Assessment, Management and Decision Making in the

Treatment of Polytrauma Patients with Head Injuries

Roman A. Hayda, MD

Epidemiologic Aspects

• 80,000 survivors of head injury annually• 40-60% of head injured patients have

extremity injury• 32,000-48,000 head injury survivors with

orthopaedic injuries annually

Overview• 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

Evaluation

• ATLS—ABC’s• History

– loss of consciousness• Physical exam

– Glasgow Coma Scale• Radiographic studies

– CT Scan

Evaluation

• Must exclude head injury by evaluation if – history of loss of consciousness– significant amnesia– confusion, combativeness*– neurologic deficits on exam of cranial nerves or

extremities

* Cannot be simply attributed to drug or alcohol use

Physical Exam

• Exam of head and cranial nerves for lateralizing signs– dilated or sluggish pupil(s)

• Extremities– unilateral weakness– posturing

• decorticate (flexor)• decerebrate (extensor)

Glasgow Coma Scale• Eye opening

– Spontaneous 4– To speech 3– To pain 2– None 1

• 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

• Verbal response– Oriented 5– Confused 4– Inappropriate 3– Incomprehensible 2– None 1

Glasgow Coma Scale

• Sum scores (3-15)– <9 considered severe– 9-11 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

Radiographic Studies

• CT scan– required in ALL cases except when LOC is brief AND that patient can be observed and 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

Frontal Contusion

Factors Influencing Prognosis• Age

– 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• Hypotension--50% increase in mortality with single episode

of hypotension• Hypoxia• Delay in treatment

– prolonged transport– surgical delay when lateralizing signs present

Treatment

• Initial– Intubation if unresponsive or combative to give

controlled ventilation– pharmacologic paralysis (after exam is

completed)– Blood pressure and O2 saturation monitoring

• keep systolic > 90 mm Hg• 100% O2 saturation

ICP Monitoring

• Indications– severe head injury (GCS < 9)

• abnormal head CT or• normal CT and at least two of the following

– age over 40– uni- or bilateral flexor or extensor posturing– history of systolic BP < 90 mm Hg

– when unable to follow serial neurologic exams– i.e. for operative or lengthy diagnostic procedures

ICU Management Goals

• Mean arterial pressure 90-110 mm Hg

• O2 saturation 100%• ICP < 20 mm Hg• Cerebral Perfusion

Pressure (CPP=MAP-ICP) >70 mm Hg

• PaCO2= 35±2 mm Hg• HCT~ 30-33%• CVP= 8-14 mm Hg• avoid dextrose IV• maintain euthermia or

mild hypothermia

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

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• Serum markers under investigation (s-

100B) has an accuracy of 83% (Woertgen, J Trauma, 1999)

Prognosis of the SeverelyHead 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

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

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

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

Early Osteosynthesis

• Hofman (J Trauma ‘91):– 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

Early Osteosynthesis

• Bone (J Trauma ‘94): – 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

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)

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

Fracture Care

• Management decisions made in conjunction with trauma/neurosurgical team

• 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

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

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

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

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 is not significantly affected

Complications

• Heterotopic Ossification– up to 89-100% incidence

periarticular injury with head injury

• Contractures• Malunion

Recurrent elbow dislocation secondary to extensor posturing and heterotopic ossification

Heterotopic Ossification• Associated with ventilator dependency• Avoid periarticular procedures• Use approaches/techniques less associated

with H.O.• Prophylaxis

– XRT– Indocin

• Excision

Contractures

• Occurs due to spasticity/posturing• Effects

– Inhibits restoration of function– Complicates nursing care– Predisposes to decubitus ulcers

Contractures

• Treatment: – Prevention

• splinting/positioning• early physical and occupational therapy

– Established• serial casting• manipulation• surgery• nerve blocks

Associated Injuries

• Normal methods of clinical and radiologic assessment may not apply in the head injured patient– C spine injury– Occult fractures and injury

C Spine Injury• Incidence increases with increasing severity of head

injury

Demetraiades (J Trauma, ’00)

• Evaluation more difficult • Optimal protocol for evaluation and management

controversial

10.2%<96.8%9-121.4%13-15

IncidenceGCS

C Spine Injury

• Minimum requirement– Cervical collar– Plain films (3 views)– CT of at least C1 and C2

• Adjuncts– CT of entire cervical spine– MRI– “Dynamic” flexion extension radiographs in the

obtunded patient

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%)

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 injury @ 72 hrs

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

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