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Journal of Trauma-Injury Infection & Critical Care:
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Central Hemodynamics during Reamed Intramedullary Nailing of Unilateral Tibial Fractures

Helttula, Ilmo MD; Karanko, Meri MD; Gullichsen, Eero MD

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Abstract

Background: Intramedullary nailing of a long-bone fracture results in intravasation of bone marrow contents into the right atrium and pulmonary vascular bed and, therefore, may alter cardiac and pulmonary hemodynamics.

Methods: Central hemodynamic changes were recorded in 12 healthy adults with a unilateral simple tibial fracture undergoing intramedullary nailing. The patients were cannulated with a pulmonary artery catheter. Reamed intramedullary nailing was performed during general anesthesia. Preoperative and immediate postoperative hemodynamic variables were compared and intraoperative changes studied.

Results: During the operation, the right ventricular preload as represented by central venous pressure and the right ventricular afterload as presented by mean pulmonary arterial pressure increased significantly. Preoperative and postoperative arterial oxygen tension values demonstrated hypoxia. Abnormal pulmonary shunting and increased oxygen consumption were observed as well.

Conclusion: Changes in cardiac and pulmonary hemodynamics are already present after the trauma and before the reamed intramedullary nailing procedure.

Intramedullary nailing of long-bone fractures as introduced by Küntscher 1 has gained wide acceptance as a safe internal fracture stabilization method. However, there are several clinical and experimental studies which suggest that the reaming and nailing procedure may lead to increased intramedullary pressure and adverse intravasation of bone marrow in to the pulmonary circulation. Echocardiographic monitoring of the right heart during reaming and nailing has been reported to exhibit a snowstorm-like embolization of bone marrow particles, which are deposited in the lung because of its effective filtering action. 2,3

Consequently, cardiac and pulmonary hemodynamics are altered in patients subjected to intramedullary nailing of a long-bone fracture. Central hemodynamic monitoring is commonly used in patients with multiple injuries and circulatory shock. 4,5 Hence, altered hemodynamic parameters cannot causally be directly addressed to the fracture and operation. A unilateral displaced tibial shaft fracture is a relatively common trauma among the adult healthy population. Therefore, it can be regarded as a “reproducible” long-bone fracture pattern. The purpose of the present study was to analyze immediate preoperative, perioperative, and postoperative cardiac and pulmonary hemodynamic changes in healthy patients undergoing reamed intramedullary nailing because of a displaced tibial shaft fracture.

© 2000 Lippincott Williams & Wilkins, Inc.

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