Current Orthopaedics (2001) 15, 167d175
^ 2001 Harcourt Publishers Ltd
doi:10.1054/cuor.2001.0170, available online at http://www.idealibrary.com on
MINI-SYMPOSIUM: MAJOR TRAUMA
(i) Assessmenteprinciples and management of
major trauma beyond ATLS]
A. Platz, M. Heinzelmann and O. Trentz
Division of Trauma Surgery, University Hospital ZuK rich, RaK mistrasse 100, CH-8091 ZuK rich, Switzerland
INTRODUCTION
Definition of ‘Polytrauma’
‘Polytrauma’ defines a syndrome of multiple injuries that
exceed an injury severity score (ISS) of 17 with con-
secutive systemic reactions which may lead to dysfunction
or failure of remoteeprimarily not injuredeorgans
and vital systems.
Importance of fractures
Fractures are frequently associated with polytraumatized
patients and must be considered as wounds of bone and
soft tissue which create stress, pain and haemorrhage.
Fractures can be contaminated. They may cause compart-
ment syndromes with ischaemia-reperfusion injury. The
unstable skeleton enforces immobility and may not
permit optimal positioning of those patients for intensive
care with chest and brain injuries.
TIMING AND PRIORITIES OF
SURGERY
The primary objective in the initial care of poly-
traumatized patients is survival with normal cognitive
functions. The first priority is resuscitation to ensure
adequate perfusion and oxygenation of all vital organs.
Endpoints of resuscitation are listed in Table 1. This
can usually be accomplished by conservative means such
as intubation, ventilation and volume challenge according
to ATLS] protocol. If the response to such measures is
not successful, immediate life-saving surgery is necessary
(Fig. 1).
Correspondence to: AP. E-mail: andreas.platz@chi.usz.ch.
LIFE-SAVING SURGERY
Access to life support systems
If the ABC’s of the ATLS] protocol cannot be achieved
by conventional measures, immediate surgical access to
life support systems must be established. If tracheal
intubation is not successful, a life-saving access to the
airway has to be performed by cricothyroidotomy. When-
ever appropriate i.v.-lines cannot be established by per-
cutaneous techniques, surgical cut-downs are mandatory.
Decompression of body cavities
Tension pneumothorax
A tension pneumothorax has to be suspected in patients
with thoracic trauma who suffer from increasing
respiratory distress despite, or soon after, intubation and
ventilation and present with distended neck veins.
Immediate decompression by needle thoracostomy
followed by tube thoracostomy has to be performed.
The chest tube is inserted in the 4th or 5th intercostal
space in the mid-axillary line above nipple line. After
penetration of the chest wall the pleural cavity is
explored with a finger and the tube is guided either
anteriorly}superiorly for a pneumothorax or, in
combination with a haemothorax, posteriorly}inferiorly.
The ‘trochar’ technique is too dangerous and should be
abandoned.
Cardiac tamponade
When cardiac tamponade is suspected, aspiration of the
pericardium may confirm the diagnosis and temporarily
solve the problem.
The aspiration is performed via a paraxyphoid route.
The direction of the aspiration aims towards the tip of
the scapula. In severe trauma this manoeuvre buys time
for emergency thoracotomy or sternotomy. During
crash laparotomy the release of a cardiac tamponade is
168
Table 1 Endpoints of resuscitation
Stable haemodynamics
No need for vasoactive or inotropic stimulation
No hypoxaemia, no hypercapnia
