Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries

1. Assessment, Management and Decision Making in the Treatment of Polytrauma Patients with Head Injuries Roman A. Hayda, MD Created March 2004; Revised July 2006 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): 298-307, 1998. 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): 298-307, 1998.

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, 2000From Kushwaha, JAAOS, 1998. ICL, 49, 2000

3. 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

4. Evaluation ATLS�ABC�s History loss of consciousness Physical exam Glasgow Coma Scale Radiographic studies CT Scan

5. 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 GrossmanIn Marion and Grossman

6. 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 tomographyLateralizing 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

7. 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.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.

8. 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.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 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.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 Verbal response Oriented 5 Confused 4 Inappropriate 3 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.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. 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)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)

12. Radiographic Studies 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)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)

13. 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

14. 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 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.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.

15. ICU Management Goals O2 saturation 100% Mean arterial pressure 90-110 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)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)

16. 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)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. 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: 421. 1993. 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.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: 421. 1993. 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.

18. 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: 421. 1993. 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.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: 421. 1993. 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.

19. 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 neurotraumaScale developed to roughly score outcomes of neurotrauma

20. 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): 1126-1130, 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.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): 1126-1130, 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.

21. Outcome Prediction 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): 1126-1130, 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.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): 1126-1130, 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. 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) 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.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.

23. 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 Longer term followup improves outcomesLonger term followup improves outcomes

24. 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

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

26. 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

27. 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)

28. 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.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.

29. 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

30. 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 Hofman P, Goris J. Timing of Osteosynthesis of Major Fractures in Patients with Severe Brain Injury, J Trauma, vol 31(2): 261-263. 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) 654-659, 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) 1041-1045, 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. Hofman P, Goris J. Timing of Osteosynthesis of Major Fractures in Patients with Severe Brain Injury, J Trauma, vol 31(2): 261-263. 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) 654-659, 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) 1041-1045, 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.

31. 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 Bone J, K McNamara, B Shine, J Border: �Mortality in multiple trauma patients with fractures� J Trauma, vol 37(2), 262-265, 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. Bone J, K McNamara, B Shine, J Border: �Mortality in multiple trauma patients with fractures� J Trauma, vol 37(2), 262-265, 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.

32. 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 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)739-745, 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): 839-845, 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. 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)739-745, 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): 839-845, 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.

33. 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): 470-481, 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) 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): 470-481, 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)

34. 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): 977-983, 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) 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): 977-983, 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)

35. 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

36. 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

37. 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 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.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.

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

39. 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 patientCasting, 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

40. 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 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) 217-22, 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), 1144-1149, 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: 198-202, 1980) while femur fractures may have slightly accelerated healing rates (Garland, CORR, 166: 219-225, 1982), (Perkins JBJS 69-B521-24, 1987). Meanwhile malunion rates are 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.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) 217-22, 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), 1144-1149, 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: 198-202, 1980) while femur fractures may have slightly accelerated healing rates (Garland, CORR, 166: 219-225, 1982), (Perkins JBJS 69-B521-24, 1987). Meanwhile malunion rates are 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.

41. Complications Heterotopic Ossification up to 89-100% 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. 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.

42. Heterotopic Ossification Associated with ventilator dependency Avoid periarticular procedures 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: 376-382, 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: 190-196, 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: 1208-1213, 1989).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: 376-382, 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: 190-196, 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: 1208-1213, 1989).

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

44. Contractures Treatment: Prevention 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 131:111-120, 1978.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 131:111-120, 1978.

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

46. 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 Demetraiades D, K Charalambides, S Chahwan et al: Nonskeletal cervical spine injuries: Epidemiology and Diagnostic pitfalls. J Trauma, vol 48 (4): 724-727, 2000. Retrospective review of 14,755 blunt trauma admissions. 292 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. Demetraiades D, K Charalambides, S Chahwan et al: Nonskeletal cervical spine injuries: Epidemiology and Diagnostic pitfalls. J Trauma, vol 48 (4): 724-727, 2000. Retrospective review of 14,755 blunt trauma admissions. 292 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.

47. C Spine Injury Minimum requirement Cervical collar Plain films (3 views) CT entire C spine 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: 941-957, 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.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: 941-957, 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.

48. 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: 162-165, 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: 136-144, 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): 298-307, 1998.Garland D, S Bailey Undetected injuries in head injured adults, CORR 155: 162-165, 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: 136-144, 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): 298-307, 1998.

49. 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 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. 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.

50. 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