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External Fixation as a Bridge to Intramedullary Nailing for Patients with Multiple Injuries and with Femur Fractures: Damage Control Orthopedics

Scalea, Thomas M. MD; Boswell, Sharon A. RN, CEN; Scott, Jane D. ScD, MSN; Mitchell, Kimberly A. MS; Kramer, Mary E. RN; Pollak, Andrew N. MD

Journal of Trauma-Injury Infection & Critical Care: April 2000 - Volume 48 - Issue 4 - pp 613-623
Annual Meeting Articles

Background: The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures.

Methods: Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur.

Results: Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure.

Conclusion: EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications.

Although the benefits of early fracture fixation are well documented, questions remain concerning the optimal timing of fracture fixation in adult trauma patients with multiple injuries. 1–6 Early intramedullary nail (IMN) fixation of long bone fractures in patients with multiple injuries has been associated with a reduced risk of pulmonary complications. 2,4,6 However, some recent reports have implicated fat embolization associated with IMN worsening pulmonary complications for patients with certain lung injury profiles. 7 Additional studies suggest that patients with severe traumatic head injury may experience poorer outcomes if treatment of musculoskeletal injuries includes early surgical intervention. 8,9 Substantial blood loss associated with major operative procedures certainly complicates optimal fluid resuscitation in the patient with a brain injury, and general anesthesia interferes with the ability to serially assess neurologic function. Additional patient populations at particular risk for complications from major operative procedures include those who are hypothermic, coagulopathic, or hemodynamically unstable.

External fixation (EF) plays an important role in primary management of pelvic fractures in patients with multiple injuries and with competing injuries in many centers. 10,11 In the past 3 years , we have largely adopted the use of EF for femur fixation in unstable trauma patients with multiple injuries. We use EF as a “bridge” or “temporizing device” to achieve the benefits of early fracture stabilization during early resuscitation, and postpone the additional stresses posed by IMN until the patient is stabilized.

The purpose of this study was to investigate the clinical course and outcomes of all adult trauma patients admitted to our center with femur fracture who were treated primarily with EF versus IMN. We were specifically interested in determining the characteristics of the EF and IMN populations, and outcomes of mortality, length of stay, and discharge disposition. We were additionally interested in determining the reasons provided in the medical record for selecting EF as the primary repair procedure. Our central premise is that, although patients with primary EF of the femur should be more severely injured than patients with primary IMN, survival would be comparable for EF and IMN groups.

From the R. Adams Cowley Shock Trauma Center (T.M.S., S.A.B.), University of Maryland Medical System, Program in Trauma (T.M.S.), Charles McC. Mathias Jr. National Study Center for Trauma and EMS (J.D.S., K.A.M., M.E.K.), and Division of Orthopedics and Program in Trauma (A.N.P.), University of Maryland School of Medicine, Baltimore, Maryland.

Address for reprints: Thomas M. Scalea, MD, R. Adams Cowley Shock Trauma Center, 22 South Greene Street, Room T3R35, Baltimore, MD 21201-1595.

Submitted for publication September 24, 1999.

Accepted for publication December 31, 1999.

This study was not funded from corporate or other sources. The authors contributed their time to the study.

Presented at the 59th Annual Meeting of the American Association of the Surgery of Trauma, September 16–18, 1999, Boston, Massachusetts.

© 2000 Lippincott Williams & Wilkins, Inc.