Front. Med.

2012, 6(3): 234–242

DOI 10.1007/s11684-012-0218-2 REVIEW

Orthopaedic management in the polytrauma patient

Jason J. Halvorson, Holly T-P. Pilson ( ✉), Eben A. Carroll, Zhongyu John Li
Department of Orthopaedic Surgery, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27103, USA

© Higher Education Press and Springer-Verlag Berlin Heidelberg 2012

Abstract The past century has seen many changes in the management of the polytraumatized orthopaedic
patient. Early recommendations for non-operative treatment have evolved into early total care (ETC) and damage
control orthopaedic (DCO) treatment principles. These principles force the treating orthopaedist to take into
account multiple patient parameters including hypothermia, coagulopathy and volume status before deciding
upon the operative plan. This requires a multidisciplinary approach involving critical care physicians,
anesthesiologists and others.

Keywords damage control orthopaedics; early total care; polytrauma

Introduction
The management of the polytraumatized orthopaedic patient
is ever-changing and wrought with controversy. It can be
daunting, confusing and intimidating. Great advances in
understanding the physiology, treatment strategies, and
outcomes in this patient population have occurred over the
past five decades as both overall resuscitation measures and
advances in orthopaedic trauma techniques have evolved.
Despite advances in knowledge, timing and method of
fracture fixation continues to be the subject of debate as
further understanding of the body’s response to both
traumatic insult as well as surgical/resuscitative measures
continues.
Early total care
Prior to the 1970s, multi-trauma patients with orthopaedic
injuries were typically treated conservatively, as the thought
was that these patients were “too sick” to undergo surgery.
This primarily stemmed from the recognition of fat emboli
syndrome and pulmonary complications in this population.
However, as AO (Arbeitsgemeinschaft für Osteosynthesefra-
gen) techniques advanced and fracture care and trauma
resuscitation efforts improved, the 1980s brought about a
decade of early total care (ETC) in which polytraumatized
Received June 14, 2012; accepted July 10, 2012
Correspondence: hpilson@wakehealth.edu
patients with orthopaedic injuries were not only being treated,
but being treated within a short window of time post-injury
[1]. ETC can be defined as complete, primary, definitive
fracture stabilization within the first 24–48 h of injury. Bone
et al. further strengthened this movement with their
prospective study in the late 1980s, confirming that multi-
injured patients treated with ETC appeared to do better in
regards to pulmonary complications, length of ICU stay, and
total number of days in the hospital [2]. At this point, many
orthopaedic surgeons adopted the philosophy that these
patients were “too sick not to operate on.” This change in
practice allowed patients to mobilize earlier, begin rehabilita-
tion sooner and be discharged more timely. In addition,
complications associated with prolonged bed rest (pneumo-
nia, decubitus ulcers, infection, muscle atrophy/decondition-
ing) were decreased. However, as with many new trends
within orthopaedics, early stabilization of all multi-injured
patients began to prove to be deleterious in certain patient
populations, namely those with significant thoracic trauma/
pulmonary injuries. Thereafter, emphasis began to shift
toward expeditious temporary stabilization of fractures with
the goal to decrease future operative time and blood loss.
Damage control orthopaedics
The term “damage control orthopaedics” (DCO) was adopted
from the US Navy’s strategy for keeping heavily damaged
ships/vessels afloat despite their tremendous insults. Origin-
ally coined “damage control surgery,” this philosophy was
applied to abdominal trauma surgery in which three phases
Jason J. Halvorson et al.
were developed. Phase I was immediate surgery for
contamination and hemorrhage. This was followed by
Phase II — resuscitation in the ICU for reversal of
hypothermia, coagulopathy and hypovolemia. Phase III then
consisted of return to the operating room for definitive
surgery, once the patient stabilized [3]. This was later
extrapolated to orthopaedics, where Phase I consisted of
control of hemorrhage and stabilization of fractures, Phase II
by resuscitation in the ICU, and Phase III by the conversion to
definitive fixation of fractures. While the work-horse of
orthopaedic damage control has become the external fixator,
one must not forget about the important role that temporary
fracture reduction, splinting and skeletal traction can play in
the stabilization of the multi-injured patient. In at least one
study, skeletal traction was found to be equal to the external
fixation of femur fractures in regards to the rate of
development of acute respiratory distress syndrome
(ARDS), multi-organ system failure, pneumonia, deep
venous thromboembolism (DVT), pulmonary embolism
(PE), ICU stay, and death [4].
