External fixation of femoral fractures in multiply injured intensive care unit patients

We report the results of a prospective study of 42 patients with multiple injuries, including femoral fractures, who required intensive care unit (ICU) admission and whose fractures were treated by means of external fixation. The Injury Severity Score (ISS) ranged from 18 to 41 and the average Glasgow Coma Scale (GCS) on admission was 12. Seventeen fractures were open. All patients had their fractures stabilised within 6 hours from admission by means of external fixation. After a follow-up of 11 months (range 4-20), 28 fractures had healed within 6 months (range 4.5-8) and 13 developed non-union which was treated successfully with secondary intramedullary nailing. One patient developed deep infection following secondary nailing and another patient died from adult respiratory distress syndrome (ARDS). We conclude that external fixation of severe femoral fractures in critically ill patients is an easy and quick method of stabilisation which does not compromise their condition. If however it is intended to be used as a final method, these patients require a close follow-up since the rate of delayed and non-union is high.     

Erythropoiesis in multiply injured patients

Posttraumatic anemia in multiply injured patients is caused by hemorrhage, reduced red blood cell survival, and impaired erythropoiesis. Trauma-induced hyperinflammation causes impaired bone-marrow function by means of blunted erythropoietin (EPO) response, reduced iron availability, suppression and egress of erythroid progenitor cells. To treat posttraumatic anemia in severely injured patients, symptomatic therapy by blood transfusion is not sufficient. Furthermore, EPO, iron, and the use of red cell substitutes should be considered. The posttraumatic systemic inflammatory response syndrome (SIRS) induces posttraumatic anemia. Thus, a worsening of SIRS by a "second-hit" through blood transfusion ought to be avoided.     

The multiply injured patient

The multiply injured patient with significant thoracic and extra-thoracic injuries poses a number of challenges. Pericardial tamponade, tension pneumothorax and massive hemothorax can and should be diagnosed clinically. In more stable patients, chest computed tomography (CT) scan is an excellent screening test. The concept of damage control resuscitation and damage control surgery have shown promise in patients with multiple, critical injuries. Beta-blockade of patients with blunt thoracic aortic injuries can be used as a temporizing damage control measure when the risks of operation or intervention are very high (traumatic brain injury, severe right or bilateral pulmonary contusion, unstable pelvic fractures). Patients with multiple penetrating wounds require the surgical team to be expeditious and flexible, and damage control is a helpful strategy in these patients.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

The multiply injured child

The treatment of multiple traumas in children requires knowledge of common injury patterns, incidence, mortality, and the consequences and differences between these injuries in children and adult patients. However, epidemiological studies concerning pediatric multiple trauma are rare. To address this, data were collected and analyzed from 682 multiple trauma patients treated at a Level I trauma center. The patients were divided into four age-related groups (< 6 years, 6-12 years, 13-18 years, and 18-40 years) and were evaluated for trauma mechanism, injury distribution, and cause of death. Children aged 6 to 17 years mostly were injured as pedestrians and cyclists whereas infants, preschoolers, and adults more commonly were injured as car passengers. Pediatric patients suffered a significantly higher mortality than adults, with a threefold increased risk of death when injured as passengers in car accidents. Injuries to the head and the legs were most common. A lower incidence of thoracic (28% versus. 62%), abdominal (20% versus 36%), pelvic (22% versus 35%), and upper limb (32% versus 43%) trauma was observed in children (< 18 years) than in adults (18-40 years). Nevertheless, trauma to the thorax, abdomen, and head were associated with a high risk of death in all groups. Spinal cord injuries, especially in the cervical region, also carried a high risk of mortality (36.8 in the group of patients younger than 18 years and 18.9 in the group of patients 18-40 years). Children younger than 6 years had the most severe head injuries. The data show that there are important differences in incidence, mortality, and injury patterns between pediatric and adult patients with multiple traumas.     

External fixation of the injured pelvis. The functional outcome

External fixation was used in 42 patients as the sole definitive treatment for their unstable pelvic fractures. At an average follow-up of 40 months, the anatomical outcome was related to the functional outcome using defined criteria. The functional results were better than the anatomical results. Function improved during the first 18 months and thereafter was stable. The stab and percutaneous techniques for pin insertion had lower rates of infection than the incisional technique. External fixation has a definite role in the treatment of unstable pelvic fractures. In contrast to internal fixation, this method has two major advantages: safety and simplicity.     

External fixation of fractures in children.

We report a series of 20 children with 24 fractures that were treated using the AO tubular external fixator in a paediatric orthopaedic unit. There were no major complications related to fixator use. There were two cases of superficial pin track sepsis and one case of non-union. There were no cases of refracture after fixator removal or of leg length inequality.     

External fixation of femur fractures in children.

