Multiple Complex Trauma

The CT scan above belongs to a gentleman who fail from the third-floor building he was working on and sustained 5 fractures ( Quadrirami Rami, acetabulum, sacrum, tibia, and calcaneus) for whom we performed percutaneous and minimally invasive fixation for his 5 fractures in different parts of the body on the same surgery.

What is it?

Multiple trauma in Orthopedics means having several serious musculoskeletal injuries from a forceful trauma. The injuries could result in multiple level bone fractures and could be associated with other organ system injuries. These are life-threatening conditions and require a multidisciplinary teamwork approach to save the victim’s life.

Cause

A high-velocity injury like a car crash and fall from height causes multiple trauma.

Symptoms

These life-threatening injuries have different degrees of manifestations from pain on multiple locations to severe symptoms entailing a life and death situation. Even patients that are talking and looking stable, could deteriorate at any point in time and hence need a very close watch in a hospital setting.

Diagnosis

All forceful injuries will routinely be x-rayed as part of the initial trauma patient assessment. The x-rays include chest, pelvis, and neck in addition to specific anatomic regions based on the location of the injury.

X-ray shows most of the bony injuries but needs to be taken with various views from different angles.

A computerized tomography (CT) scan is an important imaging modality on various parts of the body. Complex structure in the body is better assessed with CT. It will also enable us to see three-dimensional (3D) reconstruction of the injuries.

At times when the need arises ultrasound scans and a magnetic resonance image  (MRI) might be needed.

Blood tests to assess the degree of blood loss and the function of the liver and kidneys, and testing of the urine to look for damage to the urinary tract system will be conducted.

Treatment

Minimally invasive surgery is performed through tiny incisions instead of the large openings.

1. Emergency lifesaving interventions

Trauma in different body parts can be a life-threatening injury. Hence, the primary goal of initial treatment in these patients is to conduct lifesaving measures.

  • Stabilizing the neck
  • Controlling excessive bleeding.
  • Replacing the lost blood
  • Initial fracture stabilizations
  • Antibiotics as needed, especially for open injuries
  • Blood thinners to prevent blood clotting

Hence, timely arrival to the appropriate facility and initiation of appropriate treatment is key; and preventive medication like antibiotics in open fractures and blood thinner is crucial.

After addressing the life-threatening condition, we then focus on how to best hold the bones still to allow healing.

2. Fractures treatment

Treatment of these complex fractures requires a systematic approach to further minimize the damage that can be made worse by surgical trauma. These can be conducted in either of two ways:

Staged fixation

When patients with these multiple injuries are assessed to be too sick to operate on, we conduct initial temporary fracture stabilization while conducting lifesaving interventions. These could be done:

  • Non-surgical: with tractions or splints; or
  • Surgically by using:
    • External fixation: Pins that project out of the skin on both sides of the fractures attached to bars outside the skin can be used to provisionally stabilize.
    • Percutaneous fracture stabilization: when the fractures are amenable to fixation with minimal surgical trauma decreasing the risk of further blood loss and damage to vital organs, minimally invasive techniques can be used to perform fracture stabilization as a definitive means of treatment.
  • After initial fracture stabilization, definitive fixation will be carried out once the patient is stable enough to undergo further surgery.

Early total care

For patients that are relatively stable with minimal risk to life-threatening conditions, all fractures can be treated definitively initially. Early definitive treatment can be carried out as follows:

  • Minimal invasive fixation:

Small stab incisions are used to carry out fracture fixation using implants that will be buried under the skin. Various minimally invasive techniques are used to bring the displaced fracture fragments together before fixation.  This technique minimizes bleeding and is well tolerated even for a patient in bad shape following a severe traumatic injury. Such an example is shown in the image above on a gentleman for whom we performed percutaneous and minimally invasive fixation for his 5 fractures in different parts of the body on the same surgery.

  • Open reduction and internal fixation:
    Surgical opening is used to reposition displaced bone fragments back into their alignment. They are then held in place with screws, metal plates attached to the surface of the bone, or metal roads put in the medullary canal of long bones (known as an intramedullary nail).

Compiled and written on June 2021. By Dr. Samuel Hailu.

*Disclaimer:*The information contained herein is for educational purposes only. This should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your healthcare provider because of any information you read on this topic.