Saratov State Medical University named after V.I. Razumovsky, 

Saratov, Russia

 

Locomotor injuries (LI) are noted in 92 % of polytrauma cases, being dominating injuries in 22-43 % of patients [7, 9]. Multiple skeletal injuries are identified in 70 % of patients with polytrauma. Complex limb fractures are in 42-64 % of patients (B and C types according to AO/ASIF classification). Open fractures are identified in each third patient. Pelvic injuries are unstable in 44.2 % (with pelvic ring injury) [38]. Concomitant and multiple skeletal injuries result in multiple life dangerous complications and require long term hospital treatment and labor-consuming rehabilitation, as well as cause decreasing life quality and disability. Therefore, their treatment is one of the keystones in rendering assistance for polytrauma [40].

In cases of internal organ injuries in polytrauma the treatment tactics is defined clearly, but many disputable and unsolved issues are related to skeletal injuries. There is an uncertainty about optimal duration and volume of surgical interventions, sequence and fixation techniques for fractures of different locations.

In 1950-1960s early osteosynthesis procedures for polytrauma were not performed in most cases or were delayed for 12-14 days (or more) until full stabilizing the main functions of the body was achieved. As result, improper delay of surgery often resulted in multiple complications conditioned by patient’s stationary position, difficulties of adequate examination and nursing process [18, 28].

In the end of 70s and beginning of 80s the new osteosynthesis techniques were developed: stable osteosynthesis according to AO principles, low invasive locked osteosynthesis. Also advancements in anesthesiology and critical care medicine took place. The multiple results, which are confirmed by the modern studies, testified that early osteosynthesis for long bones and unstable pelvic injuries in polytrauma:

-          stabilizes patient’s state and presents anti-shock measure;

-          prevents further injury with soft tissue fragments, development of secondary immune responses, adult respiratory distress syndrome, DIC, fat embolia, multiple organ insufficiency (MOI), phlebothrombosis and local infectious complications;

-          allows activization of patients and prevents hypostatic complications;

-          facilitates nursing process;

-          reduces rehabilitation period and improves functional outcomes [2, 46].                      

Early surgical treatment of locomotor system in polytrauma is accompanied by early normalization of relative contents of alpha-1 and alpha-2 globulins, decreasing activity of blood cytosolic enzymes and increasing activity of membrane-associated enzymes. It testifies restoration of plastic exchange and integrity of compensatory abilities of the body [45].

The orientation to maximally early osteosynthesis is basically related to femoral fractures, unstable pelvic and spinal fractures (mostly, the pelvis and the spine define patient’s mobility) [6, 11, 40]. For patient with concomitant thoracic injury early osteosynthesis is extremely necessary for prevention of pulmonary complications which are already provoked by trauma [18].

In 1980-90s Early Total Care concept for patients with polytrauma was developed and widely used. The concept implied surgical treatment for all injuries (orthopedic and cavitary) during 24 hours after trauma. However in late 80s of the 20th century it was clear that the concept was uniform and effective for other patients, but not for only patients without critical injuries. A drive to final osteosynthesis for all injuries increased surgical trauma and resulted in severe complications, which neutralized positive moments of fracture fixation.

Multiple studies confirm that surgical procedures produce “the second hit” and initiate immunologic response, which is similar with the response to severity of basic injury (“the first hit”). It is testified by development of lymphopenia, increasing levels of corticosterone, IL-1ß, TNF-α in the blood plasma, decreasing expression of HLA-DR on the monocytes and increasing expression of trigger receptors on the myeloid cells [26, 43].                  

Therefore, the contradiction appeared between need for maximally early stable fixation of “main” fractures and danger of significant worsening state and even death after such operations. It was found that a possibility of lethal outcome in polytrauma is significantly worsened by long term and traumatic emergent surgical intervention, if it is carried out to the full extent.

