Session IV - PolyTrauma

*External Femoral Fixation of Unstable Blunt Polytrauma Patients

Barry L. Riemer, MD, Medical College of Pennsylvania, Pittsburgh, PA

Introduction: Immediate fixation of femoral shaft fractures among blunt polytrauma patients is standard care at level I trauma centers. Systemic instability renders some patients too unstable for internal fixation. External fixation has been employed to stabilize femoral fractures in blunt polytrauma patients in extremis.

Methods: Between 1983 and 1992, 23 blunt polytrauma patients with 25 femoral diaphyseal fractures (3% of 665 fractures) presented to a level I trauma center. When they could not be adequately stabilized for internal fixation within 24 hours, a unilateral external fixator was applied. The average ISS was 38, and the average age was 29. Fifteen fractures were open (7 grades 1 or 2, 6 grade IIIA, 1 IIIB and 1 IIIC). One patient died, one had an AKA for clostridial infection and one was lost, leaving 20 patients with 22 fractures for analysis.

Results: Eighteen fractures displaced in the frame. Due to continued systemic instability, only 12 early reconstructions were performed at an average of 18 days. Plates were chosen in 10 cases to avoid potential medullary contamination of pin sites by a nail. Two of the plated fractures healed with residual deformities, one plate failed, and one nonunion after plating required reconstruction. Among the 10 fractures that were not reconstructed, one was lost with a nonunion. Six deformities were accepted because patients remained too unstable for reconstruction (2 corrective osteotomies post-union were performed). Ten late infections developed (6 at pin sites and 4 plates). All patients regained full extension and flexion averaged 116 degrees. Fractures united in 21 weeks average.

Discussion: Unilateral femoral external fixation is a rapid, minimally invasive procedure for femoral fixation. Adequate stability for patient mobilization can be achieved but not for maintenance of reduction. Secondary internal fixation carries a high incidence of infection. The frequency of open fractures in this study may have prejudiced these results. Similar complications might not be seen when applying external fixators to patients with lesser systemic or orthopedic injuries or with IM nail reconstructions.

Conclusion: External femoral fixation of blunt polytrauma patients is an interim measure for early stabilization of patients in extremis. Infections and deformities are frequent. Reconstructions are difficult. Benefits of early fracture stabilization and patient mobilization must be weighed against these potential orthopedic complications.