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Journal of the American Academy of Orthopaedic Surgeons
154
In a level I trauma center, it is usu-
ally the trauma-trained general sur-
geon who is the leader of the multi-
disciplinary trauma team caring for
the severely injured patient, and
the orthopaedic surgeon functions
as a member of that team. In many
community hospitals, a general
surgeon is often in charge of the
overall management of the trauma
patient, but the orthopaedic sur-
geon plays an important role and
may, at times, serve as the leader.
Therefore, it is incumbent on the
orthopaedic surgeon to be thor-
oughly familiar with the evaluation
and management of the trauma
patient, from assessment through
discharge and rehabilitation.
1
Injuries due to blunt trauma
(the most common being motor-
vehicle accidents), industrial acci-
dents, and falls frequently affect
more than one system. For exam-
ple, flexion-distraction injuries to
the lumbar spine are associated
with a 50% incidence of intra-
abdominal injuries. Therefore, poly-

traumatized patients must be eval-
uated with an awareness of the
possibility of associated injuries and
must be managed in time-relevant
phases.
The phases of trauma care can
be designated as the prehospital
phase, the hospital phase (which
comprises the acute, primary, sec-
ondary, and tertiary periods), and
the rehabilitation phase. Each of
these periods has its own priorities
in resuscitation and injury manage-
ment, as well as predictable pat-
terns of morbidity and mortality.
In the acute and primary periods,
hemodynamic complications (e.g.,
blood loss) and lethal head injury
are the most common causes of
mortality. In the secondary period,
the most common are early organ
failure, particularly pulmonary fail-
ure. In the tertiary period, sepsis,
pulmonary failure, and delayed
organ failure are the leading causes
of death.
This article focuses on the basic
tenets of trauma care, the evalua-
tion of the multiply injured pa-
tient, and the benefits of early

orthopaedic intervention in this
setting.
Dr. Turen is Attending Orthopaedic Surgeon,
Section of Orthopaedic Traumatology, R
Adams Cowley Shock Trauma Center,
University of Maryland Medical Center,
Baltimore. Dr. Dube is Fellow, Section of
Orthopaedic Traumatology, R Adams Cowley
Shock Trauma Center. Dr. LeCroy is Fellow,
Section of Orthopaedic Traumatology, R
Adams Cowley Shock Trauma Center.
Reprint requests: Dr. Turen, Section of
Orthopaedics, R Adams Cowley Shock Trauma
Center, #T3R64, 22 South Greene Street,
Baltimore, MD 21201.
Copyright 1999 by the American Academy of
Orthopaedic Surgeons.
Abstract
The management of the multiply injured patient is a challenge for even experi-
enced clinicians. Because many community hospitals lack a dedicated trauma
team, it is often the orthopaedic surgeon who will direct treatment. Therefore,
the orthopaedic surgeon must have an understanding of established guidelines
for the evaluation, resuscitation, and care of the severely injured patient. Initial
evaluation encompasses assessment and intervention for airway, breathing, cir-
culation, disability (neurologic injury), and environmental and exposure con-
siderations. Resuscitation requires not only administration of fluids, blood, and
blood products but also emergent management of pelvic trauma and stabiliza-
tion of long-bone fractures. Judicious early use of anterior pelvic external fixa-
tion can be lifesaving in many cases. The secondary survey, which is often
neglected, must incorporate a thorough physical evaluation. Although the

method of fracture stabilization is still controversial, most clinicians agree that
early fixation offers many benefits, including early mobilization, improved pul-
monary toilet, decreased cardiovascular risk, and improved psychological well-
being. Without an understanding of the complexities of the multiply injured
patient, delays in the diagnosis and treatment of a patientÕs injuries are likely to
adversely affect outcome.
J Am Acad Orthop Surg 1999;7:154-165
Approach to the Polytraumatized Patient
With Musculoskeletal Injuries
Clifford H. Turen, MD, Michael A. Dube, MD, and C. Michael LeCroy, MD
Clifford H. Turen, MD, et al
Vol 7, No 3, May/June 1999
155
Prehospital Phase
One of the goals of trauma care is to
provide earlier evaluation and
increasingly sophisticated prehos-
pital care. Optimal transport, re-
suscitation, stabilization, and defin-
itive care of the multiply injured
patient at the receiving facility
depend on three key elements, all
of which must be in place before the
patient arrives: (1) paramedics who
are familiar with recommended life
support protocols; (2) open lines of
communication between para-
medics and hospital personnel
regarding the patientÕs medical his-
tory and the mechanism, time, and

circumstances of the injury; and (3)
dedicated space and equipment for
the management of the patient. The
number of paramedics trained in
the American College of Surgeons
Advanced Trauma Life Support
protocols
1
has risen dramatically in
the past decade. Often, this allows
patients to arrive at the emergency
room provisionally evaluated with
resuscitation started.
When indicated, the trauma
patient should arrive at the hospi-
tal with spine immobilization. This
may include use of specialized
equipment, such as a backboard
that incorporates a preformed cer-
vical spine stabilization device or
the Kendrick extrication device, or
classic sandbag immobilization.
Open wounds should be covered
with a sterile bandage. External
hemorrhage should be controlled
with direct pressure. A prefabri-
cated splint should be used to
immobilize long-bone injuries.
Provisional splinting decreases
pain and protects the soft tissues.

