Polytrauma management - What is new and what is true in 2020 ?

Abstract

This is a review of changes in the practice of treating polytrauma managemtent within the years prior to 2020. It focuses on five different topics, 1. The development of an evidence based definition of Polytrauma, 2. Resuscitation Associated Coagulopathy (RAC), 3. neutrophil guided initial resuscitation, 4. perioperative Scoring to evaluate patients at risk, and 5. evolution of fracture fixation strategies according to protocols^1,2 (Early total care, ETC, damage control orthopedics, DCO, early appropriate care, EAC, safe definitive surgery, SDS).

1. Introduction

The treatment options and strategies in multiply injured patients continue to become more standardized.1, 2 Mortality rates have dropped substantially in the 1990ies and even further after the change of the millennium. Within the past decade, more subtle improvements have occurred, which may have further positive impact on the care of these patients.

This manuscript aims to summarize the pertinent recent developments in the knowledge of post traumatic immunology, avoidance of resuscitation induced coagulopathy and scoring systems. In many medical advancements, a dialectic progress can occur, where a thesis is disapproved and maybe refuted or replaced by a new one, as discussed for many year in the opponents between early total care and damage control strategies.¹ More frequently, transitions occur, where preexisting knowledge is refined and new theories just add to the existing ones and a more precise separation of definitions occur with the “older” knowledge still being true and effective. For example, new parameters and techniques may become available and slowly replace older principles, as strategies evolve.²

Therefore, the current manuscript summarizes the pivotal changes over the recent years and it became evident that patient assessment, volume replacement strategies, and certain assessments have changed - along with modifications in the surgical care.³ In this line, the following review focuses on five different topics, i.e. 1. The development of an evidence based definition of Polytrauma, 2. Resuscitation Associated Coagulopathy (RAC), 3. neutrophil guided initial resuscitation, 4. perioperative Scoring to evaluate patients at risk, and 5. evolution of fracture fixation strategies according to protocols1, 2 (Early total care, ETC, damage control orthopedics, DCO, early appropriate care, EAC, safe definitive surgery, SDS).

2. Evidence based definition of polytrauma

To our knowledge, the term ‘polytrauma’ was first used by Tscherne et al., in 1966 for patients that demonstrated a combination of at least 2 ‘severe injuries of the head, chest or abdomen’, or ‘one of them in association with an extremity injury’.⁴ In 1975, Border et al. defined the polytraumatized patient “as any patient with two or more significant injuries”.⁵ Oestern et al. then distinguished the entity ‘polytrauma’ as ‘a patient with two or more injuries, one of them being ‘potentially life threatening’ from ‘isolated, but potentially life threatening injuries’, for which he coined the term ‘barytrauma’.⁶

Surprisingly, despite the availability of anatomic scoring systems in the 1970’s, the Injury Severity Score (ISS) was not used as part of any definition of ‘polytrauma’.⁷ In the only available publication, Balogh et al. proposed the AIS and described that measurement of ISS can be of value to identify polytrauma patients.⁸ Instead, the ISS is regularly utilized for the categorization of trauma centers, i.e. to distinguish certified level I trauma centers from others. The ISS aims at a more global anatomic overview, rather than describing a life threatening condition.⁹ It continues to be a global standard parameter and is used to assess multiply injured patients Also, it is a solid parameter to select patients and assess case volumes for certifications of level I versus level II trauma centers.

Later, a group of clinicians gathered in order to develop an evidence based definition of Polytrauma. These experts met in a series of scientific sessions and meetings, held under the auspices of several societies; American Association for the Surgery of Trauma (AAST), European Society for Trauma and Emergency Surgery (ESTES), German Trauma Society (DGU), British Trauma Society (BTS), New Zealand Association for the Surgery of Trauma (ANZAST).

