Skip to main content
SpringerLink
Log in
Book cover

The Poly-Traumatized Patient with Fractures pp 43–50Cite as

Head Injuries: Neurosurgical and Orthopaedic Strategies

  • Chapter
  • First Online:

Abstract

Traumatic brain injury (TBI) represents the leading cause of death among young people in developed countries. Due to its highly complex pathophysiology, no therapeutic drugs have been identified. Although a large number of patients with skeletal injuries requiring operative fixation sustain an associated TBI, the ideal timing and modality of fracture fixation in head-injured patients remains a topic of lively debate. While several groups advocate immediate definitive fracture fixation (“early total care”), others prefer the concept of “damage control orthopaedics” consisting of initial application of an external fixation and staged conversion to definitive internal fixation. In this chapter, we outline the pathophysiology of TBI and its impact on both fracture care and its associated clinical decision making.

This is a preview of subscription content, log in via an institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   169.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. Graham DI, McIntosh TK, Maxwell WL, et al. Recent advances in neurotrauma. J Neuropathol Exp Neurol. 2000;59:641–51.

    PubMed  CAS  Google Scholar 

  2. Koponen S, Taiminen T, Portin R, et al. Axis I and II psychiatric disorders after traumatic brain injury: a 30-year follow-up study. Am J Psychiatry. 2002;159:1315–21.

    Article  PubMed  Google Scholar 

  3. Maas AI, Dearden M, Servadei F, et al. Current recommendations for neurotrauma. Curr Opin Crit Care. 2000;6:281–92.

    Article  PubMed  Google Scholar 

  4. Orliaguet GA, Meyer PG, Baugnon T. Management of the critically ill children with traumatic brain injury. Paediatr Anaesth. 2008;18(6):455–61.

    Article  PubMed  Google Scholar 

  5. Bayir H, Clark RS, Kochanek PM. Promising strategies to minimize secondary brain injury after head trauma. Crit Care Med. 2003;31:S112–7.

    Article  PubMed  CAS  Google Scholar 

  6. Masson F, Thicoipe M, Aye P, et al. Epidemiology of severe brain injuries: a prospective population-based study. J Trauma. 2001;51:481–9.

    Article  PubMed  CAS  Google Scholar 

  7. Morganti-Kossmann MC, Rancan M, Otto VI, et al. Role of cerebral inflammation after traumatic brain injury: a revisited concept. Shock. 2001;16:165–77.

    Article  PubMed  CAS  Google Scholar 

  8. Schmidt OI, Heyde CE, Ertel W, Stahel PF. Closed head injury – an inflammatory disease? Brain Res Brain Res Rev. 2005;48:388–99.

    Article  PubMed  Google Scholar 

  9. Finfer SR, Cohen J. Severe traumatic brain injury. Resusci­tation. 2001;48:77–90.

    Article  PubMed  CAS  Google Scholar 

  10. Baethmann A, Lehr D, Wirth A. Prospective analysis of patient management in severe head injury. Acta Neurochir Suppl. 1998;71:107–10.

    PubMed  CAS  Google Scholar 

  11. Ghirnikar RS, Lee YL, Eng LF. Inflammation in traumatic brain injury: role of cytokines and chemokines. Neurochem Res. 1998;23:329–40.

    Article  PubMed  CAS  Google Scholar 

  12. Morganti-Kossman MC, Rancan M, Stahel P, et al. Inflammatory responses to traumatic brain injury: an overview for the new millennium. In: Rothwell NJ, Loddick S, editors. Immune and inflammatory responses in the nervous system. 2nd ed. Oxford: Oxford University Press; 2002. pp. 106–26.

    Google Scholar 

  13. Neugebauer E, Hensler T, Rose S, et al. Severe craniocerebral trauma in multiple trauma. An assessment of the interaction of local and systemic mediator responses. Unfallchirurg. 2000;103:122–31.

    Article  PubMed  CAS  Google Scholar 

  14. Elf K, Nilsson P, Enblad P. Prevention of secondary insults in neurointensive care of traumatic brain injury. Eur J Trauma. 2003;29:74–80.

    Article  Google Scholar 

  15. Golding EM. Sequelae following traumatic brain injury. The cerebrovascular perspective. Brain Res Brain Res Rev. 2002;38:377–88.

