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Giorgio Gasparini, MD Associate
Professor Orthopaedics and Trauma
Orthopaedic Department Catholic University Rome
(Italy)
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Multitrauma patient the orthopaedic point of view
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multitrauma
deaths from injury may increase from 5,1 million
to 8,4 million in 2020
 Murray CJ, Lopez AD Alternative projections of
mortality and disability by cause
1990-2020 Lancet 1997 May 24349(9064)1498-504
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multitrauma
multiple injuries in multiple organs
multidisciplinary approach
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multitrauma
the most frequent pattern
long bone fracture(s) head trauma one
thoracic, abdominal or pelvic injury
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multitrauma
 Schmit-Neuerburg KP, Joka T. Principles of
treatment indications for surgery in severe
multitrauma Acta Chir Belg 1985
Jul-Aug85(4)239-49
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multitrauma
when? who?
mangement timing
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!
timing
Osteosynthesis is not carried out as part of the
primary treatment but usually only one week later
Loew F. Timing in the treatment of multiple
injuries Zentralbl Neurochir 197940(4)281-5,
287-8
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timing
If one service anticipates operative management
of a specific injury, it may be coordinated with
orthopaedic needs, fracture fixation, or
reduction being carried out simultaneously
Light TR, Wu JC, Ogden JA. Diagnosis and
management of fractures in the multiply injured
patient Surg Clin North Am 1980
Oct60(5)1121-31
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timing
No patient should have orthopaedic problems
managed by benign neglect, even if the
probability of survival is low
Light TR, Wu JC, Ogden JA. Diagnosis and
management of fractures in the multiply injured
patient Surg Clin North Am 1980
Oct60(5)1121-31
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timing
Orthopaedic management in all patients should be
based on the assumption that the individual will
survive. Maximum functional recovery should be
expected.
Light TR, Wu JC, Ogden JA. Diagnosis and
management of fractures in the multiply injured
patient Surg Clin North Am 1980
Oct60(5)1121-31
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timing
Many "occult" fractures are often missed
initially because attention is focused on major,
life-threatening injuries
Light TR, Wu JC, Ogden JA. Diagnosis and
management of fractures in the multiply injured
patient Surg Clin North Am 1980
Oct60(5)1121-31
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timing
Pelvic and lower extremity injuries remain the
leading causes of impairment and loss of years of
productive life
Alonso JE, Lee J, Burgess AR, Browner BD. The
management of complex orthopedic injuries Surg
Clin North Am 1996 Aug76(4)879-903
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timing
Early stabilization and mobilization of the
traumatized patient decreases complications in
these patients
Alonso JE, Lee J, Burgess AR, Browner BD. The
management of complex orthopedic injuries Surg
Clin North Am 1996 Aug76(4)879-903
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timing
The golden time to prevent major complications is
6 hours
Alonso JE, Lee J, Burgess AR, Browner BD. The
management of complex orthopedic injuries Surg
Clin North Am 1996 Aug76(4)879-903
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timing
Operating time can be reduced considerably by 2
surgical teams operating simultaneously or
overlapping
 Schmit-Neuerburg KP, Joka T. Principles of
treatment indications for surgery in severe
multitrauma Acta Chir Belg 1985
Jul-Aug85(4)239-49
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life threatening emergency
primary treatment within 6 hours
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emergency
tretment to restore the function
non-delayed from 6 to 12 hours delayed within
24 hours
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treatment
life threatening emergency vascular complicated
lesions
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treatment
1 fracture stabilization (external fixation) 2
vascular damage repair 3 nerve repair
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treatment

• non-delayed emergency
• myelic vertebral fractures
• unstable pelvic fractures
• open fractures
• major articulations dislocations
• epiphyseal fractures in childood

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treatment

• non-delayed emergency
• unstable closed fractures
• nerve lesions
• tendons lesions
• traumatic amputations

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treatments

• delayed emergency
• articular fractures
• stable closed fractures

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priorities of treatment
4-stage-schedule
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stage 1

• intubation and hyperventilation
• pain relieving
• sedation
• volume replacement by central venous catheter

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stage 1

• provisional immobilisation
• emergency x-ray of cervical spine, chest,
  abdomen, pelvis
• diagnostic peritoneal lavage
• MRI, CT

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stage 2

• emergency surgery of internal and external
  bleeding
• stabilization of open fractures by external
  fixation