Pape et al. temporally delineate the eras of ECT and DCO
as being from January 1, 1981 to December 31, 1989 for the
former and from January 1, 1993 to December 31, 2000 for
the later, with an intermediate period in between, January 1,
1990 to December 31, 1992 [5].
DCO versus ETC
Management of the polytraumatized orthopaedic trauma
patient is often a team effort among several specialists
including orthopaedic surgeons, general surgery traumatolo-
gists, critical care practitioners, neurosurgeons, plastic
surgeons, emergency medicine physicians and interventional
radiologists, and should always begin with the Advanced
Table 1 Temporal relationship of four parameters involved in the natural progression of the polytrauma patient (Adapted with permission from Pape
et al. [6])
Clinical parameter Parameter indicative of Time to normalization in
high-risk patients uneventful course
Admission (day 1)
Shock BP<90 mmHg <1 day
Transfusion requirement
>2 Units/2 h
Lactate>2.5 mmol/L
Base excess>8 mmol/L
Coagulation Platelet count<90 000 1–2 days
Core temperature <33°C Hours
Soft tissue injury PaO2/FiO2<300 <2–4 days
Lung contusions, AIS>2
Chest trauma score; TTS>II
Abdominal trauma (Moore>II)
Complex pelvic trauma
BP, blood pressure; AIS, abbreviated injury scale; TTS, thoracic trauma score; BW, body weight.
235
Trauma Life Support (ATLS) principles in mind. Airway,
breathing, and circulation are of critical importance and
should be addressed prior to any orthopaedic interventions.
This is followed by attempts at reversing the so-called lethal
triad of hypothermia, coagulopathy, and acidosis. Hypother-
mia begins at traumatic insult and is exacerbated thereafter by
hypoperfusion, prolonged exposure and inactivity, and age
[3]. Historically, patients have been considered clinically
hypothermic when their temperature drops below 35°C.
Studies have shown that up to 21% of trauma patients are
hypothermic at presentation, which increases to 46% when
leaving the operating room [3]. Acidosis, the abnormal
increase in acidity of the blood, is often a byproduct of
hemorrhage and the state of shock and is routinely corrected
via aggressive fluid resuscitation. Acidosis is usually defined
by a blood pH of less than 7.4. Multiple markers for adequate
resuscitation have been determined and will be discussed
later. Coagulopathy, a state of disorder in the blood’s ability to
control the balance between bleeding and clotting, is caused
by multiple factors including dilution from resuscitation,
hypothermia, acidosis and even calcium levels, which have
all been shown to affect both the intrinsic and extrinsic
clotting cascades [3]. Recently, a fourth parameter, soft tissue
injury, has been added to encompass thoracic and abdominal
trauma and extensive orthopaedic injury. Table 1 highlights
these parameters as adopted form Pape et al. [6]
The use of these parameters has been helpful in developing
four “clinical conditions,” established at initial presentation:
stable, borderline, unstable, and in extremis (Table 2) [6].
Based on these data, it has been advocated by some that
definitive surgery be performed either within 24 h (ETC), or
after a 4-day waiting period (DCO), to allow normalization of
these parameters. Fig. 1 provides a treatment algorithm for
management of these patients.
If ETC is to be undertaken, minimizing the amount of time
Parameter indicative of high-risk patients
Clinical course (2 days) Comment
Catecholamine dependency Irrelevant after resuscitation
>2 days
>3 days below 100 000 or Simple parameter, good indicator
failure to increase
Irrelevant after re-warming
PaO2/FiO2<300 for>2 days Lung function often close to
Pathologic extravascular normal for 2–3 days (PaO 2 /
lung water (>10 ml/kg BW) FiO2>300)
236 Orthopaedic management in the polytrauma patient

Table 2 Assessment of four clinical grades and parameters for determining them in the polytrauma patient (Adapted with permission from Pape et al.
