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Orthopaedic approach to the multiply injured patient 

Orthopaedic approach to the multiply injured patient
Chapter:
Orthopaedic approach to the multiply injured patient
Author(s):

Andrew C. Gray

DOI:
10.1093/med/9780199550647.003.012003
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date: 12 December 2019

Major trauma results in a systemic stress response proportional to both the degree of initial injury (1st hit) and the subsequent surgical treatment (2nd hit).

The key physiological processes of hypoxia, hypovolaemia, metabolic acidosis, fat embolism, coagulation and inflammation operate in synergy during the days after injury/surgery and their effective management determines prognosis.

The optimal timing and method of long bone fracture fixation after major trauma remains controversial. Two divergent views exist between definitive early intramedullary fixation and initial external fixation with delayed conversion to an intramedullary nail once the patient’s condition has been better stabilised.

There is agreement that the initial skeletal stabilisation should not be delayed and that the degree of initial injury has a more direct correlation with outcome and the development of subsequent systemic complications rather than the method of long bone fracture stabilisation.

Trauma patients can be screened to identify those more ‘at risk’ of developing systemic complications such as respiratory insufficiency. Specific risk factors include: A high injury severity score; the presence of a femoral fracture; the combination of blunt abdominal or thoracic injury combined with an extremity fracture; physiological compromise on admission and uncorrected metabolic acidosis prior to surgery.

The serum concentration of pro-inflammatory cytokine interleukin (IL) 6 may offer an accurate method of quantifying the degree of initial injury and the response to surgery.

The effective management of the polytraumatised patient involves a team approach and effective communication with allied specialties and theatre staff. A proper hierarchy of the injuries sustained can then be compiled and an effective surgical strategy made.

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