Pathophysiology of Trauma:
Influence on surgical timing
and implant selection
Piotr Blachut MD FRCSC
University of British Columbia
Vancouver, Canada
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23 yr old male
skiing accident 4 hours ago
isolated, closed injury
neurovascular normal
• 19 yr old male
• head on MVA
• Head injury
– GCS 6
• Multiple fractures
• Investigations
– CXR - normal
– C spine - normal
– Pelvis - normal
– CT head
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cerebral edema
hemispheric hemo. foci
SA blood
L tripod #
– CT abdo
• normal
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54 yr old male
fall from 25 ft.
no LOC
chest pain / SOB
pelvic / R ankle / L thigh pain
• hypotensive
• cold
• What do we need to fix?
• When should we fix it?
• How should we fix it?
Priorities
• Life threatening
• Limb threatening
• Function threatening
Priorities
• Life threatening
• Limb threatening
• Function threatening
- pelvic hemorrhage
Priorities
• Life threatening
- pelvic hemorrhage
• Limb threatening
-vascular injury
- compartment syndrome
- open fracture
- irreducible dislocation
• Function threatening
Priorities
• Life threatening
- pelvic hemorrhage
• Limb threatening
-vascular injury
- compartment syndrome
- open fracture
- irreducible dislocation
- articular fracture
• Function threatening
- distal extremity frac.
Priorities
• Life threatening
- pelvic hemorrhage
• Limb threatening
-vascular injury
- compartment syndrome
Long
fracture ?
- openbone
fracture
- irreducible dislocation
- articular fracture
• Function threatening
- distal extremity frac.
War experiences
•Splintage
•Early evacuation
•Early definitive treatment
Thomas splint
1960’s & 1970’s
• System of operative fracture
stabilization
• first applied to isolated injuries
• later application to polytrauma
• Improvement in anesthesia / critical
care management
Eric Riska, Finland 1977
• 47 pts.
• multiple trauma
• all long bone fractures fixed with
stable fixation
• 1 death (80 y.o.)
Vivoda, Meek, 1978
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71 pts., all multiple trauma, all ICU
two groups
no difference in AGE or ISS
Mortality
CONSERVATIVE 14/49 (28.5%)
OPERATIVE …… 1/22 (4.5%)
( 5:1 ratio)
1980’s
Early Total Care (ETC)
fracture stabilization (especially long bone
fracture within 24 hrs)
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Riska 1982
Goris 1982
Johnson 1985
Border
 FES
stabilization -  ventilation
1/5 rate of ARDS
1/5 rate “pulm. septic state”
1980’s
Cause of complications with delayed
stabilization
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fat embolism syndrome
supine position -> atelectasis -> sepsis
 narcotic use
inflammatory mediator release from
hematoma / soft tissue injury
Seibel, Ann Surg 1985
1980’s
Early Total Care (ETC)
– Bone et al., Dallas 1989
• Prospective randomized study
• Early vs. late femoral nailing
•  pulmonary complications
•  ICU length of stay
•  hospital costs
1980’s
• reamed IM
nailing the
standard of care
for femoral
shaft fractures
• known marrow
embolization
1990’s
Three types of patients:
• Isolated injuries
• Multiple fractures
• Multiple system
Does ETC apply to all ?
1990’s
Three types of patients:
• Isolated injuries
• Multiple fractures
• Multiple system
Does ETC apply to all ?
1990’s
• In severely injured patient
– significant chest injury
– significant head injury
• Is there a detrimental effect of
added major surgery
–  stress
–  blood loss
– fluid shifts
1990’s
• How show we fix it?
1990’s
• CHEST INJURY
Pape, Hannover,1993
• pts with pulmonary
contusion and early
reamed femoral nail
• increase in ARDS
and death
• ? unreamed femoral
nail / delayed nail
• ? femur group sicker
Charash, 1994
• replicated Pape study
• without chest trauma pulmonary
complications lower in early fixation
group (10% VS 38%)
• with severe chest trauma pulmonary
complications lower in early fixation
group ( 16% VS 56%)
Bosse et al, 1997
• institution randomized series
• early plating vs. early IM nailing
• 453 patients
• no  ARDS, PE, MOF, pneumonia or
death
• compared to plating or chest injury
alone
Dunham et al., 2001
Practice Management Guidelines for the Optimal
Timing of Long-Bone Fracture Stabilization in
Polytrauma Patients: The EAST Practice
Management Guidelines Work Group
• There is no compelling evidence that early longbone stabilization in patients with chest injury
either enhances or worsens outcome.
1990’s
• HEAD INJURY
Head injury
• Secondary brain injury in severe head
injury if exposed to:
– hypotension
– hypoxemia
– increased ICP (intercranial pressure)
– reduced CPP (cerebral perfusion pressure)
Head injury
• Early Fracture Fixation May Be
Deleterious After Head Injury
Jaicks RR, Cohn SM, Moller BA, J Trauma 42(1):1-6, 1997
Early
19
 fluid requirement
 hypoxia intra op
 hypotension
 GCS on discharge
Delayed
14
 neuro complic.
 ICU stay
 hospital stay
Head injury
EARLY FIXATION
DELAYED FIXATION
• Hofman 1991
• Poole 1992
• McKee 1997
• Starr 1998
• Smith 2000
• Brundage 2002
•Jaicks 1997
•Townsend 1998
All retrospective studies !!!
Head injury
EARLY
FIXATION
DELAYED
FIXATION
•  length of stay
• fluid requirement
•  mortality
•hypoxia
•  pulm. complic
neuro outcome ?
All retrospective studies !!!
Dunham, 2001
Practice Management Guidelines for the Optimal
Timing of Long-Bone Fracture Stabilization in
Polytrauma Patients: The EAST Practice
Management Guidelines Work Group
• There is no compelling evidence that early
long-bone stabilization in mild, moderate,
or severe brain injured patients either
enhances or worsens outcome.
Evolving concepts of
pathophysiology
• course after severe blunt trauma
dependant on:
– initial injury ( “first hit” )
– individual biologic response
– type of treatment ( “second hit” )
•Stable
1st HIT
•Borderline
•Unstable
•In extremis
Biological response
Therapy: 2nd HIT
•Prehospital
•ER
•ICU
•ETC
•Intermediate
•Damage control
Clinical outcome: ARDS, MOF, SIRS
Kellam 2003
2 nd HIT
• Second hit from the management of
skeletal injuries is under the control of the
surgeon
• Determine the patients ability to withstand
a second hit from trauma surgery
• How to minimize the second hit
“Borderline Patient”
• Polytrauma +ISS>20 + thoracic trauma (AIS>2)
• Polytrauma + abdominal/pelvic trauma and
hemodynamic shock (initial BP< 90 mmHg)
• ISS >40
• Bilateral lung contusions on x-ray
• Initial mean pulmonary arterial pressure >24mmHg
• Pulmonary artery pressure increase during IM
nailing > 6mmHG
Factors associated with BAD outcome
• Unstable difficult resuscitation
• Coagulopathy (platelets<90,000)
• Hypothermia (<32°C)
• Shock + 25 units blood
• Head Injury: GCS < 8, bleeding, edema
1990’s & 2000’s
Damage control surgery
Damage control orthopaedic surgery
(DCO)
Damage
control
orthopaedic
surgery
≠
Nonoperative
treatment
Priorities
• Life threatening
- pelvic hemorrhage
• Limb threatening
-vascular injury
- compartment syndrome
- open fracture
- irreducible dislocation
- articular fracture
• Function threatening
- distal extremity frac.
Damage control orthopaedic surgery
Avoid:
• excessive fluid shifts
• hypothermia
• coagulopathy
• pulmonary compromise
Provide stability:
• pain control
•  inflammatory
•
mediator release
•  fat embolism
•  mobilization
Damage control orthopaedic surgery
• rapid external fixation
• delayed definitive fixation
Damage control orthopaedic surgery
Timing of secondary surgery
• 2-4 days
• 6-8 days
 multiple organ failure
 inflammatory markers
Pape et al, 2001
Damage control orthopaedic
surgery
•  risk of local complications
– infection
– poorer joint reconstruction
• not borne out in clinical experience
(so far)
– Scalea, 2000
– Nowotarski 2000
ETC versus DCO
Pape et al., J Trauma, 2002
• prospective randomized multicentre series
• 17 versus 18 patients
• early IM nailing -> sustained inflammatory
response ( IL-6)
• no clinical difference (complication rate / LOS)
What to do in 2010?
Clinical status?
stable
borderline
unstable
resuscitate
reevaluate
stabilized
ETC
uncertain
?DCO
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23 yr old male
skiing accident 4 hours ago
isolated, closed injury
neurovascular normal
19 yr old MVA
Anesthestic
management
critical !!!!!
Consider DCO !!!
54 yr old male