Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes

Damage control orthopedics and decreased in-hospital mortality: A nationwide study

INTRODUCTION

While various strategies of fracture fixation in trauma victims have been discussed, the effect of damage control orthopedics (DCO) on significant clinical outcome is inconclusive. We examined the mortality of patients managed with DCO, comparing those without DCO, using a nationwide trauma database.

PATIENTS AND METHODS

We retrospectively identified patients with extremity injury, defined as patients with an Abbreviated Injury Scale (AIS) of ≥2 in an upper or lower extremity, in the database that included more than 200 major hospitals from 2004 to 2016. We included those who were age ≥15 years and underwent ORIF. Patients with missing survival data or invalid vital signs at hospital arrival were excluded. Patient data were divided into DCO or non-DCO groups, and propensity scores were developed to estimate the probability of being assigned to the DCO group, using multivariate logistic regression analyses adjusted for known survival predictors, such as age, vital signs at arrival, Abbreviated Injury Scale in extremity, ISS, presence of vascular injury, surgical procedure before fracture treatment, and transfusion requirement. The primary outcome, in-hospital mortality, was compared between the two groups after propensity score matching. Survival analyses were performed, and hazard ratio was adjusted according to age, systolic blood pressure on arrival, and Injury Severity Score.

RESULTS

Of the 19,319 patients included in this study, 4407 (22.8%) underwent DCO. After the propensity score matching, 3858 pairs were selected. In-hospital mortality was significantly lower among patients in the DCO than those in the non-DCO groups (40 [1.0%] vs. 66 [1.7%]; odds ratio = 0.60; 95% confidence interval [CI] = 0.41-0.89; P = 0.01). Survival analyses showed that DCO was independently associated with decreased mortality in patients with extremity injury (adjusted hazard ratio = 0.30; 95% CI = 0.20-0.46; P < 0.01).

CONCLUSIONS

DCO was associated with decreased in-hospital mortality in patients with major fractures. Further clinical study on DCO by selecting patient population should be considered eventually to develop an appropriate strategy for major fractures.

Early versus late intramedullary nailing for traumatic femur fracture management: meta-analysis

INTRODUCTION

There is no consensus yet on the impact of timing of femur fracture (FF) internal fixation on the patient outcomes. This meta-analysis was conducted to evaluate the contemporary data in patients with traumatic FF undergoing intramedullary nail fixation (IMN).

METHODS

English language literature was searched with publication limits set from 1994 to 2016 using PubMed, Scopus, MEDLINE (OVID), EMBASE (OVID), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Studies included randomized controlled trials (RCTs), prospective observational or retrospective cohort studies, and case-control studies comparing early versus late femoral shaft fractures IMN fixation. Variable times were used across studies to distinguish between early and late IMN, but 24 h was the most frequently used cutoff. The quality assessment of the reviewed studies was performed with two instruments. Observational studies were assessed with the Newcastle-Ottawa Quality Assessment Scale. RCTs were assessed with the Cochrane Risk of Bias Tool.

RESULTS

We have searched 1151 references. Screening of titles and abstracts eliminated 1098 references. We retrieved 53 articles for full-text screening, 15 of which met study eligibility criteria.

CONCLUSIONS

This meta-analysis addresses the utility of IMN in patients with FF based on the current evidence; however, the modality and timing to intervene remain controversial. While we find large pooled effects in favor of early IMN, for reasons discussed, we have little confidence in the effect estimate. Moreover, the available data do not fill all the gaps in this regard; therefore, a tailored algorithm for management of FF would be of value especially in polytrauma patients.

Assessment of resuscitation as measured by markers of metabolic acidosis and features of injury

AIMS

The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.

PATIENTS AND METHODS

A cohort of 335 patients with fractures of the pelvis, acetabulum, femur, or spine were included. Patients underwent definitive fixation within 36 hours if one of the following three parameters were met: lactate < 4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L. If all three parameters were met, resuscitation was designated full protocol resuscitation (FPR). If less than all three parameters were met, it was designated an incomplete protocol resuscitation (IPR). Complications were assessed by an independent adjudication committee and included infection; sepsis; PE/DVT; organ failure; pneumonia, and acute respiratory distress syndrome (ARDS).

