Wade R. Smith

Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures

ObjectiveTo determine whether the evolution of the authors’ clinical pathway for the treatment of hemodynamically compromised patients with pelvic fractures was associated with improved patient outcome. Summary Background DataHemodynamically compromised patients with pelvic fractures present a complex challenge. The multidisciplinary trauma team must control hemorrhage, restore hemodynamics, and rapidly identify and treat associated life-threatening injuries. The authors developed a clinical pathway consisting of five primary elements: immediate trauma attending surgeon’s presence in the emergency department, early simultaneous transfusion of blood and coagulation factors, prompt diagnosis and management of associated life-threatening injuries, stabilization of the pelvic girdle, and timely insinuation of pelvic angiography and embolization. The addition of two orthopedic pelvic fracture specialists led to a revision of the pathway, emphasizing immediate emergency department presence of the orthopedic trauma attending to provide joint decision making with the trauma surgeon, closing the pelvic volume in the emergency department, and using alternatives to traditional external fixation devices. MethodsUsing trauma registry and blood bank records, the authors identified pelvic fracture patients receiving blood transfusions in the emergency department. They analyzed patients treated before versus after the May 1998 revision of the clinical pathway. ResultsA higher proportion of patients in the late period had blood pressure less than 90 mmHg (52% vs. 35%). In the late period, diagnostic peritoneal lavage was phased out in favor of torso ultrasound as a primary triage tool, and pelvic binding and C-clamp application largely replaced traditional external fixation devices. The overall death rate decreased from 31% in the early period to 15% in the later period, as did the rate of deaths from exsanguination (9% to 1%), multiple organ failure (12% to 1%), and death within 24 hours (16% to 5%). ConclusionsThe evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed by joint decision making between trauma surgeons and orthopedic traumatologists, has resulted in improved patient survival. The primary benefits appear to be in reducing early deaths from exsanguination and late deaths from multiple organ failure.

Analysis of Efficacy and Failure in Proximal Humerus Fractures Treated With Locking Plates

Objective: The purpose of this study was to determine the efficacy of proximal humerus locking plates (PHLP) and to clarify predictors of loss of fixation. Design: Retrospective review of patients with proximal humerus fractures fixed with a PHLP. Setting: Five Level 1 trauma centers. Patients: One hundred fifty-three patients (111 female, 42 male) 18 years or older with a displaced fracture or fracture-dislocation of the proximal humerus treated with a PHLP between January 1, 2001 and July 31, 2005. Intervention: Demographic data, trauma mechanism, surgical approach, and perioperative complications were collected from the medical records. Fracture classification according to the AO/OTA, radiographic head-shaft angle, and screw tip-articular surface distance in true anteroposterior (AP) and axillary lateral radiographs of the shoulder were measured postoperatively. Varus malreduction was defined as a head-shaft angle of <120 degrees. Main Outcome Measurements: Statistical analysis was done to establish correlations between loss of fixation and postoperative head-shaft angle in the true AP radiograph, patient age, fracture type, trauma mechanism, number of locking head screws, and type of plate. Results: The mean age was 62.3 ± 15.4 years (22-92) and the mean injury severity score (ISS) was 9.5 ± 10.16 (4-57; n = 73). The surgical approach was deltopectoral (90.2%) or transdeltoid (9.8%). No intraoperative complications were reported. The mean postoperative head-shaft angle was 130 degrees (95 degrees to 160 degrees; SD = 13). The overall incidence of loss of fixation was 13.7%. There was a statistically significant association between varus reduction (<120 degrees) and loss of fixation (30.4% when the head-shaft angle was <120 degrees versus 11% when the head-shaft angle was ≥120 degrees; P = 0.02). Conclusion: This series presents the experience using PHLP in 5 Level 1 trauma centers. There were no intraoperative complications related to the locking plate systems. Despite the use of fixed-angle devices, loss of fixation occurred, primarily in the presence of varus malreduction. Our findings suggest that avoiding varus should substantially decrease the risk of postoperative failures.

Mouse closed head injury model induced by a weight-drop device

Traumatic brain injury represents the leading cause of death in young individuals. Various animal models have been developed to mimic human closed head injury (CHI). Widely used models induce head injury by lateral fluid percussion, a controlled cortical impact or impact acceleration. The presented model induces a CHI by a standardized weight-drop device inducing a focal blunt injury over an intact skull without pre-injury manipulations. The resulting impact triggers a profound neuroinflammatory response within the intrathecal compartment with high consistency and reproducibility, leading to neurological impairment and breakdown of the blood–brain barrier. In this protocol, we define standardized procedures for inducing CHI in mice and determine various severity grades of CHI through modulation of the weight falling height. In experienced hands, this CHI model can be carried out in as little as 30 s per animal, with additional time required for subsequent posttraumatic analysis and data collection.

Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures

OBJECTIVE To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation. METHODS A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n=20) or early pelvic angiography (ANGIO group, n=20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded. RESULTS The PACK group underwent operative packing at a median of 45min from admission; the median time to angiography in the ANGIO group was 130min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage. CONCLUSIONS Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.

Early predictors of mortality in hemodynamically unstable pelvis fractures.

Objectives: To determine reliable, early indicators of mortality and causes of death in hemodynamically unstable patients with pelvic ring injuries. Design: This was a retrospective review of a prospective pelvic database. Methods: In all, 187 hemodynamically unstable patients with pelvic fractures (persistent systolic blood pressure <90 mm Hg after receiving 2 L of intravenous crystalloid) admitted from April 1998 to November 2004 were included. Intervention was Level 1 Trauma Center-Pelvis Fracture standardized protocol. Main outcome measurements were: Injury Severity Score (ISS), Revised Trauma Score (RTS), age, blood transfusion, mortality, and multisystem organ failure (MOF). Results: Group 1 (39 patients) did not survive their injury. Group 2 (148 patients) survived their injury. Fracture pattern (χ2 = 9.1, P = 0.33), and treatment with angiography/embolization (χ2 = 0.054, P = 0.84) were not predictive of death. Patients requiring more blood had a statistically significant higher mortality rate. The ISS (t = −5.62, P < 0.001), RTS (t = 6.10, P < 0.001), age >60 years old (χ2 = 5.4, P = 0.03), and transfusion (t = −2.70, P = 0.010) were statistically significant independent predictors of mortality. A logistic regression analysis and receiver operating characteristic curves indicated that of these variables, RTS was the most predictive independent variable. However, a model including all four variables was superior at predicting mortality. Most deaths were attributed to exsanguination (74.4%) or MOF (17.9%). Conclusions: Predictors of mortality in pelvis fracture patients should be available early in the course of treatment in order to be useful. Death within 24 hours was most often a result of acute blood loss while death after 24 hours was most often caused by MOF. Improved survival will depend upon the evolution of early hemorrhage control and resuscitative strategies in patients at high mortality risk.

Pharmacology of Traumatic Brain Injury: Where Is the "Golden Bullet"?

Traumatic brain injury (TBI) represents a major health care problem and a significant socioeconomic challenge worldwide. In the United States alone, approximately 1.5 million patients are affected each year, and the mortality of severe TBI remains as high as 35%–40%. These statistics underline the urgent need for efficient treatment modalities to improve posttraumatic morbidity and mortality. Despite advances in basic and clinical research as well as improved neurological intensive care in recent years, no specific pharmacological therapy for TBI is available that would improve the outcome of these patients. Understanding of the cellular and molecular mechanisms underlying the pathophysiological events after TBI has resulted in the identification of new potential therapeutic targets. Nevertheless, the extrapolation from basic research data to clinical application in TBI patients has invariably failed, and results from prospective clinical trials are disappointing. We review the published prospective clinical trials on pharmacological treatment modalities for TBI patients and outline future promising therapeutic avenues in the field.

Syndesmosis Fixation: A Comparison of Three and Four Cortices of Screw Fixation Without Hardware Removal:

Background: Great variability exists in methods of stabilization for syndesmotic disruptions of the ankle. We hypothesized that syndesmotic screw fixation with 3.5-mm fully threaded cortical screws through either three or four cortices would have similar strength and rate of mechanical failure and that retention of screws after fracture healing would not result in adverse clinical symptoms. Methods: In a prospective, surgeon-randomized study at a Level-one trauma center, 127 patients with syndesmotic disruptions were treated surgically. Seven patients were lost to followup, leaving 120 for review. Syndesmotic disruptions were stabilized with 3.5-mm fully threaded cortical screws placed through three or four cortices. Screws were removed only if symptomatic. Outcome criteria were screw failure, loss of reduction, and need for hardware removal. Results: Fifty-nine patients received fixation through three cortices and 61 patients received fixation through four cortices. Mean follow-up was 150 days. In the group with stabilization through three cortices, hardware failure occurred in five patients (8%) and three had a loss of reduction. In the group with stabilization through four cortices, hardware failure occurred in four patients (7%); all were asymptomatic and did not require screw removal. There was no loss of reduction in that group. Comparing the two groups using binary logistic analysis, there was no difference in loss of reduction (p = 0.871), screw breakage (p = 0.689), or need for hardware removal (p = 0.731). Conclusion: The data suggest that either three or four cortices of fixation can be used when stabilizing syndesmotic injuries of the ankle. There was a trend towards higher loss of reduction in the group with tricortical fixation when weightbearing restrictions were not followed. Retention of the syndesmotic screws, even with mechanical failure, does not pose a clinical problem. Weightbearing can be allowed at 6 to 10 weeks without routine removal of screws.

