Skip to main content

Timing of Treatment in the Multiply Injured Patient

  • Chapter
  • First Online:
Orthopedic Traumatology

Abstract

This chapter focuses on the clinical presentation, diagnosis, treatment options, and long-term prognosis of the multiply injured patient utilizing both retrospective and prospective data ranging from 1975 to 2017.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–8.

    Article  CAS  Google Scholar 

  2. Gutierrez G, Reines HD, Wulf-Gutierrez ME. Clinical review: hemorrhagic shock. Crit Care. 2004;8(5):373–81.

    Article  Google Scholar 

  3. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248(3):447–58.

    PubMed  Google Scholar 

  4. Wafaisade A, Maegele M, Lefering R, et al. High plasma to red blood cell ratios are associated with lower mortality rates in patients receiving multiple transfusion (4</=red blood cell units<10) during acute trauma resuscitation. J Trauma. 2011;70(1):81–8. discussion 88-89.

    Article  Google Scholar 

  5. Zink KA, Sambasivan CN, Holcomb JB, et al. A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. Am J Surg. 2009;197(5):565–70. discussion 570.

    Article  Google Scholar 

  6. Beckman SB, Scholten DJ, Bonnell BW, et al. Long bone fractures in the polytrauma patient. The role of early operative fixation. Am Surg. 1989;55(6):356–8.

    CAS  PubMed  Google Scholar 

  7. Behrman SW, Fabian TC, Kudsk KA, et al. Improved outcome with femur fractures: early vs. delayed fixation. J Trauma. 1990;30(7):792–7. discussion 797-798.

    Article  CAS  Google Scholar 

  8. Bone LB, Johnson KD, Weigelt J, et al. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71(3):336–40.

    Article  CAS  Google Scholar 

  9. Bone LB, McNamara K, Shine B, et al. Mortality in multiple trauma patients with fractures. J Trauma. 1994;37(2):262–4. discussion 264-265.

    Article  CAS  Google Scholar 

  10. Charash WE, Fabian TC, Croce MA. Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma. J Trauma. 1994;37(4):667–72.

    Article  CAS  Google Scholar 

  11. Seibel R, LaDuca J, Hassett JM, et al. Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state. Ann Surg. 1985;202(3):283–95.

    Article  CAS  Google Scholar 

  12. Pape HC, Auf'm'Kolk M, Paffrath T, et al. Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion--a cause of posttraumatic ARDS? J Trauma. 1993;34(4):540–7. discussion 547-548.

    Article  CAS  Google Scholar 

  13. Jaicks RR, Cohn SM, Moller BA. Early fracture fixation may be deleterious after head injury. J Trauma. 1997;42(1):1–5. discussion 5-6.

    Article  CAS  Google Scholar 

  14. Townsend RN, Lheureau T, Protech J, et al. Timing fracture repair in patients with severe brain injury (Glasgow coma scale score <9). J Trauma. 1998;44(6):977–82. discussion 982-973.

    Article  CAS  Google Scholar 

  15. Henry SM, Tornetta P, Scalea TM. Damage control for devastating pelvic and extremity injuries. Surg Clin North Am 1997;77(4):879–895.

    Article  CAS  Google Scholar 

  16. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma Acute Care Surg. 2000;48(4):613–23.

    Article  CAS  Google Scholar 

  17. Lefaivre KA, Starr AJ, Stahel PF, et al. Prediction of pulmonary morbidity and mortality in patients with femur fracture. J Trauma Acute Care Surg. 2010;69(6):1527–36.

    Article  Google Scholar 

  18. Vallier HA, Wang X, Moore TA, et al. Timing of Orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013;27(10):543–51.

    Article  Google Scholar 

  19. Vallier HA, Super DM, Moore TA, et al. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course. J Orthop Trauma. 2013;27(7):405–12.

    Article  Google Scholar 

  20. Vallier HA, Moore TA, Como JJ, et al. Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. J Orthop Surg Res. 2015;10:155.

    Article  Google Scholar 

  21. Vallier HA, Moore TA, Como JJ, et al. Teamwork in trauma: system adjustment to a protocol for the Management of Multiply Injured Patients. J Orthop Trauma. 2015;29(11):e446–50.

    Article  Google Scholar 

  22. Vallier HA, Dolenc AJ, Moore TA. Early appropriate care: a protocol to standardize resuscitation assessment and to expedite fracture care reduces hospital stay and enhances revenue. J Orthop Trauma. 2016;30(6):306–11.