Acute Hospital Period
(Initial 1 to 2 Hours)
On patient arrival, it is important
to follow a logical, systematic ap-
proach for evaluation and manage-
ment. This includes a primary sur-
vey, with rapid assessment of vital
signs and patient status with use of
the ÒABCDEÓ management proto-
col
1
(Table 1); acute resuscitation,
which may include orthopaedic
intervention; and a secondary sur-
vey involving a complete head-to-
toe evaluation of the patient. In a
well-staffed trauma center, many
components of the protocol may be
performed concurrently, reducing
the time for evaluation and resusci-
tation.
The primary survey should be
accomplished rapidly. This survey
may be altered on the basis of
information received from the
field, especially for patients with
trauma resulting from certain
mechanisms of injury. For exam-
ple, side-impact motor-vehicle col-
lisions are more likely to cause

pelvic fractures due to lateral com-
pression, solid-viscus injuries, and
closed head injuries. During this
survey, the patientÕs blood pres-
sure, pulse, respiratory rate, uri-
nary output, and arterial blood gas
values should be monitored close-
ly, as they are good indicators of
the patientÕs response to resuscita-
tion. Measurement of oxygen satu-
ration by pulse oximetry may also
provide a good reflection of the
patientÕs airway, breathing, and
circulatory status.
Airway
The first priority in the assess-
ment of a trauma patient is to
ascertain the status of the airway.
The evaluation must be performed
with constant care to protect the
cervical spine until a concomitant
injury has been ruled out. The up-
per airway should be cleared of
any foreign bodies, blood, or secre-
tions, and the mandible, larynx,
and trachea should be quickly eval-
uated for fractures. The use of a
chin lift or jaw thrust, as well as a
nasopharyngeal or oropharyngeal
airway in the unconscious patient,

may help maintain a patent airway.
A lateral radiograph of the cervi-
cal spine, including the C7-T1 inter-
space, should be obtained early in
the assessment protocol. A normal
study combined with a negative
physical examination of a patient
who is alert and is not intoxicated
can be considered to rule out spine
trauma. In the patient who is un-
conscious or intoxicated or who has
neck pain, a negative lateral cervi-
cal spine radiograph does not nec-
essarily clear the spine; other plain-
radiographic views or radiologic
studies may be needed for a com-
plete evaluation. A computed to-
mographic (CT) scan should be
obtained in all cases in which the
entire cervical spine is not visual-
ized, as well as whenever it is indi-
cated clinically or radiographically.
Breathing and Ventilation
As the airway is being assessed,
the adequacy of ventilation is eval-
uated by observing the patientÕs
chest for the rise and fall of normal
breathing, auscultating for normal
breath sounds, percussing to evalu-
Table 1

Mnemonic Device for Primary Evaluation of the Polytraumatized Patient
A - Airway maintenance with cervical spine control
B - Breathing and ventilation
C - Circulation with hemorrhage control
D - Disability evaluation (neurologic status)
E - Exposure and environmental control (completely undress the patient but
prevent hypothermia)
The Polytraumatized Patient With Musculoskeletal Injuries
Journal of the American Academy of Orthopaedic Surgeons
156
ate for pneumothorax or hemotho-
rax, and palpating to determine
whether there are chest wall abnor-
malities or fractures. All trauma
patients should receive supplemen-
tal oxygen. Placement of an orotra-
cheal, nasotracheal, or surgical air-
way is mandatory if there are
mechanical factors preventing nor-
mal breathing (e.g., tension pneu-
mothorax), if the airway cannot be
maintained, or if the patient is
unconscious. These procedures
must be accomplished with ade-
quate control of the cervical spine.
If ventilation still cannot be estab-
lished, the clinician should suspect
pneumothorax or hemothorax and
perform an immediate needle or
tube thoracotomy. Occasionally,

due to the emergent nature of the
clinical scenario, these procedures
may be performed before obtaining
the initial chest radiograph.
Circulation and Hemorrhage
The third step is the assessment
of circulation and blood volume.
Loss of consciousness; pale, cool
skin; and thready or absent pulses
can indicate hypovolemia. In
young patients, these signs may be
the only indications of significant
loss of circulating blood volume.
Hypotension in the multiply in-
jured patient may be due to diverse
causes, including hemorrhage,
brain injury (inability to regulate
blood pressure), quadriplegia (loss
of peripheral vascular resistance),
hypothermia, myocardial infarc-
tion, and mediastinal shock (aortic
transection, pericardial tamponade,
cardiac rupture). Hemorrhage is the
most frequent cause of hypoten-
sion, accounting for 95% of cases in
blunt trauma patients. If bleeding
has been excluded as the cause of
hypotension, other causes should
be sought. Signs indicating other
causes of hypothermia include

decreasing blood pressure with a
decreasing heart rate, fixed and
dilated pupils, and loss of gag
reflex (terminal brain injury); core
temperature of less than 95¡C
(hypothermia); ST-segment eleva-
tion on an electrocardiogram and
poor ventricular wall motion and/or
decreased ejection fraction on an
echocardiogram (myocardial in-
farction); widening pulse pressure;
decreased or muffled heart sounds;
and audible cardiac murmur (medi-
astinal shock). If the patient is
awake and alert, quadriplegia as a
cause of hypotension can usually be
diagnosed. However, in the unre-
sponsive patient, the cause of hypo-
tension can be difficult to identify,
and the physician must rely on a
process of exclusion.
After blunt trauma, blood loss or
accumulation may be external,
intrathoracic, intraperitoneal, or
extraperitoneal or may occur in the
area of long-bone fractures. The
location must be identified so that
appropriate controls can be imple-
mented. External hemorrhage is
the easiest to diagnose and can usu-

ally be controlled by application of
pressure and a compressive dress-
ing by paramedics or the resus-
citation team. Less obvious sites of
hemorrhage are the abdominal cav-
ity (splenic and liver lacerations),
the thorax (aortic tears), the ret-
roperitoneum (pelvic fractures),
and muscle and fascial planes
(extremity fractures). Significant
intrathoracic bleeding usually can
be identified by decreased breath
sounds on physical examination or
will be visualized on an upright
chest film. Free intraperitoneal
blood can be evaluated by radiogra-
phy, ultrasound, lavage, and physi-
cal examination (shifting dullness
to percussion and abdominal dis-
tention). Long-bone fractures can
be identified through physical
examination (e.g., crepitus, ecchy-
mosis, angulation, swelling, tender-
ness) and radiography. Extraperi-
toneal hemorrhage may be inferred
from the presence of pelvic frac-
tures. Pelvic fractures may cause
life-threatening retroperitoneal
hemorrhage and mandate immedi-
ate intervention.

