BACKGROUND The nomenclature for patients with multiple injuries with high mortality rates is highly variable, and there is a lack of a uniform definition of the term polytrauma. A consensus process was therefore initiated by a panel of international experts with the goal of assessing an improved, database-supported definition for the polytraumatized patient. METHODS The consensus process involved the following: 1. Expert panel. Multiple meetings and consensus discussions (members: European Society for Trauma and Emergency Surgery [ESTES], American Association for the Surgery of Trauma [AAST], German Trauma Society [DGU], and British Trauma Society [BTS]). 2. Literature review (original articles before June 8, 2014). 3. A priori assumptions by the expert panel. The basis for a new definition should include the Injury Severity Score (ISS) based on the Abbreviated Injury Scale (AIS); “A patient classified as polytraumatized should have a mortality rate of approximately 30%, twice above the established mortality of ISS > 15.” 4. Database-derived resources. Deductive calculation of parameters based on a nationwide trauma registry (TraumaRegister DGU) with the following inclusion criteria: multiple injuries and need for intensive care therapy. 1. Expert panel. Multiple meetings and consensus discussions (members: European Society for Trauma and Emergency Surgery [ESTES], American Association for the Surgery of Trauma [AAST], German Trauma Society [DGU], and British Trauma Society [BTS]).2. Literature review (original articles before June 8, 2014).3. A priori assumptions by the expert panel. The basis for a new definition should include the Injury Severity Score (ISS) based on the Abbreviated Injury Scale (AIS); “A patient classified as polytraumatized should have a mortality rate of approximately 30%, twice above the established mortality of ISS > 15.”4. Database-derived resources. Deductive calculation of parameters based on a nationwide trauma registry (TraumaRegister DGU) with the following inclusion criteria: multiple injuries and need for intensive care therapy. RESULTS A total of 28,211 patients in the trauma registry met the inclusion criteria. The mean (SD) age of the study cohort was 42.9 (20.2) years (72% males, 28% females). The mean (SD) ISS was 30.5 (12.2), with an overall mortality rate of 18.7% (n = 5,277) and an incidence of 3% of penetrating injuries (n = 886). Five independent physiologic variables were identified, and their individual cutoff values were calculated based on a set mortality rate of 30%: hypotension (systolic blood pressure ≤ 90 mm Hg), level of consciousness (Glasgow Coma Scale [GCS] score ≤ 8), acidosis (base excess ≤ −6.0), coagulopathy (international normalized ratio ≥ 1.4/partial thromboplastin time ≥ 40 seconds), and age (≥70 years). CONCLUSION Based on several consensus meetings and a database analysis, the expert panel proposes the following parameters for a definition of “polytrauma”: significant injuries of three or more points in two or more different anatomic AIS regions in conjunction with one or more additional variables from the five physiologic parameters. Further validation of this proposal should occur, favorably by mutivariate analyses of these parameters in a separate data set.

Bone grafting is involved in virtually every procedure in reconstructive orthopaedic surgery. Although autologous bone grafts have excellent biologic and mechanical properties, considerable donor site morbidity and the limited volume available must be taken into consideration. Currently, there are no heterologous or synthetic bone substitutes available that have superior biologic or mechanical properties. This review article summarizes the biologic and mechanical properties of autologous bone grafts, differentiates various autologous bone graft types, and compares them with other bone substitutes.

The timing of definitive fixation for major fractures in patients with multiple injuries is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an external fixateur with later conversion to an intermedullary nail and documented the postoperative clinical condition. Multiply injured patients with femoral shaft fractures were randomized to either initial (16 points, or 3 fractures and Abbreviated Injury Scale score ≥2 points and another injury (Abbreviated Injury Scale score ≥2 points), and age 18 to 65 years. Exclusion: patients in unstable or critical condition. Patients were graded as stable or borderline (increased risk of systemic complications). Incidence of acute lung injuries. Ten European Centers, 165 patients, mean age 32.7 ± 11.7 years. Group intramedullary nailing, n = 94; group external fixation, n = 71. Preoperatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity between the 2 treatment groups, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison with those who underwent external fixation, P < 0.05. Intramedullary stabilization of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared with those who underwent external fixation and later conversion to intermedullary nail. Therefore, the preoperative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries.

Overlooked injuries and delayed diagnoses are still common problems in the treatment of polytrauma patients. Therefore, ongoing documentation describing the incidence rates of missed injuries, clinically significant missed injuries, contributing factors and outcome is necessary to improve the quality of trauma care. This review summarizes the available literature on missed injuries, focusing on overlooked muscoloskeletal injuries. Manuscripts dealing with missed injuries after trauma were reviewed. The following search modules were selected in PubMed: Missed injuries, Delayed diagnoses, Trauma, Musculoskeletal injuires. Three time periods were differentiated: (n = 2, 1980-1990), (n = 6, 1990-2000), and (n = 9, 2000-Present). We found a wide spread distribution of missed injuries and delayed diagnoses incidence rates (1.3% to 39%). Approximately 15 to 22.3% of patients with missed injuries had clinically significant missed injuries. Furthermore, we observed a decrease of missed pelvic and hip injuries within the last decade. The lack of standardized studies using comparable definitions for missed injuries and clinically significant missed injuries call for further investigations, which are necessary to produce more reliable data. Furthermore, improvements in diagnostic techniques (e.g. the use of multi-slice CT) may lead to a decreased incidence of missed pelvic injuries. Finally, the standardized tertiary trauma survey is vitally important in the detection of clinically significant missed injuries and should be included in trauma care.

The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.