ELSEVIER Injury, Int. J. Care Injured 30 (1999) S-B29-S-B33 Combined injuries to the lower limbs M. Liebergall, D. Segal, A. Peyser, R. Mosheiff Orthopaedic Surgery Department, The Hadassah-Hebrew University Medical School, Jerusalem Summa@ Several patterns of severe lower limb injuries are pre- sented. They all indicate high energy trauma and affect the immediate care of the patient. The improvement of evacuation systems and resuscitating methods in inten- sive care create many reconstruction challenges for the orthopaedic surgeon. Awareness of the different combi- nations which are presented can serve as a tool that may be helpful in these demanding injuries. Guidelines for management of combined injuries are essential to improve the outcome of these life-threatening situations. Keywords: multiple trauma, lower limb injuries, bilateral femoral fracture, floating joint Injury 2999, Vol. 30, Suppl. 2 Introduction Combined injuries (polytrauma) to the lower limbs are critical since they are associated with life threatening conditions as well as being a threat to the basic func- tions of the injured limb. For more than two decades, it has been clear that orthopaedic intervention, i.e. early fracture fixation, plays an important role in the treat- ment of blunt trauma, affecting both survival and cost expenditure (1,2). The orthopaedic surgeon has become an important member of the trauma team and often the most active since about 70% of the operations in blunt trauma have proven to be orthopaedic. The combination of high energy, lower limb injuries seems to have become more complex since improved trauma care has raised the chances of survival of the 1 Abstracts in German, French, Italian, Spanish, Japanese and Russian are printed at the end of this supplement. injured. These improvements are often associated with more complex treatment procedures and are the result of concepts which include optimal resuscitation, rapid transport from the scene of the accident to a trauma cen- tre which can provide the required care. At the hospi- tal, the combination of trauma teams, intensive care units, and modern resuscitation equipment have defin- itely improved patients’ chances of survival (1,3). Other reasons apart from medical improvement have also increased the challenges facing the orthopaedic sur- geon. Safety equipment like the seat belt and airbag have also changed the pattern of injuries. The safety equip- ment protects certain organs, but exposes other parts of the body to high energy injuries. Nowadays, in high energy accidents, which in the past ended in fatality, the vital organs are relatively well protected, but the lower extremities are exposed to injuries, often complex frac- tures (3). The combined injuries of the lower limb may include fractures at multiple levels within one bone (a segmen- tal fracture), or multiple fractures involving several dif- ferent skeletal units in the same limb. High energy increases the likelihood of associated injuries to vital organs as well as injuries to the soft tissue of the limb involved. Although, the treatment of associated life- threatening injuries is obviously given priority, the treat- ing surgeons must be aware of the impact of short-term problems, and the long-term disability which may result from inappropriate care of lower limb injuries (4,5). Bilateral femoral fractures A fractured shaft of the femur occurs as a result of high energy force. This becomes especially important when one considers the impact of trauma on other organs as 0020-1383/99/$ - see front matter 0 1999 Published by Elsevier Science Ltd. All rights reserved. PII: SO020 - 1383(99)00180-I