[6])
Parameter Stable Borderline Unstable In extremis
(Grade I) (Grade II) (Grade III) (Grade IV)
Shock BP (mmHg) ≥100 80–100 60–90 <50–60
Blood units (2 h) 0–2 2–8 5–15 >15
Lactate levels Normal range Approx 2.5 >2.5 Severe acidosis
Base deficit (mmol/L) Normal range No data No data >6–18
ATLS classification I II–III III–IV IV
UO (ml/h) >150 50–150 <100 <50
Coagulation Platelet count (µg/ml) >110 000 90 000–110 000 <70 000–90 000 <70 000
Factor II and V (%) 90–100 70–80 50–70 <50
Fibrinogen (g/dl) >1 Approx 1 <1 DIC
D-Dimer Normal range Abnormal Abnormal DIC
Temperature >34°C 33–35°C 30–32°C 30°C or less
Soft tissue injuries Lung function; PaO2 >350 300 200–300 <200
/FiO2
Chest trauma scores; AIS I or II AIS≥2 AIS≥2 AIS≥3
AIS
TSS O I–II II–III IV
Abdominal trauma ≤II ≤III III ≥III
(Moore)
Pelvic trauma (AO A B or C C C (crush, rollover with
classification) abd trauma)
Extremities AIS I or II AIS II–III AIS III–IV Crush, rollover, extremi-
ties
Surgical strategy DCO or definitive ETC ETC if stable DCO DCO
surgery (ETC)
BP, blood pressure; ATLS, Advanced Trauma Life Support; UO, urine output; TTS, thoracic trauma score; AIS, abbreviated injury scale; DCO, damage control
orthopaedics; ETC, early total care; DIC, disseminated intravascular coagulation.

Fig. 1 Treatment protocol for major fractures in polytrauma (Adapted with permission from Pape et al. [13]). ABG, arterial blood gas;
SBP, systolic blood pressure; FAST, focused assessment with sonography in trauma; UO, urine output.
Jason J. Halvorson et al.
in the operating room (OR) to less than two hours total is of
paramount importance. Prolonged operations have been
attributed to the “second hit” phenomenon. The patient’s
initial response to the traumatic stimulus heightens the
immune system and inflammatory response, causing
increased neutrophil adherence to cell walls, release of
autolytic enzymes and subsequent edema [7]. This, in turn,
may promote multi-system organ failure and/or ARDS.
Surgery can also influence this cascade by increasing the
inflammatory response, perhaps pushing the borderline
patient into an unstable or in extremis category and causing
a “second hit.” [7] Fat emboli and hypoxic events which may
result from early surgery can add insult to injury in the setting
of lungs already damaged by pulmonary contusions, rib
fractures, etc. This has been implicated as a primary cause of
early organ failure and ARDS in this patient population.
Tachhakra et al. followed arterial blood gases in patients with
long bone (femur or tibia) fractures from admission through
their hospitalization [8]. They found that roughly 64% of
patients were “hypoxic” on admission. In addition, hypoxic
events were demonstrated in over 50% of patients undergoing
fracture manipulation, with 12 out of 17 (70%) patients with
hypoxia prior to the operation having worsening of hypoxia
afterwards, versus only 9 of 21 (43%) patients having
worsening hypoxia when their oxygenation was normal going
into surgery. Pape et al. demonstrated an overall six times
greater risk of developing pulmonary complications if
intramedullary nailing was undertaken within the first 24 h
in borderline compared with stable patients [9].