Pelvic packing or angiography: Competitive or complementary?

Pelvic angiography is an established technique that has evolved into a highly effective means of controlling arterial pelvic haemorrhage. The current dominant paradigm for haemodynamically unstable patients with pelvic fractures is angiographic management combined with mechanical stabilisation of the pelvis. However, an effective rapid screening tool for arterial bleeding in pelvic fracture patients has yet to be identified. There is also no precise way to determine the major source of bleeding responsible for haemodynamic instability. In many pelvic fracture patients, bleeding is from venous lacerations which are not effectively treated with angiography to fractured bony surfaces. Modern pelvic packing consists of time-saving and minimally invasive techniques which appear to result in effective control of the haemorrhage via tamponade. This review article focuses on the recent body of knowledge on angiography and pelvic packing. We propose the optimal role for each modality in trauma centres.

Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient.

BACKGROUND Optimal timing and treatment of patients with concomitant head, thoracic, or abdominal injury and femoral shaft fracture remain controversial. This study examines acute patient outcomes associated with early total care with intramedullary nailing (ETC group) versus damage control external fixation (DCO group) for multiple-injured patients with femoral shaft fractures. We propose DCO as a safe initial treatment for the multiple-injured patient with femur shaft fractures. METHODS This study was a retrospective review of the trauma registry and multisystem organ failure registry data at a Level I trauma center. Two cohorts were identified to compare multiple-injured patients with femoral shaft fractures treated with early total care and damage control orthopaedic surgery. Primary outcome measures included mortality, pulmonary complications (adult respiratory distress syndrome [ARDS] score), transfusion requirements, and multiple organ failure (MOF score). Operative time, estimated blood loss, intensive care unit length of stay (LOS), and hospital length of stay (LOS) were also compared. RESULTS During the study period, 462 patients with 481 femoral shaft fractures were identified. Of 462 patients with femoral shaft fractures, 97 met the inclusion criteria (42 ETC and 55 DCO). The DCO group had a significantly shorter operative time (22 minutes vs. 125 minutes) and less estimated blood loss from their operative procedure (37 mL vs. 330 mL). There was no significant difference between the groups for ARDS, lung scores, MOF, MOF score, intensive care unit LOS, or hospital LOS. CONCLUSION Fracture fixation method did not have an impact on the incidence of systemic complications in multiple-injured patients with femoral shaft fractures. Although minimal differences were noted between DCO and ETC groups regarding systemic complications, DCO is a safer initial approach, significantly decreasing the initial operative exposure and blood loss.

The effect of pelvic fracture on mortality after trauma: An analysis of 63,000 trauma patients

BACKGROUND The understanding of the mortality risk posed by pelvic fracture is incomplete. The purposes of this study were (1) to compare the mortality risk associated with a pelvic fracture with the risk conferred by other injuries and (2) to determine if the association of a pelvic fracture with mortality varies when combined with other known risk factors. METHODS Trauma registry records from two level-I trauma centers were examined. Regression analysis was done on 63,033 patients to assess the odds ratio for mortality associated with pelvic fracture compared with other variables such as age, shock, head injury, abdominal or chest injury, and extremity injury. A second analysis was carried out to determine if the impact of a pelvic fracture on mortality varied when combined with other known risk factors for mortality. RESULTS Logistic regression analysis demonstrated that pelvic fracture was significantly associated with mortality (p < 0.001). The odds ratio for mortality associated with a pelvic fracture (approximately 2) was similar to that posed by an abdominal injury. Hemodynamic shock, severe head injury, and an age of sixty years or more all had an odds ratio for mortality greater than that associated with pelvic fracture. CONCLUSIONS For the majority of trauma patients, pelvic fracture is significantly associated with a greater risk of mortality. However, pelvic fracture is one variable among many that contribute to mortality risk, and it must be considered in relation to these other variables.