    Article  PubMed  Google Scholar 

  16. Rosomoff HL, Kochanek PM, Clark R, et al. Resuscitation from severe brain trauma. Crit Care Med. 1996;24:S48–56.

    PubMed  CAS  Google Scholar 

  17. Stahel PF, Smith WR. Closed head injury. In: Bland KI, Büchler MW, Csendes A, et al., editors. General surgery: principles and international practice. 2nd ed. London: Springer; 2009. p. 131–42.

    Google Scholar 

  18. Jeremitsky E, Omert L, Dunham CM, et al. Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion. J Trauma. 2003;54:312–9.

    Article  PubMed  Google Scholar 

  19. Wu XH, Shi XY, Gan JX, et al. Dynamically monitoring tissue factor and tissue factor pathway inhibitor following secondary brain injury. Chin J Traumatol. 2003;6:114–7.

    PubMed  CAS  Google Scholar 

  20. Ransohoff RM. Chemokines in neurological trauma models. Ann NY Acad Sci. 2002;961:346–9.

    Article  PubMed  CAS  Google Scholar 

  21. Ransohoff RM. The chemokine system in neuroinflammation: an update. J Infect Dis. 2002;186 Suppl 2:S152–6.

    Article  PubMed  CAS  Google Scholar 

  22. Stahel PF, Morganti-Kossmann MC, Kossmann T. The role of the complement system in traumatic brain injury. Brain Res Rev. 1998;27:243–56.

    Article  PubMed  CAS  Google Scholar 

  23. Zhuang J, Shackford SR, Schmoker JD, et al. The association of leukocytes with secondary brain injury. J Trauma. 1993;35:415–22.

    Article  PubMed  CAS  Google Scholar 

  24. Schoettle RJ, Kochanek PM, Magargee MJ, et al. Early polymorphonuclear leukocyte accumulation correlates with the development of posttraumatic cerebral edema in rats. J Neurotrauma. 1990;7:207–17.

    Article  PubMed  CAS  Google Scholar 

  25. Gebhard F, Huber-Lang M. Polytrauma-pathophysiology and management principles. Langenbecks Arch Surg. 2008;393(6):825–31.

    Article  PubMed  CAS  Google Scholar 

  26. Stahel PF, Smith WR, Moore EE. Role of biological modifiers regulating the immune response after trauma. Injury. 2007;38:1409–22.

    Article  PubMed  Google Scholar 

  27. Woolf PD. Hormonal responses to trauma. Crit Care Med. 1992;20:216–26.

    Article  PubMed  CAS  Google Scholar 

  28. Tracey KJ. The inflammatory reflex. Nature. 2002;420:853–9.

    Article  PubMed  CAS  Google Scholar 

  29. Tracey KJ, Czura CJ, Ivanova S. Mind over immunity. FASEB J. 2001;15:1575–6.

    Article  PubMed  CAS  Google Scholar 

  30. Arand M, Melzner H, Kinzl L, et al. Early inflammatory mediator response following isolated traumatic brain injury and other major trauma in humans. Langenbecks Arch Surg. 2001;386:241–8.

    Article  PubMed  CAS  Google Scholar 

  31. Grotz MR, Giannoudis PV, Pape HC, et al. Traumatic brain injury and stabilisation of long bone fractures: an update. Injury. 2004;35:1077–86.

    Article  PubMed  CAS  Google Scholar 

  32. Davis DP, Serrano JA, Vilke GM, et al. The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury. J Trauma. 2006;60:985–90.

    Article  PubMed  Google Scholar 

  33. Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. J Neurotrauma. 2007;24 Suppl 1:S7–13.

    PubMed  Google Scholar 

  34. Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. VIII. Intracranial pressure thresholds. J Neurotrauma. 2007;24 Suppl 1:S55–8.

    PubMed  Google Scholar 

  35. Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitoring. J Neurotrauma. 2007;24 Suppl 1:S37–44.

    PubMed  Google Scholar 

  36. Edwards P, Arango M, Balica L, et al. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005;365:1957–9.

    Article  PubMed  Google Scholar 

  37. Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004;364:1321–8.

    Article  PubMed  Google Scholar 

  38. Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma. 2007;24 Suppl 1:S59–64.

    PubMed  Google Scholar 

  39. Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. VII. Intracranial pressure monitoring technology. J Neurotrauma. 2007;24 Suppl 1:S45–54.

    PubMed  Google Scholar 

  40. Kenning TJ, Gandhi RH, German JW. A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis. Neurosurg Focus. 2009;26:E6.

    Article  PubMed  Google Scholar 

  41. Paci GM, Sise MJ, Sise CB, et al. Preemptive craniectomy with craniotomy: what role in the management of severe traumatic brain injury? J Trauma. 2009;67:531–6.

    Article  PubMed  Google Scholar 

  42. Leker RR, Shohami E. Cerebral ischemia and trauma-different etiologies yet similar mechanisms: neuroprotective opportunities. Brain Res Rev. 2002;39:55–73.

    Article  PubMed  Google Scholar 

  43. Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009;40 Suppl 4:S27–35.

    Article  PubMed  Google Scholar 

  44. Stahel PF, Smith WR, Moore EE. Hypoxia and hypotension, the “lethal duo” in traumatic brain injury: implications for prehospital care. Intensive Care Med. 2008;34:402–4.

    Article  PubMed  Google Scholar 

  45. Stiefel MF, Udoetuk JD, Storm PB, et al. Brain tissue oxygen monitoring in pediatric patients with severe traumatic brain injury. J Neurosurg. 2006;105:281–6.

    PubMed  Google Scholar 

  46. Sagraves SG, Toschlog EA, Rotondo MF. Damage control surgery – the intensivist’s role. J Intensive Care Med. 2006;21:5–16.

    Article  PubMed  Google Scholar 

  47. Spinella PC, Priestley MA. Damage control mechanical ventilation: ventilator induced lung injury and lung protective strategies in children. J Trauma. 2007;62:S82–3.

    Article  PubMed  Google Scholar 

  48. Holcomb JB. Damage control resuscitation. J Trauma. 2007;62:S36–7.

    Article  PubMed  Google Scholar 

  49. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62:307–10.

    Article  PubMed  Google Scholar 

  50. Spahn DR, Cerny V, Coats TJ, et al. Management of bleeding following major trauma: a European guideline. Crit Care. 2007;11:R17.

    Article  PubMed  Google Scholar 

  51. Diaz-Parejo P, Stahl N, Xu W, et al. Cerebral energy metabolism during transient hyperglycemia in patients with severe brain trauma. Intensive Care Med. 2003;29:544–50.

    PubMed  Google Scholar 

  52. Garg R, Chaudhuri A, Munschauer F, et al. Hyperglycemia, insulin, and acute ischemic stroke: a mechanistic justification for a trial of insulin infusion therapy. Stroke. 2006;37:267–73.

    Article  PubMed  CAS  Google Scholar 

  53. Kinoshita K, Kraydieh S, Alonso O, et al. Effect of posttraumatic hyperglycemia on contusion volume and neutrophil accumulation after moderate fluid-percussion brain injury in rats. J Neurotrauma. 2002;19:681–92.

    Article  PubMed  Google Scholar 

  54. Holbein M, Bechir M, Ludwig S, et al. Differential influence of arterial blood glucose on cerebral metabolism following severe traumatic brain injury. Crit Care. 2009;13:R13.

    Article  PubMed  Google Scholar 

  55. Stahel PF, Ertel W, Heyde CE. Traumatic brain injury: impact on timing and modality of fracture care. Orthopade. 2005;34:852–64.

    Article  PubMed  CAS  Google Scholar 

  56. Keel M, Trentz O. Pathophysiology of polytrauma. Injury. 2005;36:691–709.

    Article  PubMed  Google Scholar 

  57. Rose S, Marzi I. Mediators in polytrauma – pathophysiological significance and clinical relevance. Langenbecks Arch Surg. 1998;383:199–208.

    Article  PubMed  CAS  Google Scholar 

  58. Bone LB, Johnson KD, Weigelt J, et al. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71:336–40.

    PubMed  CAS  Google Scholar 

  59. Bose D, Tejwani NC. Evolving trends in the care of polytrauma patients. Injury. 2006;37:20–8.

    Article  PubMed  CAS  Google Scholar 

  60. Giannoudis PV, Veysi VT, Pape HC, et al. When should we operate on major fractures in patients with severe head injuries? Am J Surg. 2002;183:261–7.

    Article  PubMed  Google Scholar 

  61. Kalb DC, Ney AL, Rodriguez JL, et al. Assessment of the relationship between timing of fixation of the fracture and secondary brain injury in patients with multiple trauma. Surgery. 1998;124:739–44; discussion 744-735.

    Article  PubMed  CAS  Google Scholar 

  62. Velmahos GC, Arroyo H, Ramicone E, et al. Timing of fracture fixation in blunt trauma patients with severe head injuries. Am J Surg. 1998;176:324–9; discussion 329–330.

    Article  PubMed  CAS  Google Scholar 

  63. Wang MC, Temkin NR, Deyo RA, et al. Timing of surgery after multisystem injury with traumatic brain injury: effect on neuropsychological and functional outcome. J Trauma. 2007;62:1250–8.

    Article  PubMed  Google Scholar 

  64. Bhandari M, Guyatt GH, Khera V, et al. Operative management of lower extremity fractures in patients with head injuries. Clin Orthop Relat Res. 2003;407:187–98.

    Article  PubMed  Google Scholar 

  65. Kotwica Z, Balcewicz L, Jagodzinski Z. Head injuries coexistent with pelvic or lower extremity fractures – early or delayed osteosynthesis. Acta Neurochir (Wien). 1990;102:19–21.

    Article  CAS  Google Scholar 

  66. Poole GV, Miller JD, Agnew SG, et al. Lower extremity fracture fixation in head-injured patients. J Trauma. 1992;32:654–9.

    Article  PubMed  CAS  Google Scholar 

  67. Reynolds MA, Richardson JD, Spain DA, et al. Is the timing of fracture fixation important for the patient with multiple trauma? Ann Surg. 1995;222:470–8; discussion 478–481.

    PubMed  CAS  Google Scholar 

  68. Hofman PA, Goris RJ. Timing of osteosynthesis of major fractures in patients with severe brain injury. J Trauma. 1991;31:261–3.

    PubMed  CAS  Google Scholar 

  69. Nau T, Aldrian S, Koenig F, et al. Fixation of femoral fractures in multiple-injury patients with combined chest and head injuries. ANZ J Surg. 2003;73:1018–21.

    Article  PubMed  Google Scholar 

  70. Brundage SI, McGhan R, Jurkovich GJ, et al. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma. 2002;52:299–307.

    Article  PubMed  Google Scholar 

  71. Seibel R, LaDuca J, Hassett JM, et al. Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state. Ann Surg. 1985;202:283–95.

    Article  PubMed  CAS  Google Scholar 

  72. Johnson KD, Cadambi A, Seibert GB. Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures. J Trauma. 1985;25:375–84.

    Article  PubMed  CAS  Google Scholar 

  73. Charash WE, Fabian TC, Croce MA. Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma. J Trauma. 1994;37:667–72.

    Article  PubMed  CAS  Google Scholar 

  74. Starr AJ. Timing fracture repair in patients with severe brain injury (Glasgow Coma Scale score <9). J Trauma. 1998;45:980.

    Article  PubMed  CAS  Google Scholar 

  75. Stahel PF, Moore EE, Schreier SL, et al. Transfusion strategies in postinjury coagulopathy. Curr Opin Anaesthesiol. 2009;22:289–98.

    Article  PubMed  Google Scholar 

  76. Lehmann U, Rickels E, Krettek C. Multiple trauma with craniocerebral trauma. Early definitive surgical management of long bone fractures? Unfallchirurg. 2001;104:196–209.

    Article  PubMed  CAS  Google Scholar 

  77. Mousavi M, Kolonja A, Schaden E, et al. Intracranial pressure-alterations during controlled intramedullary reaming of femoral fractures: an animal study. Injury. 2001;32:679–82.

    Article  PubMed  CAS  Google Scholar 

  78. Lehmann U, Reif W, Hobbensiefken G, et al. Effect of primary fracture management on craniocerebral trauma in polytrauma. An animal experiment study. Unfallchirurg. 1995;98:437–41.

    PubMed  CAS  Google Scholar 

  79. Anglen JO, Luber K, Park T. The effect of femoral nailing on cerebral perfusion pressure in head-injured patients. J Trauma. 2003;54:1166–70.

    Article  PubMed  Google Scholar 

  80. Townsend RN, Lheureau T, Protech J, et al. Timing fracture repair in patients with severe brain injury (Glasgow Coma Scale score <9). J Trauma. 1998;44:977–82; discussion 982-973.

    Article  PubMed  CAS  Google Scholar 

  81. Jaicks RR, Cohn SM, Moller BA. Early fracture fixation may be deleterious after head injury. J Trauma. 1997;42:1–5; discussion 5-6.

    Article  PubMed  CAS  Google Scholar 

  82. Forteza AM, Koch S, Romano JG, et al. Transcranial Doppler detection of fat emboli. Stroke. 1999;30:2687–91.

    PubMed  CAS  Google Scholar 

  83. Giannoudis PV, Pape HC, Cohen AP, et al. Review: systemic effects of femoral nailing: from Kuntscher to the immune reactivity era. Clin Orthop Relat Res. 2002;404:378–86.

    Article  PubMed  Google Scholar 

  84. Harwood PJ, Giannoudis PV, van Griensven M, et al. Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma. 2005;58:446–52; discussion 452-444.

    Article  PubMed  Google Scholar 

  85. Gray AC, White TO, Clutton E, et al. The stress response to bilateral femoral fractures: a comparison of primary intramedullary nailing and external fixation. J Orthop Trauma. 2009;23:90–7; discussion 98–99.

    Article  PubMed  CAS  Google Scholar 

  86. Pape HC. Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery. J Orthop Res. 2008;26:1478–84.

    Article  PubMed  Google Scholar 

  87. Pape HC, Rixen D, Morley J, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246:491–9; discussion 499–501.

    Article  PubMed  Google Scholar 

  88. Nowotarski PJ, Turen CH, Brumback RJ, et al. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82:781–8.

    Article  PubMed  CAS  Google Scholar 

  89. Scalea TM. Optimal timing of fracture fixation: have we learned anything in the past 20 years? J Trauma. 2008;65:253–60.

    Article  PubMed  Google Scholar 

  90. Rixen D, Grass G, Sauerland S, et al. Evaluation of criteria for temporary external fixation in risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients: “evidence-based medicine” versus “reality” in the trauma registry of the German Trauma Society. J Trauma. 2005;59:1375–94; discussion 1394-1375.

    Article  PubMed  Google Scholar 

  91. Flierl MA, Stoneback JW, Beauchamp KM, et al. Femur shaft fracture fixation in head-injured patients – when is the right time? J Orthop Trauma. 2010;24:107–14.

    Article  PubMed  Google Scholar 

  92. Marinkovic I, Strbian D, Pedrono E, et al. Decompressive craniectomy for intracerebral hemorrhage. Neurosurgery. 2009;65:780–86; 781 p following 786; discussion 786.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado Denver School of Medicine, 777 Bannock Street, Denver, CO, 80204, USA

    Michael A. Flierl

  2. Department of Neurosurgery, Denver Health Medical Center, University of Colorado Denver School of Medicine, 777 Bannock Street, Denver, CO, 80204, USA

    Kathryn M. Beauchamp

  3. Department of Orthopaedic Surgery and Department of Neurosurgery, Denver Health Medical Center, University of Colorado Denver School of Medicine, 777 Bannock Street, Denver, CO, 80204, USA

    Philip F. Stahel

Authors
  1. Michael A. Flierl
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kathryn M. Beauchamp
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Philip F. Stahel
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Philip F. Stahel .

Editor information

Editors and Affiliations

  1. Klinik für Unfallchirurgie, Universitätsklinikum Aachen, Pauwelsstraße 30, Aachen, 52057, Germany

    Hans-Christoph Pape

  2. Florida Orthopaedic Institute, N. Telecom Parkway 13020, Temple Terrace, 33637, Florida, USA

    Roy Sanders

  3. Southwestern Medical Center at Dallas, University of Texas, Harry Hines Blvd. 5323, Dallas, 75390, Texas, USA

    Joseph Borrelli, Jr.

Rights and permissions

Reprints and permissions

Copyright information

© 2011 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

Flierl, M.A., Beauchamp, K.M., Stahel, P.F. (2011). Head Injuries: Neurosurgical and Orthopaedic Strategies. In: Pape, HC., Sanders, R., Borrelli, Jr., J. (eds) The Poly-Traumatized Patient with Fractures. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-17986-0_6

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-17986-0_6

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-642-17985-3

  • Online ISBN: 978-3-642-17986-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation