic packing for
Neurochir Suppl 2000;76:439-444. 37. Fakhry SM, Rutledge R, Dahners LE, hemodynamically unstable pelvic
Kessler D: Incidence, management, and fractures: A paradigm shift. J Trauma
26. Miller JD: Head injury and brain outcome of femoral shaft fracture: A 2007;62:834-839.

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