Further evidence to support the increased inflammatory
response in multi-injured patients comes from direct
monitoring of the inflammatory cascade, more specifically,
levels of Il-6 or IL-8 [10]. After trauma, pro-inflammatory
cytokines such as TNF-α, IL-1, IL-6, and IL-8 are released
from macrophages and monocytes [11]. This, in turn,
increases the presence of adhesion molecules, raising
endothelial cell permeability and allowing migration of cells
into tissues. While trauma patients have been shown to have
increased levels of TNF-α, its relationship to sepsis has not
been fully proven [11]. IL-6 helps regulate the acute phase
response and the complement cascade, and its increase has
been shown to directly correlate with tissue damage and
multiple organ failure [11]. IL-6 has also been shown to
increase after primary intramedullary nailing (IMN), but not
with DCO [11], supporting the argument of the second hit
phenomenon. Pape et al. [12] compared the insertion of an
unreamed femoral nail to that of an uncemented femoral total
hip prosthesis. In his study, IL-6 levels increased post-
operatively in all patients, but those with the highest burden
of IL-6 pre-operatively had larger increases post-operatively.
This was also correlated with prolonged ventilation times.
Therefore, the question remains — if DCO is undertaken,
at what point is it safe to convert to definitive stabilization?
Days 2–4 post injury are generally considered by many to be a
“danger time” in which the patient may be inadequately
237
resuscitated, with fluid shifts equilibrating, and the inflam-
matory response just beginning to normalize. This is
supported in a study of over 4 000 patients in which those
receiving an operation within 2–4 days of greater than 3 h
duration were found to have a statistically significant increase
in multiple organ failure compared with those who underwent
definitive fixation at 6–8 days [13]. According to Pape [6],
subtle clinical changes should be respected when planning a
secondary definitive procedure. These include a positive fluid
balance (In/Out ratio above 500 ml/day) that has not cleared
after days 2 to 3 after injury, and airway pressures ( > 30 cm
H2O), both of which are indicative of systemic and/or
pulmonary interstitial fluid accumulation. Also, any evidence
of coagulopathy, such as failure of the platelet count to
rise > 100 000 should be seen as a warning sign. Scalea et al.
demonstrated minimal complications in conversion from
external-fixation to intramedullary nailing of femoral shaft
fractures in 43 patients at an average of 4.8 days after the
index procedure [14].
Femur fractures and DCO vs. ETC
Much of the literature examining the timing of fracture
fixation in the polytrauma patient focuses on femoral shaft
fractures, with DCO utilizing external fixation as initial
treatment and ETC either reamed or unreamed intramedullary
nailing. Advocates of DCO demonstrate a decreased systemic
inflammatory response in those patients treated with initial
external fixation followed by conversion to intramedullary
nailing [15]. Fig. 2 demonstrates the use of spanning external
fixation in the temporary stabilization of an unstable
polytruma patient with bilateral femoral shaft fractures.
In examining the United States National Trauma Database
over a 4-year period from 2000 to 2004, a 50% decrease in
mortality was found in patients under-going ETC for femur
fractures if performed greater than 12 h after arrival,
compared to those fixed within the first 12 h [16]. It was
also found that those with serious abdominal trauma
benefitted the most from a delay in ETC. Pape et al. [5]
found statistically better outcomes in regards to multi-organ
failure and ARDS in the “era” of DCO (January 1, 1993 to
December 31, 2000), compared to previous time periods at
their institution imploring ETC and a more intermediate
treatment algorithm. While one could argue that medical
advances (i.e., respiratory care, evaluation and treatment of
abdominal and thoracic trauma, etc.) also contributed to this
difference in outcome, they also found statistically higher
rates of ARDS in those patients treated with IMN versus
primary external fixation in the DCO era [5]. Taeger et al. [17]
supported this claim, showing decreased initial operating time
and blood loss with overall decreased predicted mortality
with DCO compared to ETC. In at least one study, overall
pulmonary morbidity and death did not seem to be decreased
with early definitive care ( < 48 h) in patients with severe
238
Fig. 2 Utilization of DCO in bilateral femoral shaft fractures. (A) CT scanogram showing bilateral femoral shaft fractures. (B) Post-
operative CT scanogram demonstrating use of spanning external fixation in the temporary stabilization of bilateral femoral shaft fractures.
