1. March 2004; Revised July 2006, November 2010
Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries
General references:
Grossman R, C Loftus: Principles of Neurosurgery, 2nd ed, New York: Lippincott-Raven, 1998.
Moore E, K Mattox, D Feliciano: Trauma, 2nd ed, Norwalk, CT: Appleton and Lange, 1998.
Marion D “Head Injury” in: The Trauma Manual, Peitzman A, M Rhoades, C Schwab, D Yealy eds, New York: Lippincott-Raven, 1998.
Kushwaha V, D Garland. Extremity fracture in the patient with traumatic brain injury JAAOS, 6(5): , 1998.
Roman A. Hayda, MD
Original Author
March 2004; Revised July 2006, November 2010

2. Epidemiologic Aspects
80,000 survivors of head injury annually
125,000 children <15yo head injured annually
40-60% of head injured patients have extremity injury
32,000-48,000 head injury survivors with orthopaedic injuries annually
From Kushwaha, JAAOS, 1998.
ICL, 49, 2000

3. Overview Pathophysiology Initial evaluation Prognosis
Management of Head Injury
Orthopaedic Issues
Operative vs. nonoperative treatment
Timing of surgery
methods
Fracture healing in head injury
Associated injuries
Complications

4. 2nd hit 1st hit 1st hit: Head mechanical insult to brain tissue
blunt or penetrating
2nd hit: Head
release of inflammatory mediators
Hypoxia
Acidosis
Coagulopathy
1st hit: body
mechanical insult
chest, abdomen
extremities
2nd hit: body
systemic inflammation
SURGERY
There is a complex interplay between brain injury and systemic insults. The imflammatory cytokines, chemokines, work in the central nervous system as well as systemically. There is also a breakdown of the usual blood brain barrier magnifying the ill effects of systemic injury on the brain.
Flierl et al Femur Shaft Fixation in Head –Injured Patients: when is the right time? J Orthop Trauma, 24, 2010.

5. Evaluation ATLS—ABC’s History Physical exam Radiographic studies
loss of consciousness
Physical exam
Glasgow Coma Scale
Radiographic studies
CT Scan

6. Evaluation Must exclude head injury by evaluation if
history of loss of consciousness
significant amnesia
confusion, combativeness
Cannot be simply attributed to drug or alcohol use
neurologic deficits on exam of cranial nerves or extremities
In Marion and Grossman

7. Physical Exam Exam of head and cranial nerves for lateralizing signs
dilated or sluggish pupil(s)
Extremities
unilateral weakness
posturing
decorticate (flexor)
decerebrate (extensor)
Lateralizing signs must be sought as they are indicators of a severe and potentially surgical lesion. Loss of pupil reactivity is a well known indicator of a mass lesion with which most physicians are familiar. Asymmetry of greater than 1 mm is considered significant with the dilated side usually corresponding to that of the intracranial lesion. Corneal reflexes and dolls eyes are also indicators of intracranial lesion but are best left to the treating neurosurgeon. Lateralized extremity (upper and lower) weakness may indicate an intracranial or cord lesion. Posturing classically indicates advanced cortical or cerebellar injury with a poor prognosis but can have functional recovery. None of these exam findings supplant the requirement of early computed tomography

8. Glasgow Coma Scale Eye opening: 1-4 Motor response: 1-6
Verbal response: 1-5
Developed in Glasgow by Jennett, Teasdale and others in the late 60’s and 70’s to provide a prognostic scale. Due to its simplicity, reproducibility and prognostic ability (albeit limited) has become a standard component of the initial examination in the care of the head injured patient.

9. Glasgow Coma Scale Eye opening Spontaneous 4 To speech 3 To pain 2
None 1
Developed in Glasgow by Jennett, Teasdale and others in the late 60’s and 70’s to provide a prognostic scale. Due to its simplicity, reproducibility and prognostic ability (albeit limited) has become a standard component of the initial examination in the care of the head injured patient.

10. Glasgow Coma Scale Motor response Obeys commands 6
Purposeful response to pain 5
Withdrawal to pain 4
Flexion response to pain 3
Extension response to pain 2
None 1
Developed in Glasgow by Jennett, Teasdale and others in the late 60’s and 70’s to provide a prognostic scale. Due to its simplicity, reproducibility and prognostic ability (albeit limited) has become a standard component of the initial examination in the care of the head injured patient.

11. Verbal response Glasgow Coma Scale Oriented 5 Confused 4
Inappropriate
Incomprehensible 2
None 1
Developed in Glasgow by Jennett, Teasdale and others in the late 60’s and 70’s to provide a prognostic scale. Due to its simplicity, reproducibility and prognostic ability (albeit limited) has become a standard component of the initial examination in the care of the head injured patient.

