Assessment, Management and Decision Making in The Treatment of Polytrauma Patients With Head Injuries
Assessment, Management and Decision Making in The Treatment of Polytrauma Patients With Head Injuries
Assessment, Management and Decision Making in The Treatment of Polytrauma Patients With Head Injuries
Epidemiologic Aspects
80,000 survivors of head injury annually
125,000 children <15yo head injured
annually
40-60% of head injured patients have
extremity injury
32,000-48,000 head injury survivors with
orthopaedic injuries annually
Overview
Pathophysiology
Initial evaluation
Prognosis
Management of Head Injury
Orthopaedic Issues
Operative vs. nonoperative treatment
Timing of surgery
methods
1st
hit
2n
d
hit
Evaluation
ATLSABCs
History
loss of consciousness
Physical exam
Glasgow Coma Scale
Radiographic studies
CT Scan
Evaluation
Must exclude head injury by evaluation if
history of loss of consciousness
significant amnesia
confusion, combativeness
Cannot be simply attributed to drug or alcohol use
Physical Exam
Exam of head and cranial nerves for
lateralizing signs
dilated or sluggish pupil(s)
Extremities
unilateral weakness
posturing
decorticate (flexor)
decerebrate (extensor)
4
3
2
1
6
5
4
3
2
1
Verbal response
Oriented
Confused
Inappropriate
Incomprehensible
None
5
4
3
2
1
Radiographic Studies
CT scan
Frontal
Contusion
lesions
focal--epidural, subdural hematoma,
contusions
diffuse--diffuse axonal injury
Plain films
useful only to detect skull fracture
setting wastes time
Treatment
Initial
Intubation if unresponsive or combative to give
controlled ventilation
pharmacologic paralysis
after neurologic exam is completed
ICP Monitoring
Indications
severe head injury (GCS < 9)
abnormal head CT
or
Coma >6 hrs
ICU Adjuncts
HCT~ 30-33%
PaCO2= 352 mm Hg
CVP= 8-14 mm Hg
avoid dextrose IV
maintain euthermia or mild hypothermia
Potentially controllable!!
Outcome
Glasgow Outcome Score:
1-dead
2-vegetative
3-cannot self care
4-deficits but able to self care
5-return to preinjury level of function
Outcome Prediction
Glasgow scale (post resuscitation) 44-66%
accuracy in determining ultimate outcome
39% with an initial GCS of < 5 made functional
recovery
Outcome Prediction
Serum markers (S-100B)
Accuracy of 83% (Woertgen, J Trauma, 1999)
Good sensitivity in moderate to severe injury
even with extracranial injury (Savola, J Trauma, 2004)
May be elevated in 29% fx pts without head
injury (Unden, J Trauma, 2005)
Prognosis
Significant disability @ 1 yr
Disability even in mild injury
Glasgow cohort: 742 pts with 71% follow-up
Rate of combined severe and moderate disability similar among
groups (48%, 45% and 48%)
Age >40, previous head injury, comorbidities increased disability
(Thornhill, BMJ, 2000)
Dead or
vegetative
Severe
disability
Moderate
disability
8%
16%
20%
22%
28%
24%
45%
38%
38%
29%
19%
14%
Good
recovery
Resuscitation: Role of
Orthopaedics
Goal: limit ongoing hemorrhage and
hypotension
pelvic ring injury-external fixation reduced
mortality from 43% to 7%
(Reimer, J Trauma, 93)
elevated ICP
Early Osteosynthesis
Hofman (J Trauma 91):
58 patients with a GCS < 7
lower mortality and higher GOS with operative treatment
within 24 hours
Poole ( J Trauma 92):
114 patients with head injury
delayed fixation did not protect the injured brain
McKee (J Trauma 97):
46 head injured with femur fractures matched with 99
patients without fracture
no difference in neurologic outcome or mortality
Early Osteosynthesis
Bone (J Trauma 94):
in 22 patients (age <50) with a GCS 4-5
13.6% (early fixation) vs 51.3% (delayed fixation)
mortality rates
Early Osteosynthesis
Kalb (Surgery 98):
123 patients, head AIS > 2, 84 early, 39 late fixation
early group had increased fluid requirement but no
other difference in mortality or complication
emphasized the role of appropriate monitoring
Delayed Osteosynthesis
Reynolds (Annals of Surg 95):
Mortality 2/105 patients, both early rodding (<24 hrs)
one due to neurologic and the other pulmonary
deterioration
Delayed Osteosythesis
Townsend (J Trauma 98):
61 patients with GCS < 8;
hypotension 8 X more likely if operated < 2 hrs and 2
X more likely when operated within 24 hrs
no difference noted in GOS
Fracture Care
Ultimate neurologic outcome continues to be
difficult to predict
Presume recovery
Avoid treatments that may compromise neurologic
outcome
Alignment
Articular congruity
Early rehabilitation
Facilitated nursing
care
MUST minimize
hypotension
hypoxia
elevated ICP
use
appropriate
monitors
Nonoperative Fracture
Management
Treatment of choice when
nonoperative means best treat that particular fracture
operative risks outweigh potential benefits
Modalities
splint
brace
cast
traction
Caveat
device must be removed periodically to inspect underlying skin
for decubiti
Bone Healing in
the Head Injured Patient
Humoral osteogenic factors are released by
the injured brain
Exuberant callus MAY be seen
Soft tissue ossification is
common
Ultimate union rate
of fractures inconsistently
affected
Complications
Heterotopic Ossification
up to 89-100% incidence
periarticular injury
with head injury
Contractures
Malunion
Recurrent elbow dislocation
secondary to extensor posturing
and heterotopic ossification
Heterotopic Ossification
Associated with ventilator dependency
Use approaches/techniques less associated
with H.O.