    PubMed  Google Scholar 

  23. Reich MS, Dolenc AJ, Moore TA, et al. Is early appropriate care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients? J Orthop Surg Res. 2016;11(1):1–6.

    Article  Google Scholar 

  24. Pape HC, Andruszkow H, Pfeifer R, et al. Options and hazards of the early appropriate care protocol for trauma patients with major fractures: towards safe definitive surgery. Injury. 2016;47(4):787–91.

    Article  CAS  Google Scholar 

  25. Nahm NJ, Vallier HA. Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: a systematic review of randomized and nonrandomized trials. J Trauma Acute Care Surg. 2012;73(5):1046–63.

    Article  Google Scholar 

  26. Nahm NJ, Moore TA, Vallier HA. Use of two grading systems in determining risks associated with timing of fracture fixation. J Trauma Acute Care Surg. 2014;77(2):268–79.

    Article  Google Scholar 

  27. Nahm NJ, Como JJ, Wilber JH, et al. Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma Acute Care Surg. 2011;71(1):175–85.

    Article  Google Scholar 

  28. Harvin JA, Harvin WH, Camp E, et al. Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1,376 diaphyseal femur fractures. J Trauma Acute Care Surg. 2012;73(6):1442–9.

    Article  Google Scholar 

  29. Childs BR, Vallier HA. Cost savings associated with a multidisciplinary protocol that expedites definitive fracture care. Am J Orthop. 2014;43(7):309–15.

    PubMed  Google Scholar 

  30. Bosse MJ, Mackenzie EJ, Riemer BL, et al. Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study. J Bone Joint Surg Am. 1997;79(6):799–809.

    Article  CAS  Google Scholar 

  31. Johnson KD, Cadambi A, Seibert GB. Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures. J Trauma. 1985;25(5):375–84.

    Article  CAS  Google Scholar 

  32. Riska EB, von Bonsdorff H, Hakkinen S, et al. Prevention of fat embolism by early internal fixation of fractures in patients with multiple injuries. Injury. 1976;8(2):110–6.

    Article  CAS  Google Scholar 

  33. Boulanger BR, Stephen D, Brenneman FD. Thoracic trauma and early intramedullary nailing of femur fractures: are we doing harm? J Trauma Acute Care Surg. 1997;43(1):24–8.

    Article  CAS  Google Scholar 

  34. Reynolds MA, Richardson DJ, Spain DA, et al. Is the timing of fracture fixation important for the patient with multiple trauma? Ann Surg. 1995;222(4):470–81.

    Article  CAS  Google Scholar 

  35. Brundage SI, McGhan R, Jurkovich GJ, et al. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma Acute Care Surg. 2002;52(2):299–307.

    Article  Google Scholar 

  36. Morshed S, Miclau T, 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(1):3–13.

    Article  Google Scholar 

  37. Abramson D, Scalea TM, Hitchcock R, et al. Lactate clearance and survival following injury. J Trauma. 1993;35(4):584–8. discussion 588-589.

    Article  CAS  Google Scholar 

  38. Meregalli A, Oliveira RP, Friedman G. Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care. 2004;8(2):1–6.

    Article  Google Scholar 

  39. O’Toole RV, O’Brien M, Scalea TM, et al. Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics. J Trauma Acute Care Surg. 2009;67(5):1013–21.

    Article  Google Scholar 

  40. Crowl AC, Young JS, Kahler DM, et al. Occult Hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma Acute Care Surg. 2000;48(2):260–7.

    Article  CAS  Google Scholar 

  41. Morshed S, Corrales LA, Lin K, et al. Femoral nailing during serum bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction in multi-system trauma patients. Injury. 2011;42(7):643–9.

    Article  Google Scholar 

  42. Pape HC, Rixen D, Morley J, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246(3):491–9. discussion 499-501

    Article  Google Scholar 

  43. Pape HC, Giannoudis PV, Krettek C, et al. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma. 2005;19(8):551–62.

    Article  Google Scholar 

  44. Pape HC, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg. 2002;183(6):622–9.

    Article  Google Scholar 

  45. Childs BR, Nahm NJ, Moore TA, et al. Multiple procedures in the initial surgical setting: when do the benefits outweigh the risks in patients with multiple system trauma? J Orthop Trauma. 2016;30(8):420–5.

    Article  Google Scholar 

  46. Weinberg DS, Narayanan AS, Moore TA, et al. Prolonged resuscitation of metabolic acidosis after trauma is associated with more complications. J Orthop Surg Res. 2015;10(1):1–8.