12. Glasgow Coma Scale Sum scores (3-15)
<9 considered severe
9-12 moderate
13-15 mild*
Modifiers—xT– if intubated (Best score possible 11T) xTP – if intubated and paralyzed (Best score possible is 3TP)
Done in the field but best in trauma bay following initial resuscitation
GCS < 9 is considered comatose. Until recently this group had a mortality as high as 40% and survivors demonstrated significant residual deficits. The moderate injury group is somewhat arbitrary but demonstrate persistent neurobehavioral deficits long term. The mild group particularly those with a demonstrable lesion on CT may also demonstrate persistent deficits similar to those in the moderate group while those with a normal CT did much better. (see Moore)
Intubation and paralysis render parts of the Glasgow Coma scale untestable therefore this should be appropriately annotated. The maximal score when intubated , for instance, is 11T and when intubated and paralyzed 3TP. (See Marion)

13. Radiographic Studies CT scan Plain films required in ALL cases EXCEPT:
Frontal
Contusion
CT scan
required in ALL cases EXCEPT:
LOC is brief
AND
patient can be serially examined
lesions
focal--epidural, subdural hematoma,
contusions
diffuse--diffuse axonal injury
Plain films
useful only to detect skull fracture but in the trauma setting wastes time
Epidural hematoma is usual arterial in origin (66%). Although uncommon (0.5-9% of comatose head injured patients) if recognized and treated early, the prognosis is good. Subdural hematomas are usually venous. They are more common and carry a worse prognosis (mortality as high as 60%). However, early treatment may reduce this rate. Contusions are common and carry a variable prognosis depending on multiple factors.
Diffuse lesions encompass concussions and diffuse axonal injury. Simple concussions lasting less than 6 hours typically recover well with no other intervention. Diffuse axonal injury involves a more profound coma. In the severe form posturing and subsequent long term disability is seen. Autonomic dysfunction is also observed in these cases.
(from Moore, Trauma, 1998)

14. Treatment
Initial
Intubation if unresponsive or combative to give controlled ventilation
pharmacologic paralysis
after neurologic exam is completed
Blood pressure and O2 saturation monitoring
keep systolic > 90 mm Hg
100% O2 saturation

15. ICP Monitoring Indications severe head injury (GCS < 9)
abnormal head CT or
Coma >6 hrs
Intracranial hematoma requiring evacuation
Delayed neurologic deterioration from mild to moderate (GCS>9) to severe (GCS < 8)
Requirement for prolonged ventilation
Pulmonary injury, surgery etc.
ICP monitoring is an invaluable adjunct in monitoring the head injured patient. The ability to detect pressure increases and intervene when elevated by positioning and pharmacologic methods has been credited with decreasing the sequelae of head injury. The ability to monitor is particularly useful when operative interventions or lengthy diagnostic studies are indicated since the patient cannot be examined for evidence of deterioration. Should changes occur patient management can be changed so that neurologic complications are minimized. This constitutes a relative indication for the placement of this device.

16. ICU Management Goals O2 saturation 100%
Mean arterial pressure mm Hg
ICP < 20 mm Hg
Cerebral Perfusion Pressure (CPP=MAP-ICP) >70 mm Hg
From Marion, The Trauma Manual, 1998: By maintaining these parameters until the head injury stabilizes (up to 7 days), secondary brain injury may be avoided. Chestnut et al, (J Trauma, 1993) determined that secondary injury caused by controllable factors contributes to the outcome of the initial neurologic insult. Therefore these elements should be controlled during the early period of treatment. Otherwise cerebral ischemia occurs contributing to the ultimate neurologic deficit.
The role of hyperventilation is controversial but should be avoided if at all possible especially in the first 24 hours. Hypercarbia can contribute to cerebral edema while prolonged hyperventilation may cause cerebral vasoconstriction. The respiratory alkalosis also decreases oxyhemoglobin oxygen release. Some centers set lower levels of pCO2 (25-30 mm Hg). (see Grossman, 1998 and Feliciano, 1998)

17. ICU Adjuncts HCT~ 30-33% PaCO2= 35±2 mm Hg CVP= 8-14 mm Hg
avoid dextrose IV
maintain euthermia or mild hypothermia
From Marion, The Trauma Manual, 1998: By maintaining these parameters until the head injury stabilizes (up to 7 days), secondary brain injury may be avoided. Chestnut et al, (J Trauma, 1993) determined that secondary injury caused by controllable factors contributes to the outcome of the initial neurologic insult. Therefore these elements should be controlled during the early period of treatment. Otherwise cerebral ischemia occurs contributing to the ultimate neurologic deficit.
The role of hyperventilation is controversial but should be avoided if at all possible especially in the first 24 hours. Hypercarbia can contribute to cerebral edema while prolonged hyperventilation may cause cerebral vasoconstriction. The respiratory alkalosis also decreases oxyhemoglobin oxygen release. Some centers set lower levels of pCO2 (25-30 mm Hg). (see Grossman, 1998 and Feliciano, 1998)
Glycemic control has also been associated with better outcome.