chest trauma and long bone fracture as compared to those
patients with severe chest trauma without long bone fracture
[18]. This is in contrast to a study by Weninger et al. who
demonstrated no difference in those patients with thoracic
trauma with and without femur fracture who received
unreamed intramedullary nailing within 24 h [19]. Likewise,
the Canadian Orthopaedic Trauma Society conducted a
prospective randomized trial of multiply injured trauma
patients (defined as Injury Severity Score > 18) receiving
either reamed or unreamed femoral nails. In their study, no
difference was found in the incidence of ARDS or other
pulmonary complications between groups, leading them to
conclude that reamed and unreamed nails are safe for early
stabilization of femur fractures in the poly-trauma patient
[20]. Nahm et al. found fewer complications when femur
fractures were treated with ETC, with an overall complication
rate of 18.9% (treatment < 24 h), compared to a rate of 42%
(treatment > 24 h) [21]. Interestingly, they admit that
preferential treatment was given to the femur and that other
fractures within these patients were not treated with ETC (i.e.,
forearm fractures were splinted, etc.). Therefore, their true
definition of ETC is used loosely as it relates only to femur
fracture fixation. O’Toole et al. [22] propose that ETC is safe
and can be performed within the first day, pointing to their
cohort of reamed IMN for femur fracture at an average of 14 h
after injury with minimal incidence of ARDS or complica-
tion. They propose that 14 h post-injury provides adequate
time for the patient time to be resuscitated and stabilized.
Tuttle et al. [23] also found no difference between femur
fractures originally treated with external fixation versus those
treated primarily with intramedullary nailing in regards to
ICU length of stay, hospital length of stay, ventilator days,
Orthopaedic management in the polytrauma patient
multi-system organ failure, or ARDS score. They did,
however, find that a DCO approach caused overall less initial
OR time and blood loss. Those patients with bilateral femur
fractures deserve special attention as mortality is proven to be
increased in this patient population; upwards of 30% in one
study [24]. In addition, the association of bilateral femur
fractures with injuries in different systems (up to 80%) may
heighten the mortality risk. There is a paucity of literature to
guide treatment strategies of this special circumstance.
Therefore, we feel that the best strategy is to assess the
overall patient status and attempt to classify them as stable,
borderline, or unstable and act accordingly.
There are also data to support ETC for femur fractures in
patients with severe head injuries. In their study, Brundage et
al. [25] found improved outcomes in this population
(primarily improved Glasgow Coma Scale at discharge) in
patients with femoral shaft fractures treated within 24 h
compared to those treated within 2–5 days. In addition,
fixation within 24 h did not lead to increased mortality. A
retrospective review of patients with severe head injuries
(GCS ≤ 8) and long bone fractures requiring surgical
fixation found no difference in terms of intra- and post-
operative hypoxic and hypotensive episodes, neurologic,
orthopaedic or general complications between those who
underwent early versus late fixation [26]. On the other hand,
another retrospective review of patients with significant
closed head injuries requiring operative fracture fixation
found increased rates of hypoxemia and hypotension (both
risk factors for secondary brain injury) in those undergoing
early ( < 24 h) versus late ( > 24 h) surgery [27]. This was
felt to be due, in part, to the significantly higher amount of
fluids received by this population in the first 48 h following
Jason J. Halvorson et al.
injury, likely resulting in deleterious increases in intracranial
pressure, fluid shifts and edema. Although the available
literature does not provide clear-cut guidance on the
management of fractures in the presence of head injuries,
the trend is toward a better outcome with earlier fixation [28].
Pelvic ring injuries
Perhaps where the orthopaedic surgeon can be of most benefit
in the early management and resuscitation of the multiply-
injured trauma patient is in the area of pelvic trauma.
Accounting for approximately 3%–8% of all fractures, a high
rate of mortality has been assigned to pelvic ring disruption,
especially in association with hemorrhagic shock, and has
been reported to be as high as 50% in one series [29]. With
advances in resuscitation and management, mortality directly
related to pelvic trauma is most likely closer to 7% [30].
Although many classification systems for pelvic ring
disruption exist, perhaps the most widely used for both
mechanism of injury as well as prediction of resuscitation,
hemorrhage and associated injury is that of Young-Burgess.
While a comprehensive overview of pelvic ring classification
is beyond the scope of this review, pelvic ring disruptions can
be combined into lateral compression (LC) in which an
internal rotation force is directed to the hemi-pelvis,
anteroposterior compression (APC) in which an anteriorly
directed force exerts external rotation deformities to the
pelvic ring (the so-called “open book pelvis”), vertical shear
(VS) in which one hemi-pelvis is sheared cranial/caudal, and
finally a combined mechanism [31]. It is important for us to
note the classification of pelvic ring disruption as this has
been shown to have prognostic influence in regards to
mortality and transfusion requirement [29,30]. For example,
anteroposterior compression (APC) injuries are associated
with the highest mortality and blood transfusion require-
ments, being on average 20% and 14.8 units, respectively, as
opposed to lateral compression injuries 7% and 3.6 units [31].
In addition, the stability of the pelvic ring can help with
diagnosis of the most likely source of hemorrhage. In one
series, patients with stable pelvic ring disruptions (LC I and
APC I) and hypotension were found to have an intra-
abdominal source of hemorrhage in 85% of cases [29]. This is
in contrast to unstable pelvic ring injuries where bleeding was
found from a pelvic source in 59% of patients. This is also
supported by Dalal et al. who found that as APC grade
increased, intra-abdominal injury, pelvic vessel injury, retro-
peritoneal hematoma, shock, sepsis, ARDS and volume needs
increased [32]. In addition, APC III patterns carried the
highest mortality risk. Likewise, LC injuries increased rates
of pelvic vessel disease, retroperitoneal hemorrhage, shock
and resuscitation needs with increasing grade [32]. While the
majority of the literature focuses on pelvic ring disruption and
transfusion requirements, acetabular fractures are also
associated with increased transfusion requirements. More
239
specifically, T-type patterns and fractures involving the
anterior column are noted to have increased transfusion
requirements over the first 24 hours than other fracture
patterns [33]. The orthopaedic surgeon is in a unique position
to help guide resuscitation efforts in those patients with pelvic
ring disruption to help identify the most common location of
bleeding resulting in hypotension.
In the patient with hypotension and a pelvic ring
disruption, acute management should focus on stopping and
controlling death from hemorrhage. Common sites of
bleeding include the iliac vessels and their branches.
However, venous disruption/hemorrhage as well as bleeding
from cancellous bone is also a major contributor. The pelvis
and retroperitoneum can hold up the 4 L of fluid volume [34].
While bleeding eventually stops from tamponade, this may
not be the case in pelvic ring disruption, as pelvic integrity is
compromised, allowing more and more expansion as
bleeding continues. The pelvis can be thought of as either a
cylinder or a sphere, as defined by the equation πr2 or 4/3πr3,
respectively. Regardless of which three dimensional structure
one wishes to assign to the pelvis, the bottom line is that as the
radius increases, there is exponential increase in volume. It is
rare that ETC is undertaken in the patient with hypotension
and a pelvic ring disruption. External fixation (either in the
iliac wing or in the anterior inferior iliac spine) to help control
pelvic disruption is less utilized as in the past. One thought is
that the pivot point of external fixation is located anterior.
Therefore, in pelvic ring injuries which are predominantly
unstable posteriorly, compression through an external fixation
device, while compressing the front, may actually widen the
posterior pelvis and worsen the problem. While external
fixation can certainly still play a role in pelvic stabilization,
pelvic binding, either with use of commercial devices such as
the TPOD®, or with a sheet, are efficient, easy, and effective
ways to decrease intra-pelvic volume and stabilize the
unstable pelvic ring disruption [35]. It should be noted that
these methods are typically used for APC varietal fracture
patterns where the pelvic volume continues to expand. Fig. 3
demonstrates the use of DCO with pelvic binding utilizing a
TPOD®.
In lateral compression type injuries, pelvic sheets and
binders do little to improve hypotension/prevent hemorrhage.
Simple internal rotation of both feet to help close down pelvic
volume has also been advocated [36]. In extreme cases,
damage control iliosacral screws, even through a pelvic
binder, may be used safely and effectively [37]. There is some
support to consider pelvic and acetabular fractures within the
same realm as femur fractures in that multi-trauma patients
benefit from earlier total care of these injuries than delayed. In
a study of 645 patients, Vallier et al. found an overall
complication rate of 12.4% vs. 19.7% in this patient
population treated in less than and greater than 24 h from
injury, respectively, including less ARDS and pneumonia
[38]. As pelvic and acetabular fractures are often treated with
traction and prolonged recumbency, early fixation gives the
240 Orthopaedic management in the polytrauma patient

Fig. 3 Utilization of DCO in a 46-year-old woman with an open book (APC-III) pelvic ring injury. (A) Injury AP pelvis radiograph.
(B) AP pelvis radiograph after application of a TPOD® pelvic binder. (C) Clinical picture of the patient on the operating table with the
TPOD® replaced with a sheet binder to facilitate operative fixation of the pelvic ring injury while maintaining compression with the
binder. (D) Post-operative outlet pelvis radiograph showing definitive fixation. (E) Post-operative AP pelvis radiograph showing definitive
fixation.

benefit of earlier mobilization, pulmonary rehabilitation, pain
control, and therapy.
Pelvic packing for help with hemostasis has been
advocated by some as method of DCO in unstable patients
with pelvic ring disruption [39,40]. In a systematic review of
three studies, Papakostidis et al. stated that pelvic packing
may be useful in select patients as part of a general damage
control philosophy [40]. However, complication rates were
not insignificant and included infection (35%), multiple organ
failure (9%), and an overall mortality of 23%.
The use of angiography and embolization is also routinely
used as a first-line therapy for pelvic hemorrhage. While
venous bleeding and bone bleeding are unable to be
controlled by angiography, significant arterial bleeding occurs
in roughly 2%–8% of patients[41–43]. Patients with a pelvic
fracture who are not responding to resuscitative efforts are the
ones who benefit most from angiography. In this select group
of patients, the negative and positive predictive value for
angiography was 100% and 73%, respectively [44]. The most
common sites of arterial bleeding include the superior gluteal,
lateral sacral, internal pudendal, inferior gluteal and obturator
arteries [45]. Karadimis et al. [43] in a systematic review of
26 studies demonstrated an overall rate of embolization of
8.4% in pelvic fractures. Mortality from pelvic hemorrhage
was found to be 25%, however, effectiveness of arteriography
and embolization varies from 59%–100%. While a powerful
tool for controlling hemorrhage in pelvic trauma, arterio-
graphy does have negatives. Institutions caring for pelvic
trauma require this service to be available 24 h/day, 7 days/
week. In addition, the angiography suite should be located
near the Emergency Department to limit transport of unstable
patients. In the setting of hypotension, false negative
angiography may also be found, with some series reporting
undiagnosed arterial bleeding in up to 50% of patients [46].
Certain patients who may be a set-up for repeat angiography
include those with a widened pubic symphysis, increasing
resuscitation needs, two arterial bleeders, and pre-hospital
hypotension [47].
Summary
The management of orthopaedic injuries in the polytrauma-
tized patient can be very difficult and requires the concerted
efforts of a multidisciplinary team. Complex systems and
processes are at play and are constantly changing in this
population, leaving short windows of opportunity to
effectively treat orthopaedic injuries without causing addi-
tional harm. Various patient parameters such as blood
pressure, base deficit and core body temperature to name a
few, allow for the treating surgeon to classify this population
into a range of clinical conditions from “stable” to “in
extremis” which can be very useful in guiding treatment.
Jason J. Halvorson et al.
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