Review Question - QID 5492

The patient has multiple injuries including pelvic trauma resistant to initial resuscitative measures as evidenced by the persistently elevated lactate. External fixation of both the femur and pelvis should be employed at this time to avoid additional insult to a patient with evidence of end-organ hypoperfusion.

Early total care versus stabilization and eventual definitive fixation remains controversial. Indications to employ DCO include an injury severity score (ISS) >40 without thoracic trauma, ISS>20 with thoracic trauma, severe pelvic/abdominal injuries and hemorrhagic shock, bilateral femur fractures, pulmonary contusions, and a base deficit >2. Early definitive fixation can cause a "second hit" and increase the risk for acute respiratory distress syndrome (ARDS) and multi-organ failure.

D'Alleyrand et al. review the current evidence and practical applications of early appropriate care. They conclude that controversy continues regarding which "borderline" patients benefit from DCO and the ideal timing of fracture fixation surgery. They state that patients with closed head injuries, poor response to resuscitation, and poor ventilator parameters are good candidates for DCO.

Pape et al. review the timing of fracture fixation in polytrauma patients. They conclude that DCO, which uses external fixation as a primary tool, is most appropriate for patients in severe hemorrhagic shock or any other life-threatening condition.

Figure A demonstrates a pelvic ring injury with widening of pubic symphysis, associated anterior column acetabular fracture, and widening of the left SI joint. Figure B demonstrates a comminuted femoral shaft fracture.

Incorrect Answers:
Answers 1, 3, 4: All have definitive fixation of either the pelvis or femur that may lead to a "second hit".
Answer 5: Splinting of the femur would limit the ability to mobilize the patient. Additionally, continued motion at the fracture site may potentiate local and systemic inflammation.