Lactate (2 mmol/l
Normal coagulation
Normothermia
Urinary output '1 ml/kg h!1
Figure 1 Priorities and timing of surgery depending on effect of
resuscitative efforts.
performed through the subxiphoid membranous
diaphragm route.
Intracranial mass lesion
The primary goal of the treatment of severe brain injury
is to avoid secondary brain damage. Therefore,
restoration and maintenance of adequate cerebral
perfusion and oxygenation of the brain is of pivotal
importance.
Immediate evacuation of the haematoma is essential in
focal brain lesions like acute epidural or subdural
haematoma. Usually, a computed tomograpy (CT)
scan will be performed before surgery. In specific
circumstances like increasing mydriasis (and contralateral
motor deficit) emergency burr holes on the side of the
enlarged pupils with no prior CT scan can be life-saving.
After this decompression the burr hole is usually
extended to a craniotomy for definitive treatment.1
Compression of the cervical cord
According to the ATLS] criteria, protection of the
cervical spine is part of the airway management. The
CURRENT ORTHOPAEDICS
protection is maintained also during extrication and
emergency treatment at the scene by means of lateral
supports stiff collar, tape, and spinal board.
A cross-table lateral C-spine X-ray is mandatory. In
cases of inadequacy of the X-ray a CT scan of the
cervico-thoracal junction is necessary. If fractures,
dislocations, or jumped/locked facets of the cervical
spine are identified, sufficient splinting (stiff collar) or
immediate closed reduction are the next treatment
steps.
Control of exsanguinating haemorrhage
Resuscitative thoracotomy. Emergency department
thoracotomy (EDT) or resuscitative thoracotomy has
become an established therapy for patients with acute
cardiopulmonary arrest after injury. Patient selection is
vitally important to achieve a good outcome without
wasting resources. Signs of life, location of major injury
and mechanism of injury should be taken into
consideration when deciding whether to perform EDT
or not.2
Penetrating wounds of central large arteries
Due to life-threatening bleeding these wounds need an
immediate vascular control by temporary balloon
occlusion or cross-clamping. The repair is performed
by lateral repair or intravascular shunt until definitive
reconstruction is possible.
Traumatic amputation and mangled extremity
Compression dressings, temporary applied toumiquets
or vascular clamping easily obtain haemorrhage control
in complete amputation. The development of micro-
surgical techniques for free vascularized tissue transfers
has increased the chances of saving ‘mangled extremi-
ties’, amputated or nearly amputated limbs.3 In poly-
trauma patients, however, such salvage procedures are
mostly not indicated due to their inherent increase of
systemic inflammatory load. In situations with incomplete
amputation or mangled or crushed extremity in
combination with severe polytrauma an amputation
should be performed at a ‘safe’ level with a ‘Guillotine’
technique and subsequent open wound management.
The ‘Mangled Extremity Severity Score’"MESS can
assist in decision making whether an amputation should
be performed.4
Open pelvic fractures
Exsanguinating external bleeding from open pelvic
fractures cannot be stopped by external measures like
pneumatic splinting (MAST"military anti-shock
trousers). Only aggressive surgical control of the
PRINCIPLES AND MANAGEMENT OF MAJOR TRAUMA BEYOND ATLS] 169

