Aims . To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. . Patients and Methods. A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients’ injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. Results. In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. Conclusion. Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255–60

Introduction and objectives. High-energy pelvic fractures are life-threatening injuries. Approximately 15% to 30% of patients with high-energy pelvic injuries are hemodynamic unstable, hemorrhagic shock remains the main cause of death in patients with pelvic fractures, with an overall mortality rate from 6% to 35%. The correlation between fracture pattern and mortality in polytrauma with pelvic fracture has been previously investigated. However, the purpose of our investigation was to evaluate the relationship of hemodynamic instability with the pelvic fracture pattern according to different classifications. Materials and Methods. A retrospective study of high-energy pelvic fractures was performed for consecutive patients admitted to the emergency Level I trauma center in the polytrauma unit of our institution from June 2007 to June 2010. A total of 759 patients polytrauma were attended, whom 100 had a pelvic fracture and were included in our study. Demographic data, mechanism of injury and associated injuries were recorded. The patients were classified as hemodynamic stable or unstable according to the ATLS protocol. The pelvic fracture patterns were divided into stable and unstable according to Young-Burgess and Tile classifications. Statistical analysis was performed to determine the relationship between fracture pattern and hemodynamic stability. Secondary outcomes were obtained: the relationship with TCE and pulmonary injury, usefulness of the external fixation, relationship between fracture pattern and embolization requests. Chi-square test was used for the analysis and OR test. Results. Male was the gender most frequent (70%), the average age was 45.2 years and the mortality rate was 24%, the main mechanism of injury was motor vehicle injury (41%). Pelvic fracture pattern (neither Tile classification nor Young-Burgess classification) showed no correlation with hemodynamic situation (p>0.05). Neither death could not be predicted on the basis of pelvic fracture pattern (p>0.05). We found statistical association between patients affected by pelvic fracture in polytrauma and head injury, and death (p<0.01). Conclusion. Pelvic fracture pattern is not useful to predict hemodynamic instability in polytrauma, regardless the classification system used. Pelvic fracture is not significantly associated with high risk of mortality; however it contributes to increase mortality risk in cases of head injury associated

Introduction and Aims: Open femoral fracture is a serious injury. We have asked the question: do open femur fractures in polytrauma patients correlate with higher injury severity scores, increased length of stay and higher mortality rates than in closed femur fracture polytrauma patients. Method: We undertook a retrospective review of a prospectively gathered trauma database at a Level 1 trauma centre. We identified multiple-injured patients with femur fractures who presented in a 36 month period. The cases were divided into 2 groups; open femur fractures (n=33) and closed femur fractures (n=80). Data was collected on demographics, precipitating event, length of stay spent in the ICU, number of associated injuries, ISS, AIS for affected systems, number of femoral surgeries and disposition. Data was analyzed using parametric statistical tests with a significance level of 0.05. Results: Our analysis revealed that an average, patients in the open femur fracture group spent 8 + 9 days in ICU, sustained 4 + 1 associated injuries, underwent 2 + 1 femoral surgeries, had an ISS of 29 + 13, and died of their injuries in 30.3% of cases. Patients in the closed femur fracture groups spent 8 + 9 days in ICU, sustained 4 + 1 associated injuries, underwent 1 + 1 femoral surgeries, had an ISS of 29 + 14, and died of their injuries in 12.5% of cases. One-way ANOVA showed no statistically significant difference between groups in terms of time spent in ICU, ISS and number of associated injuries. The average number of surgeries was significantly greater in the open femur fracture group (p-value 0.000). A Chi-squared analysis of disposition indicated that patients with femur fractures were more likely to die of their injuries (p-value 0.020). Conclusions: Findings of the current study demonstrate that while the presence of an open femur fracture does not correlate with an increase in ISS or increase ICU length of stay it may act as a marker for more serious prognosis in polytrauma patients

Introduction and Aims: Open femoral fracture is a serious injury. We have asked the question: do open femur fractures in polytrauma patients correlate with higher injury severity scores, increased length of stay and higher mortality rates than in closed femur fracture polytrauma patients. Method: We undertook a retrospective review of a prospectively gathered trauma database at a Level 1 trauma centre. We identified multiple-injured patients with femur fractures who presented in a 36-month period. The cases were divided into two groups: open femur fractures (n=33) and closed femur fractures (n=80). Data was collected on demographics, precipitating event, length of stay spent in the ICU, number of associated injuries, ISS, AIS for affected systems, number of femoral surgeries and disposition. Data was analysed using parametric statistical tests with a significance level of 0.05. Results: Our analysis revealed that on average, patients in the open femur fracture group spent eight + nine days in ICU, sustained four + one associated injuries, underwent two + one femoral surgeries, had an ISS of 29 + 13, and died of their injuries in 30.3% of cases. Patients in the closed femur fracture groups spent eight + nine days in ICU, sustained four + one associated injuries, underwent one + one femoral surgeries, had an ISS of 29 + 14, and died of their injuries in 12.5% of cases. One-way ANOVA showed no statistically significant difference between groups in terms of time spent in ICU, ISS and number of associated injuries. The average number of surgeries was significantly greater in the open femur fracture group (p-value 0.000). A Chi-squared analysis of disposition indicated that patients with femur fractures were more likely to die of their injuries (p-value 0.020). Conclusions: Findings of the current study demonstrate that while the presence of an open femur fracture does not correlate with an increase in ISS or increase ICU length of stay, it may act as a marker for more serious prognosis in polytrauma patients

Background and Objectives: Damage control orthopaedics (DCO) seeks to minimize surgical impact while treating all long bone and pelvic fractures in an emergency basis. Temporary external fixation is the preferred method for DCO in polytrauma care and mass casualty events.. External fixation allows stabilisation of long bone fractures without prolonged surgical procedures; reduce blood loss and systemic inflammatory response, although it is not clear which is the effect on complications and mortality. Materials and Methods: Case series. Retrospective analysis of data trauma registry data. We studied the clinical outcome of a consecutive group of by DCO concepts for long bone and pelvic fractures, including a mass casualty event with multiple victims from a bomb attack. We analyzed the clinical outcomes in terms of systemic complications and mortality measured by TRISS methodology. Inclusion criteria: Age > 15, ISS> 16, external fixation in first 6 hours for long bone or pelvic fractures. Results: Between 2003 and 2008 45 patients met the inclusion criteria. Average age was 33 yrs, means ISS 35, and most patients suffered road traffic accidents. We performed 65 temporary external fixators in forty five patients. Most frequent procedures were femur external fixation in 30 cases followed by tibia external fixation in 25 patients. Systemic complication rate was high. Six patients died. We found a reduction in mortality between probability of survival by TRISS and real mortality of 0.18 (0, 67 Ps versus 0, 85 real survival). Conclusions: External fixation for early fixation of long bone fractures in polytrauma patient is a safe and successful treatment. DCO seems to reduce mortality in severe polytrauma patients with multiple fractures

Damage Control Surgery minimises ARDS in trauma. Originally adapted for abdominal trauma, Pape et al extended it for ‘borderline cases’ in Orthopaedics, categorised by narrow parameters such as (ISS) > 40. The rest of the cases are treated by Primary Total Care. ARDS developed due to two ‘hits’ – first, the extent of the trauma, second, the extent and timing of surgery. By manipulating the second hit, better outcomes are obtained. We discuss our usage of Damage Control Orthopaedics (DCO) principles in India. We reviewed 1456 patients operated between January 2002 and June 2005 (mean follow-up 29.5 months). 40 patients with polytrauma (28 male), mean age 39.9 years (range 18-77) and mean ISS 21.65 (range 13-41) satisfed our inclusion criteria (at least 2 long bones fractured or 2 systems injured presenting more than 48 hours after injury). Patients were admitted under the joint care of intensivists and surgeons, and had twice daily physiotherapy with early mobilisation. Fractures awaiting fixation were mobilised with braces and plasters temporarily. Acid-base, nutritional and electrolyte imbalances were corrected on a priority basis. An average of 3.4 procedures was performed on each patient (range 2-7) including 45 long bone nailings. Mean interval between admission and last surgery was 11.1days (range 6-19). 37 patients needed significant pre-operative resuscitation including 5 with ARDS. Post-operatively 39/40 survived and 35/40 returned to normal lives. The only post-operative ARDS died. Furthermore we describe ‘the third hit’ phenomenon which is the collective adverse impact of late presentation of trauma cases, inadequate and incompetent primary care, pre-existing medical conditions, financial, social and infrastructural constraints. Polytrauma patients, even with low ISS, can develop ARDS if they present late to a trauma centre. Appropriate medical therapy and slow but systemic approach to surgery along with aggressive physiotherapy, use of orthosis and early mobilisation saves lives