RESULTS

In total, 66 patients (19.7%) developed 90 complications. An historical cohort of 1441 patients had a complication rate of 22.1%. The complication rate for patients with only one EAC parameter at the point of protocol was 34.3%, which was higher than other groups (p = 0.041). Patients who had IPR did not have significantly more complications (31.8%) than those who had FPR (22.6%; p = 0.078). Regression analysis showed male gender and injury severity score to be independent predictors of complications.

CONCLUSIONS

This study highlights important trends in the IPR and FPR groups, suggesting that differences in resuscitation parameters may guide care in certain patients; further study is, however, required. We advocate the use of the existing protocol, while research is continued for high-risk subgroups. Cite this article: Bone Joint J 2017;99-B:122-7.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

When is the best time to fix fractures?

The best time to operate on a fracture is governed in part by the nature of the fracture itself. It is also influenced by the premorbid condition of the patient and by the degree that associated injuries have disrupted normal processes. It is likely that some patients have a period of increased physiological risk for intervention, during which a second insult will result in further harm. The picture is not yet fully clear but relates to variations in the inflammatory response to trauma. One consistent lesson appears to resonate throughout the published literature. The most predictable risk factor for iatrogenic physiological disturbance is transfer to the operating theatre before adequate resuscitation of the patient has taken place.

Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation

BACKGROUND

Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.

METHODS

Three hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.

RESULTS

All 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80%) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71%. Complications occurred in 16.3% of patients fixed within 36 h and in 33.3% of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1%, p = 0.017) and shorter length of stay (LOS) (p = 0.018).

CONCLUSIONS

Our EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.

In-hospital mortality from femoral shaft fracture depends on the initial delay to fracture fixation and Injury Severity Score: a retrospective cohort study from the NTDB 2002-2006

BACKGROUND

Optimal surgical timing for definitive treatment of femur fractures in severely injured patients remains controversial. This study was performed to examine in-hospital mortality for patients with femur fractures with regard to surgical timing, Injury Severity Score (ISS), and age.

METHODS

The National Trauma Data Bank version 7.0 was used to evaluate in-hospital mortality for patients presenting with unilateral femur fractures. Patients were stratified into four groups by surgical timing (ST) and four groups by ISS. χ tests were used to evaluate baseline interrelationships. Binary regression was used to examine the association between time to surgery, ISS score, age, and mortality after adjusting for patient medical comorbidities, and personal demographics.

RESULTS

A total of 7,540 patients met inclusion criteria, with a 1.4% overall in-hospital mortality rate. For patients with an isolated femur fracture, surgical delay beyond 48 hours was associated with nearly five times greater mortality risk compared with surgery within 12 hours (adjusted relative risk, 4.8; 95% confidence interval, 1.6-14.1). Only severely injured patients (ISS, 26+) had higher associated mortality with no delay in surgical fixation (ST1 < 12 hours) relative to ST2 of 13 hours to 24 hours with an adjusted relative risk of 4.2 (95% confidence interval, 1.0-16.7). The association between higher mortality rates and surgical delay beyond 48 hours was even stronger in the elderly patients.

CONCLUSION

This study supports the work of previous authors who reported that early definitive fixation of femur fractures is not only beneficial, particularly in the elderly, but also consistent with more recent studies recommending at least 12-hour to 24-hour delay in fixation in severely injured patients to promote better resuscitation.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care

OBJECTIVES

The purpose was to define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures. A model was developed to predict the complications.

DESIGN

Statistical modeling based on retrospective database.

SETTING

Level 1 trauma center.

PATIENTS

A total of 1443 adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures.

INTERVENTION

All fractures were treated surgically.

MAIN OUTCOME MEASUREMENTS

Univariate and multivariate analysis of variance assessed associations of parameters with complications. Logistic predictive models were developed with the incorporation of multiple fixed and random effect covariates. Odds ratios, F tests, and receiver operating characteristic curves were calculated.

