Abstract
Purpose
The timing of definitive fixation for major fractures in polytrauma patients is controversial. To clarify this aspect of trauma management, we randomised patients with blunt multiple injuries to either initial definitive stabilisation of the femur shaft with an intramedullary nail or an external fixator which was converted to an intramedullary nail at a secondary procedure and documented the post-operative clinical condition.
Methods
Multiply injured patients with femoral shaft fractures were randomised to either initial (<24 hours) intramedullary femoral nailing or to initial external fixation and conversion to an intramedullary nail at a later phase. Inclusion criteria: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score >2 points and another injury (Abbreviated Injury Scale score >2 points), and age 18 to 65 years. Exclusion criteria: unstable or patients in extremis. Patients were graded as stable or borderline (increased risk of systemic complications). OUTCOMES: Incidence of acute lung injuries.
Results
Ten European Centres, 165 patients, mean age 32.7 ±11.7 years. Group of intramedullary nailing, n = 94; Group of external fixation, n = 71. Pre-operatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison to the external fixation group, P < 0.05.
Conclusion
Intramedullary stabilisation of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared to those that underwent initially external fixation. Therefore, the pre-operative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries.