18. Factors Influencing Prognosis
Age
Younger pts have greatest potential for survival and recovery
61-75% mortality if over 65
90% mortality in elderly with ICP >20 and coma for more than 3 days
100% mortality if GCS < 5, uni- or bilateral dilated pupils, and age over 75
Early aggressive management of head injured patients is indicated to avoid these complications. Simple interventions of fluid management, oxygenation, and early diagnosis and treatment of surgical mass lesions can favorably impact on outcome. (from Marion, The Trauma Manual, 1998)
Hariri R, A Firuk, S Shepard: “Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain compliance” J Neurosurg 79: Demonstrated that hypotension has a very deleterious effect on outcome. Combined morbidity and mortality rates may be as high as 80% following a hypotensive event in a head injured patient.
Bottom line: survival and recovery not predictable except in old pts
Treat presuming recovery

19. Factors Influencing Prognosis
Hypotension--50% increase in mortality with single episode of hypotension
Hypoxia
Delay in treatment
prolonged transport
surgical delay when lateralizing signs present
Early aggressive management of head injured patients is indicated to avoid these complications. Simple interventions of fluid management, oxygenation, and early diagnosis and treatment of surgical mass lesions can favorably impact on outcome. (from Marion, The Trauma Manual, 1998)
Hariri R, A Firuk, S Shepard: “Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain compliance” J Neurosurg 79: Demonstrated that hypotension has a very deleterious effect on outcome. Combined morbidity and mortality rates may be as high as 80% following a hypotensive event in a head injured patient.
Potentially controllable!!

20. Outcome Glasgow Outcome Score: 1-dead 2-vegetative 3-cannot self care
4-deficits but able to self care
5-return to preinjury level of function
Scale developed to roughly score outcomes of neurotrauma

21. Outcome Prediction
Glasgow scale (post resuscitation) 44-66% accuracy in determining ultimate outcome
39% with an initial GCS of < 5 made functional recovery
CT based scoring (Marshall Computed Tomographic score) only 71% accurate
From Woertgen C, R Rothoerl, C Metz, A Brawanski: Comparison of clinical, radiologic, and serum markers as prognostic factors after severe head injury, J Trauma, vol 47 (6): , 1999.
Prospective study of 44 pts with a GCS <9. Glasgow Outcome score (GOS) (1--dead; 2--vegetative; 3--cannot self care; 4--deficits but able to self care; 5--return to preinjury level of function) determined at mean of 11 months post injury. 42% died, 51% favorable (GOS 4-5). Accuracy as listed in slide.
Regardless of method predictive indices alone are poor in determining ultimate outcome and are not entirely useful in decision making. When combined with other factors such as age, nonvegetative survival can be better predicted but are still imperfect except at the extremes of injury.

22. Outcome Prediction Clinical utility not defined Serum markers (S-100B)
Accuracy of 83% (Woertgen, J Trauma, 1999)
Good sensitivity in moderate to severe injury even with extracranial injury (Savola, J Trauma, 2004)
May be elevated in 29% fx pts without head injury (Unden, J Trauma, 2005)
From Woertgen C, R Rothoerl, C Metz, A Brawanski: Comparison of clinical, radiologic, and serum markers as prognostic factors after severe head injury, J Trauma, vol 47 (6): , 1999.
Prospective study of 44 pts with a GCS <9. Glasgow Outcome score (GOS) (1--dead; 2--vegetative; 3--cannot self care; 4--deficits but able to self care; 5--return to preinjury level of function) determined at mean of 11 months post injury. 42% died, 51% favorable (GOS 4-5). Accuracy as listed in slide.
Regardless of method predictive indices alone are poor in determining ultimate outcome and are not entirely useful in decision making. When combined with other factors such as age, nonvegetative survival can be better predicted but are still imperfect except at the extremes of injury.
Clinical utility not defined

23. Prognosis Significant disability @ 1 yr
Disability even in “mild” injury
Glasgow cohort: 742 pts with 71% follow-up
Rate of combined severe and moderate disability similar among groups (48%, 45% and 48%)
Age >40, previous head injury, comorbidities increased disability
(Thornhill, BMJ, 2000)
Dead or vegetative
Severe disability
Moderate disability
Good recovery
Mild (GCS 13-15) 8%
20%
28%
45%
Mod (GCS 9-12)
16%
22%
24%
38%
Severe (GCS <9)
29%
19%
14%
Severity of initial injury related to survival and good recovery but the “middle ground” at one year of mod and severe disability persisted among groups.

