Sat., 10/16/10 Polytrauma & Femur, Paper #66, 10:12 am OTA-2010
Δ Do Patients with Multiple System Injury Benefit from Early Fixation of Unstable Axial Fractures? The Effects of Timing of Surgery on Initial Hospital Course
Heather A. Vallier, MD; Dennis M. Super, MD, MPH;
Timothy A. Moore, MD; John H. Wilber, MD;
MetroHealth Medical Center, Cleveland, Ohio, USA
Purpose: Unstable fractures of the pelvis, acetabulum, femur, and thoracolumbar spine require bed rest and recumbency until they are stabilized. While fixation will promote mobilization, the timing of that fixation is influenced not only by the availability of surgeon specialists, but also by associated injuries to other systems, which add to the total hemorrhage and the risk of systemic inflammation and immune dysfunction. Damage control orthopaedics using external fixation as a temporizing measure has been advocated to reduce complications; however, many of these fractures are not amenable to external fixation. Our general practice has been early definitive management of major axial skeletal injury in a team-based fashion. We hypothesized that early definitive management of unstable fractures of the pelvis, acetabulum, femur, and spine would reduce complications and shorten length of stay.
Methods: Over an 8-year period, 1,005 skeletally mature patients with multiple system trauma were treated surgically for unstable fractures of the pelvis (n = 259), acetabulum (n = 266), proximal or diaphyseal femur (n = 569), and/or thoracolumbar spine (n = 98) at a Level 1 trauma center. Associated injuries of the chest (n = 447), abdomen (n = 328), and head (n = 489) were present. Timing of definitive surgical treatment for these fractures was within 24 hours in 572 patients and after 24 hours of injury in 433 patients. Hospital records and radiographs were reviewed. Early complications including wound infections, sepsis, pneumonia, deep venous thrombosis (DVT), pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), organ failure, and death were identified.
Results: The mean injury severity score (ISS) was 29.1 ± 9.3 for patients treated within 24
hours of injury, versus 32.5 ± 11.3 when after 24 hours (P = 0.001), and the mean age was 36.2
years for early versus 40.1 years for delayed (P < 0.001). However, the mean initial pH and
base excess were 7.32 ± 0.09 versus 7.34 ± 0.12 (P = 0.004) and –5.5 ± 4.3 versus –4.4 ± 5.6 (P
=0.005), respectively, for early versus delayed patients, indicating a greater level of initial
acidosis in the early group. Both the days in ICU and the overall length of stay were lower
in the early group (5.1 ± 8.8 vs 8.4 ± 11.1 ICU days; 10.5 ± 9.8 vs 14.3 ± 11.4 total days; P <
0.001). These differences remained significant after adjusting for ISS and age. In addition,
the early group had lower rates of overall complications (24.0% vs 35.8%), ARDS (1.7% vs
5.3%), pneumonia (8.6% vs 15.2%), and sepsis (1.7% vs 5.3%), with P = 0.040, P = 0.048, P =
0.070, and P = 0.054, respectively, after adjusting for ISS, severity of chest injury, and age.
Rates of DVT, PE, wound infection, other organ failure, and death were not significantly
different between the two groups.
Conclusion: 1,005 patients with multiple system injury and 1,192 unstable fractures of the pelvis, acetabulum, femur, and thoracolumbar spine were reviewed. Patients who had definitive management of all of these fractures within 24 hours of injury had shorter ICU and hospital stays and lower overall rates of complications and ARDS, compared with those treated later, even when adjusted for age and associated injury types and severity. While fracture fixation serves a role in reducing ongoing bleeding and in promoting mobility from bed, surgical timing must be determined with consideration of the overall physiological status of the patient and the complexity of the surgery needed. Parameters should be established within which it is safe and efficacious to proceed with fixation. These data will serve as a baseline for comparison for prospective evaluation of such parameters in the future.
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• 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.