bleeding with stabilization of the pelvic ring by external

or internal fixation and tight pelvic packing can save these
patients.5,6

Control of haemorrhage into body cavities

Massive haemothorax. Urgent thoracotomy in
situations with severe thoracic haemorrhage is indicated
when the blood loss via the chest tube exceeds 1500 ml
at the time of thoracostomy or 500 ml for 1 h or
200 ml/h for 4 h. Severe laceration of lung tissue is
repaired by suture or partial lung resection. Greater
vessel injuries are controlled by cross-clamping and
repaired.
In patients with major deceleration trauma aortic
rupture has to be suspected. The diagnosis has to be
confirmed or ruled out with transoesophageal sono-
graphy or arch aortography. Figure 2 Pelvic disruption (C-type) in a patient who was hit by
A penetrating thoracic trauma with a sucking wound a shovel.
requires a sterile airtight occlusive dressing and a large
bore chest tube. This measure buys time for definitive
surgery. Ongoing severe haemorrhage with output from
the chest tube '500 ml blood in the first hour requires
urgent thoracotomy.

Massive haemoperitoneum. A patient who has

a highly unstable circulation or is in extremis due
to exsanguinating haemorrhage into the abdominal
cavity requires a resuscitative crash laparotomy. If
an EDT is necessary preliminary cross-clamping of the
descending aorta should be performed prior to a crash-
laparotomy to avoid cardiac arrest due to sudden
decompression of the abdominal cavity. Alternatively,
a balloon catheter introduced from the groin can
temporarily block the aorta.7 Crash laparotomy is
performed by a midline abdominal incision, that allows
a quick access, a good overview and allows an extension
into the chest.
If supradiaphragmatic control of the aorta cannot be
performed, manual compression of the subdiaphragmatic
aorta is carried out first. The next step is the
examination of all four quadrants, followed by packing
to stop venous bleeding. In patients with ongoing
arterial haemorrhage cross-clamping of the sub-
diaphragmatic aorta or inflow control of an identified
injured organ are performed. Patients in extremis with
severe polytrauma have better chances of survival when
definitive repair of intraabdominal injuries is delayed
after effective resuscitation and stabilization in the
ICU. In this situation the concept of ‘damage control’
is performed, this includes haemorrhage control, source
control, packing and rapid temporary closure of the
abdominal cavity or the wound, followed by stabilization
of the physiological systems at the intensive care
unit (ICU). Definitive surgery follows 6}12 h after
trauma.8}10
Figure 3 After supracondylar traction and C-clamp good re-
duction of the pelvis.
Massive haemorrhage due to crushed pelvis. Pelvic
crush or disruption of the pelvic ring (open book-,
vertical shear-injuries) (Fig. 2) can produce exsang-
uinating external or internal haemorrhage into the retro-
peritoneal space, into the peritoneal cavity or into
a (semi)-circular degloving (Morel}LavalleH Syndrome).
Apart from aggressive volume challenge these patients
require immediate reduction and fixation of the pelvic
ring by external fixator or a pelvic compression clamp
(C-clamp)6,11 (Fig. 3). With a good haemodynamic
response the diagnostic work up can be completed and
pelvic reconstruction can be performed as staged
surgery (Fig. 4). If the patient remains unstable urgent
laparotomy for damage control is mandatory. In these
circumstances the pelvic ring must be stabilized by
external or internal fixation followed by surgical bleeding
170
control, tight pelvic packing, and provisional closure
of the abdomen (Ethizip] )5,6 (Fig. 5). The occurrence
of an abdominal compartment syndrome (ACS) has
to be monitored. The ACS can be detected by
continuous monitoring of the bladder pressure
and should be treated by decompression of the
abdomen.12,13 After recovery in the ICU one or two
‘2nd looks’ are mandatory, followed by definitive
pelvic osteosynthesis and closure of the abdominal
wall.
Figure 4 Postoperative view after secondary reconstruction
5 days after trauma.
Figure 5 Pelvic ring disruption with exsanguinating bleeding. Treatment with C-clamp, pelvic packing and closure of the abdomen with
an Ethizip] . Here the situation before the removal of the retroperitoneal tamponade, 24 h after the accident.
CURRENT ORTHOPAEDICS
DELAYED PRIMARY SURGERY
(<
< 24 h AFTER TRAUMA)
If resuscitation efforts are successful, delayed primary
surgery can be performed.
Body cavities
Brain injury
Intracranial haematomas should be evacuated during the
phase of ‘life-saving surgery’. Further evaluation of
patients with severe head injury is done with a CT scan.
Also in situations without mass lesion, but severe brain
injury (GCS(9) shearing injuries, multiple contusions
intracranial pressure (ICP)-monitoring is of upmost
importance especially with polytrauma. Treatment of
hypotension and maintenance of cranial perfusion
pressure (CPP) prevents secondary brain damage.
Abdominal injuries
All visceral injuries that do not lead to mass bleeding
have to be diagnosed after the acute phase.
Rupture of the diaphragm is often overlooked or
concealed by associated thoracic trauma (lung
contusions, haemothorax). Chest X-ray with a naso-
gastric tube will show an intrathoracically displaced
stomach. In most cases operative treatment is necessary.
Small bowel and mesenteric injuries are the most
frequent bowel injuries in blunt trauma compared with
colon injuries. The combination of fractures of the
PRINCIPLES AND MANAGEMENT OF MAJOR TRAUMA BEYOND ATLS] 171