Prophylaxis
XRT
Indocin
Excision
Contractures
Occurs due to spasticity/posturing
Effects
Inhibits restoration of function
Complicates nursing care
Predisposes to decubitus ulcers
Contractures
Treatment:
Prevention
splinting/positioning
early physical and occupational therapy
Established
serial casting
manipulation
surgery
nerve blocks
Associated Injuries
Normal methods of clinical and radiologic
assessment may not apply in the head
injured patient
C spine injury
Occult fractures and injury
C Spine Injury
Incidence increases with increasing severity of head
injury
C spine injury
GCS
Incidence
13-15
1.4%
9-12
6.8%
Demetraiades,<9
J Trauma, 0010.2%
Evaluation more difficult
Optimal protocol for evaluation and management
controversial
C Spine Injury
Minimum requirement
Cervical collar
CT entire C spine with reconstructions
Adjuncts
MRI
Difficult in vent patient
May over call injury
Occult Injuries
Fractures, dislocations and peripheral nerve
injuries may be missed
Up to 11% of orthopaedic injuries may be
missed
Peripheral nerve injuries are particularly
common (as high as 34%)
Occult fractures in children with head injury are
also common (37-82%)
Occult Injuries
Detailed physical exam with radiographs of
any suspect area due to bruising, abrasion,
deformity, loss of motion
Consider EMG for unexplained neurologic
deficits
Bone scan advocated in children with
severe head injury @ 72 hrs
Summary
Orthopaedic injuries are common in head injured
polytrauma patients
Head injury outcome is difficult to predict
Management requires multidisciplinary approach
Operative management is safe and often improves
functional outcome if secondary brain insults are
avoided
Hypotension, hypoxia, increased ICP
References
Bayir H, Clark RS, Kochanek PM. Promising strategies to minimize secondary brain injury after head trauma. Crit Care Med. 2003;31:S112S117.
Bandari M, Guyatt GH, Khera V, et al. Operative management of lower extremity fractures in patients with head injuries. Clin Orthop Relat Res.
2003;407:187198.
Boes M, Kain M, Kakar S, et al. Osteogenic Effects Of Traumatic Brain Injury On Experimental Fracture-Healing. JBJS-A. 88:738-743, 2006.
Bone J, K McNamara, B Shine, J Border: Mortality in multiple trauma patients with fractures J Trauma, 37, 262-265, 1994
Brohi K Healy M, Fotheringham T, et al.Helical Computed Tomographic Scanning for the Evaluation of the Cervical Spine in the Unconscious,
Intubated Trauma Patient. J Trauma. 2005;58:897901.
Cadosch D, Gautschi O, Thyer M, et al. Humoral Factors Enhance Fracture-Healing and Callus Formation in Patients with Traumatic Brain Injury.
JBJS-A. 91:282-288, 2009
Demetraiades D, K Charalambides, S Chahwan et al: Nonskeletal cervical spine injuries: Epidemiology and Diagnostic pitfalls. J Trauma, 48 (4):
724-727, 2000.
Davis DP, Serrano JA, Vilke GM, et al. The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in
moderate-to-severe traumatic brain injury. J Trauma. 2006;60:985990.