Forty-two children (44 femur fractures) were treated by primary external fixation and early weightbearing (1984-1989). The fractures were reduced anatomically when possible. Average age at fracture was 9 years 7 months (range, 2 years 5 months to 17 years 8 months). Duration of external fixation averaged 70 days (range 42-117 days). Of 176 pins, 15 (8.5%) were inflamed and five (2.8%) required intravenous antibiotics; none resulted in osteomyelitis. Most patients returned to school by 4 weeks, and all had full knee motion 6 weeks after fixator removal. Of 16 patients with documented follow-up of at least 18 months, only six (38%) had overgrowth from 2 to 10 mm (average 5.8 mm).     

Evaluating the multiply injured patient radiographically

In the multiply injured patient there are obvious lesions that often overshadow other lesions, creating a significant possibility that they will be overlooked. Because of the high incidence of missed lesions in such patients, it is a good idea to approach the patient with the presumption that one may be overlooking something and ask oneself what other lesions may be associated with the known lesions. We have enumerated several injuries that frequently occur together and have called them clinical dyads. It is hoped that knowledge of the associations will prevent oversight of the second lesion. The radiographic examination serves as an extension of the physical examination, confirming clinical suspicions and documenting the extent of many injuries. We have outlined what we believe is a prudent radiographic examination in a multiply injured patient. It provides information about the areas most likely to have injuries but is not so extensive that it hinders patient care. It is a starting place or survey and may lead to other, more complicated radiographic studies should the findings warrant them.     

The importance of early internal fixation in multiply injured patients to prevent late death due to sepsis

Three hundred and seventy-one multiply injured patients with 1063 fractures, who were admitted to our service over an 8-year period (1978-1985), were studied retrospectively. The impact of early osteosynthesis on the overall, and especially of the late, mortality due to sepsis was analysed. The patients were divided into two groups depending on whether they were treated with osteosynthesis (group I) or underwent conservative fracture treatment (group II). The late mortality (more than 7 days after injury) due to sepsis fell to 1.8 per cent in patients treated with osteosynthesis compared with 13.5 per cent (P less than 0.001) in patients treated conservatively. The best results were obtained when the osteosynthesis was performed within 24 hours after injury; less than 1 per cent died from late sepsis. We feel that fractures in multiply injured patients should be treated with early osteosynthesis in order to reduce the late mortality from sepsis.     

Outcome of foot injuries in multiply injured patients

In the past, foot injuries in patients with multiple trauma were thought to be of lesser importance than fractures of long bones. In one prospective study from the authors' institutions, however, multiple-trauma patients with foot injuries were shown to have a poorer functional outcome compared with matched controls. To address these concerns, this article has two parts. The first part is an overview of general principles in the treatment of foot injuries in polytrauma patients. The treatment of specific injuries is beyond the scope of this article, but an approach is highlighted that can be remembered when decisions are made regarding these severely injured patients. The second part reviews the findings from the authors' study, focusing on functional outcomes of multiple-trauma patients with foot injuries.     

Occult orthopaedic trauma in the multiply injured patient

A retrospective review of 111 multitrauma patients revealed that of 401 orthopaedic injuries, 24 injuries (6%) were not initially diagnosed in 20 patients. Patients with occult injuries tended to have greater overall trauma, as reflected by lower trauma and lower Glasgow coma scores and longer hospital and intensive-care unit stays. Twenty prospectively identified cases were added to the series to further define risk factors. Seventy percent of occult bony injuries were ultimately diagnosed by physical examination and plain radiographs alone. Only 27% of cases required sophisticated imaging techniques for diagnosis. Based on these 44 cases of occult injuries in multitrauma victims, the following risk factors were identified: (1) significant multisystem trauma with another more apparent orthopaedic injury within the same extremity, (2) trauma victim too unstable for full initial orthopaedic evaluation, (3) altered sensorium, (4) hastily applied emergency splint obscuring a less apparent injury, (5) poor quality or inadequate initial radiographs, and (6) inadequate significance assigned to minor signs/symptoms in a major trauma victim. Due to the nature and extent of the overall trauma, all injuries cannot be diagnosed on initial patient evaluation.     

External fixation for the foot and ankle in children

During the last decade, external fixation for the pediatric foot and ankle has evolved as a result of advances in technology (eg, Taylor spatial frame, hydroxyapatite-coated external fixator pins) and preoperative deformity planning. Although complications are common, most are minor and can be addressed nonoperatively while treatment continues. This article reviews the indications and applications of external fixation for soft tissue contractures, idiopathic and teratologic clubfoot, osteotomies, metatarsal lengthening, tibial lengthening, and foot and ankle trauma.     

External fixation of lower limb fractures in children.