The definite treatment of closed or compound fractures of the long bones in polytrauma patients, who had been treated by bridging external fixation during the damage control phase is challenging, especially if it is performed delayed when the risk of infection is increased. In such cases the use of ring type external fixators seems to be a good choice. During the last two years (mean FU 16 months), 22 Polytrauma patients with fractures of the long bones were treated with the use of ring type external fixators as the definite method. Multiplanar reduction at the fracture site could be achieved with this method. 14 patients had a high ISS score in the emergency department. 14 had sustained fracture of the femur while the remaining 8 patients had suffered a tibial fracture. In all but one patient the bone union was achieved in a mean time of 19 months. In a patient with a tibial fracture where a bone defect the bone union was accomplished with bone grafting and the use of growth factors. No complications or loss of reduction were seen, while local signs of infection at the site of half pins insertion in three patients were subsided with administration of local antibiotics. The definite treatment with ring type external fixators of long bone fractures in polytrauma patients seems to be a very good choice. Bone consolidation with no evidence of bone infection was achieved in all patients. while low rate of complications were seen

Introduction: Road side accidents resulting in polytrauma with an associated fracture of femur is a common pattern of injury in asian countries. We hypothesised that the use of unreamed nailing in the management of such fractures has better outcome than reamed nailing. Material and Methods: We retrospectively reviewed 116 cases of polytrauma with associated fracture of shaft of femur admitted in our tertiary teaching hospital in North India bewteen Jan 1996 to Dec 2001. The patients were initially resuscitated according to the advanced trauma life support protocol. They were randomally managed by interlocking nail using reamed (n=48) and unreamed (n=68) technique after being haemodynamically stabilized. Five intraoperative parameters were recorded – the surgical time, fluoroscopy time, the intraoperative blood loss, intraoperative oxygen saturation, and any intraoperative complications. The patients were assessed postoperatively for ninety six hours for features of adult respiratory distress syndrome. All patients were clinically and radiologically assessed at 6 weekly intervals till union. The follow-up reassessments were performed by a single surgeon (AG). Results: There were 80 males, 30 females (6 were bilateral), with an average age of 26 years (range 19 to 64 years). The fractures were closed in 74 and open in 42 (Gustillo Grade 1;n=28, Grade 2;n=9, Grade 3;n=5). 48 were managed by reamed interlock nailing (Group 1) and 68 by unreamed interlock nailing (Group 2). 58 patients had an associated blunt trauma chest, 36 had blunt trauma abdomen, 18 had an associated head injury and 12 had spine injuries. The average surgical time for Group 1 was 118 minutes and for Group 2 was 94 minutes (p=0.014). The average fluorscopy time for Group 1 was 4.30 minutes and for Group 2 was 4.06 minutes. The average intra-operative blood loss for Group 1 was 254 millilitres and for Group 2 was 202 millilitres. The average intraoperative oxygen saturation fall as measured at the time of reaming and nail insertion was 2% in Group 1 and 6% in Group 2. The intraoperative complications were 11 (22.91%) in Group 1 and 18 (26.47%) in Group 2. The features of ARDS were observed in 6 patients in Group 1 (12.5%) and 4 patients in Group 2 (5.88%). The average union time was 25 weeks in Group 1 as compared to 19.4 weeks in Group 2 (p=0.012). The reoperation rate was 6.25% in Group 1 and 11.76% in Group 2. Discussion: The unreamed interlock nailing is the definitive management of fractures of femur in patients with polytrauma or blunt trauma chest as it requires lesser operative time (and thus exposing the patient to shorter period of anaesthesia), lesser blood loss and lesser fluoroscopy exposure. The incidence of ARDS is significantly lower with unreamed nailing in polytrauma patients. However the union time was significantly longer in unreamed nailing as compared to reamed nailing