24. Prognosis of the Severely Head Injured Patient
Gordon (J Neurosurg Anes ’95)
1,294 pts with severe injury(GCS <9) at 10 year follow-up
55% good recovery
19% significant disability
7% vegetative
19% mortality
Sakas (J Neurosurg ‘95)
40 pts with fixed and dilated pupils
55% younger than 20 years made independent functional recovery
25% mild to moderate functional disability
43% mortality
Longer term followup improves outcomes

25. Orthopaedic Issues in the Head Injured Patient
Role in resuscitation
pelvic ring injury
open injuries
long bone fractures
Treatment methods and timing
Associated injuries
Complications

26. Initial Surgery in the Head Injured is Damage Control Surgery

27. Damage Control Orthopaedics
Goal
Limit ongoing hemorrhage, hypotension, and release of inflammatory factors
Limit stress on injured brain
Initial surgery
<1-2 hrs
limit surgical blood loss

28. Damage Control Orthopaedics
Methods
Initial focus on stabilization
External fixation
Limited debridement
Limited or no internal fixation or definitive care
Delayed definitive fixation (5-7 days)

29. Resuscitation: Role of Orthopaedics
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
In cases where pelvic ring injury was felt to be unstable and potentially contributing to hemodynamic instability, application of an external fixator in the head injured patient reduced mortality from 43 to 7% (Reimer, J Trauma, 1993). Any injury which contributes to hypotension and hypoxia will also contribute to secondary brain injury and a poorer outcome. Therefore orthopaedic procedures that can limit these play a significant role in the resuscitation and ultimate patient neurologic function.

30. Long Bone Fracture in the Head Injured Patient
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
Advocates of early and delayed treatment

31. Early Osteosynthesis Hofman (J Trauma ‘91): Poole ( J Trauma ‘92):
58 patients with a GCS < 7
lower mortality and higher GOS with operative treatment within 24 hours
Poole ( J Trauma ‘92):
114 patients with head injury
delayed fixation did not protect the injured brain
McKee (J Trauma ’97):
46 head injured with femur fractures matched with 99 patients without fracture
no difference in neurologic outcome or mortality
Hofman P, Goris J. Timing of Osteosynthesis of Major Fractures in Patients with Severe Brain Injury, J Trauma, vol 31(2):
58 pts with GCS <8. Group A (15 pts) with fractures treated surgically within 24 hrs, Group B (43 pts) without fx or with fx treated after 24 hrs. GCS and CT of head injury similar among groups, ISS higher in group A. Mortality grp A 2/15; grp B 20/43. Functional GOS (glasgow outcome scale: see notes for slide 14: Outcome prediction) Grp A 73% Grp B 47%.
Poole GV, J Miller, S Agnew, J Griswold: “Lower extremity fracture Fixation in Head injured Patients” J Trauma, vol 32(5) , 1992.
114 pts with head injuries: 46 pts with fixation < 24 hrs, 26 pts fixed > 24 hrs, 42 pts no fx fixation. GCS lower in non operative grp (8.6 vs 12). Pulmonary complications higher in late surgery grp, adverse cerebral events higher in late and nonoperative grp (23.1% and 27.3% respectively vs 6.7% in early fixation group). Therefore delayed surgery did not protect the injured brain.
McKee MD, E Schemitsch, L O’Sullivan Vincent et al: The effect of femoral fracture on concomitant closed head injury in patients with multiple injuries” J Trauma, vol 42(6) , 1997.
46 pts with mean ISS 33.2 and mean GCS 7.8 matched with 99 patients by ISS, age, sex, GCS and mechanism. Mortality, length of stay, ICU stay, neurologic disability, cognitive testing not affected by early (<24 hr) fixation.

32. Early Osteosynthesis Bone (J Trauma ‘94): Starr (J Orthop Trauma ‘98):
in 22 patients (age <50) with a GCS 4-5
13.6% (early fixation) vs 51.3% (delayed fixation) mortality rates
Starr (J Orthop Trauma ‘98):
32 pts with head injury
14 early, 14 delayed, 4 nonoperative
delayed fixation associated with 45X greater pulmonary complications but did not affect neurologic complications
Malisano (J Orthop Trauma ‘94): 108 patients with head ISS >3
Bone J, K McNamara, B Shine, J Border: “Mortality in multiple trauma patients with fractures” J Trauma, vol 37(2), , 1994.
676 pts with early fracture fixation matched to 906 pts in the American College of Surgeons Multiple Trauma Outcome Study. Subgroups of head injured patients less than and older than 50 years of age demonstrated lower mortality rate with early fixation. However numbers are small. For head injured patients the authors conclude only that early fracture fixation is at least safe (i.e. does not contribute to mortality).
Starr A, J Hunt, D Chason, C Reinert: “Treatment of femur fracture with associated head injury” J Orthop Trauma, vol 12 (1): 38-45, 1998.
32 pts with head injury, 14 (4 GCS <9) early, 14 (12 GCS < 9) delayed, 4 nonoperative delayed fixation associated with 45X greater pulmonary complication but did not affect neurologic complications.