If the history and physical exam-
ination indicate the possibility of
intra-abdominal injury, further
studies are indicated. Historically,
diagnostic peritoneal lavage (sensi-
tivity, 100%; specificity, 84%) has
been the standard in most trauma
centers. In the United States, it may
still be the diagnostic method of
choice, especially for the unstable
patient who cannot safely undergo
CT scanning. However, for the sta-
ble patient with suspected intra-
abdominal injury, CT examination
(sensitivity, 95%; specificity, 95%)
has largely supplanted peritoneal
lavage.
2
In Europe, ultrasonography
(sensitivity, 90%; specificity, 95%)
is the screening tool of choice.
2
The
effectiveness of ultrasonography
depends in great part on the experi-
ence of the individual performing
the examination.
Continuous electrocardiograph-
ic monitoring should be performed
on all trauma patients. Cardiac

electromechanical dissociation may
be caused by cardiac tamponade,
tension pneumothorax, or extreme
hypovolemia.
Disability/Neurologic
Examination
The primary survey should
include a basic neurologic examina-
tion. The ÒAVPUÓ mnemonic
device (A = alert; V = responds to
vocal stimuli; P = responds to pain;
U = unresponsive) and the Glasgow
Coma Scale (Table 2) are useful for
a quick neurologic assessment. A
more thorough examination can be
made during the secondary survey.
A decreasing level of conscious-
ness dictates reevaluation of the
patientÕs oxygenation and ventila-
tion status. If hypoxia and hypo-
volemia have been ruled out, al-
tered consciousness may be related
directly to central nervous system
trauma, drugs, or alcohol.
Clifford H. Turen, MD, et al
Vol 7, No 3, May/June 1999
157
Environment and Exposure
Adequate exposure of the pa-
tient is a prerequisite for a thorough

examination. The patient should be
carefully logrolled to rule out poste-
rior chest wall and flank abnormali-
ties. The spine should be palpated
in its entire length. However, a
patient lying unclothed on the
examination table is at increased
risk for hypothermia, which can
cause dysrhythmias. Warm blan-
kets and heated intravenous fluids
may be appropriate for selected
high-risk patients.
Resuscitation
Concurrent with the primary
assessment, the trauma team must
begin the resuscitation of the pa-
tient. A minimum of two large-
caliber (16-gauge) intravenous cath-
eters should be placed, preferably in
the upper extremities, for adminis-
tration of fluid therapy. If routine
intravenous access is not possible,
cutdowns and/or central venous ac-
cess may be necessary. Once access
has been established, blood should
be drawn for a hemogram, blood
chemistry and clotting factor evalu-
ation, typing and cross-matching,
pregnancy test, and toxicology
screens.

Crystalloid isotonic solutions,
such as lactated RingerÕs solution,
should be administered early in the
resuscitation process. Two to three
liters may be required to increase
the mean arterial pressure to 60 mm
Hg or more. As the blood pressure
increases, the heart rate should
decrease. If the crystalloid infusion
provides only a transient response
or no response at all, the use of Rh-
negative type O or type-specific
blood, respectively, may be indi-
cated. The use of rapid-infusion de-
vices may aid in the resuscitation
effort.
Cross-matched blood should be
used to replace lost blood as indi-
cated. Crystalloid isotonic solu-
tions have no oxygen-carrying
capability and, therefore, can be
used only as an adjunct to blood
replacement. Fresh-frozen plasma
and platelets should be used in
patients who are coagulopathic or
thrombocytopenic (platelet count
below 50,000/mm
3
).
In the acute setting, (e.g., imme-

diately after fluid infusion), urinary
output should be regarded with
caution as an indicator of volume
status and organ perfusion. How-
ever, in the normotensive or stabi-
lized patient, urinary output of 0.5
to 1.0 mL/kg per hour is a good
indicator of renal perfusion. Before
catheters are placed to monitor uri-
nary output, the external genitalia
and rectum should be inspected for
injury. If a urethral injury is sus-
pected, particularly in a male pa-
tient, a retrograde urethrogram
should precede catheter placement.
Blood pressure and heart rate
are also good indicators of the ade-
quacy of resuscitation. A stable
mean arterial pressure of 60 mm
Hg or more and a heart rate of less
than 100 beats per minute usually
indicate hemodynamic stability.
The central venous pressure or
the pulmonary capillary wedge
pressure may be a better indicator
of hemodynamic stability than the
blood pressure alone in the elderly
and in patients with chest trauma.
A near-normal value for either
(adjusted for age) provides excel-

lent information on the adequacy
of resuscitation.
Lactic acid levels are also useful
measurements, because the lactate
concentration rises with anaerobic
metabolism. Increased levels may
be an indicator that significant injury
has gone unnoticed and resuscita-
tion is incomplete. Most trauma
patients receive large amounts of
fluid and blood and often go from
volume depletion to volume over-
load in a short period of time.
A nasogastric tube should be
inserted early in the resuscitation to
decompress the stomach. In pa-
tients with facial trauma, the tube
should be passed through the
mouth, rather than the nasopharynx.
Radiographs are a valuable ad-
junct in evaluation of the trauma
patient but should not interfere with
resuscitation. Three radiographs
should be obtained on all trauma
patients concurrent with the primary
survey and initial resuscitation: an
anteroposterior (AP) chest film, an
AP view of the pelvis, and a lateral
view of the cervical spine. As indi-
cated by physical examination or

protocol, additional anatomy-specific
radiographic studies can be obtained
as part of the secondary survey.
Pelvis
A major concern for the trauma
team is the presence of a pelvic frac-
Table 2
Glasgow Coma Scale
*
Eye opening
Spontaneous 4
In response to speech 3
In response to pain 2
None 1
Motor response
Obeys commands 6
Purposeful movements in
response to pain 5
Withdrawal in response
to pain 4
Flexion in response to pain 3
Extension in response to pain 2
None 1
Verbal response
Oriented 5
Confused 4
Inappropriate 3
Incomprehensible 2
None 1
*