lumbar spine with a small bowel rupture is common in
motor vehicle accidents (‘seat-belt sign’). Peritoneal
lavage is the most reliable diagnostic procedure in this
situation. Treatment consists of laparotomy and resec-
tion of the injured small bowel segment. In colonic
injuries resection and primary anastomosis is ideal but
defunctioning colostomy may be necessary.
For suspected retroperitoneal injuries like pancrea-
tic, duodenal or urogenital trauma CT scan is the standard
diagnostic procedure. The treatment (operatively or
conservatively) depends on the extent of the injury.
Thoracic injuries
Over 80% of all thoracic injuries can be treated by the
insertion of a chest tube with no further need of surgical
intervention.
In patients with an extended subcutaneous emphy-
sema in combination with a persistent air leakage
after tube thoracostomy a lesion of the tracheobronchial
tree has to be suspected. Bronchoscopy will confirm
the diagnosis of a tracheal or bronchial rupture. Repair
of the ruptured bronchus is performed as ‘day one
surgery’.
Musculoskeletal injuries
If resuscitation was successful, the phase of delayed
primary surgery can start. The following skeletal injuries
should be treated with high priority:
1. Limb-threatening and disabling injuries (including
open fractures) require at least ‘damage control’, i.e.
deH bridement, fasciotomies, reduction, fixation and
revascularization.14
2. Long bone fractures (especially femoral shaft
fractures), unstable pelvic injuries, highly unstable large
joints and spine injuries require at least reduction and
fixation. This may include temporary external fixation
with the need of a definitive fracture fixation at a later
time point.
There is a convincing body of evidence that early fracture
fixation reduces mortality and morbidity in polytrauma
patients.15}18
The arguments and experiences in favour of early
fixation of femoral fractures and unstable pelvic ring
injuries are:
䊉 Reduction of the incidence of adult respiratory distress
syndrome (ARDS) fat embolism, pneumonia, multiple
organ dysfunction syndrome (MODS), sepsis and
thromboembolic complications.
䊉 Facilitation of nursing and intensive care: such as
upright chest-position, early mobilization and a redu-
ced need of analgesics.
A definitive osteosynthesis as day-1-surgery is advisable
only when the ‘Endpoints of Resuscitation’19,20 can
be fully accomplished (Table 1). Between the 5th and
10th day post-trauma there is an ‘immunological
window’ when hyperinflammation switches to immuno-
suppression and when new cell recruitment and de-novo
synthesis of acute phase proteins has taken place.
During this ‘window of opportunity’ scheduled, definitive
surgery of long bone shaft fractures and articular
fractures can be performed relatively safely. The
period of immunosuppression takes about 2 weeks,
so that the phase of secondary reconstructive
procedures can start in the 3rd week post-trauma
(Table 2).
General aims and scopes of fracture
management in polytrauma
Fractures can have an important impact on the severity
of systemic trauma reactions:
Haemorrhage
Prolonged shock states and exsanguinating haemorrhage
are frequently associated with open or highly unstable
pelvic ring injuries or femoral fractures.

