Abbas Ali, Ayaz Khan, Mian Amjid Ali, Faaiz Ali.
Orthopedic Approach in patients with Multiple Injuries.
Ophthalmol Update Jan ;16(2):669-72.

Background: Polytrauma is the result of high energy trauma and presents itself as damage to multiple systems of the body. Since fractures frequently exist, the presence of femoral and pelvic fractures is alarming and presents a great challenge to trauma surgeons. There are two different schools of thought regarding the timing of definitive surgical involvement in polytrauma patients i.e. early total care and the damage controlled orthopaedics. Each approach has its merits and demerits. The clinical status of the patient determines the appropriate orthopaedic approach, which should aim at the survival of the patient. Objective: To assess the best possible orthopaedic approach in a patient with blunt multiple injuries. Patients and Methods: This is a retrospective study that include 40 patients of multiple trauma with associated fractures of femur or pelvis during the period of 2013 at KTH Peshawar. The patients` age was 20-60 years and the spectrum of injuries varied. All patients has deranged one or more vital functions. Road traffic accident is the main cause of multiple injuries in our series. Early total care (ETC) or damage control had orthopaedics policy was followed. We tried to find out the best possible orthopaedic approach by studying the incidence, of acute respiratory distress syndrome (ARDS), multiple organs dysfunction syndrome (MODS), pneumonia, pulmonary embolism, death rate as well as the length of ICU and hospital stay. Postoperatively patients received antibiotics and low molecular weight heparin (clexane 40 mg S/C). The effect of early total care/damage control orthopaedics (DCO) on surgical fixation is also studied. Bilateral femoral fractures were excluded from the study. They represent separate entity with different Results: The mean patients age is 38.61±10.28 (range 20-60 years). We followed Rape classification to group the patients on the basis of their clinical status. There are derangement of one or more vital functions along with fracture of femur or pelvis. We targeted to achieve control of bleeding, haemodynamics and ventilation. Subsequently the clinical status of the patient guided us to follow the policy of ETC or DCO. In our series ETC is carried out on 33 patients after resuscitation. 9 of them deteriorated after surgical stabilization of femur/pelvis. Early total care is effective in 27 stable patients (75%). Damage control orthopaedics is followed in 4 unstable patients (11.11%) 9 borderline cases in our study developed ARDS .after ETC (19.4%). The mean follow-up period is 10.08+1.11 (range 9-12 months). Bony union is achieved in all cases. Conclusion: The results of our series of multiple trauma patients indicate that the best orthopaedic approach cannot be predetermined definitely at the time of presentation of patient to emergency room. Early total care is indicated in a stable patient within 24-48 hours after injury. Damage control orthopaedics is adopted in unstable patients preferably between 5th10th days. Effectiveness of resuscitation plays important role.

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