In this regard in 1990 Hanoverian school offered damage control concept, which is based on staged programmed surgical treatment for polytrauma [25, 37]. The sense of damage control for multiple and contaminant fractures of long bones, unstable pelvic and spinal fractures, femoral and leg ruptures is early temporary fixation for fractures with using less traumatic way with following final treatment after full stabilization of patient’s state (Damage Control Orthopedics) [36]. Such tactics allowed reducing duration of primary emergent surgical procedures, carrying out osteosynthesis in optimal time and without worsening patient’s state, reducing amount of complications and postsurgical mortality in polytrauma [47]. Damage control and immune control principles became interacting concepts for polytrauma treatment [16]. Moreover, there are no generally accepted and clear indications for damage control concept and optimal terms for the second stage of surgical treatment, when surgery is not dangerous according to “second hit” provoking immunologic cascade of disorders and development of multiple organ insufficiency [48].

The general conditionality of division of emergency aid to the stages for polytrauma treatment resulted in “surgical” resuscitation concept (Gumanenko E.K., 1992). According to the concept, the main task of intensive care during polytrauma treatment is putting the body vital functions to the optimal level for realization of emergent and delayed operations.

Time realization of delayed operations is substantiated according to the concepts of traumatic disease. Separation of the second and the third periods is tactically important for traumatic disease periodization. The second period (12-48 hours after trauma) is called as the period of relative stabilization of vital functions and is determined by some researchers as the most favorable for surgical treating those injuries, which were not immediately dangerous during the first hours, but were associated with higher life threat in case of refusal from early surgery. Among the procedures one can find early osteosynthesis for open fractures of long bones and closed femoral fracture and pelvic/spinal stabilization. The third period (days 3-10) is associated with maximal possibility of complications. It is proved that delayed operations, which are carried out during this period, create additional aggression, increase a possibility of organ dysfunctions and give the worst outcomes of severe trauma treatment [24, 32].

At the present time multiple curative tactical schemes are offered. Time and volume of interventions for polytrauma are based on different clinical laboratory values and the scales for objective scoring the severity of injuries and patient’s state.

H.-C. Pape et al. (2003) and the American Academy of Orthopaedic Surgeons (AAOS) separated four degrees of severity of state in polytrauma on the basis of degrees of acidosis, coagulopathy  and hypothermia (lethal triad) and tissue injuries severity according to ISS and GCS: stable (ISS < 17), bordering (ISS 17-25), non-stable (ISS 26-40) and critical (ISS > 40) [27, 28]. H.-C. Pape offered the modified classification supplemented with values of scoring estimation for chest injuries according to AIS, abdominal injury according to ATI, pelvic and femoral fractures according to AO/ASIF classification [2, 3]. In stable state it is possible to carry out primary final osteosynthesis for all fractures. For unstable and critical states damage control orthopedics is indicated. In borderline state it is possible to use Early Total Care for locomotor injuries in cases of patient’s response to resuscitation measures, supposed surgery duration ≤ 2 hours, РаО₂/FiO₂ ≥ 250 mm Hg, body temperature ≥ 32°С, supposed infusion ≤ 5 doses of RBC, absence of significant coagulopathy [28].

E.K. Gumanenko (2009) used scales Military Field Surgery-Entry State and Military Field Surgery-Admission State for estimation of interval in state severity in patients with concomitant injuries, with ranking to compensated, subcompensated and decompensated state. In compensated state any surgical interventions are possible, in subcompensated state ‒ delayed operations in concordance with surgical resuscitation concept, in decompensated state ‒ damage control concept [32].

N.I. Berezka (2014) offers using Early Total Care for patients with multiple and concomitant locomotor injuries, with ISS < 25, surgical resuscitation concept ‒ for ISS > 40, Damage Control Orthopedics for ISS > 40. At that, for patients with ISS = 25-40 treatment tactics is confirmed with Military Field Surgery-Entry State, with age indices. If state severity according to Military Field Surgery-Entry State is 22 points, any extrafocal and intramedullary locking osteosynthesis can be used, but not internal fixation. If state severity is more than 22 points, one should use Damage Control Orthopedics [5].

The authors’ attitude to the scales for estimating severity of state is equivocal. Some authors believe that the scales are applicable for comparison of treatment outcomes in big groups of patients and are not basis for making decisions about treatment tactics for an individual patient [18]. Nevertheless, the scales for objective estimating polytrauma give a possibility for orientation in clinical situation and favor selecting optimal treatment tactics.