One score (the highest value) is
recorded for each category. Thus, the
possible combined scores range from
3 to 15. (Adapted with permission
from Teasdale G, Jennett B: Assess-
ment of coma and impaired con-
sciousness: A practical scale. Lancet
1974;2:81-84.)
The Polytraumatized Patient With Musculoskeletal Injuries
Journal of the American Academy of Orthopaedic Surgeons
158
ture in a patient with continued
hemodynamic deterioration. If
hemorrhage from the chest, thorax,
abdomen, and external sites or from
the area of a long-bone fracture has
been either excluded as the cause of
hypotension or controlled, evalua-
tion of an AP radiograph of the
pelvis may reveal that a fractured
pelvis is the site of hemorrhage. If
the fracture pattern carries a high
risk for instability, inlet (caudad)
and outlet (cephalad) films of the
pelvis should be obtained. These
more clearly depict fracture dis-
placement and are useful in identi-
fying the direction of fracture.
Obturator and iliac oblique views
are helpful in assessing acetabular

fractures.
Although TileÕs pioneering ÒABCÓ
classification of pelvic disruptions
offers a simple description of these
injuries and may be applicable for
some pelvic fractures, we have
found the classification devised by
Young et al
3,4
more effective for
guiding acute management of the
multiply injured patient. In their
system, pelvic fractures are divided
into four groups: lateral compres-
sion (LC), AP compression (APC),
vertical shear, and combined me-
chanical injury (Fig. 1). The first
two groups are further categorized
according to the severity of injury
due to the energy imparted to the
pelvis. In a review of 210 pelvic
fractures, the authors found that the
plane of the anterior ring disruption
indicated the direction of the force
imparted to the pelvis, suggested
the nature of the posterior-ring
lesion, and could be used to estab-
lish the risk of hemorrhage.
4
Lateral compression injuries are

characterized by an oblique anterior
ring fracture and are associated
with decreasing pelvic volume,
intraperitoneal or intrathoracic
hemorrhage, and a high incidence
of head injury, which may cause
hypotension. The type LC-III frac-
ture is the typical ÒrolloverÓ frac-
ture, in which one hemipelvis sus-
tains an LC injury and the other sus-
tains an AP injury, the latter most
often associated with high blood
loss. However, the high mortality
rates associated with type LC-III
injuries usually are secondary to
associated injuries rather than the
pelvic fracture.
Anteroposterior compression
injuries are characterized by vertical
pubic ramus fractures and are asso-
ciated with the greatest incidence of
hemorrhage because of the sequen-
tial disruption of the sacrotuberous
and sacrospinous ligaments (type
APC-I), the anterior sacroiliac liga-
ment (type APC-II), and the poste-
rior sacroiliac ligament (type APC-
III), as well as the neurovascular
structures adjacent to those liga-
ments. The mechanism of type

APC-I and APC-II injuries can be
likened to opening a book. The
APC-III fracture (an innominosacral
dissociation, or internal hemipel-
vectomy) can be likened to breaking
the binding of a book. This injury
pattern has been associated with
blood requirements in excess of 20
units,
5
the highest blood loss for all
pelvic fracture types.
Vertical shear injuries, often
associated with massive blood loss,
show an initial cephalad displace-
ment that is not seen in APC in-
juries until later in the postinjury
course. Combined mechanical
injuries may incorporate two or
more of these injury patterns, but it
is the APC portion that is most at
risk for hemorrhage.
During injury, the forces that
disrupt the pelvic ligaments con-
straining the ring (the anterior
sacroiliac, sacrospinous, sacrotuber-
ous, and posterior sacroiliac liga-
ments) also disrupt the associated
vessels, causing hemorrhage. Even
a small increase in pelvic diameter

exponentially increases the pelvic
volume (2/3πr
3
). A patient who
has sustained blunt trauma and has
an unstable pelvic fracture is at risk
for fatal exsanguinating hemor-
rhage because of (1) the administra-
tion of fluids to raise the blood
pressure, which impairs the bodyÕs
natural compensatory hypotension
(i.e., decreased blood pressure causes
decreased blood flow, which in-
creases clotting and thereby de-
creases hemorrhage); (2) the admin-
istration of nonclotting, often cold,
resuscitation fluids, which can limit
clotting ability; and (3) movement
for diagnostic and examination pro-
cedures.
Hemorrhage following pelvic
fractures can be managed with
angiography and embolization,
exploration and vascular ligation,
open reduction and internal fixa-
tion (ORIF), a pneumatic antishock
garment, or external fixation. The
choice of treatment depends not
only on the resources of the institu-
tion but also on the experience and

availability of required personnel.
In institutions with skilled radi-
ology personnel and trauma teams,
patients with hemodynamic insta-
bility secondary to pelvic fracture
may be managed with angiography
and embolization. Although this
technique can be used to diagnose
and treat arterial hemorrhage, it is
less than optimal for the patient in
extremis because the bleeding is
most frequently venous and be-
cause the procedure requires the
immediate availability of special-
ized personnel.
Open reduction and internal fix-
ation is mechanically the most sta-
ble form of fixation and may be per-
formed at the same time as other
emergent surgery (e.g., laparotomy
for intraperitoneal injury). How-
ever, ORIF requires a substantial
amount of surgical experience, and
special care is necessary to avoid
violating the retroperitoneal space,
thus decompressing any existing
tamponade. Recently, the use of
percutaneous iliosacral screw fixa-
tion has gained acceptance.
6

