Dr. Fathi Neana is the Chief of Orthopaedics at Dr. Fakhry & Dr. A. Al-Garzaie Hospital. The document discusses orthopaedic challenges in ancient Egypt and provides an overview of polytrauma management, including damage control orthopaedics, factors affecting mortality, and the management of multiply injured patients through initial stabilization, resuscitation, and definitive total care. It also summarizes the epidemiology and causes of trauma mortality.

1. Dr. Fathi Neana, MD
Chief of Orthopaedics
Dr. Fakhry & Dr. A. Al-Garzaie Hospital
January, 07 - 2019
Polytrauma
Part 1
Overview

3. Professor Christopher L Colton, FRCS
Chris Colton, MB, BS, LRCP, FRCS, FRCSEd (Orth), Professor emeritus,
Nottingham University,
Nottingham, UK
Orthopaedic challenges in Ancient Egypt
C. Colton
J. Bone & Joint 360 April 2013 ;2(2):2-7.
qualified in medicine and surgery in 1960, after studying at St Thomas’s Hospital Medical
School, London. He became a Fellow of the Royal College of Surgeons of England in
1963, and decided to pursue a career as an orthopaedic surgeon, studying in Bristol
and the Royal National Orthopaedic Hospital in London, Biafran civil war
He was appointed as a Consultant Orthopaedic Surgeon in Nottingham in 1973 and was
an ABC fellow in 1974. The University of Nottingham honoured him with a personal chair
in Orthopaedic and Accident He retired from surgical practice in 1997,
but has remained active as a teacher, an editor and a writer. He is also a Master Scuba
Diver (the highest qualification in recreational diving), having taken up that activity at
the age of 62.

4. Orthopaedic challenges in Ancient Egypt
C. Colton, MB, BS, LRCP, FRCS, FRCSEd(Orth), Professor emeritus
Author Affiliations 1
Nottingham University, Nottingham, UK
Correspondence should be sent to Professor C. Colton;
e-mail: colton1937@googlemail.com
Abstract
Ancient Egypt was a highly developed agrarian society with a massive civil
engineering capability. Trauma and skeletal disease were common and vestiges
of the evidence for that survive, largely in the form of hieratic images and
papyri dedicated to the practice of medicine. The earliest treatise on trauma is
the Edwin Smith papyrus, possibly the work of Imhotep. This study details
some remarkable examples of musculoskeletal pathology including fatal open
fractures, foot deformity of Tutankhamun, and the earliest recorded instances
of child abuse.
©2013 The British Editorial Society of Bone & Joint Surgery

5. • Specialty evolved after WW I
• Before 1950’s: (Unstable External fixation) >>
mal union – nonunion – stiffness
• 1950 > 1990: (Mechanical Rigid internal
fixation) >> infection – delayed union - metal
failure
• After 1990: (Biological Elastic fixation) - Surg.
Technique – implant contact (ext.fix. – int.
fixators locked plate …)
• Heritage of Orthopaedic surgery is TRAUMA
• TRAUMA is the common thread of all
Orthopaedic Subspecialties
Orthopaedic Surgery

6. DAMAGE CONTROL ORTHOPAEDICS (DCO)
• Early total care of major bone fractures in polytrauma pts was
questioned
• Are we doing good or more harm to the patient ?
Evolved in 1990’s
Research at a cellular level
Pathophysiology of multiply injured pt
Systemic inflammatory response to trauma.
(SIRS)
“Second hit” phenomenon

7. Priorities & Way of thinking changed &
became very clear
The aim is to Save lives not just fixing a
fracture in a limb
Orthopedic team become a resuscitators &
stabilizers not just a fixers
Early Skeletal fixation (DCO) is
appropriate by external fixator
As Early Total Care may be very risky in
Hemodynamic instability, Pulmonary
instability, Sever head injury
Lethal triad (Coagulopathy, Hypothermia
& Acidosis)
DAMAGE CONTROL ORTHOPAEDICS (DCO)

8. Polytrauma is a syndrome of Multiple injuries
exceeding a defined severity score ISS > = 17
With sequential Systemic Traumatic Reactions
Leading to Dysfunction (MOD) or Failure (MOF)
of Remote Systems or Organs which are not
injured
Polytrauma Patient
( The Multiply Injured Patient )

9. The incidence of Orthopedic injuries is
78%
Equal to Head injuries,
Twice the thoracic injuries,
4 times the Intra-abdominal injuries
Royal college of England B.JBJS may
1990
Polytrauma Patient
( The Multiply Injured Patient )

