Session III - Polytrauma

Fri., 10/11/02 Polytrauma, Paper #16, 4:03 PM

Management of Femoral Shaft Fractures in Polytrauma: From Early Total Care to Damage Control Orthopaedic Surgery

Hans-Christoph Pape, MD; Boris Zelle, MD; Frank Hildebrand, MD; Christian Krettek, MD, FRACS; Hannover Medical School; Hannover, Germany

Purpose: The optimal treatment of major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study was to investigate the clinical course of polytrauma patients treated at a level-1 trauma center during the last two decades in regard to the effect of changes in the management of femoral shaft fractures.

Methods: In a retrospective cohort study performed at a level-1 trauma center, the patient's injuries and clinical outcome were studied. Adult blunt polytrauma patients were included if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (including external fixation) primarily less than 8 hours after primary admission. Patients were separated according to the management strategies used for the femur fracture (°I intramedullary nailing, IMN; I° external fixation, I°EF; I° plate osteosynthesis, I° plate) followed during a certain time period: 1) early total care, ETC (1/1/1981 to 12/31/1989) and early (<24 hours) definitive stabilization; 2) intermediate, INT (1/1/1990 to 12/31/1992) change in the protocol; 3) damage control orthopaedic surgery, DCO (1/1/1993 to 12/31/2000) early (< 24 hours) temporary stabilization, secondary conversion to intramedullary nailing in patients at risk of organ failure.

Differences between groups were compared by two-way analysis of variance with repeated-measurement design. Means were tested by post hoc analysis using the Fisher's least-significant-difference method with P<0.05.

Results: The patient groups were comparable in age, sex distribution, and the mechanism of injury. Primary external fixation was performed significantly more frequently among patients in group INT (23.9%) and DCO (35.6%), compared with ETC (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 among group INT (13.6%, P = 0.03) and DCO (17.3% P = 0.01), compared with group ETC (8.1%). A higher incidence of reamed nailing was present among group ETC patients compared with the other groups (ETC96.1%, INT 73.7%, DCO 13.5%). No significant differences in the incidence of local complications was 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 adult respiratory distress syndrome, when I°IMN (15.1%) and I° EF (9.1%) in the DCO subgroup were compared.

Conclusions: 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 tract infections, delayed unions, or 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 of thoracic and abdominal injuries may play a role. Even during the DCO era, IMN was associated with a higher rate of adult respiratory distress syndrome than I° external fixation. 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 adult respiratory distress system and multiple organ failure.