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stage 2
within 6 hours

• life threatening treatments

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stage 2
within 12 hours

• not delayed surgical treatments (surgical and
  medical)

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stage 2
within 24 hours (end of stage 2)

• delayed surgical treatments

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stage 3
24-48 hours

• stabilization of vital systems
• further diagnostic evaluations

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stage 4
after 5th day

• fractures osteosyntesis
• other delayed tretments

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orthopaedic trauma

• dislocations
• closed fractures
• open fractures
• amputations

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dislocations

• shoulder
• hip
• elbow
• knee
• cervical spine
• hand

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dislocations
treatment must be not delayed
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dislocations

• vascular injury
• nerve injury
• residual functional damage

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closed fractures

• vertebral fractures
• pelvic fractures
• long bone fractures

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vertebral fractures

• evaluations criteria
• lesion type
• (fracture, dislocation-fracture)
• lesion level
• stability or non-stability
• neurological involvement

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vertebral fractures

• with spinal cord involvement
• without spinal cord involvement

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spinal cord involvment

• 32.1 per million of trauma per year in USA
• veicular crashes, sport traumatology

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spinal cord involvment

• spinal chord lesion seqelae
• contusion
• compression
• laceration
• ischemia

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spinal cord involvment

• treatment aims
• stabilizations of vital systems
• restore neurological function
• achieve spine stability

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without spinal cord involvment

• if unstable
• closed tratment
• open tratment in selected cases

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without spinal cord involvment

• if unstable
• closed tratment
• open tratment in selected cases

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pelvic fractures

• pelvic ring fractures

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pelvic fractures

• acetabulum fractures

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pelvic ring fractures

• AP compression
• lateral compression
• share

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pelvic ring fractures
high mortality for associated internal lesions

• Peltier 9 (1965)
• McMurtry 19 (1980)
• Tile 10 (1988)

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severe pelvic trauma

• mortality rate 28
• 2/3 in the emergency room due to
  uncontrollable bleeding
• 1/3 in the intensive care unit from
  multi-organ failure

Siegmeth A, Mullner T, Kukla C, Vecsei V.
Associated injuries in severe pelvic
trauma Unfallchirurg 2000 Jul103(7)572-81
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pelvic ring fractures

• associated injuries
• long bones 85
• chest 62
• head 46
• abdomen 29
• urogenital 12
• vascular 6

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pelvic ring fractures

• stable
• unstable

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pelvic ring fractures classification
Type A stable Type B rotationally
unstable Type C rotationally and
vertically unstable
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pelvic ring fractures
Tile, 1988
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pelvic ring fractures
stable fractures (type A)
no surgical treatment
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pelvic ring fractures
unstable fractures (type B, C)

• pelvic clamps
• external fixator
• internal fixation

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management of pelvic ring injuries
surgical stabilization of unstable pelvic ring

• urgent control of shock
• protection of soft tissues
• safe, comfortable mobilization
• early ambulation

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pelvic ring fractures
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acetabular fractures
treatment can be delayed if no displacement has
occurred
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acetabular fractures
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long bone fractures

• closed
• open

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closed fractures

• immediat treatment
• reduction (alignment)
• trans-skeletal traction
• immobilization

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closed fractures
treatment cannot be delayed if neuro-vascular
injuries are associated
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closed fractures
bleeding control ? fracture stabilization ?
revascularization
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open fractures

• treatment aims
• preventing infections
• fracturess healing

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open fractures
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open fractures

• type I
• antibiotic therapy
• wound washing (no sutures)
• traction tecnique
• delayed internal fixation

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open fractures

• Type II
• antibiotic therapy
• wound washing (no sutures)
• traction tecnique
• delayed internal fixation

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open fractures

• type IIIa
• antibiotic therapy
• wound washing
• debridement
• fractur stabilization

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open fractures

• external fixator
• versatile device
• easy to perform
• wound approach
• mantained till fracture healing

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open fractures
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open fractures
Type IIIb e IIIc
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traumatic amputations

• reimplant indications
• site and type of amputation
• condition of the amputated part
• time of ischemia

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traumatic amputations

• revascularization risks
• patients clinical parameters
• specializated hospital

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traumatic amputations

• surgical technique
• debridement
• bone stabilization
• muscles, tendons, nervs suture
• vascular anasthomoses

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conclusions
early orthopaedic treatment allows a better and
quicker functional recovery and facilitates
associated lesions treatment
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grazie