12. Trauma in the US
•Major modern epidemic
•Leading cause of death in < 45 age
group
• Blunt trauma accounts for 80% of
mortality in the < 34 age group
•75 billion U$D annual loss in income
due to death and disability

13. Trauma in the UK
Deaths & Injuries due to Accidental
Trauma reaches an epidemic
Polytrauma the most common cause of
death at age >35 years
14500 Deaths /year
545000 Hospital admission /year
Royal College of surgeons. England.
B.JBJS may1990

14. Trauma in the M. East ?

15. Trauma Epidemiology
• Number of polytrauma patients increasing
– Higher speed limits, aggressive driving
– Air bags-polytrauma patients surviving
– Ethnic wars and conflicts
• Some regional trauma centers lack adequate funding
• Trauma affects all Orthopedists regardless of interest
and subspecialty

16. Trauma Centers
• One per population of 5 million or less
• Studies demonstrate a 30-40% preventable death
rate due to inadequate trauma systems
– West, Trunkey: Arch Surgery, 1979
– West, Cales: Arch Surgery, 1983
– Baker, et al: J Trauma, 1987

17. Initial Assessment of
The Multiply Injured
Patient

18. Injury Severity Score (ISS)
Degree of Anatomical Injury
7 Sites ISS:
1- Head & Face
2- Neck
3- Thorax
4- Abdominal & pelvic
Viscera
5- Spine
6- Bony pelvis
7- Extremities
5 Grades
1- Minor;
2- Moderate
3- Serious
4- Severe
5- Critical
Ex.: Anatomical Sites: (3) - Grade: (Critical) (5) - ISS = 3 × (5^2 ) = 75

19. AIS Score Injury
1 Minor
2 Moderate
3 Serious
4 Severe
5 Critical
6 Unsurvivable
Is an anatomical scoring
system first introduced in 1969
Injuries are ranked on a scale
of 1 to 6
6 represents the 'threat to life'
associated with an injury and
is not meant to represent a
comprehensive measure of
severity
American association for the
surgery of trauma are mapped
to the AIS score for calculation
of the injury severity score (ISS)
Abbreviated Injury Scale (AIS)
AIS 9 sites:
1- Head
2- Face
3- Neck
4- Thorax
5- Abdomen
6- Spine
7- Upper
Extremity
8- Lower
Extremity
9- External and
other.

20. Recently, researchers have proposed a new injury severity score
(NISS)
unlike the ISS, it considers the three most severe injuries, regardless
of body region.
The NISS is computed as the simple sum of squares of the three most
severe AIS (grade 5) (1990 revision) injuries.
NISS = 3 × (5^2 ) = 75 (maximum) as grade 6 = death
To date, two studies have reported that the NISS is more predictive
of survival and performs better, statistically, than the ISS.
The New Injury Severity Score (NISS)

21. Venous plexus
Cancellous bone
Major iliac vessels
Branch of Hypogastric
artery
Sacral arteries
Pelvic Fracture
Causes of Bleeding

23. ISS 26 in survivors ------------ ISS 40 is Fatal
Average ISS 30 ……….…..... mortality 30%
Age > 70 y ………………….. mortality 40%
Age < 70 y ………….…........ mortality 80%
Age< 40 + Wound III + Unstable fracture (1 for each)
(0) Mortality 0% -- ( 1-2) M. 26% -- ( 3) M. 100%
(British JBJS,March,1991)
Pelvic Fracture
Review of 43 open pelvic fractures
Most cases treated by External Fixator

24. LD 50
Injury Severity Score (ISS) Lethal to 50% of Patients
at given Age Group
LD 50 ……. 15 - 44 years old = 40 (ISS)
LD 50 ……. 45 - 64 years old = 29 (ISS)
LD 50 …..….. < 65 years old = 20 (ISS)

25. Ontario Trauma Centre
ISS > LD50 in 53-58% 0f deaths
Edinburgh Trauma Centre
ISS > LD50 in 25-69.6% 0f deaths
Reasons:
71% of consultations done by genior staff
50% misdiagnosed or mismanaged prior of referral from other G.H.
Other Ontario Hospitals
ISS > LD50 in < 53% 0f deaths
Reasons:
No polytrauma Policy – No treating team system
Royal College of surgeons England B.JBJS may1990
LD 50
Injury Severity Score (ISS) Lethal to 50% of Patients
at given Age Group