33. Early Osteosynthesis Kalb (Surgery ‘98): Scalea (J Trauma ‘99):
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
Kalb D, A Ney, J Rodriguez, et al: “Assessment of the relationship between timing of fixation of the fracture and secondary brain injury in patients with multiple trauma” Surgery vol 124 (4) , 1998.
123 patients with head AIS > 1, 84 early (avg GCS 9.7) 39 late(avg GCS 9.9) fixation. Early group had increased fluid requirement but no other difference in hypotension, hypoxia, elevated ICP. Furthermore no difference in mortality, length of stay or neurologic complications noted. Therefore early fixation is safe with appropriate monitoring and resuscitation.
Scalea T, J Scott, R Brumback, et al: “Early fracture fixation may be just fine after head injury: No difference in central nervous system outcomes” J Trauma vol 46 (5): , 1999.
171 patients, mean GCS 9, 147 early (< 24 hrs), 24 late fixation (> 24 hrs). Early fixation no effect on blood product administration, ICU or hospital length of stay, mortality, CNS complications or outcome. Early fixation group did receive more crystalloid fluids.

34. 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)
Reynolds MA, J Richardson, D Spain, et al: “Is the timing of fracture fixation important for the patient with multiple trauma” Annals of Surgery, vol 222(4): , 1995.
424 patients with femur fracture 105 with ISS > 17. Could not show that early (<24 hr) fracture fixation reduced ICU stay or complications. Concluded that “clinical judgement” was the most important determinant of outcome and delays may be reasonable to stabilize the patient. However this study did not specifically focus on the head injured patient.
Jaicks R, S Cohn, B Moller: “Early fracture fixation may be deleterious after head injury” J Trauma, vol 42 (1): 1-6) 1997.
33 patients with AIS > 2; 19 early fixation 14 late; early group required more fluid in 48 hrs (14 vs 8.7 l); same number of neurologic complications (16% early vs 21% late) more intraoperative hypotension (16% vs 7%); lower discharge GCS (13.5 vs 15)

35. Delayed Osteosythesis
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
Townsend R, T Lheureau, J Protetch et al: “Timing fracture repair in patients with sever brain injury (Glasgow coma scale < 9) J Trauma vol 44 (6): , 1998
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 (see notes slide 14: Outcome prediction)

36. Advances in Care of Head Injured
ICP monitoring
Evolution of anesthetic agents
Improvement in neuroanesthetic techniques
Allow for safer surgery in the head injured

37. Fracture Care
Ultimate neurologic outcome continues to be difficult to predict
Presume recovery
Avoid treatments that may compromise neurologic outcome
All interventions must strive to reduce musculoskeletal complications inherent in the head injured patient
Management decisions made in conjunction with trauma/neurosurgical team

38. Algorithm for Fracture care in Head injured
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

39. Operative Fracture Care
Surgery is often optimal form of fracture treatment in the head injured polytrauma patient
Advantages
Alignment
Articular congruity
Early rehabilitation
Facilitated nursing
care
Galleazzi, ulna and olecranon fx
with compartment syndrome

40. Operative Fracture Care
Perform early surgery when appropriate
MUST minimize
hypotension
hypoxia
elevated ICP
Consider temporary methods
(external fixation)
Fixation must be adequate
Patient may be non compliant
“accelerated” healing cannot be relied upon
use
appropriate
monitors
As the previous slides have demonstrated, operative management and even early operative procedures are generally safe. However the literature advocating either early or late operation is limited by the variety of assessment methods used. These are retrospective studies with a wide range of inclusion criteria and assessment measures that do not lend themselves to comparison. Current methodologies to measure outcomes in the head injured patient are imprecise and do not lend themselves to comparisons among patients. Meanwhile it is well accepted that hypotension, hypoxia, and increased intracranial pressure have a deleterious effect on neurologic outcome. Given the current state of knowledge, injuries that mandate emergent treatment such as open fractures and irreducible dislocations should be treated surgically emergently. Femur fracture stabilization is also be beneficial within the 24 hour period in the polytraumatized patient. When early stabilization is undertaken, careful technique that minimizes blood loss and hypothermia is warranted. Invasive monitoring with arterial lines, central venous pressure monitors, AND ICP monitors in conjunction with modern anesthetic techniques can render these procedures safe in the acute period and assist in the overall management of the patient. However lengthy procedures such as articular reconstructions may be best delayed while the head injury stabilizes within days of the initial insult. In such an instance temporizing methods such as a joint spanning external fixator are useful.

41. Nonoperative Fracture Management
Treatment of choice when
nonoperative means best treat that particular fracture
operative risks outweigh potential benefits
Modalities
splint
brace
cast
traction
Caveat
device must be removed periodically to inspect underlying skin for decubiti
Casting, bracing and splinting may be the optimal form of treatment for certain injuries in the head injured patient. Those fractures that are amenable to such treatment (specifically those best treated nonoperatively regardless of the presence or absence of head injury) such as those of the distal radius, certain hand fractures, humerus fractures* as well as those of the foot and ankle can be effectively treated with these techniques. Serial casting is also an effective means of dealing with or preventing contractures in these patients. If the soft tissue condition allows it and the treatment does not adversely affect the ability to provide appropriate nursing care, casting should be used. However, the position of the limb in the cast or immobilization device and the underlying skin must be inspected periodically to assure that pressure sores have not developed since the patient lacks their normal protective responses.
There may exist certain other situations such as ongoing patient instability, sepsis or other systemic or local process which also render operative measures inappropriate. In these instances nonoperative means of casting, bracing and traction may be utilized as a temporizing or even definitive means of treatment. These as highly individualized decisions based on a multitude of factors.
*Standard indications for operative treatment of the upper extremity such as inability to maintain adequate closed reduction, need for the extremity to participate in weight bearing and facilitation of nursing care are reasonable relative indications for operative intervention in the head injured patient

