Surgical Window and Treatment Strategy for Patient with Multiple Fractures Escaping Inflammatory Response: A Case Report

Background: Today’s Orthopedic surgeons must be adept at the evaluation and management of complicated Multiple Injured Patients (MIP). Despite dynamic strategies, advance modern medical care, the mortality rate of 50-70% has been reported due to high-velocity accidental cases with femoral shaft fractures associated with pelvic fractures and injuries to other organs. We hereby present an interesting case of MIP with the unstable pelvic acetabulum, ipsilateral femoral shaft fracture, floating elbow, and distal radius fracture. It is essential to follow an optimal protocol for such complex fractures. Therefore, we stated the appropriate surgical window and treatment intervention to fix all the major fractures by overcoming the hyperinflammatory state.


INTRODUCTION
The high-velocity accidents are associated with multiple fractures and mortality rates as high as 50%-70%. 1 By appropriately prioritizing care and optimizing fracture management, a decrease in morbidity, mortality, and hospital stays results in improved utilization of resources and reduced societal cost in association with a frequent injury of these populations. Likewise, proper timing on the Pelvis, acetabulum, femoral shaft, other upper extremities fractures, organs injuries associated with an inflammatory state of the body is very important for improved long-term functional outcomes of patients. Hence, we have proposed a case report on the strategy and management for multiple -traumatic patient.

CASE REPORT
A 30-year-old man sustained multiple injuries in a major road traffic accident and had loss of consciousness with no spontaneous movement, no purposeful movement and no verbalization. Primary resuscitation was done at a local hospital. After 6 hours of resuscitation, he got oriented with speech, nonpurposeful movement, and makes an incomprehensible sound as his GCS was 9 out of 15. Patient had no nausea, vomiting, or hematuria. He was referred to West Chain Hospital after 48 hours from the time of the accident.
On admission, this patient was in a state of compensatory hemorrhagic shock and was found to have multiple injuries. His vitals were: blood pressure 100/75mmHg, 98-105 beats per minute, respiratory rate 22-27 per minute. According to Advance Trauma Life Support (ATLS) protocol, a Primary and Secondary assessment was done. Extended Focused Assessment Sonography (EFAST) for trauma) was done to exclude any source of visceral organ hemorrhage. On examination, the left elbow, left humerus, left midshaft forearm, the right wrist was swollen and tender on palpation with restricted motion. The left hip had pain on palpation and an attempt to move. The pelvis compression test was positive. CT and X-rays of affected parts were taken. The final diagnosis was made as:

DISCUSSION
There are a paucity and disarray about the management of polytraumatic patients and its surgical innervation. 3 Polytrauma injuries consist of serious head injuries, abdominal, thoracic, elementary or multiple fractures, vascular injuries. However, existing data is often debatable and controversial when the patient sustains polytrauma. Patients require adequate resuscitation to the maintenance of hemodynamics, vitals stabilization, and intracranial pressure monitoring when suffers  long bone combined with the pelvis, head injury, and pulmonary. Therefore, polytraumatic patients need timely resuscitation, ICU care, and an optimal time window for osteosynthesis.
The early era consists of early stabilization of major skeletal injuries (Early Total Care, ETC). After the '90s, the Damage Control Orthopedics (DOC) begun which emphasized temporary stabilization of unstable fractures allowing hemodynamic stability. 4,5 The polytraumatized and hemodynamically unstable patient who is not fit for the definitive surgery might need skeletal traction, temporary external fixation, or splintage as a part of DOC. It generally stabilizes the long bone and unstable pelvis or acetabulum fractures with dislocation. Immediate definitive management of pelvis and long bone would cause a higher prevalence of "secondary hit" resulting in fat embolization, multiple organ failure, and ARDS. 6 This allows patients to recover from the systemic inflammatory reaction to trauma. While several inflammatory mediators and coagulative parameters such as interleukin-6(IL-6), IL-1, IL-8, IL-10, tumor necrosis factorα (TNF-α), IL-1β are raised. In contrast, IL-6 and IL-8 are markers that are magnitude of acute systemic inflammation and determinant of postinjury mortality. 7 These remains elevated for more than 5 days in traumatic patients with high ISS scores. 8,9 Therefore, current evidence of Damage Control Orthopedics (DOC) should be the primary focus on stabilizing the condition of unstable hemodynamic and multi-bone fracture patients. Aftermath definitive fixation procedure proceeds in a staged way manner by giving priority to the femoral fracture over pelvis or    The second staged osteosynthesis of left distal humerus fracture and ORIF for ulnar shaft was delayed for 10 days after the first elective surgery. In the review of 4134 patients undergoing surgery, Multiple Organ Failure (MOF) was avoided when the second procedure was delayed until post-injury day six. 11 Studies suggested that by day six, there would be normalization of IL-6 and abnormal laboratory values which would avoid the "Secondary Hit". 12

CONCLUSION
The principle of prioritizing resuscitation, operative timing, and strategy are essential to sustain the inflammatory state for improvement of a multi-traumatic patient for better functional recovery and to escape the systemic complications. 13 Management of multi-trauma patients requires a multi-disciplinary approach that must initially ensure stabilization of general condition and vital function . The limitation of this case lacks a wide variety of trauma and only an individualized treatment strategy. Thus, Orthopaedic surgeons should have a dynamic role in decision making regarding the best surgical window, surgical approaches, and primarily resuscitation.