Changes in the Management of Femoral Shaft Fractures in Polytrauma Patients: From Early Total Care to Damage Control Orthopedic Surgery
- 1 September 2002
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Journal Of Trauma-Injury Infection and Critical Care
- Vol. 53 (3), 452-462
- https://doi.org/10.1097/00005373-200209000-00010
Abstract
Background The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of polytrauma patients treated at a Level I trauma center within the last two decades regarding the effect of changes in the management of their femoral shaft fracture. Methods In a retrospective cohort study performed at a Level I trauma center, the patient’s injuries and clinical outcomes were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the femur fracture (I° intramedullary nailing [I°IMN]; I° external fixation [I°EF]; I° plate osteosynthesis [I°plate]) followed during a certain time period: (1) early total care (ETC) (January 1, 1981–December 31, 1989) and early (< 24 hours) definitive stabilization; (2) intermediate (INT) (January 1, 1990–December 31, 1992) change in the protocol; or (3) damage control orthopedic surgery (DCO) (January 1, 1993–December 31, 2000), early (< 24 hours) temporary stabilization, and secondary conversion to intramedullary nailing in patients at risk of organ failure. Results The patient groups were comparable regarding age, gender distribution, and the mechanism of injury. Primary external fixation was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups compared with the ETC group (16.6%) (p = 0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I°EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I°IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdominal injuries accounted for significantly higher numbers of patients submitted to I°EF in the INT (13.6%, p = 0.03) and DCO (17.3%, p = 0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of multiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I°IMN (15.1%) and I°EF (9.1%) in the DCO subgroup were compared. Conclusion A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an increased awareness toward thoracic and abdominal injuries may have played a role. Even during the DCO era, IMN was associated with a higher rate of ARDS than I°EF. In view of a lower complication rate despite higher injury severity compared with the ETC period, the introduction of DCO appears to be an adequate alternative for patients at high risk of developing posttraumatic systemic complications such as ARDS and multiple organ failure.Keywords
This publication has 40 references indexed in Scilit:
- External Fixation as a Bridge to Intramedullary Nailing for Patients with Multiple Injuries and with Femur Fractures: Damage Control OrthopedicsJournal Of Trauma-Injury Infection and Critical Care, 2000
- Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fracturesThe Journal of Bone and Joint Surgery, 1999
- Timing Fracture Repair in Patients with Severe Brain Injury (Glasgow Coma Scale Score <9)Journal Of Trauma-Injury Infection and Critical Care, 1998
- Femur Fractures in Chest-Injured Patients: Is Reaming Contraindicated?Journal of Orthopaedic Trauma, 1998
- Early Fracture Fixation may be Deleterious after Head InjuryJournal Of Trauma-Injury Infection and Critical Care, 1997
- PRIMARY INTRAMEDULLARY FEMUR FIXATION IN MULTIPLE TRAUMA PATIENTS WITH ASSOCIATED LUNG CONTUSION—A CAUSE OF POSTTRAUMATIC ARDS?Journal Of Trauma-Injury Infection and Critical Care, 1993
- PACKING AND RE-EXPLORATION FOR PATIENTS WITH NONHEPATIC INJURIESJournal Of Trauma-Injury Infection and Critical Care, 1992
- Abbreviated Laparotomy and Planned Reoperation for Critically Injured PatientsAnnals of Surgery, 1992
- Blunt Multiple Trauma (ISS 36), Femur Traction, and the Pulmonary Failure-Septic StateAnnals of Surgery, 1985
- Incidence of Adult Respiratory Distress Syndrome in Patients with Multiple Musculoskeletal InjuriesJournal Of Trauma-Injury Infection and Critical Care, 1985