Selection of osteosynthesis method, as well as sequence and possibility of single-step operations for multiple skeletal injuries is extremely important for treatment of polytrauma. Meanwhile, there is no single view about these issues.

Many domestic authors advocate low traumatic transosseous osteosynthesis as a method of choice and final fixation technique in polytrauma [24, 42]. Most adherers of transosseous osteosynthesis advocate precise reposition and rigid fixation of fractures on the surgical table. As for acute period of polytrauma, only in case of severe state the authors recommend to be limited by simple devices, without fragment reposition with aim of decreasing duration and traumatic effects of surgery, with device remounting at the second stage of surgery. D.V. Samusenko (2014) offered to call such tactics as damage control Ilizarov [35].

According to the foreign literature data, transosseous osteosynthesis is rarely used in multiple fractures. The disadvantages of the technique are necessity for continuous control and long period of hospital management, complexity of closed device reposition in multi-fragmented, peri- and intraarticular fractures, high frequency of transfixation contractures of adjacent joints, thromboembolic and infectious complications [4]. The disadvantages of pelvic instrumental fixation are insufficient strength of fixation for the posterior pelvic ring. Fixation frameworks make obstacles for realization of surgical interventions for abdominal organs, small pelvis and femurs, as well as carrying out some diagnostic procedures (CT, MRI) [39].

The advantages of internal fixation are a possibility for precise reposition of bone fragments, restoration of correct configuration of pelvic ring and functionally stable fixation of injuries [4]. Meanwhile, plate osteosynthesis is traumatic, is accompanied by significant blood loss and, as result, is impossible for early realization in patients with polytrauma [44]. Osteosynthesis with angle stability bridge plate from two small incisions outside fracture region is less traumatic and is alternative technique for treatment of lower limb fractures [23]. But plates do not allow achieving interfragmental compression in fragmented fractures dominating in patients with polytrauma. Persistent interfragmental diastasis and long period of union of comminuted fractures result in fatigue failure of plates [8].

At the same time, extrafocal osteosynthesis is a method of choice for treatment of most multi-fragmented and opened fractures with extensive soft tissue injuries [17].

Continuous intrapelvic hemorrhage is similar with intraabdominal bleeding according to its danger. Surgical procedures for bleeding arrest are indicated as emergent in ATLS, 9^th revision (2013) [1] and in European Manual for Treating Bleeding in Severe Injury [41]. Pelvic ring stabilization with external device is recommended, but in case of inefficiency or unstable hemodynamics ‒ packing for presacral and prevesical spaces, and X-ray immobilization for injured pelvic arteries [20]. Besides hemostatic effect, surgical fixation for non-stable pelvic fractures prevents development of endotoxemic syndrome and DIC because of depleting clotting factors, syndrome of massive infusion by means of decreasing volumes of transfused hemotransfusion media [21]. In 1992 R. Hanz offered anti-shock C-shaped frame (pelvic forceps) for temporary stabilization of vertical non-stable pelvic injuries, but it does not provide pelvic stability, it limits patient’s mobility and complicates nursing process. Administration of AO devices for module construction allows achieving more precise restoration of the pelvic ring and proper fixation [40].

However in long period of fixation, which is necessary for consolidation of multiple fractures, the negative aspects of extrafocal osteosynthesis overrule the positive aspects. Therefore, many traumatologists successfully use two-staged treatment for polytrauma. At the first stage one performs low traumatic, quickly realized and technically simple osteosynthesis with rod and pin-rod devices for long bones and pelvic bones, as part of anti-shock complex and prevention of complications [4]. Achieving reposition is desirable, but not obligatory requirement [21]. Devices are dismounted at the second stage (from 3-10 days to 2-3 weeks) after full stabilization of disordered functions, before or after full wound healing and in absence of infectious complications [13].

In critically ill patients with polytrauma the combination of two techniques of external fixation (external fixation at the first stage, and transition to internal osteosynthesis at the second stage) allows using the advantages of both techniques and corresponds to Damage Control Orthopaedics [1]. External fixation is considered as a forced temporary measure for severe patients, but also it can be a final measure in case of contraindications to internal fixation [15].

