activity in vitro, to augment clinical performance in infected wounds.
2. Indications for use include the management of complex full-thickness wounds including exposed tendons, bone, and orthopaedic hardware.
a. Especially useful in patients who were not deemed suitable candidates for routine surgical management with standard local or free flap techniques.
b. Tissue regeneration covers defects, tendons, and hardware for skin graft coverage over durable tissue layers.
Suggested Readings
Blank A, Riesgo A, Gitelis S, Rapp T. Bone grafts, substitutes, and augments in benign orthopaedic conditions current concepts. Bull Hosp Jt Dis (2013) 2017;75(2):119–127
Hegde V, Jo JE, Andreopoulou P, Lane JM. Effect of osteoporosis medications on fracture healing. Osteoporos Int 2016;27(3):861–871
Kadam A, Millhouse PW, Kepler CK, et al. Bone substitutes and expanders in spine surgery: a review of their fusion efficacies. Int J Spine Surg 2016;10:33
Kim JH, Liu X, Wang J, et al. Wnt signaling in bone formation and its therapeutic potential for bone diseases. Ther Adv Musculoskelet Dis 2013;5(1):13–31
Marcucio RS, Nauth A, Giannoudis PV, et al. Stem cell therapies in orthopaedic trauma. J Orthop Trauma 2015;29(Suppl 12):S24–S27
Zhang D, Potty A, Vyas P, Lane J. The role of recombinant PTH in human fracture healing: a systematic review. J Orthop Trauma 2014;28(1):57–62
9 Polytrauma
Timothy S. Achor and Krishna Chandra Vemulapalli
Introduction
Orthopaedic surgeons face numerous challenges when treating multiply injured patients with orthopaedic injuries. The initial evaluation focuses on life and limb threatening conditions. Early identification and appropriate immobilization of pelvis and extremity injuries (open/closed fracture, vascular insult, compartment syndrome) may improve pain, aid in systemic resuscitation, and limit blood loss. This chapter will explore injury characteristics and factors of patient physiology that influence fracture treatment toward damage-control temporizing measures with external fixation versus initial definitive management. Finally, potential complications of poorly timed and executed fracture interventions in polytrauma patients are discussed.
Keywords: polytrauma, damage control orthopaedics, early appropriate care
I. Priorities and Goals of Treatment
A. Trauma is the leading cause of death in the United States for patients < 45 years of age and is a significant source of morbidity.
B. The emergent evaluation and management of the polytraumatized patient requires a coordinated effort between the emergency room physicians, trauma surgeons, and orthopaedic consultant.
C. Patients with multiple fractures frequently have associated injuries to the head, neck, chest, and/or abdomen.
D. Hemodynamic status and systemic physiology are intimately related to musculoskeletal injury.
1. Life—immediately identify and emergently manage life-threatening injuries.
2. Limb—identify and emergently manage limb-threatening injuries.
3. Function—identify and treat injuries that can cause long-term disability.
II. Evaluation
A. Advanced Trauma Life Support (ATLS) and physical examination.
1. Sixty percent of trauma patients have injuries to the musculoskeletal system.
B. Primary survey—it reveals obvious life- and limb-threatening injuries and begins the resuscitation process. Brief history from patient and/or EMS (age, mechanism, extrication time, fatalities at scene, obvious injuries and wounds) with simultaneous vital signs and airway, breathing, and circulation (ABC).
1. Airway:
a. Ability to protect airway.
b. Intubate the patient if necessary.
2. Breathing:
a. Measure respiratory rate, oxygenation.
b. Assess breath sounds and utilize needle decompression or chest tube as necessary.
3. Circulation:
a. Assess hemodynamic status and external sites of hemorrhage.
b. Apply pressure and dressings to wounds.
c. Utilize tourniquet for uncontrollable bleeding or mangled limbs.
d. Obtain intravenous access and begin fluid resuscitation.
4. Disability:
a. Perform a neurologic exam.
b. Glasgow Coma Scale.
5. Environmental exposure:
a. Remove all clothes and maintain patient body temperature.
b. Warm the trauma bay.
c. Use a fluid warmer and warm blankets.
6. Fractures:
a. Identify obvious injuries.
b. Apply splints/traction.
C. Secondary survey—it reveals less obvious injuries and requires vigilance and a head-to-toe exam.
D. History
1. Past medical history: identify relevant medical conditions that may impact early decision-making and/or benefit from optimization (if obtainable).
2. Past surgical history: relevant prior operations (if obtainable).
3. Allergies.
E. Physical exam
1. Complete visual inspection and examination.
2. Take down all dressings, remove tourniquets, and clothing.
3. Head-to-toe examination with palpation of all extremities including pelvis and spine.
4. Range all joints and perform a ligamentous examination of suspected injuries.
5. Vascular exam: palpate pulses in all extremities and utilize Doppler and ankle–brachial index (ABI) when indicated.
6. A lower limb with an ABI < 0.90 warrants additional investigation with either computed tomography (CT) angiogram, formal angiogram, or vascular consultation.
7. Motor and sensory examination with documentation.
8. Compartment syndrome—increased intracompartmental pressure causing decreased limb perfusion.
a. Identify injuries and patients at risk, and remain vigilant.
b. High-energy injuries, tibia fractures, forearm fractures, segmental injuries, open fractures, and severe swelling all should raise concern.
c. Diagnosis:
i. Accuracy of the traditional “5 Ps” (pain with passive stretch, paresthesias, paralysis, pulselessness, and pallor) has been questioned. Refer to Chapter 13, Acute Compartment Syndrome, for a more in-depth discussion.
ii. Typical exam findings include:
• Pain out of proportion.
• Pain with passive stretch of the muscle in the affected compartment.
• Paresthesias.
• Anesthesia or decreased sensation.
•