RESULTS

Twelve percent had pulmonary complications, with 8.2% overall developing pneumonia. The pH and base excess values were lower (P < 0.0001) and the rate of improvement was also slower (all Ps < 0.007), with pneumonia or any pulmonary complication. Similarly, lactate values were greater with pulmonary complications (all Ps < 0.02), and lactate was the most specific predictor of complications. Chest injury was the strongest independent predictor of pulmonary complication. Initial lactate was a stronger predictor of pneumonia (P = 0.0006) than initial pH (P = 0.047) or the rate of improvement of pH over the first 8 hours (P = 0.0007). An uncomplicated course was associated with the absence of chest injury (P < 0.0001) and definitive fixation within 24 (P = 0.007) or 48 hours (P = 0.005). Models were developed to predict probability of complications with various injury combinations using specific laboratory parameters measuring residual acidosis.

CONCLUSIONS

Acidosis on presentation is associated with complications. Correction of pH within 8 hours to >7.25 was associated with fewer pulmonary complications. Presence and severity of chest injury, number of fractures, and timing of fixation are other significant variables to include in a predictive model and algorithm development for Early Appropriate Care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated.

Population-based epidemiology of femur shaft fractures

BACKGROUND

The management of patients with femoral shaft fractures (FSFs) is often a decision making dilemma (damage-control orthopedics vs. early total care), with equivocal evidence. The comprehensive, population-based epidemiology of patients with FSF is unknown. The purpose of this prospective study was to describe the epidemiology of patients with FSF, with special focus on patient physiology and timing of surgery.

METHODS

A 12-month prospective population-based study was performed on consecutive patients with FSF in an area with 850,000 population including all ages and prehospital deaths. Patient demographics, mechanism, Injury Severity Score (ISS), shock parameters (systolic blood pressure, base deficit and lactate), transfusion requirement, fracture type [Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (OA/OTA)], comorbidities, procedures, and outcomes were recorded. Patients hemodynamic status was described as stable, borderline, unstable, and "in extremis."

RESULTS

A total of 126 patients (21 per 100,000 per year) with 136 femur fractures (62% male; age, 38 [28] years; ISS, 20 [19]; 51% multiple injuries) were identified in the region. Sixty patients (48.4%) sustained a high-energy injury with 19 (31.1%) of these being polytrauma patients (ISS, 28 [12]; systolic blood pressure, 98 [39]; base deficit, 6.5 [5.8]; lactate 4 [2]).Fifteen polytrauma patients (94%) required massive transfusion (12 [12] U of packed red blood cells, 8 [5] fresh frozen plasma, 1 [0.4] platelet, 13 [8] cryoprecipitate). Twenty-one patients (16.7%) died at the prehospital setting (3.5 per 100,000 per year). From the 105 hospital admissions, 68.3% was stable (14.3 per 100,000 per year), 8.7% was borderline (1.8 per 100,000 per year), 4.0% was unstable (0.8 per 100,000 per year) and 2.4% (0.5 per 100,000 per year) was in extremis. Six patients (5.7%) died. The length of stay (LOS) was 18 (15) days, and the intensive care unit LOS was 5 (6) days. Fourty-five patients sustained a low-energy injury that had in 85% of cases multiple comorbidities. Eight low-energy patients needed 3 (1) transfusions, and none of the patients died. The LOS was 15 (11) days.

CONCLUSION

Patients with low-energy FSF have a hospital admission rate similar to the patients with high-energy FSF. Sixty-eight percent of patients with FSF are complicated (open, compromised physiology, multiple injuries, bilateral, elderly with comorbidities, etc.), requiring major resources and highly specialized care.

LEVEL OF EVIDENCE

Epidemiology study, level III.

Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: a systematic review of randomized and nonrandomized trials

BACKGROUND

Optimal timing of definitive treatment of femoral shaft fractures in patients with multiple injuries remains controversial. This study aimed to determine the impact of timing of definitive treatment (early, delayed, or damage-control orthopedics [DCO]) of femoral shaft fractures on the incidence of adult respiratory distress syndrome (ARDS), mortality rate, and hospital length of stay (LOS) in patients with multiple injuries.