Al-
though this modality can provide
Clifford H. Turen, MD, et al
Vol 7, No 3, May/June 1999
159
stability to the posterior pelvis and
control pelvic volume, the tech-
nique is exacting, and incorrect
placement of the screw can violate
the neural canal posteriorly or the
vessels and/or nerve roots anteri-
orly as the screw traverses the
sacral ala. Certain injuries, such as
hollow-viscus perforation with
contamination of the wound, are
relative contraindications to ORIF.
Pneumatic antishock garments
are effective as a temporary splint
for the pelvis and lower extremi-
ties, but prolonged use limits eval-
uation of, and access to, lower-
extremity trauma. Their use is
contraindicated in the treatment of
open fractures and may potentiate
a compartment syndrome.
7
Recent
reports questioning the use of
pneumatic antishock garments
have focused on penetrating, not

blunt, injuries.
8
In many instances, use of an
external fixator is the method of
choice for controlling hemorrhage
in a blunt trauma victim with
hypotension secondary to pelvic
disruption. The fixator can be
applied in the emergency room,
but it is most often applied in the
operating room if a patient remains
hypotensive after resuscitation.
Early external fixation stabilizes the
pelvic ring, controls pelvic volume,
minimizes dislodgment of clots
formed during the bodyÕs initial
attempt to control the hemorrhage,
aids in controlling cancellous
bleeding, and facilitates early pa-
tient mobilization, promoting good
pulmonary toilet through an up-
right chest.
To apply an external fixator,
pins are inserted between the cor-
tices of the ilium through separate
stab incisions (Fig. 2, A). Pelvic
clamps are used to attach the pins
in groups. Connecting rods are
loosely attached to the clamps to
form a frame. The pelvis is re-

duced by posterior manual com-
pression on the pelvis (not the
pins) at the level of the sacroiliac
joint and by longitudinal traction,
and the frame is locked. The frame
construct should allow further
abdominal and chest diagnostic
studies or intervention without
Fig. 1 Classification system for pelvic frac-
tures devised by Young et al.
3,4
Lateral
compression (LC) fractures: type LC-I is a
stable injury with ipsilateral sacral crush;
type LC-II is an injury with ipsilateral hori-
zontal pubic ramus fractures, anterior
sacral crush, and crescent fractures through
the iliac wing; type LC-III is a type I or II
fracture with ipsilateral opening of the
sacroiliac joint posteriorly and disruption of
the sacrotuberous and spinous ligaments.
Anteroposterior compression (APC) frac-
tures: type APC-I is a stable injury that
opens the pelvis but leaves the posterior
ligamentous structures intact; type APC-II
is a rotationally unstable fracture with dis-
ruption of the sacrospinous and sacrotuber-
ous ligaments and anterior sacroiliac joint
opening; type APC-III is an unstable injury
with complete disruption of all ligamentous

supporting structures. A vertical shear (VS)
fracture is an unstable fracture involving
vertical ramus fractures and disruption of
all ligamentous structures.
LC-I
APC-I
APC-III
VS
APC-II
LC-III
LC-II
The Polytraumatized Patient With Musculoskeletal Injuries
Journal of the American Academy of Orthopaedic Surgeons
160
releasing the reduction (Fig. 2, B).
In patients with concurrent intra-
peritoneal and extraperitoneal in-
jury and hemorrhage, immediate
application of the fixator followed
by laparotomy can be lifesaving
(Fig. 2, C).
Reduction of major joint disloca-
tions and fracture-dislocations
should also be addressed in the
acute period. Although this should
not be the first priority in the hemo-
dynamically unstable patient, the
orthopaedic surgeon must be ag-
gressive in managing these injuries,
particularly hip and knee disloca-

tions. Reduction can usually be
accomplished without impeding
the resuscitation team. Frequently,
the patient is intubated and has
been given muscle relaxants, which
helps make the reduction atraumatic.
If there is neurovascular compro-
mise, early realignment of the joint
may help restore blood flow to the
distal extremity, avoiding ischemia
and compartment syndrome.
Primary Hospital Period
(Hours 3 to 12)
Reevaluation
During this period, the existing
history is expanded, when possible,
detailing not only allergies, medica-
tions, past and present illnesses,
and recent food intake but also the
mechanism of injury, the duration
of exposure to the elements, the
area surrounding the scene, and
other information obtained from
the patient, paramedics, and family
members. After obtaining a de-
tailed history, the physician per-
forms the secondary survey, a
head-to-toe evaluation undertaken
only after completion of the prima-
ry survey. Each area of the bodyÑ

maxillofacial, cervical, thoracic,
abdominal, perineal (including rec-
tum and vagina), musculoskeletal,
and neurologicÑis fully examined.
Because the patient is often uncon-
scious, and thus unable to help the
examiner localize injuries, a great
deal of care must be used during
this evaluation. The Glasgow Coma
Scale score (Table 2) is determined
at this time.
Fig. 2 External fixation of a pelvic fracture. A, Pins are inserted
between the inner and outer tables of the ilium into the thick can-
cellous bone above the acetabulum for maximum pin-to-bone con-
tact. B, The resuscitative pelvic fixator allows manipulation of the
frame without loss of reduction. One portion of the frame remains
locked while the other is rotated to allow access to the abdomen
and to facilitate patient positioning for CT scanning. C, The pelvic
fixator is adjusted to allow access to the abdomen for laparotomy.
(Part C reproduced with permission from Burgess AR: The man-
agement of haemorrhage associated with pelvic fractures. Int J
Orthop Trauma 1992;2:101-111.)
A B
C
Clifford H. Turen, MD, et al
Vol 7, No 3, May/June 1999
161
One of the most important man-
agement principles, and one that is
often overlooked, is continual re-

evaluation of the patient. A pa-
tientÕs overt, overwhelming injuries
frequently mask other serious in-
juries that, if unrecognized and
untreated, may cause future dis-
ability.
During the primary period of
patient care, decisions related to
limb salvage must be considered.
Extremities with massive injuries
must be carefully evaluated for the
degree of soft-tissue damage, per-
fusion of the limb distal to the in-
jury, neurologic function in the dis-
tal limb, and the number of levels
of injury within the limb.
Unfortunately, attempts to quan-
tify the injury and outcome have
not proved uniformly successful.
However, the Mangled Extremity
Salvage Score,
9
the Abbreviated
Injury Scale (Table 3), and other
scoring systems direct attention to
the important factors, such as
ischemic time, hypotension, and
neurologic function, that must be
considered when evaluating the
feasibility of limb salvage. Physi-

cian experience may be the most
reliable determinant of whether to
salvage or amputate the limb.
Severe open fractures have the
highest treatment priority once the
patient is hemodynamically stable.
However, one must not allow the
salvage of a limb to compromise
the well-being of the patient. The
mangled limb may place too great
a metabolic load on a critically ill
patient, and amputation may there-
fore be required to ensure patient
survival.
For patients with less extensive
injuries, management of open frac-
tures should be no less aggressive.
Wounds should be examined only
once in the emergency department,
in the presence of the orthopaedic
surgeon. Drawings or Polaroid pho-
tographs of the wounds can be help-
ful in avoiding repeated inspections.
Table 3
Examples of Scores on the Abbreviated Injury Scale*
Examples Score (Description)
Head
Crush of head/brain 6 (lethal)
Brainstem contusion 5 (critical, survival uncertain)
Epidural hematoma (small) 4 (severe, life-threatening)

