Injury 51S2 (2020) S10–S14

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Fracture fixation in the polytrauma patient: Markers that matter ✩,RR

Timothy A. Moore1, Natasha M. Simske1, Heather A. Vallier1,∗
MetroHealth Medical Center, Cleveland, OH, USA

a r t i c l e i n f o a b s t r a c t

Article history: Timing and type of fracture fixation in the multiply-injured trauma patient have been important and
Accepted 16 December 2019 controversial topics. Ideal care for these patients come from providers who communicate well with one
another in a team fashion and view the whole person, rather than focusing on injury to individual sys-
Keywords: tems. This group encompasses a wide range of musculoskeletal and other injuries, further complicated
Polytrauma by the broad spectrum of patients, with variability in age, medical and social comorbidities, all of which
Femur fracture may have profound impact upon outcomes. The concept of Early Total Care arose from the realization
Damage control that early definitive fixation of femur fractures provided pulmonary and systemic benefits to most pa-
Early appropriate care tients. However, insufficient assessment and understanding of the physiological status of polytraumatized
Timing
patients at the time of major orthopaedic procedures, potentially with inclusion of multiple other pro-
Complications
cedures in the same setting resulted in more morbidity, swinging the pendulum of care toward initial
Organ failure
Damage Control Orthopaedics to minimize surgical insult. More recently, iterative assessment of response
to resuscitation using Early Appropriate Care guidelines, suggests definitive fixation of most axial and
femoral injuries within 36 h after injury appears safe in resuscitated patients, as measured by improve-
ment of acidosis.
© 2019 Elsevier Ltd. All rights reserved.

Introduction spectives on the timing of fixation of major skeletal injury, to as-

sess current evidence, and to develop recommendations for evalu-
Nearly 50% of all trauma deaths are due to the immediate ation and treatment, while acknowledging limitations and defining
injury, often lethal head injuries or exsanguinating trauma due areas for future study. Many strategies have been proposed and in-
to rupture of major vasculature. Approximately another 10% oc- stituted for performing fracture fixation in the acute setting. Two
cur within hours after the initial trauma secondary to hypov- widely described systems are early total care, which gave way to
olemic shock, hypoxia or head injury. Lastly, the remaining 45% damage control orthopaedics. Subsequent to these, Early Appropri-
of trauma deaths occur weeks later, secondary to acute respira- ate Care proposes a middle ground, offering guidelines for timing
tory distress syndrome, renal failure, or some combination of mul- of definitive care based on response to resuscitation.
tiple organ failure [1–3]. Fracture fixation in the polytrauma pa-
tient, whether provisional or definitive plays a key role in minimiz- Early total care
ing morbidity and mortality in the acute setting. Fixation of axial
and femoral fractures provides skeletal stability to promote upright Early total care evolved as a concept during the late 1980s, pri-
posture and mobility from bed [2,4–7]. It further affords pain relief, marily based on benefits of early fixation of femur fractures. It
with demonstrable reduction in narcotic requirements, and also was believed the patient was “too sick not to have femoral frac-
decreases risk of thrombotic complications [8]. While these general tures fixed” in the acute setting [2,3,9]. In a randomized trial it was
benefits are not debated, the development of a safe and appropri- shown that patients who had delayed (>48 h after injury) femur
ate plan of care, including method and timing of fixation has been fracture fixation had more respiratory and other morbidity, includ-
disputed. The purposes of this paper are to review historical per- ing acute respiratory distress syndrome, fat embolism and pneu-
monia, when comparison was made with those patients who had
intramedullary nailing of their femur fracture within 24 h [9]. The
✩
All devices used in this study are FDA-approved.
RR
delayed group was further noted to have longer lengths of hospi-
This paper is part of a supplement supported by the Osteosynthesis and Trauma
Care Foundation (OTCF) through a research grant from Stryker.
tal and ICU stay and greater costs of care. About half of the cohort
∗
Corresponding author. was polytraumatized patients with an ISS > 18, and the benefits
E-mail address: hvallier@metrohealth.org (H.A. Vallier). of early femur fixation were noted to be even greater among these
1
Affiliated with Case Western Reserve University. patients when compared with those with femur fractures and low

https://doi.org/10.1016/j.injury.2019.12.024
0020-1383/© 2019 Elsevier Ltd. All rights reserved.
 T.A. Moore, N.M. Simske and H.A. Vallier / Injury 51S2 (2020) S10–S14 S11