Materials and methods: We treated 415 patients with pelvic fractures. According to the classification of M. Tile, the fractures were allocated in the following manner: A-40%, B-31%, C-29%. 46% of these patients were admitted with different rates of severity of the shock state. Osteosynthesis was carried out in 51% cases: 27%- the external fixation only, 10%–internal constructions only and 14%–combined synthesis. The treatment of pelvic fractures must correspond to the requirements of anti-shock measures and to the treatment of intra-articular lesions. The most informative method of the radial diagnosis is CT examination with three-dimensional pelvic reconstruction. We oriented toward the severity of pelvic lesion (A, B, C) for the determination of the terms, the volume and the order of surgical interventions. We carried out the total volume of surgical interventions in the consideration of the severity of pelvic lesions in the shock of I and II rates. We used the internal or combined osteosynthesis in the partial or total loss of pelvic stability (B and C types). Internal osteosynthesis of the pelvis is biomechanically substantiated, because it regains the circular form, consequently, the pelvic stability too, it decreases the hemorrhage from the fractures regions, removes the pain more rapidly. Hemorrahage compensation was realized by intraoperative autohemotransfusion. In case of another dominant lesion, we operated by means of two brigades. In the shock of III and IV rates we carried out the pelvic stabilization only by the external fixation apparatus for the improvement of common state of the patient. The closed reposition and the osteosynthesis by external fixation apparatus with anterior frame do not ensure completely in the fractures of type C, but it is the most rapid method to obtain and to maintain of reposition in the future. Results: Functional results were appreciated at the moment of discharge and after 12 months according to Majeed S.A. scale (1989) and according to data of computerized optic topography to appreciate the postural balance. Good and excellent results (70–100 points for the workers and 55–80 points for non-workers) were in 49% patients at the moment of discharge and in 82% patients after 12 months. Lethality value was 5,3%. Invalidism value was 6,9%. The mean terms of hospital stay were 32 days and the mean terms of resuscitation department stay were 1,5 days. Conclusion:. The treatment of the patients with severe injuries of pelvis in polytrauma must be realized in special clinics, with necessary equipment and specially prepared nursing. Treatment tactics depends on the severity of common state and on the severity of pelvic injuries

Aim: In this study we present the results of the management of muskoloskeletal injuries accompanied by rupture of a main arterial vessel, focusing on the priorities in salvaging the affected limp. Material – methods: In a period of 5 years (Sep.1999– Sep 2004), 24 patients having sustained multiple injuries were admitted with signs of poor vascularization distally to the lesion. 19 were male and 5 female, their ages ranging from 16 to 49 years (av. 28 years). The musculoskeletal injuries were: open III C humeral fracture in 2 patients, open III C femoral fractures 4, open III C tibial shaft fractures 10, knee joint dislocations 8 patients. All patients had a preoperative angiography in order to assess the severity of the vascular lesion. Immediate stabilization of the fracture with an external fixation system was performed, followed by restoration of the vascular injury by means of a by-pass, end-to-end suture or interposition of a “stent”. Results: Postoperative follow-up ranged from 6 to 54 months (mean 34 mon.). Amputation was performed in 4 patients due to failure of the revascularization procedure 2 weeks postoperatively. External fixation was maintained as a final method of treatment in 7 cases, while in 13 cases we exchanged it to intramedullary nailing. In the 8 cases of knee dislocation, ligament reconstruction was imperative. Eventually 20 limps were salvage with a satisfactory functional outcome. Conclusion: In polytrauma patients with both musculoskeletal and vascular injuries the immediate application of an external fixator represents a precausative for a successful vascular operation. Exchanging the external fixation system to interlocking intramedullary nailing accelerates the healing process