METHODS

A systematic review of published English-language reports using MEDLINE (1946-2011), Embase (1947-2011), and Cochrane Library. Search terms included femoral fractures, multiple trauma, fracture fixation, and time factors. This study reviewed randomized and nonrandomized studies that (1) compared early and delayed treatment or early treatment and DCO and (2) reported the incidence of ARDS, mortality rate, or LOS. Extraction of articles was performed by one of the authors using predefined data fields.

RESULTS

Thirty-eight studies met our inclusion criteria. Studies were grouped into heterogeneous injuries with early versus delayed treatment (17 studies), heterogeneous injuries with early versus DCO (8 studies), head injury (13 studies), and chest injury (7 studies). Most of the studies (≥ 50%) reporting ARDS and mortality rate showed no difference in each of these groups. However, 6 of 7 and 2 of 3 studies reporting LOS in the heterogeneous injuries with early versus delayed and heterogeneous injuries with early versus DCO, respectively, showed shorter stay for early treatment. Pooled analyses were not conducted owing to changes in critical care delivery during the study period and variations in definitions of early treatment, ARDS, and multiple injuries. Thirty-five reports were based on nonrandomized trials and were subject to biases inherent in retrospective studies. The review process was limited by language and publication status.

CONCLUSION

The literature suggests that early definitive treatment may be used safely for most patients with multiple injuries. However, a subgroup of patients with multiple injuries may benefit from DCO [corrected].

LEVEL OF EVIDENCE

Systematic review, level III.

Physiological assessment of the polytrauma patient: initial and secondary surgeries

The timing of fracture fixation in polytrauma patients has been debated for a long time. The decision between DCO (damage control orthopaedics) and ETC (early total care) is a difficult dilemma. Overzealous ETC in haemodynamically compromised patients with significant chest and head injuries can be detrimental. It has been shown, however, that early fracture fixation has a trend towards better outcome in patients with less severe injuries. Delaying all orthopaedic surgery in critically injured patients can be a safe alternative, but has several disadvantages like longer ICU stay and septic complications. The literature shows equivocal evidence for both settings. This article will summarize the historical background and controversies regarding patient assessment and decision making during the treatment of polytrauma patients. It will also give guidance for choosing DCO versus ETC in the clinical setting.

Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries

BACKGROUND

Type and timing of treatment of femur fractures is controversial. Although reported as safe and effective in many reports, others have suggested that early definitive stabilization may cause complications, particularly in patients with chest and head injuries. Damage control orthopedics was proposed as an alternative in unstable patients. This study examines the effects of timing of fixation and investigates risk factors for complications.

METHODS

Seven hundred fifty patients with femur fractures treated between 1999 and 2006 were reviewed. Skeletally mature patients with mean age 35.8 years and mean Injury Severity Score (ISS) 23.7 were included. Four hundred ninety-two patients had ISS ≥18. Early stabilization (n = 656) was defined as definitive treatment of the femur fracture within 24 hours of injury.

RESULTS

Early definitive stabilization in patients with multiple injuries was associated with fewer complications than delayed stabilization (18.9% vs. 42.9%, p < 0.037) after adjusting for patient age and ISS. Early treatment was also associated with shorter hospital stay, intensive care unit stay, and ventilator days (p < 0.001). Severe (Abbreviated Injury Scale score ≥3) abdominal injury was associated with more complications than severe head (Glasgow Coma Scale score ≤8) and chest (Abbreviated Injury Scale score ≥3) injuries (44.2% vs. 40.9%, p = 0.68, and 34.4%, p = 0.024, respectively) and was an independent risk factor for complications (p < 0.0001). Chest injury was an independent risk factor for pulmonary complications (p < 0.001), but surgical delay in patients with chest injury was also associated with pulmonary complications (p = 0.04). More sepsis was noted patients with severe head injury (22.7% vs. 4.5%, p = 0.037) or severe chest injury (10.2% vs. 2.5%, p = 0.044) when treated on a delayed basis. More patients transferred from other hospitals were treated on a delayed basis (48.9% vs. 37.5%, p = 0.04).

