Session I - Polytrauma

Thurs., 10/5/06 Polytrauma, Paper #1, 2:15 pm

Resuscitation Prior to Stabilization of Femoral Fractures Limits ARDS in Polytrauma Patients Despite Low Utilization of Damage Control Orthopaedics

Robert O'Toole, MD1'(n); Michael O'Brien, MD1 (n); Nader Habashi, MD2 (n); Andrew N. Pollak, MD1 (n); Clifford Turen, MD1 (n);
1R. Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical School, Baltimore, Maryland, USA;
2R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland Medical School, Baltimore, Maryland, USA

Purpose: Femoral shaft fractures are associated with acute respiratory distress syndrome (ARDS). There is theoretical support for the idea that primary intramedullary nailing increases the incidence of ARDS. Our approach to treating femur fractures in polytrauma patients is reamed nailing after resuscitation as demonstrated by normalizing lactate plus optimized ventilatory and hemodynamic parameters. Damage control orthopaedics (DCO - primary external fixation) is usually reserved for rare patients who do not respond to resuscitation. Our hypothesis was that this policy yields a low rate of ARDS.

Methods: A prospective trauma database was searched for all femoral shaft fractures treated at a level I trauma center over 3 years, yielding 615 fractures. Exclusion criteria included death before treatment (n = 9), age less than 16, age greater than 65, and fractures that were not amenable to nail fixation, leaving 524 fractures. We defined ARDS as a mean PaO2/FiO2 <200 for 5 or more consecutive days.

Results: Of the 524 fractures, only 7% were treated initially with an external fixator and 93% were treated with reamed nails. Results for polytrauma patients with ISS >17 (table below) demonstrated lactate values that decreased significantly on the operative day compared with the presenting value (P <0.05). Patients with lung injury (n = 158) who were treated with a nail had an ARDS rate of 1.9% and a death rate of 2.5%. The ARDS rate for the most severely injured patients (ISS >28, lung Abbreviated Injury Score >2, n = 61) was only 3.3% and 3.3% died after nail fixation.

Femoral Shaft Fractures With ISS >17
 Initial Rx  Patients  ISS  Initial Lactate  Best lactate on OR day  Death  ICU Days  ARDS
 Nail  n = 216 (87%)   27.4* 3.9*  2.2*#  2.0%*  7.4*  1.4%
 DCO  n = 33 (13%)  35.0  6.4  2.7#  18%  16.7  0.0%

*P <0.05 for all values comparing DCO to reamed nail
#P <0.05 comparing presenting lactate to best lactate on day of treatment

Conclusions: The literature has reported higher ARDS rates despite utilization of DCO in up to 36% of polytrauma patients with femur fractures. In the context of our resuscitation protocol, our rate of ARDS was lower (P <0.001) and more in keeping with historical controls, despite infrequent use of DCO. An explanation for this discrepancy may be based on differences in preoperative resuscitation or medical care of shock.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
· The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an "off label" use). · · FDA information not available at time of printing.