Face
External carotid laceration (major) 3 (severe, not life-threatening)
Le Fort III fracture 3
Optic nerve laceration 2 (moderate)
Neck
Crushed larynx 5
Pharyngeal hematoma 3
Thyroid gland contusion 1 (minor)
Thorax
Open chest wound 4
Aorta, intimal tear 4
Esophageal contusion 2
Myocardial contusion 3
Pulmonary contusion (bilateral) 4
Two or three rib fractures 2
Abdomen and pelvic contents
Bladder perforation 4
Colon transection 4
Liver laceration >20% blood loss 3
Retroperitoneal hematoma 3
Splenic laceration, major 4
Spine
Incomplete brachial plexus 2
Complete spinal cord injury at C4 or below 5
Herniated disk with radiculopathy 3
Vertebral body compression >20% 3
Upper extremity
Amputation 3
Elbow crush 3
Shoulder dislocation 2

Open forearm fracture 3
Lower extremity
Amputation
Below knee 3
Above knee 4
Hip dislocation 2
Knee dislocation 2
Femoral shaft fracture 3
Open pelvic fracture 3
External
Hypothermia 31¡C to 30¡C 3
Electrical injury with myonecrosis 3
Second- or third-degree burns over
20% to 29% of body surface area 3
* Adapted with permission from Kellam JF, Bosse MJ: Orthopaedic management decisions in
the multiple trauma patient, in Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Skeletal
Trauma: Fractures, Dislocations, Ligamentous Injuries, 2nd ed. Philadelphia: WB Saunders, 1998, p 153.
The Polytraumatized Patient With Musculoskeletal Injuries
Journal of the American Academy of Orthopaedic Surgeons
162
The patient should then be taken
urgently to the operating room for
aggressive surgical debridement of
wounds, removing all devitalized
skin, muscle fascia, and bone.
Irrigation should be performed with
copious amounts of crystalloid solu-
tion, preferably via pulsatile lavage.
Wounds should be reinspected at
the conclusion of the initial debride-

ment and irrigation for any nonvi-
able tissue that was missed. Bone
fragments should be stabilized
under a different surgical setup
(new drapes and surgical instru-
ments). Whenever possible, frac-
tures should be stabilized with inter-
nal or external fixation. Repeat
inspection and debridement should
occur within the next 48 hours.
Early soft-tissue coverage is neces-
sary for optimal functional outcome.
Prophylactic antibiotic therapy
with a first-generation cephalo-
sporin should be given in the emer-
gency department and continued for
up to 48 hours after debridement.
The addition of a second antibiotic is
infrequently necessary but is appro-
priate in special circumstances, such
as after exposure to barnyard con-
taminants and brackish water. With
each additional debridement, the
patient should again receive a pro-
phylactic course of antibiotics.
Benefits of Early Fracture
Stabilization
It is generally recognized that
proper management of the multiply
injured patient requires a multidis-

ciplinary, team-oriented approach.
Standardized trauma protocols
have resulted in improved patient
outcomes.
1
A critical component of
modern trauma care is early stabi-
lization of major pelvic and long-
bone fractures. Unfortunately, this
does not always translate into clini-
cal practice. Orthopaedic injuries
are frequently overlooked initially
in the interest of acute resuscitation
of the multiply injured patient.
However, many studies have shown
that aggressive early management
of these injuries increases long-term
survival and decreases morbidity.
Fixation of unstable fractures of
the pelvis, femur, and tibia should
be performed within the first 24
hours after injury if medically fea-
sible. The goal is stable skeletal fix-
ation with the use of internal
and/or external orthopaedic im-
plants that will allow early mobi-
lization of the patient. Early frac-
ture stabilization has been shown
to have many beneficial effects on
the clinical course of the multiply

injured patient, decreasing compli-
cations and improving outcome.
Decreased Musculoskeletal Morbidity
Musculoskeletal morbidity is the
primary source of long-term disabili-
ty for survivors of multisystem trau-
ma, particularly those with spinal
cord injury. Early fracture stabiliza-
tion minimizes morbidity secondary
to the loss of musculoskeletal func-
tion. Early patient mobilization,
facilitated by early fracture stabiliza-
tion, allows early range-of-motion
and muscle-strengthening exercises,
thereby decreasing rehabilitation
time and long-term disability.
10,11
Decreased Hospital Stay
Early fracture stabilization re-
duces the length of time in the
intensive care unit and the overall
hospital stay, which translates into
a substantial reduction in the cost
of hospital care for the multiply
injured patient.
10,12,13
Bone et al
10
found that multiply injured pa-
tients managed with early stabi-

lization averaged 2.8 intensive care
unit days and 17.3 hospital days,
compared with 7.6 and 26.6 days,
respectively, for those treated with
delayed stabilization. The average
total hospital cost was 66% higher
for the delayed-stabilization group.
Other Benefits
Other benefits of early skeletal
stabilization are more subjective but
nevertheless clinically significant in
the management of the multiply
injured patient. Early fracture fixa-
tion allows rapid patient mobili-
zation, improved nursing care, and a
decreased incidence of decubitus
ulcers. Early fracture stabilization
also improves patient comfort, there-
by reducing the need for narcotic
analgesics, with their associated res-
piratory depressant side effects.
It has also been argued that early
fracture stabilization increases the
risk of complications from skeletal
fixation in the already stressed mul-
tiply injured patient. However, no
prospective study to date has
shown increased rates of infection
or nonunion in patients managed
with early fracture stabilization.