Background: Polytrauma patients with bilateral femur shaft fractures are known to have a higher rate of complications when compared with those who have sustained unilateral fractures. The current study tests the hypothesis that the high incidence of posttraumatic complications in patients who have no severe head or chest injury is caused by accompanying injuries rather than by the additional femur fracture. Methods: Prospective cohort study. Inclusion criteria: Injury severity score > 16 points; No AIS score value of the head or chest > 3 points. Two study groups: a unilateral (group USF) (n=146) and a bilateral femur shaft fracture (group BSF) (n=29). A further differentiation was made according to the patient’s status. All patients underwent early (< 24 hours after injury) fixation of their extremity fractures. Endpoints monitored were: Pneumonia, Acute lung injury (ALI), Systemic inflammatory response syndrome (SIRS), Sepsis. Statistics: Pearson chi-square test for binary indicators of injury severity, regression analyses regarding clinical complications. Results: Patients with bilateral femur fractures exhibited a longer ICU stay (p< 0.01), a higher incidence of pneumonia (p< 0.02) and SIRS (p=0.04) than those with unilateral fractures. Following corrective analyses for injury severity, no differences in blood transfusion rates, length of ICU stay, or complications was observed. Patients in borderline condition spend significantly more time in the ICU in comparison to those in stable condition. For analyses predicting presence of systemic inflammatory response syndrome, only the variable indicating receipt of a blood transfusion upon admission to the hospital emerged as a significant predictor. Bilateral fracture patients who were in uncertain condition preoperatively, developed significantly more complications postoperatively(p=0.02). Conclusions: Polytrauma patients with bilateral femur shaft fractures have a similar clinical course as those with unilateral fractures when no significant head or chest injury is present. An increased incidence of systemic inflammatory response syndrome was associated with three variables: presence of borderline condition, hemothorax and requirement of blood transfusion. This may have important treatment implications, including the management of major fractures

The purpose of this study was to determine the effect of positioning (lateral vs. supine) on pulmonary patho-physiology following pulmonary contusion and fat embolism in a canine model of polytrauma. Platelet and neutrophil activation were assessed using flow-cytometry. There were no significant differences between groups in CD62P and CD11/18 MCF (markers of platelet and neutrophil activation, respectively) following fat embolism. However, only animals in the lateral position displayed significant increases in both measures as compared to baseline values. Lateral positioning may exert an early effect on proinflammatory and coagulation activation, and may play a role in the development of acute lung injury. It has previously been suggested that acute lung injury can be influenced by patient positioning, be it lateral or supine. The purpose of this study was to determine the effect of positioning on pulmonary pathophysiology associated with concomitant pulmonary contusion and fat embolism in a canine model of polytrauma. Twelve dogs were randomly assigned to one of two surgical positioning groups, lateral and supine. The dogs were subjected to pulmonary contusion by application of force between 200–250 N/m. 2. for thirty seconds in three areas of one lung. Two hours later, fat embolism was induced via reaming of the ipsilateral femur and tibia and cemented nailing. Two hours later, the dogs were sacrificed. For flow-cytometric evaluation of platelet and neutrophil activation, venous blood samples were stained with fluorescence-conjugated antibodies against CD62P and CD11/18, respectively. There were no significant differences between the groups in CD62P and CD11/18 mean channel fluorescence (MCF) following pulmonary contusion and fat embolism. However, only animals in the lateral positioning group displayed significant increases in CD62P and CD11/18 MCF at two hours following fat embolism as compared to baseline values. Our findings suggest that lateral positioning, autoregulation and preferential blood flow to the contused non-dependent lung may render lung tissue more susceptible to congestion and lead to activation of both platelets and neutrophils. Lateral positioning may have an early effect on activation of the inflammatory and coagulation cascades and may be significant in the development of posttraumatic acute lung injury

