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Skeletal Traction Versus External Fixation in the Initial Temporization of Femoral Shaft Fractures in Severely Injured Patients

Scannell, Brian P. MD; Waldrop, Norman E. MD; Sasser, Howell C. PhD; Sing, Ronald F. DO; Bosse, Michael J. MD

Journal of Trauma-Injury Infection & Critical Care: March 2010 - Volume 68 - Issue 3 - pp 633-640
doi: 10.1097/TA.0b013e3181cef471
Original Article

Background: Damage control with external fixation (DC-EF) of femoral shaft fractures in polytrauma patients is becoming standard treatment in many trauma centers. However, skeletal traction (ST) has long been used in the temporization of fractures. The purpose of this study was to compare the major physiologic clinical outcomes of provisional ST with DC-EF of femoral shaft fractures in severely injured patients.

Methods: We retrospectively reviewed 205 patients sustaining blunt trauma, a femoral shaft fracture, and an Injury Severity Score ≥17 from 2001 to 2007 at a level I trauma center. Patients underwent definitive fixation in the first 24 hours with intramedullary nailing (IMN) (N = 126), initial DC-EF with delayed definitive treatment (N = 19), or initial ST with delayed definitive treatment (N = 60). Incidences of adult respiratory distress syndrome, multiple organ failure, sepsis, pneumonia, pulmonary embolism, and deep vein thrombosis were evaluated. Length of stay (LOS), intensive care unit LOS, days of mechanical ventilation, and mortality were also compared.

Results: There were no significant differences between ST and DC-EF groups in age, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score on arrival, mean time to definitive fixation (4.1 days versus 5.0 days, respectively), or Abbreviated Injury Scale for chest. However, the ST group had a higher Abbreviated Injury Scale-head (2.5 versus 1.0, p = 0.0026). There were no significant differences in subsequent rates of adult respiratory distress syndrome, multiple organ failure, pulmonary embolism, deep vein thrombosis, pneumonia, mechanical ventilation days, intensive care unit LOS, and death. However, the ST group had a lower rate of sepsis (8.3% versus 31.6%, p = 0.0194) and a shorter LOS (26.5 days versus 36.2 days, p = 0.0237) than the EF group.

Conclusion: DC-EF of femur fractures in severely injured patients offers no significant advantage in clinical outcomes compared with ST. Unless initially subjected to general anesthesia for life saving procedures, the use of ST as a temporization method remains a practical option.

From the Department of Orthopaedic Surgery (B.P.S., N.E.W., M.J.B.), Dickson Institute of Health Studies (H.C.S.), and Department of General Surgery (R.F.S.), Carolinas Medical Center, Charlotte, North Carolina.

Submitted for publication November 25, 2008.

Accepted for publication November 6, 2009.

Presented at the 67th Annual Meeting of the American Association for the Surgery of Trauma, September 24-27, 2008, Maui, Hawaii.

Address for Reprints: Ronald F. Sing, DO, FACS, FCCP, Department of Surgery/MEB 601, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203; email:

© 2010 Lippincott Williams & Wilkins, Inc.