Therefore, it is now accepted that
surgical intervention should be
undertaken as soon as possible after
injury, when the nutritional status is
optimal and the probability of colo-
nization by drug-resistant nosoco-
mial organisms is lowest.
The Role of Reaming of Femoral
Fractures
Although the benefits of early
long-bone fracture stabilization are
now well recognized, some clini-
cians have voiced concerns about
the potentially harmful effects of
intramedullary reaming of femoral
fractures in the multiply injured
patient. Intramedullary reaming
has been shown to result in embo-
lization of fat and marrow contents,
but the clinical significance of this
with respect to pulmonary function
in the polytraumatized patient
remains controversial.
Pape et al
14
retrospectively stud-
ied the relationship between reamed
intramedullary nailing of femoral
shaft fractures and posttraumatic
pulmonary complications. Their

data suggest that patients with asso-
ciated pulmonary injury have a
higher incidence of posttraumatic
adult respiratory distress syndrome
(ARDS) when treated with immedi-
Clifford H. Turen, MD, et al
Vol 7, No 3, May/June 1999
163
ate reamed nailing. To minimize the
potential for development of pul-
monary complications, Pape et al
15
recommend nonreamed intramedul-
lary nailing for the treatment of
femoral shaft fractures in the multi-
ply injured patient.
Other researchers have found the
harmful effects of reaming to be
negligible in both animal models
and retrospective clinical studies.
Duwelius et al
16
utilized a sheep
model without thoracic trauma and
found that reaming produced only a
modest and transient effect on pul-
monary vascular resistance. Simi-
larly, in a sheep model with coexis-
tent thoracic trauma, Neudeck et al
17

found no difference in pulmonary
hemodynamics between treatment
of femoral shaft fractures with
reamed nails, nonreamed nails, or
plate fixation. Recently, Bosse et al
18
reviewed the data on two groups of
multiply injured patients with
femoral shaft fractures and pul-
monary injuries who had been treat-
ed at two different trauma centers
with either plate fixation or reamed
intramedullary nailing. They found
no difference in the incidence of pul-
monary complications in the two
groups of patients, suggesting that
reamed nailing does not potentiate
the development of ARDS.
Pulmonary Complications After
Trauma
Although fat embolism syn-
drome may be a component of
ARDS, the latter may occur in the
absence of fat embolism syndrome,
as occurs with pulmonary contu-
sion. Therefore, these two concepts
will be discussed separately.
Fat Embolism Syndrome
After musculoskeletal trauma,
marrow fat from the fracture site or

sites can embolize and become con-
centrated in the pulmonary vascu-
lar bed. This embolization activates
a complex series of interactions,
including the coagulation cascade,
increased platelet function, and
release of vasoactive substances.
Clinically, fat embolism syndrome
is characterized by acute hypox-
emia, mental status alteration, and
interstitial infiltration evidenced on
chest radiographs. In patients with
isolated long-bone fractures, the
incidence is 0.5% to 2.0%; that in
multiply injured patients with
pelvic and/or lower-extremity frac-
tures approaches 10% to 15%.
19
Studies have demonstrated that
early fracture stabilization results
in a decreased incidence of fat
embolism syndrome. Riska and
Myllynen
19
compared two groups
of multiply injured patients and
found that the incidence of fat
embolism syndrome was 1.4% in
those treated with early fracture
stabilization and 22% in those treat-

ed without it. Similarly, in a pro-
spective randomized series of early
versus delayed stabilization of
femoral shaft fractures, Bone et al
10
found no cases of fat embolism
syndrome in the early-stabilization
group.
Adult Respiratory Distress Syndrome
Adult respiratory distress syn-
drome, a particularly devastating
complication of trauma, is charac-
terized by refractory hypoxemia
and diffuse infiltrative changes on
the chest radiograph. Prolonged
intubation and mechanical ventila-
tion are usually necessary, with the
attendant risks to the patient. The
condition is known to be associated
with late septic complications, multi-
system organ failure,
12,20
and high
mortality rates.
20
A growing body of evidence has
shown that early fracture stabiliza-
tion can substantially decrease the
incidence of ARDS.
10,12,13

In a large
retrospective review, Johnson et
al
12
found that delaying fracture
stabilization for more than 24 hours
was associated with a fivefold in-
crease in the incidence of ARDS,
particularly in more severely in-
jured patients. When such patients
were treated with delayed stabi-
lization, the incidence of ARDS was
75%; when managed with early sta-
bilization, it was 17%.
Thromboembolic Complications
Thromboembolic complications
(deep venous thrombosis and pul-
monary embolism) can adversely
affect patient outcome and have
been reported to occur more fre-
quently in multiply injured patients
than in patients with isolated in-
juries.
10
Early fracture stabilization
facilitates early patient mobilization
and may decrease the incidence of
thromboembolic complications. In a
prospective study, Bone et al
10

found
only one thromboembolic complica-
tion in a group of 178 multiply
injured patients managed with early
stabilization.
Mechanical devices, such as the
sequential compression device,
and chemical agents, such as low-
molecular-weight heparin, are
indicated for prophylaxis of deep
venous thrombosis. The use of
anticoagulants may be contraindi-
cated in multiply injured patients.
Patients with documented deep
venous thrombosis and those
undergoing pelvic surgery may
benefit from placement of a vena
cava filter. However, the use of a
vena cava filter is not without
potential complications, such as
severe lower extremity edema.
Secondary Period (Hours
13 to 72)
At the conclusion of the primary
period, a plan for fixation of the
remaining fractures must be for-
mulated, taking into consideration
the patientÕs overall status and
always subject to alteration because
of changes in that status. It is