ISS. During the following years, trauma practices, especially in US fect a patient similarly, such as mechanically unstable spine, pelvis,
centers promoted early (generally defined as within 24 h) defini- and acetabulum fractures, are not often amenable to external fix-
tive fixation of other fractures, in addition to the femur. Little spe- ation. The specific, optimal timing of fixation was also not thor-
cific study was directed to other axial injuries, such as the spine oughly studied.
or pelvic ring, and almost no mention was made of timing of me- A grading scheme was proposed by Pape et al. to group pa-
chanically unstable acetabulum fractures. Yet, these injuries share tients with femoral shaft fractures into stable, borderline, unstable
the similar acute effects on an injured patient, in that all entail re- and in extremis categories [16,18]. This system included vital signs,
cumbent positioning, and some necessitate skeletal traction until laboratory parameters measuring cell counts, acidosis, coagulation,
reduced and stabilized. and presence and severity of injuries to other body systems, in-
Early total care was questioned by surgeons who identified se- cluding chest, abdomen and head. Initial treatment with definitive
vere pulmonary complications and demise in patients treated on fracture care versus DCO was stipulated based on which category
an early basis with reamed intramedullary nailing of the femur the patient fulfilled three of the parameters in. However, this sys-
[10–13]. Whether this was in part due to reaming, presence and tem was not data driven, although the concepts and processes rec-
severity of chest injury, or other factors, could not be discerned. ommended were based on a summary of longterm experience of
It was proposed that the injury constituted the “first hit,” while many trauma surgeons. Prospective assessment of borderline pa-
the surgical insult of more bleeding in an under-resuscitated pa- tients with femoral shaft fractures, designated to be treated with
tient constituted the “second hit,” which could exceed a theoretical either early intramedullary nailing or with DCO, was evaluated in
threshold after which severe systemic inflammatory response may a randomized study [22]. Findings included no difference in rates
pose high risk for organ failure and mortality. At this time resusci- of pneumonia, systemic inflammatory response syndrome, multi-
tation protocols had not been standardized, and parameters deter- ple organ failure, or sepsis. However, acute lung injury, a reduction
mining ideal timing of fixation had not been proposed. Neverthe- in oxygenation (PaO2 /FiO2 < 300) in the presence of bilateral pul-
less, early femoral fixation, and by extension other pelvis and ex- monary infiltrates, was detected among the patients treated with
tremity fracture fixation, were deferred by some trauma providers. early nailing [22].
Reduction and fixation of major thoracolumbar fractures was also During the past 15–20 years most trauma centers have utilized
historically done on a delayed basis, mostly due to limited surgeon a combination of DCO and early definitive fixation for femoral frac-
availability as treatment principles and techniques were evolving, tures, reserving DCO for the most critically injured patients, such
and also due to lack of supporting data regarding benefits of early as those with profound acidosis, severe head injury, and/or car-
surgery in spinal patients. Some of these spinal injuries are fur- diac demise [21–29]. In this environment a large set of data were
ther confounded by the presence of spinal cord injury, with unsub- analyzed to develop a probability model to predict and to miti-
stantiated concern for worsening neurological insult due to early gate pulmonary and other complications in patients with axial and
surgery. femoral fractures, by defining what injuries or parameters warrant
delay of definitive fixation, and by determining the optimal timing
Damage control orthopaedics of fixation, keeping in mind that 24 h had been arbitrarily main-
tained as a standard in many prior reports [29,30].
In the midst of these practice patterns, the concept of Damage
Control Orthopaedics (DCO) was developed. Initially a term used to Early appropriate care
reference the management of major damage to watercraft by com-
partmentalizing fire or water intrusions, the concept was applied Early Appropriate Care (EAC) resulted from a multidisciplinary
to patients with penetrating abdominal trauma [14]. Emergent ex- group of trauma providers proposing to define optimal type and
ploratory laparotomy with identification and control of bleeding timing of fixation in multiply-injured patients with these types of
was promoted. Abdominal packing was performed and return to fractures. This was the first model of its kind to include thora-
the operating room within a few days for more definitive abdomi- columbar trauma. The origin of the protocol was a retrospective
nal procedures was then advocated, once the patient had been re- review of 1443 polytrauma patients with an ISS ≥ 16 and 1745
suscitated and systemically stabilized. The rationale was to avoid high energy operative fractures of interest, specifically mechani-
large, definitive operations during the peak of the systemic inflam- cally unstable injuries of the thoracolumbar spine, pelvic ring, ac-
matory response, effectively minimizing the second hit. etabulum, and proximal or diaphyseal femur. Multivariate analysis
Likewise, the first reports of damage control concepts applied determined the three determinants of early complications, mainly
to the skeleton focused on provisional reduction and fixation of pneumonia, to be (1) the magnitude and duration of acidosis, (2)
femoral shaft fractures to afford skeletal stability and pain relief, the severity of chest injury, and (3) the timing of fixation, where
while acutely permitting upright posture and other mobility within patients treated with definitive fixation more than 40 h after injury
bed [15]. Damage control orthopaedics (DCO) was initially pro- were at significant risk for pulmonary decline [30,31].
posed for patients with severe head injury, massive hemorrhage Notably, most patients responded to initial resuscitation. Those
and hemodynamic instability, or other indications precluding safe who had a protracted course of resuscitated, measured by severe
early definitive fracture fixation [15–17]. Additional reports of DCO acidosis, had extremely high mortality. Etiology may have been de-
involved external fixation of femur or tibia fractures to allow trans- layed access to care, massive continuing hemorrhage, and/or fail-
port of the soldier out of the field to a center for definitive fixation. ing cardiac or pulmonary systems. Mathematical modeling within
Initial DCO was not consistently based on any particular this large data set, was used to incrementally analyze the three
physiologic parameters or objective data. While DCO has been available measurements of acidosis over time, in order to identify a
demonstrated to provide a reasonable alternative to definitive in- threshold by which definitive surgery could be recommended with
tramedullary nailing of the femur in severely compromised pa- a reasonable risk. Sequential, logistical predictive models incorpo-
tients, it has also been shown that most injured patients with rating time and magnitude of risk factors were employed. The goal
femoral shaft fractures can safely be treated on an early basis [18– of these investigators was to attempt to decrease complications by
24]. Thus, the indications for DCO in terms of severity of injuries 10% from the historical cohort. Ultimately, the threshold recom-
to other systems, physiological state of the patient, including pres- mendations were pH ≥ 7.25, base excess ≥ −5.5 mmol/L, or lactate
ence of acidosis and coagulopathy, were not addressed [23]. Addi- < 4.0 mmol/L, to proceed with definitive fixation of fractures of the
tionally, some femur fractures, as well as other injuries which af- thoracolumbar spine, pelvic ring, acetabulum, or femur, as long as
S12 T.A. Moore, N.M. Simske and H.A. Vallier / Injury 51S2 (2020) S10–S14