42. Bone Healing in the Head Injured Patient
Humoral osteogenic factors are released by the injured brain
Exuberant callus MAY be seen
Soft tissue ossification is common
Ultimate union rate of fractures inconsistently affected
Enhanced bone healing was felt to occur since exuberant callus and heterotopic ossification has been observed in head injured patients. However, there is no proof that fracture healing is truly enhanced in the head injured patient. Humoral osteogenic factors from the injured brain have been demonstrated but not defined by Klein et al (Calcified Tissue International, 65 (3) , 1999 in a brain injury rat model). Wildburger et al (Journal of Endocrinological Investigation 21 (2):78-86, 1998) found increased prolactin levels in brain injured patients with fractures when compared to brain injury or fracture only patient groups. These patients demonstrated hypertrophic callus and heterotopic ossification at the time of increased prolactin levels (5 weeks). Bidner et al (JBJS 72-A (8), , 1990) demonstrated increased growth factor activity in osteoblast cells in patients with head injury. However, union rates have not been shown to be increased in tibia fractures (Garland, CORR, 150: , 1980) while femur fractures may have slightly accelerated healing rates (Garland, CORR, 166: , 1982), (Perkins JBJS 69-B521-24, 1987). Meanwhile malunion rates may increased due to patient compliance issues. Therefore stable fixation methods must be utilized. Suboptimal fixation methods that rely or accelerated healing are not reliable and not justified for use in the head injured patient.
The radiograph in the slide is of an open segmental tibia fracture at 8 months post injury treated with an external fixator. Initial reduction was lost and despite “exuberant” callus, union had not yet been achieved meanwhile patient was returning to a functional status.

43. Fracture Healing with Head Injury
Cadosch, JBJS-A, 2009
Case matched series of 17 pts with avg GCS 5.6, treated with IM nail
Union 2X faster; 37-50%> callus; serum induced osteoblast proliferation
Boes, JBJS-A, 2006
Experimental model of 43 rats with IM nailed femur fx +/- head injury
More fx stiffness in head injury cohort
Serum of head injured rats promoted stem cell proliferation

44. Complications Heterotopic Ossification Contractures Malunion
up to % incidence periarticular injury with head injury
Contractures
Malunion
HO can occur anywhere particularly around any joint but significantly impedes motion and function about the elbow and hip and occasionally the knee but is also seen about other joints. Garland (CORR, 168: 38-44, 1982) noted up to 100% incidence of HO about the elbow after dislocation in the head injured patient.
Contractures result from the spasticity and posturing present in the head injured patient and may be independent of heterotopic ossification.
Malunion can occur due to inadequate immobilization with poor compliance Malisano (JOT 8: 1-5, 1994) had 3 malunions in 188 operatively treated fractures attributable to patient noncompliance/inadequate fixation.
Recurrent elbow dislocation
secondary to extensor posturing
and heterotopic ossification

45. Heterotopic Ossification
Associated with ventilator dependency
Use approaches/techniques less associated with H.O.
Prophylaxis
XRT
Indocin
Excision
Heterotopic ossification is potentiated by surgical trauma in the head injured patient. Therefore surgical methods and approaches that are less prone to HO should be chosen For instance acetabular surgery should be performed through a ilioinguinal approach rather than a posterior or extensile approach when possible. (see Webb et al (JOT 4: , 1990) noted 70% complication rate (23 patients) with acetabular fracture and a GCS <10; mostly HO with rate of 61%). Others have advocated the use of intramedullary devices rather than plating for forearm fractures to reduce the rate of synostosis (noted to be as high as 33% in a series of plated forearm fractures (Garland, CORR 176: , 1983).
Prophylaxis is indicated in these high risk patients who have undergone surgery about the hip and elbow and may also be considered in nonoperatively treated elbow injuries. Single dose radiation regimens within 48 hours of surgery or indomethacin (25 mg tid for 6 wks) are both effective in reducing significant HO.
In cases where motion is blocked by HO excision can be performed when process is mature and the patient can cooperate in the post surgical therapy regimen. However, recurrence is more common than in non head injured patients (50% in the proximal forearm (Failla et al JBJS 71-A: , 1989).