essential that this plan be commu-
nicated to the other members of the
treatment team.
The Polytraumatized Patient With Musculoskeletal Injuries
Journal of the American Academy of Orthopaedic Surgeons
164
Wounds that were initially de-
brided should be reassessed, and
those associated with Gustilo type II
and III open fractures should under-
go repeated excisional debridement
to remove any nonviable soft tissue or
bone. Such wounds may be closed,
or plans may be made for repeat
debridement and/or soft-tissue cov-
erage. Lacerations closed on initial
presentation must be inspected for
signs of infection and should be re-
opened and debrided if clinically
indicated.
During this period, attention
should also be given to definitive
care of fractures of the spine,
acetabulum, pelvis, and upper
extremities, as well as periarticular
fractures, if not already addressed.
Once the initial interventions for
resuscitation have ceased, efficient
evaluation of these fractures may
be made without the pressure of

ongoing resuscitation measures.
The currently recommended
treatment of unstable spine fractures
is early internal fixation. In the sec-
ondary period, spinal stabilization
sufficient to allow patient mobiliza-
tion should be completed. Occa-
sionally, the approach (anterior or
posterior) may require modification
to accommodate associated injuries.
The multiply injured patient
often depends on the upper ex-
tremities for mobilization (e.g.,
walking with crutches or wheel-
chair propulsion). Therefore, stable
fixation of upper extremity frac-
tures will facilitate rehabilitation.
It is not uncommon for these frac-
tures (such as those of the humeral
diaphysis), when seen as isolated
injuries, to be treated by closed
methods; however, in the multiply
injured patient, surgical interven-
tion is often beneficial in improv-
ing the overall outcome. The
choice of fixation method must be
tailored to the fracture pattern and
the presence of other injuries.
Displaced fractures of the calca-
neus may be addressed if swelling

has decreased sufficiently to allow
a safe surgical approach through
uncompromised skin. A compres-
sion dressing, ice, and perhaps a
foot pump may allow substantial
reduction of swelling and permit
surgery during this period.
The orthopaedic surgeon should
keep in mind the possibility of the
development of compartment syn-
drome in this period. Severely
injured limbs are at risk for com-
partment syndrome whether or not
a fracture is present. The presence
of an open fracture does not neces-
sarily decompress the limb com-
partments. Soft-tissue injury,
increased membrane permeability,
infusion of large volumes of crys-
talloid isotonic solutions, and the
presence of hypotension potentiate
the risk of compartment syndrome.
Pain out of proportion to the
apparent injury, pain with passive
stretching of a compartment, com-
partment rigidity on palpation, and
increased two-point discrimination
are excellent clinical indicators of
compartment syndrome. In the
unconscious patient, the surgeonsÕ

level of suspicion must be higher
because of the lack of some of these
symptoms. The surgeon should
not hesitate to utilize direct com-
partment pressure measurements.
When present, open fasciotomy is
the treatment of choice. If unrecog-
nized or inadequately treated, this
complication can result in a poorly
functioning, insensate limb or can
necessitate amputation.
Tertiary Period (Beyond 3
Days)
During this time, definitive wound
management is undertaken. Wounds
that were previously closed and
show no sign of infection are left
alone. Other wounds may require
delayed primary closure if the
wound bed permits. Wounds with
viable muscle and a healthy granu-
lation bed may undergo placement
of a split-thickness skin graft. If
indicated, this will provide a sealed
wound early in the patientÕs hospi-
tal course without the need for
advanced soft-tissue techniques. In
the presence of exposed bone, rota-
tion flaps (if the muscle is not in the
zone of injury) or free-tissue trans-

fers must be considered. It should
be emphasized that the guiding
principle is to obtain a closed enve-
lope around the bone as early as
possible. Injuries in the upper and
lower extremities that require bone
grafting should be addressed at the
time of wound closure.
Rehabilitation Phase
Rehabilitation should begin early,
with joint range of motion under
the supervision of a physical or
occupational therapist. This can be
accomplished passively if the
patient is unable to cooperate.
Ideally, the patient can participate
from the beginning, increasing the
type and duration of the therapy as
pain subsides. The duration of the
rehabilitation period is longer for a
polytraumatized patient than it is
for a patient with isolated injuries
because the cumulative effect of
multiple injuries is greater than the
sum of individual ones.
Delayed bone reconstruction in
the massively injured extremity
may take many forms. In injuries
at risk for nonunion, bone grafting
should be undertaken early. Blick

et al
21
showed the benefit of early
bone grafting in patients at risk for
nonunion. It must be remembered
that a healed soft-tissue envelope is
desirable before grafting.
Deformity correction and bone
transport have become more com-
monplace since the introduction of
the Ilizarov method in North
America. Although the application
of these frames may speed the recov-
ery of the patient, the techniques are
Clifford H. Turen, MD, et al
Vol 7, No 3, May/June 1999
165
demanding and require a great deal
of time, not only by the surgeon but
also by the patient, whose active par-
ticipation is mandatory.
Multitrauma patients are at
increased risk of infection because
of the inherent physiologic changes
associated with trauma. Nonortho-
paedic infections must be managed
aggressively by critical-care special-
ists and general surgical traumatol-
ogists. Wounds must be treated
aggressively, with excisional de-

bridement of all necrotic bone and
soft tissue. Wounds that were pre-
viously closed may, at this point,
require flap coverage. Initial plans
may have to be revised. Failure to
address the issue of infection may
change what might have been an
excellent outcome of a difficult
problem to a poor outcome and a
lifetime of disability.
Antibiotics should be specific for
organisms identified at the time of
debridement. Broad-spectrum cov-
erage is appropriate on presenta-
tion, but should be discontinued
once the specific organism and its
sensitivities have been identified.
Summary
The orthopaedic surgeon should be
involved in the care of the multiply
injured patient from admission
through rehabilitation. Early ortho-
paedic intervention affords the
benefits of decreased mortality,
increased hemodynamic stability,
decreased pulmonary complication
rate, early mobilization, decreased
complications of recumbency, de-
creased narcotic requirements, and
a greater likelihood of an excellent

outcome.
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