    Article  Google Scholar 

  47. Richards JE, Matuszewski PE, Griffin SM, et al. The role of elevated lactate as a risk factor for pulmonary morbidity after early fixation of femoral shaft fractures. J Orthop Trauma. 2016;30(6):312–8.

    Article  Google Scholar 

  48. Scannell BP, Waldrop NE, Sasser HC, et al. Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients. J Trauma Acute Care Surg. 2010;68(3):633–40.

    Article  Google Scholar 

  49. Even JL, Richards JE, Crosby CG, et al. Preoperative skeletal versus cutaneous traction for femoral shaft fractures treated within 24 hours. J Orthop Trauma. 2012;26(10):e177–82.

    Article  Google Scholar 

  50. Austin DC, Donegan D, Mehta S. Low complication rates associated with the application of lower extremity traction pins. J Orthop Trauma. 2015;29(8):e259–65.

    Article  Google Scholar 

  51. Bumpass DB, Ricci WM, McAndrew CM, et al. A prospective study of pain reduction and knee dysfunction comparing femoral skeletal traction and splinting in adult trauma patients. J Orthop Trauma. 2015;29(2):112–8.

    Article  Google Scholar 

  52. Pell AC, Christie J, Keating JF, et al. The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg. Nov 1993;75(6):921–5.

    Article  CAS  Google Scholar 

  53. Pape HC, Regel G, Dwenger A, et al. Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma. J Trauma Acute Care Surg. 1993;35(5):709–16.

    Article  CAS  Google Scholar 

  54. Norris BL, Patton WC, Rudd JN Jr, et al. Pulmonary dysfunction in patients with femoral shaft fracture treated with intramedullary nailing. J Bone Joint Surg Am. 2001;83-A(8):1162–8.

    Article  CAS  Google Scholar 

  55. Canadian Orthopaedic Trauma S. Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma. 2006;20(6):384–7.

    Article  Google Scholar 

  56. Duan X, Li T, Mohammed A-Q, et al. Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review. Arch Orthop Trauma Surg. 2011;131(10):1445–52.

    Article  Google Scholar 

  57. Volgas DA, Burch T, Stannard JP, et al. Fat embolus in femur fractures: a comparison of two reaming systems. Injury. 2010;41(Suppl 2):S90–3.

    Article  Google Scholar 

  58. Giannoudis PV, Tan HB, Perry S, et al. The systemic inflammatory response following femoral canal reaming using the reamer-irrigator-aspirator (RIA) device. Injury. 2010;41(Suppl 2):S57–61.

    Article  Google Scholar 

  59. Pape HC, Zelle BA, Hildebrand F, et al. Reamed femoral nailing in sheep: does irrigation and aspiration of intramedullary contents alter the systemic response? J Bone Joint Surg Am. 2005;87(11):2515–22.

    PubMed  Google Scholar 

  60. Hartsock LA, Barfield WR, Kokko KP, et al. Randomized prospective clinical trial comparing reamer irrigator aspirator (RIA) to standard reaming (SR) in both minimally injured and multiply injured patients with closed femoral shaft fractures treated with reamed intramedullary nailing (IMN). Injury. 2010;41(Suppl 2):S94–8.

    Article  Google Scholar 

  61. Streubel PN, Desai P, Suk M. Comparison of RIA and conventional reamed nailing for treatment of femur shaft fractures. Injury. 2010;41(Suppl 2):S51–6.

    Article  Google Scholar 

  62. Wang RY, Li R, Zdero R, et al. The physiologic and pathologic effects of the reamer irrigator aspirator on fat embolism outcome: an animal study. J Orthop Trauma. 2012;26(9):e132–7.

    Article  Google Scholar 

  63. Miller AN, Deal D, Green J, et al. Use of the reamer/irrigator/aspirator decreases carotid and cranial embolic events in a canine model. J Bone Joint Surg Am. 2016;98(8):658–64.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Kevin D. Phelps .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Phelps, K.D., Kempton, L.B., Bosse, M.J. (2018). Timing of Treatment in the Multiply Injured Patient. In: Sethi, M., Obremskey, W., Jahangir, A. (eds) Orthopedic Traumatology. Springer, Cham. https://doi.org/10.1007/978-3-319-73392-0_29

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-73392-0_29

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-73391-3

  • Online ISBN: 978-3-319-73392-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics