A 31-year-old male patient was admitted to the emergency department with multiple injuries from violent abuse, including intraperitoneal bladder rupture, right pulmonary contusion, bilateral closed femoral shaft fractures, bilateral closed humeral shaft fractures, and bilateral closed radius and ulna shaft fractures. Right upper extremity palsy was found. At the time of admission, the patient was conscious with a 13-15 Glasgow Coma Scale score, a pulse of 85 beats/minute, a blood pressure of 75/40 mmHg with a palpable radius and dorsalis pedis pulse, and an SpO₂ of 95%.

The prioritized problem in the patient was hemorrhagic shock from polytrauma, and he was resuscitated with normal saline and blood transfusion, oxygen therapy, and extremity-splinting while being administered intravenous analgesics before appropriate surgical correction could be applied. Interdepartmental consultation was initiated, and the patient subsequently underwent emergency surgery to suture the bladder and indwell the urinary catheter.

A day later, the patient was successfully stabilized with a pulse of 98 beats/minute, a blood pressure of 140/70 mmHg, and an SpO₂ of 99%. After consultation between the orthopedics and anesthesia departments, a decision to definitively fixate 8 broken bones simultaneously under general anesthesia was made. The middle right femur was broken transversely (32A3b according to the AO classification), and the middle left femur had an intact wedge fracture (32B2b). The other broken bones of the right upper extremities were classified as 12A3b, 2R2C2j, and 2U2A2a, while those of the left upper extremities were classified as 12A3b, 2R2A3b, and 2U2A3b.

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Both femurs were approached first to prevent further blood loss and exacerbated insults to soft tissue due to large bone fragments. One locking plate and eight screws were used for right femur fixation (Figure 1 a), while one locking plate and nine screws, including one lag screw, were used for the left femur (Figure 1 b). The entire process took 2 hours and 20 minutes.

For the left humerus, surgeons used 1 locking plate plus 6 screws for fixation (Figure 1 b). Second, we treated the radius with an anterior (Henry) approach and reduced the fracture using internal fixation with 2 straight plates and locking screws (Figure 3 b). Third, as the left ulna had a diagnosis of 2U2A2a, we used a Kirchner wire for fixation based on the fracture’s pattern (Figure 3 b). On the right side, a similar approach was applied with 1 plate and 6 locking screws to fix the humerus (Figure 2 a). A straight plate and locking screws were used to fix both the right radius and ulna fracture (Figure 3 a). The surgery for the upper part was completed in 3 hours.

After surgery, the patient was hemodynamically stable and immobilized with a long leg and long arm splint. Aggressive and early rehabilitation was implemented to improve muscle strength, proprioception, and range of motion (ROM), as well as reduce pain and swelling. A continuous passive motion device was used for the evaluation of the contraction of the quadriceps muscle and knee ROM. Physical therapy was applied to maintain appropriate movements and ROM of the shoulder joints. A cervical magnetic resonance imaging examination was performed to evaluate upper extremity palsy. Before hospitalization, a right upper injury was defined as a cervical injury (Figure 4). A urinary catheter was removed from the patient 15 days postoperatively, and he was discharged from the hospital after 20 days.

A 41-year-old female was involved in a motorcycle accident in a head collision and was admitted to the emergency department with a 10 × 3 cm (length × width) wound on the right lower leg, a 1 × 1 cm wound on the right forearm, and a 2 × 1 cm wound on the dorsal side of the right hand. X-ray showed 2R2A2c, 2U2A2c, 42B3c, 4F2c, and 77.3.2 fractures according to the AO classification (Figure 5). A head computed tomography (CT) scan appeared normal. She was diagnosed with a grade IIIA open fracture of the right tibia and fibula (according to Gustilo-Anderson Classification), a grade I open fracture of the right ulna and radius, and an open fracture of the right second metacarpal. The patient was immobilized with a Zimmer splint and a long arm splint. Her wound was also sterilized with betadine and covered with gauze pads as she awaited surgery.

The patient’s open fracture indicated emergency orthopedic surgical correction. The surgery was performed 6 hours after hospitalization under general anesthesia by 3 surgeons. First, a definitive synthesis for the tibia was made with a Φ9 mm × 30 cm Mediox tibial nail and 4 locking screws. Second, the radius was treated with a 9 cm anterior (Henry) approach, and the fracture was reduced via internal fixation with an 8-hole straight plate and 6 locking screws. Third, we approached the ulna with a 6-cm-long skin incision that ran parallel to the ulnar crest and applied a 7-hole straight plate and 6 locking screws to fix the ulna fracture. Finally, the second metacarpal fracture was reduced and fixed with a 6-hole straight plate and 5 screws through a dorsal hand incision (Figure 6, Figure 7). The surgery lasted 2 hours. The patient’s postoperative care was uneventful, and she was discharged after 14 days.

A 25-year-old comatose male patient was hospitalized with several wounds and bruises of the right lower extremity and left forearm after a traffic accident. Upon admission, the patient was unconscious with a 7-15 Glasgow Coma Scale score, a pulse of 92 beats/minute, a blood pressure of 140/80 mmHg with palpable dorsalis pedis and radial pulse, and an SpO₂ of 98%. The dorsum of the right foot had a crush wound 20 × 12 cm (length × width) in size with jagged borders. The wound was contaminated with many foreign bodies, and there was necrosis of the second and third phalanges, open dislocation of the first phalanx, and open fracture of the fifth metatarsal.

The patient was first resuscitated with an 8 l/m oxygen mask with a reservoir bag and fluid and blood transfusion; moreover, immobilization with a foothold Zimmer splint and forearm-hand splint, clean gauze bandage of the right foot, and intravenous analgesics were applied before surgery. At 2 hours after admission, the patient remained comatose with a pulse of 110 beats/minute and a blood pressure of 110/70 mmHg.

His head CT scan showed no remarkable lesions. The patient was diagnosed with a concussion, crush wound of the right foot, and a closed fracture of the right middle third femur (30B3), right middle third tibia (42B), and left distal third radius (22A2) according to the AO classification (Figure 8).

Three hours after hospitalization, emergency surgery was performed for tissue debridement of the right foot, maintenance of the first and fifth phalangeal axes with a piercing "K" wire, amputation of the second and third phalanges, and insertion of a traction pin at the right femur.

Eleven days later, definitive fixation surgery was performed. First, 2 steel wires were used to fix the greater fragment to the femur shaft, and then 1 locking plate and 9 screws were used for femur fixation. Second, an incision approximately 5 cm in length was made below the kneecap; a split was made along the patellar tendon; the triangle above the tibial tuberosity was determined; the marrow was drilled at a point 1 cm above the tibial tuberosity; the fracture site was reduced, one 9 × 320 mm nail was fixed on the C-arm screen; 2 proximal screws, 2 distal screws, and 1 drain were applied; the incision was sutured; and the gauze bandage was cleaned. Finally, an incision was made on the anterior of his left forearm approximately 7 cm in line with the Henry approach. Dissection revealed that the distal third of the radius was broken, and the fracture was cleaned. The fracture was fixed with 1 locking plate and 6 screws, the fracture site was thoroughly checked, the incision was sutured, and the gauze bandage was cleaned (Figure 9). The surgery lasted 3.5 hours from the time of anesthesia until completion. After surgery, the patient was hemodynamically stable. He was discharged from the hospital after 20 days.

After surgery, the patients continued to receive broad-spectrum antibiotics and a pain-relieving combination of patient-controlled analgesia with tramadol 0.2 g/day, paracetamol IV 3 g/day, and diazepam 5 mg at night 3 days postoperatively before a switch to paracetamol alone. No postoperative complications were recorded. Early rehabilitation was initiated after surgery. First, muscle-strengthening exercises were performed in bed for the first week. Subsequently, for tibial intramedullary nail fixation, the patients could apply partial weight-bearing for the second week and begin total free weight-bearing after 4 weeks, and the splint was removed. For femoral plate fixation, the patient was allowed to perform partial weight-bearing after 8 weeks and begin total free weight-bearing after 12 weeks, and the splint was removed. The functional outcome was good at the 6-month follow-up, with patients showing a normal ROM and walking without pain or limp.