Current updates in management of extremity injuries in polytrauma

Abstract

Injury-related morbidity and mortality have been one of the most common causes of loss in productivity across all geographic distributions. It remains to be a global concern despite a continual improvement in regional and national safety policies. The establishment of trauma care systems and advancements in diagnostics and management have improved the overall survival of severely injured. A better understanding of the physiopathological and immunological responses to injury led to a significant shift in trauma care from "Early Total Care" to "Damage Control Orthopedics." While most of these algorithms were tailored to the philosophy of "life before limb," the impact of improper fracture management on disability and societal loss is increasingly being recognized. Recently, "Early Appropriate Care" of extremities has gained importance; however, its implementation is influenced by regional health care policies, available resources, and expertise and varies between low and high-income countries. A review of the literature was performed using PubMed, Embase, Web of Science, and Scopus databases on articles published from 1990 to 2020 using the Mesh terms "Polytrauma," "Multiple Trauma," and "Fractures." This review aims to consolidate on guidelines and available evidence in the management of extremity injuries in a polytraumatized patient to achieve better clinical outcomes of these severely injured.

Keywords: Chest injury; Damage control; Fracture fixation; Polytrauma; Resuscitation; Traumatic brain injury.

Fig. 1

A 23-year-old gentleman diagnosed with closed fracture shaft of the right femur (a), closed fracture right tibia (b), closed fracture both bone right forearm (c), closed fracture left distal radius (d), and traumatic brain injury-Right frontal lobe contusion with SAH right parietal region (e). On arrival his vitals were stable, GCS was E4, V5, and M6 (15/15), Serum lactate was 1.7 mmol/L. He underwent external fixator application for the right femur and tibia fractures on day 1. Subsequently, he underwent definitive fixation of right femur (h) and tibia fractures (i) and both upper limb fractures (j,k) and achieved a good outcome.

Fig. 2

A 41-year-old gentleman diagnosed with traumatic brain injury-Subarachnoid hemorrhage with extradural hemorrhage right parietal lobe (a), APC type 2 pelvic injury (b), closed bilateral shaft of femur fracture (c,d) and closed both bone fracture right leg (e). On arrival, vitals were stable, GCS was E4, V4, and M5 (13/15), serum lactate was 4.6 mmol/L. He underwent external fixator application for pelvic injury (f), bilateral femur fractures (g,h), and tibia fracture (i) on day 1. On day 5, the patient became unstable with abdominal distension and was diagnosed with ileal perforation with closed-loop small bowel obstruction (j). Emergency laparotomy was performed with ileal resection and anastomosis. Subsequently, definitive fixation of both femur (k,l) and tibia fractures (m) were performed. The patient achieved a satisfactory outcome.

Fig. 3

A 45-year-old lady was diagnosed with bilateral hemopneumothorax with multiple rib fractures (a), pelvic injury (b), closed shaft of left humerus (c) and right femur fractures (d). On arrival, her vitals were stable, serum lactate was 2.6 mmol/L, pH was 7.34, and base excess was −0.3 mmol/L. She underwent definitive fixation of the humerus (e), femur (f), bilateral ICD insertion (g), and Right sacroiliac joint (h) as per EAC protocol within 36 h.

Fig. 4

A 18-year-old male diagnosed with grade 2 splenic laceration, intraperitoneal bladder rupture with diaphragmatic hernia left side (a) with left superior and inferior pubic rami fracture and closed diaphyseal fractures of the left femur (b) and tibia (c). On arrival, patient showed bradycardia, blood pressure of 114/60 mm Hg, GCS was E4, V5, and M6 (15/15) with absent breath sounds on the left side chest. Serum lactate was 7.2 mmol/L. After resuscitation, bladder and diaphragmatic hernia repair along with ICD insertion (f), splenectomy and external fixator application for the left femur (d) and tibia (e) fractures on day 1 were performed. Definitive fixation of the left femur (g) and tibia fractures (h) was performed later.

Fig. 5

A 40-year-old gentleman diagnosed with type 3b open side swipe injury right elbow (a,b) and Open floating knee injury right lower limb (c,d). On arrival his vitals were stable, GCS was E4, V5, and M6 (15/15), serum lactate was 2.5 mmol/L. He underwent external fixator application for the right femur and tibia fractures (e) and debridement and definitive fixation of right elbow injury on day 1 (f, i). Subsequently, he underwent definitive fixation of the right femur (g) and tibia fractures (h) and achieved good outcome.