CONCLUSIONS

Early definitive stabilization is associated with acceptably low rates of complications and is safe in most patients with multiple injuries, including some with severe abdominal, chest, or head injuries with attention to resuscitation before surgery. More complications and longer hospital stay were noted with delayed fixation after adjusting for age and ISS. Chest injury was associated with pulmonary complications; however, the presence of severe abdominal injury was the greatest risk factor for complications. Expediting access to definitive care may reduce complications and expenses.

[Early or delayed peripheral surgery in patients with severe head injury?]

Head injuries are present in up to 65 % of multiple trauma patients with a frequent association with orthopaedic injuries. The concept of early surgical stabilization of long-bone fractures in patients with multiple injuries became firmly established in the 1980s. However, optimal timing of long bone fracture fixation in trauma patients with associated severe traumatic brain injury has been a lively topic. The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. In recent years, some studies reported a worse outcome, with secondary brain damage, resulting from hypotension, hypoxia and increased intraoperative fluid administration. This review summarises the current evidence available regarding the management of these patients in particular the recent concept of early temporary surgical stabilization in the era of "damage control orthopaedic surgery".

Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient

BACKGROUND

Optimal timing and treatment of patients with concomitant head, thoracic, or abdominal injury and femoral shaft fracture remain controversial. This study examines acute patient outcomes associated with early total care with intramedullary nailing (ETC group) versus damage control external fixation (DCO group) for multiple-injured patients with femoral shaft fractures. We propose DCO as a safe initial treatment for the multiple-injured patient with femur shaft fractures.

METHODS

This study was a retrospective review of the trauma registry and multisystem organ failure registry data at a Level I trauma center. Two cohorts were identified to compare multiple-injured patients with femoral shaft fractures treated with early total care and damage control orthopaedic surgery. Primary outcome measures included mortality, pulmonary complications (adult respiratory distress syndrome [ARDS] score), transfusion requirements, and multiple organ failure (MOF score). Operative time, estimated blood loss, intensive care unit length of stay (LOS), and hospital length of stay (LOS) were also compared.

RESULTS

During the study period, 462 patients with 481 femoral shaft fractures were identified. Of 462 patients with femoral shaft fractures, 97 met the inclusion criteria (42 ETC and 55 DCO). The DCO group had a significantly shorter operative time (22 minutes vs. 125 minutes) and less estimated blood loss from their operative procedure (37 mL vs. 330 mL). There was no significant difference between the groups for ARDS, lung scores, MOF, MOF score, intensive care unit LOS, or hospital LOS.

CONCLUSION

Fracture fixation method did not have an impact on the incidence of systemic complications in multiple-injured patients with femoral shaft fractures. Although minimal differences were noted between DCO and ETC groups regarding systemic complications, DCO is a safer initial approach, significantly decreasing the initial operative exposure and blood loss.

Damage control nailing

The role of intramedullary nailing of the femur and the timing for this procedure in the trauma patient with multiple injuries has been widely debated. Recent literature has advocated the idea of "damage control orthopaedics," promoting temporary external fixation for stabilization of long bone fractures in the acute setting. This paper advances an alternative to damage control orthopaedics, the option of rapidly executed small-diameter unreamed retrograde nailing of the femur for the patient with polytrauma who will be undergoing simultaneous surgery for other injuries. This technique offers the advantages of rapid stabilization performed under controlled circumstances in the operating room, without some of the disadvantages of using external fixation in this situation.

Evaluation of criteria for temporary external fixation in risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients: "evidence-based medicine" versus "reality" in the trauma registry of the German Trauma Society

BACKGROUND

Femur-shaft fracture treatment (FSFT) follows controversial management concepts after multiple trauma: primary-definitive osteosynthesis, secondary-definitive osteosynthesis after temporary external fixation (EF) in all patients, or individualized primary- or secondary-definitive osteosynthesis ("risk-adapted damage control orthopedics"). This study compares the concepts by analyzing literature evidence and a prospective multicenter database.

METHODS

A systematic literature analysis was performed. The German Trauma Society trauma registry was used to assess variables predictive of treatment concept.