These meetings lead to a number of quality management measures, such as a preparative literature review, multiple in person meetings, and evaluation of data using data from 28.211 polytraumatized patients. The ensuing parameters consists of five pathologic conditions and ancillary parameters to describe a multiply injured patient. These were the result of an assumption that the threshold levels should be relevant to separate different mortality rates. The resulting parameters were named the “Berlin” definition of polytrauma, the city where the key strategic expert meetings took place.¹⁰

Recently, two other groups applied the Berlin Definition. Frenzel et al. compared 11 different definitions by applying them to 375 patients from their unit. They conclude that “solely the Berlin definition resulted in a patient number reflecting clinical reality, thus enabling a transparent evaluation of treatment results provided by different institutions and allowing objective comparison of published studies.¹¹ Pothmann et al. reassessed the interobserver reliability (IR) between several polytrauma definitions to identify polytrauma by using several ISS cut-off levels (ISS 16, 18, 20, and 25 points), versus the parameters summarized in the Berlin Definition. One hundred and eighty-seven patients were included for analyzation IR of the polytrauma definitions. The authors found that the addition of physiologic variables is associated with an improvement in individual rating when compared with the ISS alone. They concluded that the Berlin Definition appears to be of value to improve trauma center benchmarking, and quality assurance.¹²

3. Resuscitation Associated Coagulopathy (RAC)

When clinicians began to describe endpoints of resuscitation, a clinical phenomenon was described that appeared to be especially relevant for patients with severe acute hemorrhage. It’s consequences have been found to be due to overtreatment and represents a perfect example for a dialectic clinical knowledge improvement:

A substantial number of patients had developed coagulopathic bleeding, although adequate vascular control and apparent hemorrhage control had been achieved.13, 14, 15 Clinically, these patients presented with acute hypothermia, accompanied by coagulopathy and acidosis. The pivotal treatment of this condition consisted of rapid crystalloid infusions. This phenomenon has been refined as Acute Traumatic Coagulopathy (ATC), is associated with significant early and long-term morbidity and mortality.¹⁶ Complicating the clinical picture, ongoing in-jury and resuscitation subjects these patients to the classical ‘‘vicious triad’’ of hypothermia, acidosis, and hemodilution, long taught to be the principal causes of coagulopathy after trauma.¹⁷ Strategies to promote normothermia, mitigate acidosis, and avoid excess crystalloid administration have dramatically improved¹⁸ outcomes after injury.

The refinement of resuscitation strategies required to develop a new term, as another phenomenon became evident, which appeared to be a direct result from overzealous resuscitation.¹⁹ This nomenclatures was selected to describe side effects caused by aggressive volume infusions, as these patients developed coagulopathies. This phenomenon was named Resuscitation Associated Coagulopathy (RAC). Of note, many severely injured patients with ATC require both, massive resuscitation and surgical intervention, which is thought to lead to the development of RAC and appears to cloud the relative importance of each factor in terms of outcomes.

Kutcher et al. have convincingly differentiated ATC from RAC and concluded that patients with coagulopathy induced by trauma have mixed risk factors. They hypothesize that coagulopathy has deleterious effects independent from injury severity, shock, and the vicious triad. In general, there has been a reduction of the amount of volume administered, named “damage control resuscitation“.²⁰ Also, in a multi-center study, a new transfusion strategy has been described that focuses on a balanced delivery of plasma-platelet-red blood cell (RBC) in a ratio of 1:1:1.²¹ It appears to result in improved survival caused by exsanguination in the first 24 h.²² These results have been confirmed by a recent data bank evaluation. With the change in the transfusion management, a reduction in complication rates was found, independent of the general management (principles of damage control and safe definitive surgery).²³ These updated principles were included in the revised criteria to describe the borderline condition for polytrauma patients, as published recently²⁴ (Table 1).

Table 1.

Revised parameters to assess the borderline trauma patient in 2020.²⁴

		Parameters
Static parameters	Injury combination	•Polytrauma ISS > 20 and AIS chest > 2 •Thoracic Trauma Score (TTS) > grade 2
	Local injury chest	•Bilateral lung contusion: 1st plain film or •Chest CT: unilateral bisegmental contusion bilateral uni- or bisegmental contusion flail chest
	Local injury trunc/extr.	Multiple long bone fractures + truncal injury AIS 2 or more
	Truncal/	Polytrauma with abdominal/pelvic trauma (RR,90 mm Hg) (Moore 3) and hem. shock
	Major Surgery for non life saving conditions	“non life saving” surgeries Flexible (day 1, 2, 3) after reassessment according to individual patient physiology: Safe definitive surgery (SDS) and damage control (DCO)
	Duration of 1st operative intervention	Presumed operation time > 6 h intraoperative reassessment: •coagulopathy (ROTEM/FIBTEM) •lactate (<2.0–2.5 mmol/l) •body temperature stable •requirement > 3 pRBC/hour
Dynamic parameters	Blood transfusion requirements	massive transfusion (10 units RBCs per 6 h) initiates „goal directed therapy” (massive transfusion protocols)
	Intra/perioperative	•ROTEM/FIBTEM •Lactate clearance < 2.5 mmol/l (24 h)

4. Neutrophil guided initial resuscitation

The trauma induced systemic inflammatory reaction, characterized by activation and shedding of neutrophils into the circulation and invasion of the tissues has been well described. Early reports used the systemic release of systemic cytokine levels in trauma patients on admission and thereafter.²⁵ Evaluation of cytokines has been suggested as an important tool for early assessment of severely injured patients. However, the variation of the results is substantial and²⁶ its value for decision making for the individual patient may be difficult. Other parameters, such as free DNA²⁷ and/or NET’s²⁸ have been suggested, however have not found clinical usage on a large scale.

With the glue grant project, it became evident that neutrophils play a major role in the development of inflammatory changes after severe trauma. When neutrophil assessments of gene expressions became available, it became an option to use gene families and test whether their suppression and the associated antigen presentation/T cell activation might be useful to predict adverse outcome.²⁹ Yet, the techniques to measure their functional status acutely has not been available in a clinical setting until recently.

In this line, Pillay and co-workers³⁰ have demonstrated that the immune status of the patient can be determined based on the epitopes that are deployed on the membrane of the neutrophils. Moreover, Hietbrink et al.³¹ demonstrated that the PMN phenotype is a readout for the innate immune response. This has been further substantiated by an international study from both the Netherlands and South Africa,³² where the immune status, as demonstrated by neutrophil phenotype predicted outcome. It was shown that first day neutrophil kinetics predicts late onset sepsis.

If flow cytometry is used to perform this measurement, its time consuming and laborious technique represents a drawback. Due to new technical developments, it is now possible to have a tabletop point of care facility for fully automated evaluation of neutrophil phenotyping.³³ In this line, promising first results have just become available in the literature. In a large prospective trauma cohort from a feasibility study.³⁴ Briefly, CD16 and CD62L are used as neutrophil markers for neutrophil differentiation. Three different neutrophil phenotypes can be differentiated CD16dim/CD62Lbright neutrophils (red box), CD16bright/CD62Lbright neutrophils (green box) and CD16bright/CD62Ldim neutrophils (blue box).

The basis of neutrophil changes are demonstrated in Fig. 1, where a healthy control FACS plot is shown. A round group of neutrophils is seen, with mainly CD62 and CD16 bright cells, indicative for a baseline situation. In the second plot (B), a plot of a poly trauma patients is depicted. The image clearly shows excitation of the immune system, demonstrated by the change in form of the plot to a distinct bean shape indicating the appearance of so-called banded (in the figure the streak to the left, red box) and hyper-segmented cells (the streak toward the bottom of the graph, blue box), just after presentation at the ER. This demonstrates te stress on the immune system, which is even further demonstrated with the appearance of progenitor cells, depicted in the left lower corner of the graph.

Fig. 1.

A Healthy control B Polytrauma patient (see text for further explanation). (from Spijkerman et al. Critical Care Explorations, 2020).

Also, examples of various states of patients are shown on admission to the emergency room, shortly after trauma (Fig. 2). A clear difference in the activity of patients with low grade injuries versus life threatening conditions can be seen. These were differentiated by minor injuries (group B), Monotrauma (ISS<16, group C), polytrauma (ISS>16, group D) and presentation in extremis (group E).

Fig. 2.

Differential of immune response with ascending injury severity just moments after presentation at the Emergency room within 1 h after the incident.

Patients with only limited trauma (B) show very little CD16dim/CD62Lbright neutrophils. Monotrauma patients (C) (ISS<16) show up to 6% CD16dim/CD62Lbright neutrophils whereas polytrauma patients (D) (ISS≥16) show up to 22% CD16dim/CD62Lbright neutrophils. In patients presenting in an extremis situation (E), mature neutrophils seem to have partially disappeared from the circulation and many progenitor cells are left. This phenotype is associated with a 100% mortality rate. (Fig. 2).

From these findings, it is promising to possible take the next step in outcome prediction by acute measurements of neutrophils. It appears that the stress on the immune system is demonstrated by the derangement of the normal appearance of the FACS plot. Thus far it was shown only for the main groups the typical appearance of the FACS plots after trauma for Mono trauma, multiple trauma and patients in extremis. From this baseline, it will have to be explored in what respect this has implications on the surgical and nonsurgical treatment. For the future, hopefully immune status of the patient can guide further treatment, be it as an add on with other clinical and laboratory data, or alone by availability of the FACS facility as a point of care instrument.

5. Perioperative Scoring to evaluate patients at risk

5.1. Value of perioperative scales and scores

Physiology-based scoring systems included the description of the ‘lethal triad’ to differentiate stable from borderline, unstable and ‘in extremis’ patients.^35,36

In the meantime, several scales have been described for perioperative patient assessment within the first 24 h after admission. The first (Clinical grading scale, CGS) is a list of four different pathophysiological cascades coagulopathy, indicators of acute hemorrhage, body temperature and soft tissue injuries that were deemed to be relevant for the clinical outcome. It was based on previous recommendations and summarized the most relevant literature published thus far.³⁷ Later, it was modified by using the same four cascades, with modified threshold levels (modified Clinical grading scale, mCGS) from a different group.³⁸ The third (Early Appropriate Care Protocol) used one cascade system (the acid base status) and applied three different parameters indicative (pH, base excess, lactate levels) and was developed in a local data base.³⁹ The fourth (Polytrauma Grading Score, PTGS) was developed on the basis of a nationwide trauma registry and used deductive parameters. These resulted in clinical and laboratory parameters on patient admission and several cascade systems. Its stratification also separates stable, borderline, unstable or in extremis patients (Fig. 3).

Fig. 3.

Comparison of different published scoring systems. The colors mark different pathophysiological pathways within the scoring systems. The size of the bar in each color marks the number of parameters that were listed for the given each scoring system (Figure from 41).

For the development of a score, usually a development group and a validation group is required, where the latter has to consist of a different patient group.⁴⁰ None of these scores and scales have been submitted to a validation process until recently. It utilized all four scales in a database that is independent from all previous ones used for their development. The results of the ROC analysis demonstrates differences between the scores in regards to the prediction of early (e.g. death from hemorrhage) versus late complications (e.g. Sepsis). For the prediction of early complications, the combination of indicators of shock, coagulation and soft tissue injuries (AUC 0.77) was superior to acid base changes alone (AUC 0.67) (Fig. 4). Late complications were predicted reliably, when a similar combination was used as described above, while acid base changes had no predictive value (Table 2). There was an association between the number of pathophysiological pathways involved (Fig. 4) (Ref. 41).

Fig. 4.

Predictive capabilities of parameters in polytrauma patients. Comparison between isolated acid base changes versus the addition of coagulopathy, hemorrhage and soft tissue injuries.

Table 2.

Prediction of complications depending on the parameters used.

Ability to predict early (within 72 h) versus late (after 72 h) complications in patients classified according to The early appropriate care protocal
		Low Risk	High Risk	Pearson χ2
		n = 2745	n = 281	p-value
Early Complication	Total Mortality	22.3%	61.2%	＜0.0001
	Death within 72 h	14.2%	56.2%	＜0.0001
	Death from TBI	17.5%	25.9%	0.0006
	Death from exsanguination	1.2%	27.0%	＜0.0001
	Infection	31.3%	27.4%	ns
	Death after 72 h	8.1%	5.3%	ns
	Pneumonia	19.9%	20.9%	ns
Late Complication	Sepsis	15.9%	17.4%	ns
	Bacteraemia	7.9%	10.2%	ns
	Septic Shock	25.6%	5.6%	ns
	Death due to MOF	1.7%	3.5%	ns

ns: not significant.

TBI: Traumatic Brain Injury.

MOF: Multiple Organ Failure.

Briefly, the PTGS score was superior to other scores in assessing both early and late complications in the clinical course, while the parameters (acid base changes) used in the early appropriate care protocol were only predictive of early (<72 h) mortality, a time frame during which the surgical care should usually be completed.

The following conclusions were drawn: “Early clinical assessment in multiply-injured patients predicts both early and late complications if the score uses multiple functional pathways (e.g., shock, acidosis, coagulopathy). Recommendations based on multiple pathways reliably predict organ failure and sepsis late after trauma. Scores that use parameters from a single pathway are less equally predictive than those described in a multi-pathway approach. Pathological acid–base changes predict early mortality, but not late complications”.⁴¹

5.2. Clinical relevance of serum lactate

The value of lactate levels has recently been summarized in detail by an international group of experts ⁴², as it has been used by multiple authors since the late 1990ies.

In the more recent literature, O’Toole described the value of a defined resuscitation protocol in 2009. He also supported the value of a defined endpoint of resuscitation and selected a lactate level of 2.5 mmol/l.⁴³ This level matches the levels used in previous recommendations from a European group.⁴⁵

In 2013, Vallier et al. proposed a lactate level of 4 mmol/l as threshold and indication for definitive fracture surgery within 72 h. In the subsequent years, improvement of initially elevated lactate levels lactate came into focus as follows:

In 2016, Dezman et al. looked at serial lactate measurements in patients with an admission lactate level of >3 mmol/l. They reassessed these patients 24 h later and found a favorable outcome when these measures came down to 2 mmol/l.⁴⁵ This study clearly documents several important aspects. Their first finding is that lactate levels are not necessarily increased in all multiply inured patients, as the degree of acute hemorrhage may be variable. The second important finding is that lactate levels can rapidly change and can reflect the dynamic changes in trauma patients. These findings justify serial sampling, if the value is increased initially, of if there is unexpected worsening of the condition.

5.3. Updated on borderline criteria

The question whether it is safe to submit a patient that would classify as borderline by definitive fixation, if they improve after resuscitation was nicely addressed by Ducan et al. recently.⁴⁶ In a consecutive series of 191 polytrauma patients with multiple fractures, they focused on those with an ISS between 16 and 25. These all presented in borderline condition, improved after resuscitation, and were submitted to definitive fracture care. A certain subset of patients later developed complications and the authors discuss, that the fracture pattern may play an additional role, namely “complex” extremity fractures. The authors defined this subgroup by the magnitude of the osseous injury and associated vascular injury (bilateral femur fracture; type 32C fracture; floating knee (combined femoral and tibial fracture); associated neck of femur fracture (bifocal fracture) or traumatic hip dislocation; concomitant femoral artery injury and/or sciatic nerve injury).

In the overall comparison of injury severities, patients with complex fractures demonstrated a higher incidence of additional injuries along with the more complex regional fracture. This was found for chest trauma (56.1 vs. 40.4%, p = 0.04), and head injuries (25.6 vs 10.1%, p = 0.005). Also, patients with more complex fractures had a higher complication rate during the further hospital course, such as ARDS (12.2% vs. 3.7%, p = 0.046); longer ICU stay (12.8 vs. 7.3 days, p = 0.019) and hospital stay (24.3 vs. 15.7 days, p < 0.001).

In this line, an updated parameter list to describe for the borderline condition has been published in 2019.²⁴ The modified parameters reflect improved diagnostics for chest injuries, those indicative of platelet dysfunction (ROTEM analysis) as well as lactate clearance within 24 h (Table 1).

6. Evolution of fracture fixation strategies (ETC/DCO/EAC/SDS)

There has been an evolution in the recommendations about fracture care in polytrauma. Both the unreflected total care strategy and the avoidance of early definitive fixation have yielded into more detailed management strategies and towards safe definitive surgery as follows:

6.1. Focus on high ISS as initial guide for fracture management

Before the description of a staged surgical concept, the early total care strategy relied on the assumption that the higher the ISS (e.g. ISS 40 and above), the better the outcome would be after early fixation of the long bone.⁴⁷ There was a specific focus on risks of nailing versus plating, or whether chest injury represents as a risk factor and gave no special notification of their ISS values.^48,49,50

Following the description of staged orthopedic management in 2000 by Scalea,⁵¹ there has been a dynamic change in the timing of fracture fixation and the ideas of authors continues to vary. However, it is interesting to note that all studies demonstrate a difference in ISS levels, i.e. the patients submitted to delayed definitive fixations have a higher ISS score. This trend is to be independent of the conclusion made by the given author (Table 3). This speaks in favor of a higher awareness of the condition of the patient, if this is associated with the ISS.

Table 3.

Adaptation of patient selection for early versus late definitive fracture fixation according to the Injury severity score before and after 2000.

Author year	Mean ISS	Mean ISS	Comment
	surgery <24 h	surgery>24 h
	ETC/EAC	DCO/SDS
Johnson, 1985	49	53	subgroup (ISS > 40)
Bone,1989	31.8	31.3	randomized
Charash, 1994	25/27	24/29	chest/no chest injury, ISS
Bosse,1997	n.a.	n.a.	compares nail vs plate
Bone,1998	n.a.	n.a.	compares nail vs plate
Carlson, 1998	n.a.	n.a.	reamed vs unreamed nailing
Scalea,2000	16,8	26,8	Intro: Damage Control Orthop.
Nowotarsky, 2000	n.a.	n.a.
Taeger 2005	30.4	37.3	ISS difference: 6.9 points
Pape,2007	23.3	29	ISS difference: 5.7 points
Morshed, 2009	27.2	32.3	ISS difference: 5.1 points
O’Toole,2009	27.4	36.2	ISS difference:8.8 points
Nahm, 2011	28.8	36.4	ISS difference:7.6 points
Steinhausen, 2014	23.5	31.1	ISS difference: 7.6 points
Dukan, 2019	n.a	n.a.	Patients with ISS 16-25

n.a. = Not available.

6.2. Evidence based summary of recommendations for DC in extremity injuries

Until recently, there has not been a systematic review about any indications of damage control. Recently, two groups of international experts performed such a review.

Cimbanassi et al. published the results of the 11th trauma update consensus conference that had gathered numerous experts in Milan, Italy. I t reveals that except for 2 randomized controlled trials, the other ones represent predominantly level II studies and level III studies. In their 2020 publication, out of 6843 citations, 124 manuscripts were considered and covered the following four topics:

• 1.Pelvic fractures,
• 2.Closed long bone fractures,
• 3.Open long bone fractures,
• 4.Mangled extremities.

Their results can be quoted as follows: On the basis of their 2 day meeting and subsequent analysis, they summarized the following conclusions: “The choice between DCO and ETC depends on the patient’s physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures, early debridement within 24 h should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non–life-threatening injuries, mostly of upper limb”.⁵² These guidelines are similar to a review published by Guerado in 2019.⁵³

6.2.1. Staged surgery concepts for polytrauma or severe isolated injuries (Musculo - Skeletal Temporary Surgery, MuST) and DCO indications for extremities, spine and pelvis

In May 2020, Pfeifer et al. published the results of another expert panel that had gathered around several consensus meetings during ESTES and other meetings for polytrauma management (Frankfurt: 3/2019, Prague: 05/2019, Zurich: 9/2019). It is different from the one by Cimbanassi, as it includes different procedures, techniques for bleeding control,. Such as REBOA, and pelvic packing and focuses on all body regions, including spinal fractures with and without neurologic deficit.

2 steps were selected: In a preparative literature review, 12 surgical interventions and 79 indications for DCO were found by a standardized literature search. In this, 6040 manuscripts were screened and 646 were selected to look at all body regions. 79 indications for DCO were then graded by a panel in a second step.

For complex isolated injuries, the expert panel agreed that the term “Damage control” is misleading in isolated severe injuries with either vascular lesions, severe bone loss or open injuries that cannot be closed initially. Therefore, the authors suggest the term “MusculoSkeletal Temporary Surgery” or “MuST Surgery” algorithm to pinpoint that these patients should be definitely stabilized during the initial surgical phase. Briefly, the following were found, as listed in Table 4:

Table 4.

Indications and interventions with agreement for “MuST Surgery” in isolated musculoskeletal injuries (Pfeifer et al. ()).

	Indications	Interventions
SPINE	Unstable thoracic and lumbar spine fractures	Percutaneous dorsal instrumentation
PELVIS	Complex pelvic ring injuries with concomitant nerve or vascular injuries	External pelvic fixation
	Open pelvic injuries	External pelvic fixation
	Stabilization of the pelvis for pelvic packing	C-clamp
	Posterior pelvic ring injuries	Percutaneous screw fixation
	Hemodynamic instability with unstable pelvic fracture	Pelvic packing
EXTREMITIES	Open fractures with soft tissue contamination	External fixation of long bones
	Open fractures with large soft tissue defects	External fixation of long bones
	Large bone defects	External fixation of long bones
	Complex intra-articular fractures	External fixation of long bones
	Fractures with concomitant vascular injuries	External fixation of long bones
SOFT TISSUES	Morell-Lavallée lesion	VAC therapy
	Soft tissue contamination	VAC therapy
	Large soft tissue defects	VAC therapy
	Compartment syndrome	Compartment fasciotomy
	Mangled extremity with uncontrollable hemorrhage	Amputation

Summary

The management of the multiply injured patient continues to be complex. Due to continuous improvements in various aspects of assessment, interdisciplinary management and surgical care, sustained changes appear to have been beneficial for the outcome in these complex patients.

Declaration of competing interest

None of the authors have any conflicts of interest to declare.