Combination of low invasive techniques is a perspective direction for treatment of non-stable pelvic injuries in polytrauma. Meanwhile the anterior pelvic is properly stabilized with most devices, but for the posterior ring it is necessary to use internal techniques [22, 39]. In early period of polytrauma after patient’s state stabilizing it is possible to use low traumatic techniques for fixation of sacroiliac joints with cannulated screws [15], and pubic symphysis ‒ with external fixation devices or plate through mini-approach [14, 19]. Stable fixation in both anterior and posterior pelvic ring allows carrying out early activation without risk of reposition failure that is important for patients with polytrauma [12].

In our country and foreign countries the growing number of the authors use closed intramedullary osteosynthesis with locking nails for long bones [31, 49]. Considering the low traumatic effects and insignificant intrasurgical blood loss, locking osteosynthesis is performed during the first days after trauma before final normalization of general state, and in opened fractures with moderate tissue injuries before wound healing [17]. Significant fixation strength with high anti-rotation effect, absence of necessity for additional fixation with plaster split allow early activation of a patient and restoration of extremity functions [44]. It is recommended to abstain from drilling the intramedullary canal during early intramedullary osteosynthesis for femoral bone, especially in concomitant chest injury, because the correlation was found between drilling the intramedullary canal and development of fat embolia [31].

For early activation in all age patients with polytrauma the methods of choice are low invasive osteosynthesis for hip fracture using three cannulated spongious screws through small skin incisions [29] and closed locking osteosynthesis with PNF for acetabular and subtrochanteric fractures [30].

In case of polytrauma the choice of osteosynthesis technique depends both from location, type of fracture and fractures in adjacent and remote segments. So, in bilateral fractures of lower limb bones it is not desirable to perform plate osteosynthesis for both fractures with exclusion of early load [18]. For the same reasons it is not recommended to combine plate osteosynthesis and external fixation devices in case of ipsilateral fractures [8].

The sequence of single-step operations is important. If the sequence is correct, conduction of one operation does not hinder another and does not violate already performed osteosynthesis. For example, in ipsilateral supracondylar fractures of distal femur and tibial diaphysis fractures (floating knee) one indicate the advantages of single-step antegrade osteosynthesis with UTN in the beginning of the tibial bone, and then retrograde osteosynthesis with DFN for the femoral bone from one surgical approach in the knee joint region [44].

It is important to evaluate the priority of surgical treatment of injuries. Some authors have well founded beliefs that the first place is to be taken by emergency fixation for non-stable fractures of the pelvis, followed by the leg, humerus, forearm, the foot and the hand [18, 40]. At the same time, in case of polytrauma the main attention is given to fractures of limb long bones, but so called “secondary” fractures of the hand, the foot and ankle joints are often not diagnosed or treatment does not correspond to necessary requirements. It results in further decrease in life quality and working capability [10, 33, 34].           

 Despite of evident advantages of single-step osteosynthesis for multiple fractures it is important to evaluate surgical risk and, if any little risk is available, to refuse from simultaneous surgical procedures in favor of sequential single-step and multiple-step operations with interval of 5-7 days [18].

 

CONCLUSION

The problem of surgical tactics for skeletal injuries in polytrauma is one of the key issues and is far from its solution. It is testified by multiple publications in the domestic and foreign literature, and he multiple curative tactical schemes and concepts. Early osteosynthesis for long bones and fixation of unstable pelvic and spinal injuries in polytrauma allow reducing mortality, complications and improving functional outcomes of treatment. Duration and volume of surgical interventions for skeletal injuries in polytrauma should be chosen with consideration of severity of injuries, patient’s state and traumatic disease period. Surgery should not be additional aggression, which worsens patient’s state. Improvement in systems for objective estimation of state severity, further development and implementation of staged treatment of skeletal injuries in critically ill patients are perspective directions for optimization of surgical tactics for polytrauma with locomotor injuries. Low invasive technologies are preferable for polytrauma: extrafocal osteosynthesis, locked intramedullary osteosynthesis, fixation with cannulated screws and angle stability bridge plates, which do not worsen state severity and can be applied at resuscitation stage.