46. Contractures Occurs due to spasticity/posturing Effects
Inhibits restoration of function
Complicates nursing care
Predisposes to decubitus ulcers

47. Contractures Treatment: Prevention Established splinting/positioning
early physical and occupational therapy
Established
serial casting
manipulation
surgery
nerve blocks
Prevention is the key to good outcome in patients prone to contracture. These must be kept in mind at all times in the head injured patient even in the absence of overt posturing since neural input to the extremities is altered. Serial casting and manipulation are useful in the established cases. In select instances surgical releases and nerve blocks are useful in persistent contractures particularly those that are directly contributing to functional impairment or complications (decubiti). Garland D, M Rhoades. Orthopaedic Management of Brain Injured Adults, CORR 131: , 1978.

48. Associated Injuries
Normal methods of clinical and radiologic assessment may not apply in the head injured patient
C spine injury
Occult fractures and injury

49. C spine injury Incidence
Incidence increases with increasing severity of head injury
Demetraiades, J Trauma, ’00
Evaluation more difficult
Optimal protocol for evaluation and management controversial
C spine injury Incidence
GCS
10.2%
<9
6.8%
9-12
1.4%
13-15
Demetraiades D, K Charalambides, S Chahwan et al: Nonskeletal cervical spine injuries: Epidemiology and Diagnostic pitfalls. J Trauma, vol 48 (4): , 2000.
Retrospective review of 14,755 blunt trauma admissions C spine injuries noted (2% incidence). Lateral C spine film with CT scan was reliable in the diagnosis of fracture and subluxation. Noted that isolated cord injuries would still be missed but did not describe any sequela from this protocol. Of note is the increasing incidence of c spine injury with decreasing glasgow coma score.

50. C Spine Injury Minimum requirement Adjuncts Cervical collar
CT entire C spine with reconstructions
Adjuncts
MRI
Difficult in vent patient
May over call injury
“Dynamic” flexion extension radiographs in the obtunded patient
Safety and reliability not established
Clearance of the cervical spine relies upon a combination of clinical and radiographic findings. In the absence of the ability to perform a neurologic evaluation standard protocols are no longer useful and become reliant on radiographic evaluation (plain films,dynamic films (flexion/extension), CT and MRI). However the reliability or safety of these modalities has not been established in the obtunded patient. Meanwhile continued protection of the c-spine with a collar has its own problems (airway management, occipital and other decubiti). This is an area of continuing evaluation (see Pasquale et al J Trauma vol 44: , 1998) to develop more refined guidelines. However all reasonable efforts should be made to rule out injury prior to removal of cervical collars while minimizing risks of continuing immobilization.

51. Occult Injuries
Fractures, dislocations and peripheral nerve injuries may be “missed”
Up to 11% of orthopaedic injuries may be “missed”
Peripheral nerve injuries are particularly common (as high as 34%)
Occult fractures in children with head injury are also common (37-82%)
Garland D, S Bailey Undetected injuries in head injured adults, CORR 155: , 1981.
254 pts with 11% missed diagnoses. (10 fractures/dislocations and 29 peripheral nerve injury).
Stone L, M Keenan: Peripheral nerve injury in the adult with traumatic brain injury CORR 233: , 1988.
50 patients with head injury underwent electromyography demonstrating 34% incidence of peripheral nerve lesions:
10% ulnar n, 10% brachial plexus, 8% peroneal n)
Kushwaha V, D Garland. Extremity fracture in the patient with traumatic brain injury JAAOS, 6(5): , 1998.

52. Occult Injuries
Detailed physical exam with radiographs of any suspect area due to bruising, abrasion, deformity, loss of motion
Consider EMG for unexplained neurologic deficits
Bone scan advocated in children with severe head 72 hrs
Heinrich et al JBJS-A 1994 “Undiagnosed Fractures in Severly Injured Children and Young Adults” 48 pts with severe or head injury. Initial eval and tx done, bone scan at 72 hrs: 19 fxs diagnosed not apparent on initial xrays.

53. Summary
Orthopaedic injuries are common in head injured polytrauma patients
Head injury outcome is difficult to predict
Management requires multidisciplinary approach
Operative management is safe and often improves functional outcome if secondary brain insults are avoided
Hypotension, hypoxia, increased ICP