Table 2 Timing of surgery in the management of polytrauma patients

Physiological status Surgical intervention Timing

 &
Life-saving surgery

Response to resuscitation *
? &
‘Damage control’ Day 1
 &
Delayed primary surgery
Hyperinflammation ‘Second look’, only! Days 2}3
‘Window of opportunity’ Scheduled definitive surgery Days 5}10
Immunosuppression No surgery!
Recovery Secondary reconstructive surgery Week 3
172
Contamination
Open fractures must always be considered as
contaminatedeserious bacterial nutrient sources,
however, will develop if the wound can only be deH brided
with some delay or not radically enough. Therefore
‘second look’ deH bridements are mandatory.
Dead, ischaemic tissue with a marginally perfused
hypoxic zone
In unstable fractures or dislocations especially after high
energy impact, an early radical soft tissue deH bridement is
necessary as ‘source control’.
Ischaemia}reperfusion injury. Prolonged shock
states, compartment syndromes and fractures with
vascular injuries are prone to ischaemia}reperfusion
injury with microvascular damage. Blunt tissue con-
tusions may activate xanthine oxidase; ischaemia will add
the co-substrate oxygenethus a dangerous triad.
Stress and pain. Unstable fractures cause a
lot of stress and pain. These are important ‘afferent
inputs’21 to the CNS that stimulate a neuroendocrine,
neuroimmunological and metabolic reflex pattern
(Fig. 6).
Interference with intensive care. Unstable fractures
do not allow an optimal posture, early motion and
accurate handling of patients for intensive care.
Therefore, unstable fractures should be stabilized. In
addition, early movement has been proven to prevent
Figure 6
CURRENT ORTHOPAEDICS
muscle loss. The early movement acts as an ‘anabolic’
effect and prevents or reduces the muscle loss.
Therefore, the general aims and scopes for fracture
management are:
E Control of haemorrhage.
E Source control (contamination, dead-tissue, ischaemia}
reperfusion}injury).
E Pain relief,
E Facilitation of intensive care with early movement as
best ‘anabolic’ effect to prevent muscle loss.
E Maintaining the range of motion in the joints.
These concepts can be realized by bleeding control,
deH bridement, fasciotomies, fracture fixation and wound
coverage without tension.
For stabilization of long bones external fixators, plates
and nails are alternative fixation devices.
PROS AND CONS OF DIFFERENT
FIXATION METHODS
Nailing
From the biomechanical point of view, nailing is the
method of choice for shaft fractures of femur and tibia.
However, reamed as well as unreamed femoral nailing
may have adverse pulmonary effects. The main reason is
that manipulation of the medullary canal e.g. opening,
insertion of guidewire, reaming and insertion of a nail
increases the intramedullary pressure that results in
embolization of the pulmonary circulation with bone
marrow content, fibrin clots and debris. In addition, this
PRINCIPLES AND MANAGEMENT OF MAJOR TRAUMA BEYOND ATLS]
embolization causes activation of the coagulation and
other cascade systems.
Such an iatrogenic embolization may have relevant and
adverse clinical effects, especially if the immense clearing
capacity of the pulmonary endothelium is already
compromised by lung contusion, or massive transfusion
of allogenic blood. On the other hand, it is important to
know that simple fracture types (transverse, short
oblique fractures) in young patients with a narrow
medullary canal and well-developed muscle envelope are
much more susceptible for pulmonary embolization due
to nailing than patients with complex fractures with weak
muscles and a wide medullary canal. There is no evidence
that unreamed nailing produces less pulmonary
embolism than reamed nailing.
Plating requires a major surgical access and induces an
additional trauma. On the other hand, an extended
surgical approach allows control of bleeding to perform
fasciotomies, and an adequate deH bridement.
External fixation minimizes additional surgical trauma,
is a fast and forgiving procedure, and allows temporary
shortening to avoid compartment syndromes. Its draw-
backs are insufficient stability for definitive treatment,
pin-tract infections and obstruction of escape routes
for plastic soft tissue procedures.
Hence, each fixation method has its biological price
and should be chosen carefully. Rigid time and implant
protocols should be avoided.
FRACTURE MANAGEMENT UNDER
SPECIFIC CONDITIONS
Massive haemorrhage due to crushed or
disrupted pelvis5,22,23
Open or closed pelvic crush or disruption of the pelvic
ring can produce exsanguinating haemorrhage. Apart
from aggressive volume challenge these patients require
immediate reduction and fixation of the pelvic ring by
external fixator or a pelvic compression clamp (C-
clamp).11 With good haemodynamic response diagnostic
work-up can be completed and pelvic reconstruction is
done as staged surgery.
If the patient remains unstable, urgent laparotomy for
damage control is mandatory for active bleeding control.
In these circumstances the pelvic ring must be stabilized,
followed by surgical bleeding control, tight pelvic packing,
and provisional closure of the abdomen (Ethizip] ).
(Cave: Abdominal compartment syndrome).12,13
Angiography and embolization has been described as
alternatives for controlling pelvic fracture bleeding.24
However, only 2% of patients with pelvic ring injury
required embolization and the mortality was almost
50%. The main bleeding sources are in most cases
venous presacral plexuses that can easily be treated
173
by pelvic packing. Another disadvantage is the
transportation of a haemodynamically unstable patient
to the angiography suite and the time-consuming
procedure.6
Early fracture fixation in patient with
severe brain injury
In traumatic brain injury (TBI) it is crucial to prevent
‘secondary brain damage’,25,26 i.e. to maintain optimal
cerebral perfusion and to avoid hypotension and
hypoxaemia. Epidural or acute subdural haematomas
