Session IV - PolyTrauma

Conversion of External Fixation to Intramedullary Nailing for Femoral Shaft Fractures in Polytrauma Patients

Peter J. Nowotarski, MD, University of Tennessee; Clifford H. Turen, MD; Robert J. Brumback, MD; J. Mark Scarboro, BA, Shock Trauma Center, Baltimore, MD

Purpose: Early closed intramedullary (IM) nailing is the current treatment of choice for femoral shaft fractures. However, for critically ill patients or those with vascular compromise unable to tolerate immediate IM nailing, femoral external fixation with delayed conversion to IM nails may present a good alternative. To evaluate the safety and efficacy of this two-stage treatment, we retrospectively reviewed the records of 63 polytrauma patients with 69 femoral fractures treated with conversion of external fixation to IM nailing from 1989 to 1997 at our institution.

Methods: The 63 patients comprised <5% of the 1,507 femoral shaft fractures treated with IM nailing during the study period. Of the 63, nine patients (10 fractures) were lost to follow-up, leaving 54 patients (59 fractures) in our study group with a minimum follow-up for 4 months (average, 11 months; range, 4 to 87 months). The average Injury Severity Score was 29.4 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (44/54) had additional orthopaedic injuries (average, 3; range, 0 to 8), and associated injuries, such as severe brain injury, solid viscus rupture, chest trauma, vascular insults, and aortic tears, were common. The 40 closed and 19 open femoral fractures (Gustilo-Anderson type-II, 3; type-IIIA, 8; type-IIIC, 8) were classified according to the OTA system as 32-A (18), 32-B (24), 32-C (8), 33-A3 (3), and 33-C2 (6). IM nailing was delayed secondary to medical instability (46) or vascular injury (8) in these patients, and all femoral shaft fractures were stabilized with a unilateral external fixator within the first 24 hours postinjury (average length of procedure, 30 minutes). The duration of the external fixator averaged 6.6 days (range, 1 to 49 days) before the static interlocked IM nail procedure (49 antegrade, 10 retrograde). Of the 59 fractures, 55 were converted from external fixation to IM nailing in a one-stage procedure, and four with draining pin sites underwent skeletal traction for pin site healing for an average of 10 days (range, 8 to 15 days) after fixator removal and before IM nailing.

Results: There were three major complications: one patient died during hospitalization from a massive pulmonary embolism, one patient had a refractory, infected nonunion (1.7%), and one late nonunion with nail failure was successfully treated with retrograde exchange nailing. Four other patients required minor reoperation: two were managed with manipulations under anesthesia for knee stiffness and two underwent derotation/relocking for rotational malalignments (11% unplanned reoperation rate). Of the 59 fractures, 57 (97%) healed within 6 months, although two underwent early dynamization.

Discussion/Conclusions: We conclude that immediate external fixation followed by early closed IM nailing is a safe treatment method for femoral shaft fractures in polytrauma patients who cannot tolerate an immediate IM nailing but who will benefit from long-bone stabilization. A low and acceptable infection rate is possible in a one-stage conversion.