the patient was responding to resuscitation, and was not requiring

vasopressor support [30]. For patients with acidosis still exceeding

Prolonged lactate clearance associated with organ failure and death [29,34,41,42,44,45]. Lactate more specific than
Admission base excess predicts morbidity and mortality [29,41–43]. Complications associated with magnitude and

Femoral reaming associated with IL-6 [47,48]. High levels associated with organ failure and death [38,39,49,52].
the prescribed parameters (even minimally), definitive surgery is
deferred until repeat labs demonstrate improvement; damage con-
trol strategies may be employed.

High levels associated with organ failure and death [38,39,49]. Hyperinflammatory state associated with
The Early Appropriate Care (EAC) protocol established objec-
tive data to guide the providers in the timing of definitive fracture
surgery. Often polytrauma patients are under-resuscitated and do
not meet the objective criteria at the time of presentation. The in-
vestigators established a 36-h window from the time of injury to
performing definitive fracture care. Most patients studied prospec-
tively predictably responded to resuscitation; however, for those
with massive head injury or cardiac disease, approximately 1% of
the prospective study group, fixation timing and strategy was ad-
justed to account for those issues [31]. The study protocol was
agreed upon among all the providers caring for the patients includ-

Acidosis on admission predicts morbidity and mortality [29,41–43].

ing general surgery traumatologists, intensivists, anesthesiologists,
neurosurgeons, and orthopaedic traumatologists. The expectation

High levels associated with inflammation after trauma [46].

