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The Impact of the Quantity of Skeletal Injury on Mortality and Pulmonary Morbidity

Ziran, Bruce H. MD; Le, Toan MD; Zhou, Hong PhD; Fallon, William MD; Wilber, Jack H. MD

Journal of Trauma and Acute Care Surgery: December 1997 - Volume 43 - Issue 6 - p 916-921

Objective  To determine if the quantity of skeletal injuries (and the timing to fixation) increases the mortality or pulmonary morbidity in patients with and without chest injuries.

Design  Retrospective analysis of trauma registry. Statistical analysis with multiple logistic regression and chi squared analysis.

Methods  Looking specifically at adult patients (>16 years), skeletal injury was quantified by determining the presence or absence of a fracture in specific body regions (humeri, forearm, femur, tibia, spine, and pelvis) for a maximum of 10 skeletal injuries. The timing of fixation for fractures was categorized as <24 hours, <48 hours, <72 hours, <5 days, >5 days, or no fixation. Chest injuries and pulmonary morbidity were based on the accepted list of complications reported in the literature.

Results  Three groups were analyzed according to the presence or absence of a chest or skeletal injury: those without skeletal injury (group NSI, n = 59), those without chest injuries (group NCI, n = 108), and those with both skeletal and chest injuries (group B, n = 59) Pulmonary Complications: When all patient groups (NCI, NSI, and B) were pooled, greater chest injury (p < 0.0008), greater skeletal injury (p < 0.02), and delayed fixation (p < 0.04) were associated with increased risk of developing a pulmonary complication. In the group of patients without a chest injury (NCI), this risk was associated with greater head injury (p < 0.005) and greater skeletal injury (p < 0.04), whereas in the group without a skeletal injury (NSI), only chest injury demonstrated significance (p < 0.05). When both skeletal and chest injuries were present, greater head injury (p < 0.03) and fixation time (p < 0.03) increased the risk of developing a pulmonary complication. Mortality: With all patients pooled (NCI, B, and NSI), head injury (p < 0.02), abdominal injury (p < 0.012), and fixation time (p < 0.01) were risk factors. In patients without a chest injury (NCI), none of the indexed variables were associated with mortality. In patients without a skeletal injury (NSI), greater head injury (p < 0.01), greater chest injury (p < 0.01), and greater abdominal injury (p < 0.04) were risk factors for mortality. When both chest and skeletal injuries were present (B), only head injury (p < 0.0003) was associated with mortality. The prevalence of mortality and pulmonary complications were compared between groups NCI, NSI, and B. Group NCI had fewer pulmonary complications (p < 0.004) than the other groups (difference not significant). When examining mortality, group NCI had less mortality than groups NSI and B.

Conclusion  The combination of skeletal and chest injuries does not seem to amplify the pulmonary morbidity and mortality compared with chest injury alone. The quantity of the skeletal injury and the time to fixation of structures affecting mobilization seem to have an effect on pulmonary morbidity and mortality. Better scientific studies on the effects of skeletal injury and timing to fixation in relation to pulmonary morbidity and mortality are required.

From the Department of Orthopedic Surgery (B.H.Z.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; the Department of Orthopedic Surgery (T.L., J.H.W.), Case Western Reserve University, Cleveland, Ohio; the Department of Statistics (H.Z.), the University of California, Davis, California; and the Department of Surgery (W.F.), Metro Health Medical Center, Cleveland, Ohio. The work was performed at Metro Health Medical Center, an affiliate of Case Western Reserve University, Cleveland, Ohio.

Address for reprints: Bruce H. Ziran, MD, Department of Orthopedic Surgery, University of Pittsburgh Medical Center, 3471 5th Avenue, No. 1010, Pittsburgh, PA 15213.

© Williams & Wilkins 1997. All Rights Reserved.