Thurs., 10/16/08 Tibia/Polytrauma, Paper #13, 4:33 pm OTA-2008
The Role of the Traction Pin for Temporization of Femur Fractures in Severely Injured Patients
Brian P. Scannell, MD (n); Norman E. Waldrop, MD (n);
Michael J. Bosse, MD (a-OREF, Synthes, Zimmer; e-KCI, Medtronic); Ronald F. Sing, DO (n);
Howell C. Sasser, PhD (n);
Carolinas Medical Center, Charlotte, North Carolina, USA
Purpose: Treatment algorithms of polytrauma patients with femoral shaft fractures have changed over the years, from delayed treatment to early total care to damage control with the use of early external fixation. However, skeletal traction (ST), which does not require general anesthesia, has long been used as a method for temporary stabilization of femoral shaft fractures. The aim of this study is to compare the efficacy of provisional ST to early definitive fixation with intramedullary nailing (IMN) and damage control with external fixation (DC-EF) with respect to pulmonary complications, multisystem organ failure, and mortality. The study hypothesis is that provisional ST for temporary stabilization of femur fractures is an acceptable alternative to external fixation for these same fractures in severely injured patients, thus avoiding initial exposure to general anesthesia while providing skeletal stabilization.
Methods: An IRB-approved retrospective review was performed on patients from January 2001 to January 2007 sustaining blunt trauma resulting in a femoral shaft fracture and an Injury Severity Score (ISS) ≥17. A total of 205 patients were identified. Patients were stratified into three subgroups: early (<24 hours) definitive fixation with IMN (N = 126), DC-EF within the first 24 hours (N = 19), or initial ST with delayed definitive treatment (N = 60). Outcomes such as acute respiratory distress syndrome (ARDS), multiorgan failure (MOF), sepsis, pneumonia, pulmonary embolism (PE), deep vein thrombosis (DVT), length of stay (LOS), ICU LOS, days of mechanical ventilation (MV), and mortality were then recorded.
Results: The average time to definitive fixation was 4.1 days in the ST group and 5.1 days in the external fixation group. Comparing the ST group to the DC-EF group, there were no significant differences in age, mechanism of injury, ISS, Glasgow coma scale on arrival, or Abbreviated Injury Scale (AIS)-chest. The ST groups, however, had higher AIS-head (2.5 vs 1.0, P = 0.0026). In addition, there were no significant differences between the two groups for ARDS, MOF, PE, DVT, pneumonia, MV days, ICU LOS, and death. However, the ST group had a lower rate of sepsis (8.3% vs 31.6%, P = 0.0194), and LOS (2.65 days vs 36.2 days, P = 0.0237) than the DC-EF group.
Conclusions and Significance: In this retrospective review of severely injured patients with femoral shaft fractures, patients treated initially with skeletal traction had no difference in the rate of ARDS, MOF, PE, DVT, pneumonia, and days of MV compared to patients treated initially with external fixation. The skeletal traction group did, however, have a lower rate of sepsis and shorter LOS. These data suggest that provisional ST is a reasonable alternative to external fixation in severely injured patients with femoral shaft fractures. Eliminating early exposure to general anesthesia with the placement of provisional ST may have both clinical and economic implications.
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. Δ OTA Grant.