Flierl MA, Stonebak JW, Beauchamp KM, et al. Femur Saft Fixation in Head Injured Patients: When is the right time? J Orthop Trauma. 24: 107114. 2010
Garland D, M Rhoades. Orthopaedic Management of Brain Injured Adults, CORR 131:111-120, 1978
Grossman R, C Loftus: Principles of Neurosurgery, 2nd ed, New York: Lippincott-Raven, 1998.
Hariri R, A Firuk, S Shepard: Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain
compliance J Neurosurg 79: 421. 1993.
Hofman P, Goris J. Timing of Osteosynthesis of Major Fractures in Patients with Severe Brain Injury, J Trauma, vol 31(2): 261-263
Jaicks R, S Cohn, B Moller: Early fracture fixation may be deleterious after head injury J Trauma, vol 42 (1): 1-6) 1997
Jeremitsky E, Omert L, Dunham CM, et al. Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and
hypoperfusion. J Trauma. 2003;54:312319.
Kalb D, A Ney, J Rodriguez, et al: Assessment of the relationship between timing of fixation of the fracture and secondary brain injury in patients
with multiple trauma Surgery vol 124 (4)739-745, 1998.
Kushwaha V, D Garland. Extremity fracture in the patient with traumatic brain injury JAAOS, 6(5): 298-307, 1998.
Li J, Guo Z, Han J, et al. Expression of vascular endothelial growth factor in bony callus of patients with fracture combined with head injury
versus simple fracture patients and its clinical significance. J Clin Rehab Tissue Eng Res. 13:5453-5456, 2009.
Marion D Head Injury in: The Trauma Manual, Peitzman A, M Rhoades, C Schwab, D Yealy eds, New York: Lippincott-Raven, 1998.
Masson F, Thicoipe M, Aye P, et al. Epidemiology of severe brain injuries:a prospective population-based study. J Trauma. 2001;51:481489.
Moore E, K Mattox, D Feliciano: Trauma, 2nd ed, Norwalk, CT: Appleton and Lange, 1998.
Moppett IK. Traumatic Brain Injury: assess, resuscitation and early management. Br J Anaesth 99: 18-31. 2007.
Morshed S, Miclau T 3rd, Bembom O, et al. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem
trauma. J Bone Joint Surg Am. 2009;91:313.
Nau T, Aldrian S, Koenig F, et al. Fixation of femoral fractures in multipleinjury patients with combined chest and head injuries. ANZ J Surg.
2003; 73:10181021.
Poole GV, J Miller, S Agnew, J Griswold: Lower extremity fracture Fixation in Head injured Patients J Trauma, 32(5) 654-659, 1992.
Reimer BL, Butterfield S. Diamond DL, et al., Acute mortality associated with injuries to the pelvic ring: The role of early patient mobilization and
external fixation, J Trauma 35 (1993), 671677.
Reynolds MA, J Richardson, D Spain, et al: Is the timing of fracture fixation important for the patient with multiple trauma Annals of Surgery,
222(4): 470-481, 1995.
Savola O, Pyhtinen J, Leino T, Siitonen S, Niemel O, Hillbom M. Effects of Head and Extracranial Injuries on Serum Protein S100B Levels in
Trauma Patients. J Trauma, 5: 1229-1234, 2004
Scalea T, J Scott, R Brumback, et al: Early fracture fixation may be just fine after head injury: No difference in central nervous system outcomes
J Trauma vol 46 (5): 839-845, 1999.
Starr A, J Hunt, D Chason, C Reinert: Treatment of femur fracture with associated head injury J Orthop Trauma, vol 12 (1): 38-45, 1998.
Thornhill S, Teasdale G, Murray GD, et al. Disability in young people and adults one year after head injury: prospective cohort study BMJ 2000;
320 : 1631
Townend W,Muller K,Waterloo K, Ingebrigtsen T, Lecky F. Validation Of Serum S-100b As A Predictive Marker For Mild Head Injury Outcome.
Emerg Med Journal. 24:381, May 2007.
Townsend R, T Lheureau, J Protetch et al: Timing fracture repair in patients with sever brain injury J Trauma 44: 977-983, 1998
Undn J, Bellner J, Eneroth M, et al. Raised Serum S100B Levels after Acute Bone Fractures without Cerebral Injury J Trauma 58: 59-61. 2005
Woertgen C, R Rothoerl, C Metz, A Brawanski: Comparison of clinical, radiologic, and serum markers as prognostic factors after severe head
injury, J Trauma, vol 47 (6): 1126-1130, 1999ICL, 49, 2000
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