Bondarenko A.V., Plotnikov I.A., Guseinov R.G.

Altay State Medical University,
Regional Clinical Hospital of Emergency Medical Aid, Barnaul, Russia

The term polytrauma is determined as syndrome of multiple injuries to one or several regions of the body with development of subsequent systemic response leading to dysfunction of non-injured organs and systems or severity of injuries with ISS ≥ 17 [1]. Polytrauma (PT) is characterized by specific severity of clinical manifestations, which are accompanied by serious disorders of vital functions of the body, difficult diagnostics and complexity of choice of treatment [2-4].
Good outcomes of PT treatment depend on arrangement of care, equipment, coordinated actions of various specialists who perform assistance at all stages of treatment – prehospital, intensive care, profile clinical and rehabilitation [3].
The prehospital and intensive care stages determine the direct outcomes of PT, profile clinical and rehabilitation (long term outcomes of treatment). In other words, the aim of the initial two stages is salvation of life, and the aim of subsequent two stages – restoration of lost functions.
The priority task of arrangement of medical care is salvation of life, restoration of functions of vital organs and systems, elimination of shock and blood loss. The equally important task is treatment of locomotor injuries with restoration of functions of supporting and movement, since such injuries are noted in more than 90 % of patients with PT [5, 6].
Currently, treatment of locomotor injuries is performed with various techniques of osteosynthesis which provide the possibility for supporting and movement and create the highest quality of life and conditions of union.
Nevertheless, there are some disputable issues about choice of favorable time and adequate volume of fixation for PT, since any surgical intervention for a critically ill patient with life-threatening injuries can lead to death.
In the beginning of 2000s the damage control concept was developed. According to this concept, surgical treatment of injuries (both internal organs and locomotor system) is separated into stages. Minimal, life-saving and short term operations are conducted within the first 24 hours. Then a patient receives the intensive care until hemostasis consolidates, and only afterwards all other surgical interventions (including osteosynthesis) are conducted [7, 8].
The damage control concept with use of the modern techniques of osteosynthesis allows successful restoration of patient’s health and achievement of good functional outcomes. The rates of injuries have been constantly increasing at the present time. Sometimes one and the same person becomes a victim of injuries for several times.
In this study we would like to show our successful use of damage control and the modern techniques of osteosynthesis for treating a patient who had two occasions of severe PT. The article is accomplished with adherence to the ethical principles and the patient’s consent for analyzing the data and publishing the study.
On August 17, 2004 the patient Sh., age of 54, a civilian pilot, was transferred by the emergency team to Regional Clinical Hospital of Emergency Medical Aid. He suffered from a road traffic accident and was admitted 32 minutes after that.
The patient was examined by the traumatologist, the surgeon and the neurosurgeon in the surgery room. The laboratory, radiological and ultrasonic examination of the chest and the abdomen was conducted.
The diagnosis was made: “Severe associated injury, closed traumatic brain injury, brain concussion, blunt chest injury, lung contusion, multiple fractures of ribs on both sides complicated by bilateral hemopneumothorax, non-penetrating chest wound, opened fracture of left humeral diaphysis, closed fragmentary fracture of left femoral diaphysis, opened fracture of patella to the left”. The severity of the injuries was 34 according to ISS. The figure 1 shows the X-ray images of the patient Sh. at the moment of his admission.

Figure 1. The X-ray images of the injured segments at the moment of admission

Figure 1

Considering the severity of condition, skeletal traction from the femur, surgical preparation of the wounds and the opened fractures, and plaster immobilization of the humerus fracture were conducted. The patient was in the ICU for 24 hours. On August 20, 2004, after stabilizing hemodynamics and general condition, the internal femoral fixation with locking UFN and fixation of left patella with pins, screws and wire (according to Weber) were conducted. On August 25, 2004 the left humerus was fixed with locking UHN. The figure 2 shows the X-ray images of the patient Sh. after fixation.

Figure 2. The X-ray images of the injured segments after fixation

Figure 2

The patient was able to independently sit and stand near his bed on the 4th day after admission. On the 8th day he could move and perform self-care. The patient was discharged with satisfactory outcomes for outpatient treatment on September 11, 2004. The fracture union was achieved 4 months after osteosynthesis. The full home activity restored. In December 2005 both the nails and the metal objects were removed from the patella. The patient returned to his professional activity as civilian pilot.
Seven years later the patient suffered from a recurrent severe injury. The heavy metal gate fell on him. On April 20, 2012 the emergency team transferred him to Regional Clinical Hospital of Emergency Medical Aid (55 minutes after the injury).
The patient was examined by the traumatologist, the surgeon, the neurosurgeon and the anesthesiologist. The radiologic, ultrasonic and laboratory examinations were conducted. The diagnosis was made: “Severe associated injury, closed fractures of the ribs 4-9 to the left, opened injury to the pelvic ring, full rupture of pubic and left sacroiliac joint, rupture of urethra and bladder, extensive pelvic hematoma, a wound in pubic region, closed comminuted fracture of the left femur in the lower one-third with displacement of fragments, closed comminuted fracture of the right leg in the middle one-third with displacement of fragments, acute massive blood loss, traumatic shock of degree 3”. The severity of the injuries was 43 according to ISS. The figure 3 shows the X-ray images of the patient Sh. at the moment of admission.

Figure 3. The X-ray images of the injured segments at recurrent admission

Figure 3

The pelvic ring was stabilized with Hanz pelvic pliers. The bladder rupture was sutured and epicystostomy was applied. The injured segments of the extremities were fixed with the external fixation devices. Three days later (April 23, 2012) the anterior pelvic semiring was fixed with the external fixation devices, the posterior semiring – with ileosacral cannulated screws (7.3 mm diameter). On the 10th day (April 30, 2012) the left femur was fixed with the distal femoral plate LCP-DF 4.5/5 mm with angle stability, the right leg – with the locking UTN. The figure 4 shows the X-ray images of the patient Sh. after fixation of his pelvis and the extremities.

Figure 4. The X-ray images of the injured segments after recurrent fixation

Figure 4

Despite of thrombosis prevention, the injury was complicated by acute femoral-popliteal thrombosis, with 3 weeks of delay in vertical positioning. The pubic junction wound healed with secondary tension. The patient was discharged 1 and a half of a month after the injury. The planned plastic surgery of urethra was conducted at 6 months in the urologic hospital. One year later the control examination showed the union of the fractures and restoration of the injured segments of the locomotor system (Fig. 5).

Figure 5. The functional outcome of treatment of the patient Sh.

Figure 5

According to Mattis-Luboshyce-Schwartzberg scale, the outcome was good. The patient returned to his professional activity at the moment of 1.5 year after the injury (check pilot in a sports aviation club).
Therefore, the use of the damage control concept allowed two-time efficient arrangement of care for the patient with severe PT, and the use of the modern low invasive osteosynthesis provided the possibility for early activation and functional load to the injured segments of the locomotor system and short term restoration of professional and home activity.


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