The purpose of this study was to determine the effect of positioning (lateral vs. supine) on pulmonary pathophysiology following pulmonary contusion and fat embolism in a canine model of polytrauma. Platelet and neutrophil activation were assessed using flow-cytometry. There were no significant differences between groups in CD62P and CD11/18 MCF (markers of platelet and neutrophil activation, respectively) following fat embolism. However, only animals in the lateral position displayed significant increases in both measures as compared to baseline values. Lateral positioning may exert an early effect on proinflammatory and coagulation activation, and may play a role in the development of acute lung injury. It has previously been suggested that acute lung injury can be influenced by patient positioning, be it lateral or supine. The purpose of this study was to determine the effect of positioning on pulmonary pathophysiology associated with concomitant pulmonary contusion and fat embolism in a canine model of polytrauma. Twelve dogs were randomly assigned to one of two surgical positioning groups, lateral and supine. The dogs were subjected to pulmonary contusion by application of force between 200–250 N/m. 2. for thirty seconds in three areas of one lung. Two hours later, fat embolism was induced via reaming of the ipsilateral femur and tibia and cemented nailing. Two hours later, the dogs were sacrificed. For flow-cytometric evaluation of platelet and neutrophil activation, venous blood samples were stained with fluorescence-conjugated antibodies against CD62P and CD11/18, respectively. There were no significant differences between the groups in CD62P and CD11/18 mean channel fluorescence (MCF) following pulmonary contusion and fat embolism. However, only animals in the lateral positioning group displayed significant increases in CD62P and CD11/18 MCF at two hours following fat embolism as compared to baseline values. Our findings suggest that lateral positioning, autoregulation and preferential blood flow to the contused non-dependent lung may render lung tissue more susceptible to congestion and lead to activation of both platelets and neutrophils. Lateral positioning may have an early effect on activation of the inflammatory and coagulation cascades and may be significant in the development of posttraumatic acute lung injury

The purpose of this study was to determine the effect of positioning (lateral vs. supine) on pulmonary pathophysiology following pulmonary contusion and fat embolism in a canine model of polytrauma. Platelet and neutrophil activation were assessed using flow-cytometry. There were no significant differences between groups in CD62P and CD11/18 MCF (markers of platelet and neutrophil activation, respectively) following fat embolism. However, only animals in the lateral position displayed significant increases in both measures as compared to baseline values. Lateral positioning may exert an early effect on proinflammatory and coagulation activation, and may play a role in the development of acute lung injury. It has previously been suggested that acute lung injury can be influenced by patient positioning, be it lateral or supine. The purpose of this study was to determine the effect of positioning on pulmonary pathophysiology associated with concomitant pulmonary contusion and fat embolism in a canine model of polytrauma. Twelve dogs were randomly assigned to one of two surgical positioning groups, lateral and supine. The dogs were subjected to pulmonary contusion by application of force between 200–250 N/m. 2. for thirty seconds in three areas of one lung. Two hours later, fat embolism was induced via reaming of the ipsilateral femur and tibia and cemented nailing. Two hours later, the dogs were sacrificed. For flow-cytometric evaluation of platelet and neutrophil activation, venous blood samples were stained with fluorescence-conjugated antibodies against CD62P and CD11/18, respectively. There were no significant differences between the groups in CD62P and CD11/18 mean channel fluorescence (MCF) following pulmonary contusion and fat embolism. However, only animals in the lateral positioning group displayed significant increases in CD62P and CD11/18 MCF at two hours following fat embolism as compared to baseline values. Our findings suggest that lateral positioning, autoregulation and preferential blood flow to the contused non-dependent lung may render lung tissue more susceptible to congestion and lead to activation of both platelets and neutrophils. Lateral positioning may have an early effect on activation of the inflammatory and coagulation cascades and may be significant in the development of posttraumatic acute lung injury

Purpose: We present the results of the management of muskoloskeletal lesions accompanied by rupture of a main arterial vessel, foccusing on the priorities in salvaging the affected limp. Materials – methods: In a period of 3 years and 6 months (Sep.1999–Mar 2003), 21 patients having sustained multiple injuries were admitted with signs of poor vascularization distally to the lesion. 16 were male and 5 female, their ages ranging from 16 to 49 years (average 27 years). The musculoskeletal injuries were: open III C humeral fracture in 2 patients, open III C femoral fractures 5, open III C tibial shaft fractures 10, knee joint dislocations 4 patients. All patients had a preoperative angiography in order to assess the severity of the vascular lesion. Immediate stabilization of the fracture with an external fixation system was performed, followed by restoration of the vascular injury by means of a by-pass, end-to-end suture or interposition of a “stent”. Results: Follow-up ranged from 6 to 48 months (mean 27 mon.). Amputation was performed in 3 patients due to failure of the revascularization procedure 2 weeks postoperatively. External fixation was maintained as a final method of treatment in 5 cases, while in 9 cases we exchanged it to intramedullary nailing. In the 4 cases of knee dislocation, ligament reconstruction was imperative. Eventually 18 limps were salvage with a satisfactory functional outcome. Conclusion: In polytrauma patients with both musculoskeletal and vascular injuries the immediate application of an external fixator represents a precausative for a successful vascular operation. Exchanging the external fixation system to interlocking intramedullary nailing accelerates the healing process

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Cite this article: Bone Joint J 2023;105-B(4):361–364.