26. Trauma Mortality

27. Trauma Mortality
causes
3 Peaks
First peak (24 hours)
Second peak (2-7 days)
Third peak – delayed ( <7 days)

28. Trauma Mortality
First peak (24 hours)
Early phase - immediate death
severe brain injury, disruption of great
vessels, cardiac disruption
Second phase – within 24 hours
subdural, epidural hematomas,
hemopneumothorax, severe
abdominal injuries, multiple extremity
injuries (bleeding)

29. Trauma Mortality
Second peak (2 - 7 Days)
Acute Respiratory Distress Syndrome
(ARDS)
40 - 50% Mortality
Arterial hypoxia O2 > 60mm Hg,
increased airway resistance,
decreased lung compliance,
pulmonary arteriovenous shunting.
Pulmonary congestion, Atelectasis, Venous-
capillary engorgement, Interstitial oedema.

30. Acute Respiratory Distress Syndrome
(ARDS) 40 - 50% Mortality
Common Causes (Multi factorial)
• Trauma
• Massive Transfusion
• Embolism
• Sepsis
• Aspiration
• Abdominal Distension
• Prolonged loss of consciousness
(LOC)
• Cardiopulmonary Bypass
• Pancreatitis
• Major Burns

31. Pathophysiology
• Systemic Inflammatory Mediators
• Damage to Endothelial Lining
• Increased Capillary Permeability
• Fluid Extravasation
• Alveolar Collapse
• Decreased Pulmonary Compliance
• Ventilation Perfusion Abnormalities
• Arteriolar Hypoxemia
Acute Respiratory Distress Syndrome
(ARDS) 40 - 50% Mortality

32. Acute Respiratory Distress Syndrome
(ARDS) - Fat Embolism
Sudden respiratory insufficiency
Fever, Tachycardia, Tachypnoea, Mental
confusion & Petechiae
Bone marrow emboli or free fatty acids
Occurs in 0.9 – 8.5 % of all fracture patients
Up to 35 % of the multiply injured
Rare in upper limb injury and children
Mortality 2.5 %

33. Prevention
Early mobilization by immediate stabilization of skeleton.
Heparin lipolytic, antiplatlet, anticoagulant.
Correction of hypoxemia A.O2 < 70 mm Hg.
Massive steroids alveolar wall inflammation.
Low molecular Dextran plasma expander,
improve microcirculation, antiplatlet adhesiveness, ,Dextran
fibrinogen complex change charges on surface of erythrocytes
Acute Respiratory Distress Syndrome
(ARDS) 40 - 50% Mortality

34. Trauma Mortality
Third peak delayed (< 7 days)
Multisystem organ failure (MOF)
Sepsis (Septic Death)
28% Mortality

35. Septic Death
Multisystem organ failure (MOF)
Constant threat in Polytrauma patient
Death 28% due to Multisystem organ failure
(MOF)
G-ve Bacilli endotoxins : G+ve Bacilli …. 2:1
E.coli, klebsiella, proteus, psuedomonas,
bactroids
Genito-urinary tract the most common site
Fever, shaking chills, jaundice, tachycardia,
cold sweaty skin, clouded sensorium,
lethargy, hypotension

36. Septic Death
Multisystem organ failure (MOF)
Endo toxins – vasoconstriction — tissue
anoxia — metabolic acidosis —
vasodilatation — stagnant anoxia —
tissue necrosis — capillary damage —
fluid loss — hypovolaemia — shock.
High index of suspicions .
Don't wait for +ve blood culture.
Antibiotics, fluid replacement,
corticosteroids.

37. Factors Affecting
Mortality

38. Factors Affecting Mortality
3 Rights
Right Patient, Right Hospital, Right Time
Delayed arrival increase Infection rate (3rd
peak of death)
Delayed or Inappropriate Surgery increase ARDS rate
(2nd
peak of Death)
Trauma centre vs. usual G. hospital
Treating Team (senior orthopedic trauma)

39. Factors Affecting Mortality
Patient transfer
Rate of Infection 194 Open
fractures (John Webb)
Helicopter ..………..… 3.55%
Ambulance + Doctor ... 9.1%
Ambulance …….….… 12.2%
Hospital to Hospital ... 22%
Death Rate
Helicopter Deaths .. 30% ISS 30
Ambulance Deaths . 30% ISS 18
60% Drop in Mortality rate by
adopting Helicopter Rescue
on 1970 in Germany