54. References
Bayir H, Clark RS, Kochanek PM. Promising strategies to minimize secondary brain injury after head trauma. Crit Care Med. 2003;31:S112–S117.
Bandari M, Guyatt GH, Khera V, et al. Operative management of lower extremity fractures in patients with head injuries. Clin Orthop Relat Res. 2003;407:187–198.
Boes M, Kain M, Kakar S, et al. Osteogenic Effects Of Traumatic Brain Injury On Experimental Fracture-Healing. JBJS-A. 88: , 2006.
Bone J, K McNamara, B Shine, J Border: “Mortality in multiple trauma patients with fractures” J Trauma, 37, , 1994
Brohi K Healy M, Fotheringham T, et al.Helical Computed Tomographic Scanning for the Evaluation of the Cervical Spine in the Unconscious, Intubated Trauma Patient. J Trauma. 2005;58:897–901.
Cadosch D, Gautschi O, Thyer M, et al. Humoral Factors Enhance Fracture-Healing and Callus Formation in Patients with Traumatic Brain Injury. JBJS-A. 91: , 2009
Demetraiades D, K Charalambides, S Chahwan et al: Nonskeletal cervical spine injuries: Epidemiology and Diagnostic pitfalls. J Trauma, 48 (4): , 2000.
Davis DP, Serrano JA, Vilke GM, et al. The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury. J Trauma. 2006;60:985–990.
Flierl MA, Stonebak JW, Beauchamp KM, et al. Femur Saft Fixation in Head Injured Patients: When is the right time? J Orthop Trauma. 24:
Garland D, M Rhoades. Orthopaedic Management of Brain Injured Adults, CORR 131: , 1978
Grossman R, C Loftus: Principles of Neurosurgery, 2nd ed, New York: Lippincott-Raven, 1998.
Hariri R, A Firuk, S Shepard: “Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain compliance” J Neurosurg 79:
Hofman P, Goris J. Timing of Osteosynthesis of Major Fractures in Patients with Severe Brain Injury, J Trauma, vol 31(2):
Jaicks R, S Cohn, B Moller: “Early fracture fixation may be deleterious after head injury” J Trauma, vol 42 (1): 1-6) 1997
Jeremitsky E, Omert L, Dunham CM, et al. Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion. J Trauma. 2003;54:312–319.
Kalb D, A Ney, J Rodriguez, et al: “Assessment of the relationship between timing of fixation of the fracture and secondary brain injury in patients with multiple trauma” Surgery vol 124 (4) , 1998.
Kushwaha V, D Garland. Extremity fracture in the patient with traumatic brain injury JAAOS, 6(5): , 1998.
Li J, Guo Z, Han J, et al. Expression of vascular endothelial growth factor in bony callus of patients with fracture combined with head injury versus simple fracture patients and its clinical significance. J Clin Rehab Tissue Eng Res. 13: , 2009.
Marion D “Head Injury” in: The Trauma Manual, Peitzman A, M Rhoades, C Schwab, D Yealy eds, New York: Lippincott-Raven, 1998.
Masson F, Thicoipe M, Aye P, et al. Epidemiology of severe brain injuries:a prospective population-based study. J Trauma. 2001;51:481–489. 

55. Moore E, K Mattox, D Feliciano: Trauma, 2nd ed, Norwalk, CT: Appleton and Lange, Moppett IK. Traumatic Brain Injury: assess, resuscitation and early management. Br J Anaesth 99: Morshed S, Miclau T 3rd, Bembom O, et al. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am. 2009;91:3–13. Nau T, Aldrian S, Koenig F, et al. Fixation of femoral fractures in multipleinjury patients with combined chest and head injuries. ANZ J Surg. 2003; 73:1018–1021. Poole GV, J Miller, S Agnew, J Griswold: “Lower extremity fracture Fixation in Head injured Patients” J Trauma, 32(5) , Reimer BL, Butterfield S. Diamond DL, et al., Acute mortality associated with injuries to the pelvic ring: The role of early patient mobilization and external fixation, J Trauma 35 (1993), 671–677. Reynolds MA, J Richardson, D Spain, et al: “Is the timing of fracture fixation important for the patient with multiple trauma” Annals of Surgery, 222(4): , Savola O, Pyhtinen J, Leino T, Siitonen S, Niemelä O, Hillbom M. Effects of Head and Extracranial Injuries on Serum Protein S100B Levels in Trauma Patients. J Trauma, 5: , 2004 Scalea T, J Scott, R Brumback, et al: “Early fracture fixation may be just fine after head injury: No difference in central nervous system outcomes” J Trauma vol 46 (5): , Starr A, J Hunt, D Chason, C Reinert: “Treatment of femur fracture with associated head injury” J Orthop Trauma, vol 12 (1): 38-45, Thornhill S, Teasdale G, Murray GD, et al. Disability in young people and adults one year after head injury: prospective cohort study BMJ 2000; 320 : 1631 Townend W,Muller K,Waterloo K, Ingebrigtsen T, Lecky F. Validation Of Serum S-100b As A Predictive Marker For Mild Head Injury Outcome. Emerg Med Journal. 24:381, May Townsend R, T Lheureau, J Protetch et al: “Timing fracture repair in patients with sever brain injury J Trauma 44: , 1998 Undén J, Bellner J, Eneroth M, et al. Raised Serum S100B Levels after Acute Bone Fractures without Cerebral Injury J Trauma 58: Woertgen C, R Rothoerl, C Metz, A Brawanski: Comparison of clinical, radiologic, and serum markers as prognostic factors after severe head injury, J Trauma, vol 47 (6): , 1999ICL, 49, 2000

56. If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to
OTA
about
Questions/Comments
Return to
General/Principles
Index