Thirty-four tibial and femoral shaft fractures in 32 children between the ages of 3 and 15 years were treated by external fixation over a 5-year period. The indications were fractures occurring in association with other major injuries and failure of conservative treatment to maintain satisfactory reduction. There was one case of delayed union and one early refracture. The overall pin track infection rate was 6%, but the rate for the tibial pins (2.1%) was much lower than for the femoral pins (10.3%). Union was achieved at an average of 11.7 weeks in the femoral fractures and 10.0 weeks in the tibial fractures. The use of external fixation is recommended for childhood femoral and tibial fractures, particularly in children with multiple injuries.     

Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients

BACKGROUND: From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing. METHODS: Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. RESULTS: The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees). CONCLUSIONS: We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.     

External fixation

Summary The conclusion from the above clinical and experimental presentation is that stabilization by using external fixation in problematic cases is the method of choice because the risk of infection is better than by using the standard methods of plating and nailing.Using external fixation based on the tubular system of ASIF we can achieve rigid stability. Correct application allows early mobilization ensuring alignment even in bone defects. This method of treatment also facilitates the care of wounds.Our experimental and clinical information provides us with the opportunity to offer a systematic classification of each individual type of external fixation and its merits, as described above in types I, II, and III and its application in different situations.Our clinical experience also shows that external fixation has greatly reduced the risk of amputation in these problematic cases, but it has not solved all the problems associated with the primary injury.The advantage of the three-dimensional external fixation type III can also be seen in the case of arthrodesis of the knee joint. Here there is a better neutralization of the bending moment, than by using type II.Finally we would like to emphasize that the external fixation is not the panacea for every problematic case and each surgeon should be well aware of its methodical and correct application, as abuse of external fixation may lead to secondary complications.

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Zusammenfassung Die Osteosynthese mit dem Fixateur exteren bietet ein Behandlungsverfahren für klinische Problemfälle, bei denen sich aus der lokalen Schädigung oder einer sekundär aufgetretenen Komplikation ein erhöhtes Risiko für die Nagel- oder Plattenosteosynthese ableiten läßt.Mit dem Rohrfixateur externe der AO kann in den meisten Fällen Übungsstabilität erzielt werden, bei offenen und bei infizierten Frakturen ist die Weichteilbehandlung erleichtert.Auf Grund klinisch-experimenteller Untersuchungen schlagen wir eine Klassifizierung der Anwendungsformen der Fixateur-externe-Osteosynthese vor, unterscheiden in Typ I, II, III und zeigen die entsprechenden Indikationen auf.Die Fixateur-externe-Osteosynthese hat bei klinischen Problemfällen die Amputationsgefahr verringert.Auch für die Kniearthrodese empfehlen wir die Anwendungsform Typ III, mit der gegenüber Typ II das ventral auftretende Biegemoment durch Neutralisiexung der Zugkräfte nicht zur Auswirkung kommt.Die Fixateur-externe-Osteosynthese erfordert eine korrekte Technik und wie jede andere Osteosynthese die Beachtung der Regeln der Asepsis.

     

Morbidity of early spine surgery in the multiply injured patient

Introduction

The optimal timing of surgery for multiply injured patients with operative spinal injuries remains unknown. The purported benefits of early intervention must be weighed against the morbidity of surgery in the early post-injury period. The performance of spine surgery in the Afghanistan theater permits analysis of the morbidity of early surgery on military casualties. The objective is to compare surgical morbidity of early spinal surgery in multiply injured patients versus stable patients.

Materials and methods

Patients were retrospectively categorized as stable or borderline unstable depending on the presence of at least one of the following: ISS >40, ISS >20 and chest injury, exploratory laparotomy or thoracotomy, lactate >2.5 mEq/L, platelet <110,000/mm³, or >10 U PRBCs transfused pre-operatively. Surgical morbidity, complications, and neurologic improvement between the two groups were compared retrospectively.

Results

30 casualties underwent 31 spine surgeries during a 12-month period. 16 of 30 patients met criteria indicating a borderline unstable patient. Although there were no significant differences in the procedures performed for stable and borderline unstable patients as measured by the Surgical Invasiveness Index (7.5 vs. 6.9, p = 0.8), borderline unstable patients had significantly higher operative time (4.3 vs. 3.0 h, p = 0.01), blood loss (1,372 vs. 366 mL, p = 0.001), PRBCs transfused intra-op (3.88 vs. 0.14 U, p < 0.001), and total PRBCs transfused in theater (10.18 vs. 0.31 U, p < 0.001).

Conclusions

The results indicate that published criteria defining a borderline unstable patient may have a role in predicting increased morbidity of early spine surgery. The perceived benefits of early intervention should be weighed against the greater risks of performing extensive spinal surgeries on multiply injured patients in the early post-injury period, especially in the setting of combat trauma.