40. Factors Affecting Mortality
Early fracture stabilization
Pulmonary failure & Septic shock are
related to Immobilization (Border et al)
Supine position – Retained pulmonary
secretions – Atelectasis
Usually Intubed --- Lack of oral feeding –
Gut mucosa atrophy
Endotoxins from intestines stimulate Liver
macrophages + systemic septic response
(SIRS) – multisystem organ failure (MOF)
with high mortality rate (Septic death)

41. Factors Affecting Mortality
Early fracture stabilization
Statistically significant difference in Morbidity,
ARDS, Pulmonary complications, & Hospital
stay.
Johnson et al
ARDS, Pulmonary dysfunction, Pulmonary
embolism, & Pneumonia …. 2.2% with
early stabilization of femoral fractures
within 24 hours compared to 38% after 48
hours
Bune et al

42. Factors Affecting Mortality
Delayed or Inadequate surgery
Analysis 1200 Deaths Due to
polytrauma (Criss 1986)
60% ... At the Scene of Accident
40% …….… At the Hospital
50% …….... Head Injuries
50% ……… Other injuries
20% Are avoidable Due to :
Delayed or Inadequate surgery
Inadequate or No Surgery
Royal College of surgeons England
B.JBJS may1990
Study of 1000 Deaths Due to
polytrauma
47% CNS Insult …... (7% avoidable)
43% NON CNS (49% Inadequate or
No Surgery)

43. Factors Affecting Mortality
Trauma centre vs. usual G. hospital
Trauma centre San Diego
Improvement of trauma care
Suboptimal care ….......… 32% … 4.2%
Delay in evaluation ……... 41% ... 10%
Delay in disposition …….… 53% .. 7%
Suboptimal assessment … 22% ... 1%
Mortality rate ……………… 22% ... 8.2%

44. Management of
The Multiply Injured
Patient

45. Plan of management:
1- Damage control
2- Resuscitation
3- Definitive total care
Polytrauma Patient
( The Multiply Injured Patient )

46. Damage Control Orthopaedics
(DCO)
Goal
– Limit ongoing hemorrhage,
hypotension, and release of
inflammatory factors
– Limit stress on injured
brain
– Initial surgery < 1-2 hrs
– limit surgical trauma and
blood loss
Methods
– Initial focus on stabilization
• External fixation
• Limited debridement
• Limited or no internal fixation or
definitive care
– Delayed definitive fixation
(5-7 days)

47. Resuscitation: Role of Orthopaedics
in the Head Injured Patient
Goal
- limit ongoing hemorrhage
and hypotension
- pelvic ring injury
external fixation reduced
mortality from 43% to 7%
(Reimer, J Trauma, ‘93)
open injury--limit bleeding
- long bone fracture
controversial
Long Bone Fracture controversial
Advocates of early and delayed
treatment:
Early fixation (<24 hours) well
accepted in the polytrauma patient
In the head injured patient early
fixation may be associated with
Hypotension – elevated ICP - blood
loss – coagulopathy – hypoxia

48. Long Bone Fracture
in the Head Injured Patient
Early Osteosynthesis
. Kalb (Surgery ‘98):
– 123 patients, head AIS > 2, 84
early, 39 late fixation
– early group had increased fluid
requirement but no other
difference in mortality or
complication
– emphasized the role of
appropriate monitoring
• Scalea (J Trauma ‘99):
– 171 patients, mean GCS 9, 147
early, 24 late fixation
– early fixation no effect on length
of stay, mortality, CNS
complications
Delayed Osteosynthesis
. Reynolds (Annals of Surg ‘95):
– Mortality 2/105 patients, both early
rodding (<24 hrs)
– one due to neurologic and the other
pulmonary deterioration
• Jaicks (J Trauma ‘97):
– 33 patients with head AIS > 2; 19 early
fixation 14 late
– early group required more fluid in 48
hrs (14 vs 8.7 l); more intraoperative
hypotension (16% vs 7%); lower
discharge GCS (13.5 vs 15)
• Townsend (J Trauma ‘98):
– 61 patients with GCS < 8;
– hypotension 8 X more likely if
operated < 2 hrs and 2 X more likely
when operated within 24 hrs
– no difference noted in GOS

49. Algorithm for Fracture care
in Head injured Patient
• Severe Head injury (GCS<9) or unstable pt
DAMAGE CONTROL SURGERY
Convert to definitive at 5+ days
• Mild head injury (GCS 13-15); stable pt
Consider EARLY TOTAL CARE
• Intermediate head injury
Determined by pt stability; complexity of surgery

50. 35Y M. ISS 41

55. >65Y M. ISS 66

57. 35Y M. ISS 41
MRSA infected open fracture lt femur
With (MOD)