Purpose. The timing of definitive fixation for major fractures in polytrauma patients is controversial. To clarify this aspect of trauma management, we randomised patients with blunt multiple injuries to either initial definitive stabilisation of the femur shaft with an intramedullary nail or an external fixator which was converted to an intramedullary nail at a secondary procedure and documented the post-operative clinical condition. Methods. Multiply injured patients with femoral shaft fractures were randomised to either initial (<24 hours) intramedullary femoral nailing or to initial external fixation and conversion to an intramedullary nail at a later phase. Inclusion criteria: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score >2 points and another injury (Abbreviated Injury Scale score >2 points), and age 18 to 65 years. Exclusion criteria: unstable or patients in extremis. Patients were graded as stable or borderline (increased risk of systemic complications). OUTCOMES: Incidence of acute lung injuries. Results. Ten European Centres, 165 patients, mean age 32.7 ±11.7 years. Group of intramedullary nailing, n = 94; Group of external fixation, n = 71. Pre-operatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison to the external fixation group, P < 0.05. Conclusion. Intramedullary stabilisation of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared to those that underwent initially external fixation. Therefore, the pre-operative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries

Abstract

Purpose: To determine any relation between scapular fracture, severity of chest injury and mortality in patients with multiple injuries.

Patients and Methods: We reviewed 621 consecutive patients admitted over a five year period (1995–1999) with multiple injuries. All had an associated chest injury. Such details were recorded and analyzed as – mechanism of injury, ISS, AIS for chest, GCS, ICU stay, total hospital stay, operations performed, presence or absence of scapular fracture, complications and mortality. Patients with chest injury but without scapula fracture formed the control group of the study.

Results: Out of 621 patients with multiple injuries (mean ISS 27.5), 79 (17 women) (12.72%) – group 1 were identified with scapular fractures. 542 (122 women) patients with chest injury but no scapular fracture formed the control group – group 2. The mean age of group 1 was 42 years versus 40 years of group 1 and the mean ISS was 27.12 (SD 15.13) and 28. 41 (SD 14.21) in group 1 and group 2 respectively (p value > 0.05). In group 1 the chest AIS was 3.46 (SD 1.10) and 3.18 (SD 1.06) in group 2 (p value < 0.05).The most common associated chest injury in group 1 was pneumothorax (28%) followed by pulmonary contusion (15.2%) whereas in group 2 it was likewise pneumothorax (20%) followed by pulmonary contusion (21%). There were 8 (10.1%) flail segments in the scapula group, versus 50 flail segments (9%) in the non scapula group. In group 1 there was an incidence of 3.8 % associated thoracic vertebral fractures compared to 8.3% in group 2. 2.6 % of patients in group 1 had major vessel injury or cardiac laceration as compared to 3 % in group 2. There were 4 brachial plexus injuries in group 1 (5.1%) versus nil in group 2. In group 1, 32 (40.5%) patients had sustained associated abdominal injuries mean AIS 3.1 versus 190 (34.6%) in group 2 with a mean AIS of 2.9. In the scapula group there were 31 clavicle fractures, 12 humerus fractures and 4 shoulder dislocations. In the non-scapula group there were 137 clavicle fractures, 93 fractures of the humerus and 2 shoulder dislocations. The mean hospital stay in both groups was 22 days (range 5–153). In group 1 the mortality rate was 11.4% (9 patients) mean ISS 48 (range 24–75) versus 25% (136 patients) mean ISS 41.3 (range 17–75) in group 2.

Conclusion: Patients with scapular fractures were found to have a higher chest and abdominal AIS. Overall, the scapular fracture was not associated with higher ISS or higher mortality and does not correlate with a poorer outcome.