require urgent surgical evacuation and control. Patients
with TBI and a Glasgow Coma Score(9 or patients
that underwent craniotomy need an ICP-monitoring
immediately after the phase of ‘life-saving surgery’. After
good response to resuscitation (stable haemodynamic
and adequate oxygenation) early fracture fixation has
a positive effect in brain-injured patients: ease of nursing,
reduction of painful stimuli (‘afferent input’), and reduced
requirement of sedation and analgesia. Extended fracture
reconstruction should be postponed to the ‘window of
opportunity’ after initial damage control with external
fixation.
Early fixation of femoral shaft fractures
in severe polytrauma or polytrauma
with chest injury
Several studies have documented the advantages of early
fixation of long bone fractures especially in femoral
polytrauma. These advantages include facilitation of
nursing care, early mobilization with improved pulmo-
nary function, shorter artificial ventilation time and reduced
morbidity and mortality.15,16,18
Locked intramedullary nailing has become the
standard method to stabilize closed and open femoral
shaft fractures. However, there is abundant experimental
and clinical evidence demonstrating that intramedullary
nailing (especially in ‘simple’ fractures) increases
intramedullary pressure significantly. In turn, this leads
to a significant passage of emboli into the lung. This can
be impressively demonstrated by transoesophageal
echocardiography.27 Generally, this embolization is likely
to contribute to pulmonary decompensation as an
additional distress to a target organ that may already be
close to decompensation because of the exposure of the
pulmonary endothelium to traumatic debris, lung
contusion and allogenic blood. Although these side-
effects of nailing can be neglected in patients with
isolated fractures, they are likely to cause rapid
pulmonary deterioration of the multiply injured
patients.28,29
For reasons of pulmonary protection, one should
refrain from using the biomechanically better method in
174
favour of a technique that provides less distress to the
compromised endogenous defence systems and the
pulmonary endothelium.
For these reasons, primary femoral nailing can only be
recommended for polytraumatized patients without
significant chest injury with a trauma severity
corresponding to an ISS(25 points. When the ISS
exceeds 40 points, only external fixators should be used
for primary stabilization. Plating may be a good
alternative for trauma severity between these margins
and the soft tissue conditions require deH bridement,
fasciotomy and active control of haemorrhage. Seriously
compromised soft tissues may react to additional
distraction with a further decay of perfusion, facilitating
a compartment syndrome. For this reason, a shortening
fixation technique has to be occasionally accepted (e.g.
by using a temporary external fixator). The suggested
procedure concerning the injury severity especially
addresses the nailing of A- and B-type fractures in the
AO-classification. Due to the destruction of the
medullary cavity, with comminuted fractures, the range
of indications for nailing can be extended because no
substantial pressure increase can occur. Moreover,
clinical and experimental data indicate that the use of
solid nails with smaller diameters like the unreamed
femoral nail (UFN) may also cause relevant pulmonary
impairment and is therefore not different from that of
conventional nails.
Solid nails should predominantly be used with open
fractures (solid instead of hollow profile) and are
especially recommended when a scheduled reosteo-
synthesis from external to internal fixation is intended.
With primary use of external fixation, the change to
a biomechanically better concept should be planned
at an early stage. The period between the 5th and the
10th day trauma seems to be optimal for a scheduled
reosteosynthesis.
The concept of staged surgery in these critically ill
patients appears to be generally accepted in Central
Europe.
In contrast, a variety of investigations from North
America continue to argue that all femoral shaft fractures
should be submitted to primary nailing, regardless of the
patient’s clinical status.30}32 These retrospective studies,
however, have a variety of inconsistencies regarding
patient selection and comparability of study groups.
A prospective randomized trial has not been conducted.
Limb salvage vs amputation
The development of microsurgical techniques for free
vascularized tissue transfers has increased the chances of
salving ‘mangled extremities’ and amputated or nearly
amputated limbs.3 In polytrauma, however, such salvage
procedures are mostly not indicated due to their
inherent increase of systemic inflammatory load.
CURRENT ORTHOPAEDICS
The ‘Mangled Extremity Severity Score’ (MESS) can
assist the decision making.4 Rarely indicated salvage
attempts require a multi-stage concept with initial
deH bridement, revascularization, fasciotomies and fracture
fixation followed by repeated deH bridements and early
soft tissue reconstruction during a ‘window of
opportunity’.
If the decision is made to amputate the mangled
extremity, the amputation should be performed at a safe
level with ‘Guillotine’ technique and with primary open
wound management.
SUMMARY
Polytrauma must be considered as a surgical systemic
disease. Thus, successful management requires solid
pathophysiological understanding, complete resuscita-
tion, correct triage and timing and well-negotiated titration
of care. Algorithms should attempt to optimize patients’
physiological state prior to non-life-saving surgery
and provide procedures which are intentionally safe,
simple, quick and well executed.
Primary objective is survival of the patient. Early
fixation of major fractureseperformed with the right
concepteis proven as an important tool to gain the
primary objective.
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