High levels associated with organ failure and death [39,49].

of the study was the patient would go to the operating room for
definitive fracture fixation within 36 h as long as they were ade-

Modulates systemic inflammation after trauma [50].

quately resuscitated, based on the improvement of acidosis to rec-
ommended levels, even when the lactate may remain marginally

post-trauma immunosuppression [46,51,52].

elevated. During cases involving multiple procedures on the same
patient, labs may be repeated several times as the discretion of
the treating team; as long as EAC parameters are met, and the
patient’s condition is stable, additional procedures are undertaken.
Using EAC guidelines complications were reduced, and major cost-

duration of acidosis [29,34].

savings have been realized [32]. Interestingly, measurements of co-

Markers of resuscitation. Method of sample, time until results available, costs in US dollars, and supporting evidence are presented.
agulopathy were also studied, and the authors noted that the co-

base excess [29,41].

agulopathy improved along a time similar to the normalization of

Supporting evidence
acidosis, and that incorporation of measurements of coagulopathy
into the model, did not improve the fit [33–37].
This protocol necessitates all providers communicate effectively.
It engages active resuscitation from the general surgery traumatol-
ogists and intensivists; definitive management of head trauma by
neurosurgery; operating room availability on a daily basis for ap-
propriately resuscitated patients controlled by the anesthesia and
Tissue oxygenation, acidosis

Tissue oxygenation, acidosis

Tissue oxygenation, acidosis

Anti-inflammatory cytokine
Pro-inflammatory cytokine
Pro-inflammatory cytokine
Pro-inflammatory cytokine

Pro-inflammatory cytokine
managerial staff; and orthopaedic traumatology staff availability af-
ter hours for definitive surgery. EAC often involves multiple proce-
dures under the same anesthesia, including cases with operative
fractures of the thoracolumbar spine [37]. Importantly, EAC neces-
sitates proficient spine surgeons be available each day to poten-
Definition

tially perform complex procedures to treat spinal injuries. While

on paper, this may exist for major trauma centers; in practice, ex-
pedited management of severe spine trauma, represents a major
cultural shift. Even within the trauma center where EAC originated,
it took over 15 months before delays for surgeon preference oc-
(USD)
∗

$164∗
$164

$332
$332
$378
$332
$317
Cost

$92

curred less than 10% of the time [34].

48–72 h
48–72 h
48–72 h
48–72 h
48–72 h

Future directions
30 min

30 min

30 min
Time

arterial blood gas includes both measurements.

Future directions include the need for additional refinement

of the EAC recommendations. Injured patients who are medically
Arterial

Arterial
Venous

Venous
Venous
Venous
Venous
Venous
Sample

compromised, perhaps with baseline deficiencies in cardiac, renal,

or pulmonary function, may require modifed resuscitation thresh-
olds, although some work in this area suggests that EAC is safe
[38]. Other work may be directed toward investigation of differ-
Tumor necrosis factor alpha

ent parameters, which denote the level of systemic inflammation.

Markers such as interleukin (IL)-6, IL-8, IL-10, and others may be-
come helpful in identifying patients at risk for complications, and
possibly in refining the timing of definitive fracture care (Table 1)
Interleukin 10
Interleukin 1
Interleukin 6
Interleukin 8

[10,39–52]. These become elevated after injury and appear to be

Base excess

influenced by the burden of injury, defined by hemorrhage or soft

Lactate
Marker
Table 1

tissue damage, as well as they appear influenced by genetics and

pH

medical comorbidities [39,41,49]. Unfortunately, these parameters

∗

are not measured in routine practice, because it takes a long time

 T.A. Moore, N.M. Simske and H.A. Vallier / Injury 51S2 (2020) S10–S14 S13

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