RESULTS

Contradictory results in 63 controlled trials failed to support a "generalized management strategy." In all, 1,465 FSFTs in 8,057 trauma registry patients (age 39 +/- 19.5 years; Injury Severity Score [ISS] 23.5 +/- 14.9; 17.3% mortality) were treated initially (<24 hour) by EF, nail, or plate in 47.0%, 41.1%, and 11.9%, respectively. Despite large interhospital variability, EF was more likely with increasing severity of ISS, Glasgow Coma Score, thorax trauma, base excess, coagulation abnormalities, and initial probability of death.

CONCLUSIONS

Clinical "reality" reflects the controversies of "scientific evidence" for FSFT after multiple trauma in Germany. Although decision making is currently based on unvalidated criteria, anatomic and physiologic injury severity appears to influence the choice of management concept.

Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe

BACKGROUND

Although early fracture fixation is expedient in patients with multiple injuries, early total care (ETC) may be associated with posttraumatic systemic complications. This study was conducted to prospectively evaluate the concept of damage control by immediate external fracture fixation (damage control orthopedics [DCO]) and consecutive conversion osteosynthesis with regard to time savings, effectiveness, and safety.

METHODS

In a prospective controlled trial, a cohort of 1,070 patients with an Injury Severity Score (ISS) of 20.7 were admitted to a Level I trauma center over a 3.5-year period. Patients with an ISS > 15, survival of more than 24 hours, and without interhospital transfer were included. In all patients with major fractures requiring immediate stabilization, external fixation was performed (DCO). Conversion was executed at the earliest possible time as a one-stage procedure after stabilization of organ functions. TRISS was calculated for patients requiring DCO (DCO group) and for patients without major fractures (control group). Time spent on particular and all surgical procedures, blood loss, and complications of DCO were compared with data of consecutive conversion osteosyntheses which were considered as hypothetical ETC procedures (h-ETC) in identical patients.

RESULTS

Four hundred nine patients fulfilled the inclusion criteria. Seventy-five (ISS of 37.3) required DCO for 135 fractures, whereas 334 patients (ISS of 30.4) did not require immediate fracture fixation. Mean surgical time was 62 +/- 30 minutes (SEM, 3.5) for DCO. Because of fracture consolidation with external fixation (n = 3) and injury-related death (n = 15), conversion (h-ETC) was performed in 57 patients for 101 fractures. Duration of external fixation averaged 13.7 days (range, 3-46 days). Fifty-five patients (96.5%) required intensive care treatment and 42 patients (73.7%) required mechanical ventilation at the time of conversion. Mean operation time for conversion was 233 +/- 19 minutes (SEM, 18.7) with a value of p < 0.001. Also, blood loss was significantly (p < 0.001) different for DCO (<50 mL) and h-ETC (472 mL; SEM, 63). Pin-track infections were identified in five patients, two patients with acetabular plate osteosynthesis had deep wound infection, and one patient died related to bacterial sepsis with infections of all wound sites. Overall mortality in DCO patients was significantly lower than predicted by TRISS (20% vs. 39.3%), as it was in the 334 patients without immediate fracture fixation (29.5% vs. 24.3%).

CONCLUSION

DCO appears to provide a major reduction of operation time and blood loss in the primary treatment period in severely injured patients compared with h-ETC. In addition, we found that DCO is not associated with an increased rate of procedure-related complications. So far, DCO with early and one-stage conversion seems to be a safe strategy of primary fracture treatment in patients with multiple injuries.

Réunion de neuroanesthésie-réanimation. Prise en charge anesthésique du patient en hypertension intracrânienne aiguë

Transcranial Doppler and, if possible, measurement of intracranial pressure (ICP) allow preoperative diagnosis of acute intracranial hypertension (ICH) after brain trauma. The main goal of the anaesthesiologist is to prevent the occurrence of secondary brain injuries and to avoid cerebral ischaemia. Treatment of high ICP is mainly achieved with osmotherapy. High-dose mannitol administration (1.4 to 2 g/kg given in bolus doses) may be considered a better option than conventional doses, especially before emergency evacuation of a cerebral mass lesion. Hypertonic saline seems as effective as mannitol without rebound effect and without diuresis increase. Haemostasis should be normalized before neurosurgery and invasive blood pressure monitoring is mandatory. For anaesthesia induction, thiopental or etomidate may be used. In case of ICH, halogenated and nitrous oxide should be avoided. Until the dura is open, mean arterial pressure should be maintained around 90 mmHg (or cerebral perfusion pressure around 70 mmHg). If a long-lasting (several hours) extracranial surgery is necessary, ICP should be monitored and treatment of ICH should have been instituted before.

Traumatic brain injury and stabilisation of long bone fractures: an update

In the era of "damage control orthopaedics", the timing and type of stabilisation of long bone fractures in patients with associated severe traumatic brain injury has been a topic of lively debate. This review summarises the current evidence available regarding the management of these patients. There appear to be no clear treatment guidelines. Irrespective of the treatment protocol followed, if secondary brain damage is to be avoided at all times, ICP monitoring should be used, both in the intensive care unit and in the operating theatre during surgical procedures, since aggressive ICP management appears to be related to improved outcomes. Treatment protocols should be based on the individual clinical assessment, rather than mandatory time policies for fixation of long bone fractures.

Early surgery for thoracolumbar spine injuries decreases complications

BACKGROUND

The proper timing for surgical fracture repair is controversial. Early repair of long bone and cervical fractures reduces complications and is safe. Few studies exist to compare time to surgery with outcomes in thoracolumbar (TL) spine injuries.

METHODS

Patients with TL spine injuries were identified from the trauma registry and divided into two cohorts on the basis of Injury Severity Score (ISS). Cohorts were compared for infectious, respiratory, and total complications in patients who had early (<72 hours from injury) versus late (>72 hours from injury) surgical repair. A retrospective chart review was performed on High ISS patients (> or =15) to identify differences in resuscitation needs and neurologic, respiratory, and infectious complications.

RESULTS

Early surgery, Low ISS patients were younger, received fewer anterior repairs, and had shorter hospitalizations. Early patients in the High ISS cohort had significantly fewer total complications and shorter hospital and intensive care unit lengths of stay. Resuscitative requirements were similar for both surgery groups. More late surgery patients required ventilator support for noninfectious reasons. There was no difference in admission or postoperative neurologic status or the incidence of head injury.

CONCLUSION

Early surgery in severely injured patients with thoracolumbar spine trauma was associated with fewer complications and shorter hospital and intensive care unit lengths of stay, required less ventilator support for noninfectious reasons, and did not increase neurologic deficits.

The effect of femoral nailing on cerebral perfusion pressure in head-injured patients

BACKGROUND

The timing of fracture fixation in patients with head trauma is controversial. Early fracture fixation may be associated with secondary brain injury. We undertook this study to investigate the effect of reamed intramedullary nailing on cerebral perfusion.

METHODS

Seventeen patients were identified who had placement of an intracranial pressure monitor and reamed rodding of the femur. Retrospective chart review was performed.

RESULTS

Average Injury Severity Score was 35 (range, 17-50). Cerebral perfusion pressure (CPP) decreased intraoperatively for all except one. The average decrease in CPP from pre- to intraoperative values was 17 mm Hg (p = 0.0012). Seventy percent had an average intraoperative CPP below 75 mm Hg, and all patients had a minimum CPP below 75 mm Hg. The decrease in CPP was mostly attributable to a corresponding decrease in mean arterial pressure.

CONCLUSION

Patients with head trauma undergoing femoral rodding need careful attention paid to managing blood pressure to minimize CPP decreases.

Improving outcome for the injured brain and spinal cord

Although injury to the brain and spinal cord can have varied etiology and mechanisms, the common pathway appears to be mediated by occurrence of ischemia and secondary injury. Because the pathophysiology in traumatic brain injury is heterogeneous, improvement in outcome will come from better diagnosis and monitoring, so that targeted therapy can be tailored to the individual patient. This review focuses on traumatic injury to the brain and spinal cord, and highlights recent developments in this area.