Early versus delayed stabilization of femoral fractures. A prospective randomized study

A prospective randomized study comparing the results of early with delayed reduction and stabilization of acute femoral fractures in adults was performed over a two-year period in 178 patients. Only patients who were more than sixty-five years old and had a fracture of the hip were excluded. Arterial blood gases, injury-severity score at the time of admission, pulmonary function, days in the hospital, days in the intensive-care unit, and hospital costs were recorded for all patients. The patients were divided into two groups: those who had an isolated fracture of the femur and those who had multiple injuries. When stabilization of the fracture was delayed in the patients who had multiple injuries, the incidence of pulmonary complications (adult respiratory-distress syndrome, fat embolism, and pneumonia) was higher, the hospital stay was longer, and the number of days in the intensive-care unit was increased. The cost of hospital care showed a statistically significant increase for all patients who had delayed treatment of the fracture compared with those who had early stabilization.     

Early versus delayed fixation of isolated closed femur fractures in an urban trauma center

The use of intramedullary rods is accepted as the gold standard for treatment of closed femur fractures. Early fixation of these fractures has been shown to be beneficial in the multiply-injured patient. This retrospective review was undertaken to examine the isolated femur fractures in an urban trauma center over a six-year period. Of the 76 patients included in the study, 42 underwent early fixation (less than 48 hours after injury) and 34 had delayed fixation (more than 48 hours after injury). There was no statistical difference in postoperative complications between the two groups. Fixation performed within 48 hours did not seem to decrease morbidity when compared to fixation performed after 48 hours. Length of stay and hospital costs were increased with delayed fixation.     

Early versus delayed closure of open fractures

The desired outcome in the management of Type III open injuries is not merely salvage but a limb which is functional, painless and aesthetically pleasing. The aim is to also achieve this outcome with the least number of reconstructive surgical procedures and minimal hospital stay. This is now possible by the emergence of many new concepts, by which primary closure is one. While the traditional expected standard of care was to leave the wound open and delay closure, the current evidence favours primary closure in open injuries if the following indications are met: (a) debridement performed within 12h, (b) no skin loss primarily or secondarily during debridement (Ganga Hospital Score [Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J Bone Joint Surg Br 1990;72:125-8]: score of '1' or '2'), (c) skin approximation possible without tension, (d) no farmyard of gutter contamination, (e) debridement performed to the satisfaction of the surgeon and (f) no vascular insufficiency.     

Ender nail fixation of pediatric femur fractures: a biomechanical analysis.

SUMMARY: Biomechanical testing was performed to determine the effects of flexible intramedullary nail fixation on simulated transverse and comminuted midshaft femur fractures using two Ender nails. A synthetic adolescent-size femur model was used. The axial and rotational stiffness values for the simulated comminuted fracture were equivalent to those of the transverse fracture under "touch-down weight-bearing" loads. These data suggest that length and rotational control of comminuted midshaft femur fractures with two divergent Ender nails may be sufficient for early mobilization.     

Early versus delayed fixation of pelvic ring fractures

This retrospective study reports outcomes, after early and delayed surgical stabilization of fractures of the pelvic ring, in terms of pulmonary complications, length of hospital stay, and cost of hospitalization. The hospital course of 151 patients admitted to an academic teaching hospital who sustained acute fractures of the pelvic ring between June 1996 and December 2000 was reviewed. Patient demographics, Injury Severity Score (ISS), timing of operative fixation, and the incidence of pulmonary complications were analyzed. Radiographs were reviewed and fractures classified according to the modified Tile system. Tile fracture types B and C patients who underwent fixation within 1 week of injury (n = 71) were compared to those in whom surgery was delayed (n = 28). Adjusting for the ISS, early-repair patients had a lower risk of pulmonary complications (RR = 0.49, 95% CI = 0.25-0.96), a reduced length of hospital stay (12.2 vs. 20.5 days; P = 0.0005), and overall reduced cost of care (57,084 dollars vs. 158,625 dollars; P = 0.0317). Pelvic ring fixation within the first week of injury results in significantly reduced incidence of pulmonary complication, hospital stay, and cost of care regardless of injury severity. The coordinated team approach to insure prompt resuscitation, stabilization, and operative fixation results in more optimal patient outcomes.     

The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails

Flexible intramedullary fixation is an excellent technique for the stabilization of pediatric diaphyseal femurfractures when an indication for operative repair exists. They can be applied in an antegrade and a retrograde manner and can be used to stabilize fractures from the subtrochanteric region of the proximal femur to a point approximately 4 cm proximal to the distal femoral growth plate.     

骨盆环骨折早期固定与延迟固定的比较

根据4项回顾性队列研究的结论,对于骨盆环骨折患者,目前仅有少量的证据支持:与延迟固定相比,早期固定能缩短住院时间和降低肺部并发症的发生率,而且可能获得更好的短期功能恢复.但这些结论可能受到混杂因素的影响.因此,应开展随机对照研究来明确这些问题,包括明确和统一"早期"和"延迟"的定义,且对患者的长期功能恢复情况进行比较分析.     

Early versus delayed operative management of closed tibial fractures

Fractures of the tibial shaft are the most common long bone fractures. Operative treatment of isolated closed tibial shaft fractures frequently is delayed in favor of treatment of life threatening injuries. A retrospective chart review of 200 tibial fractures was performed. These injuries were managed by two surgeons at a Level 1 trauma center between 1989 and 1996. Strict inclusion criteria identified 54 patients with an isolated closed tibial fracture. Postoperative hospital stay and complication rates were recorded. At a mean followup of 3.6 years, a quality of life questionnaire was administered via telephone calls to these patients. Two patient groups were identified: Group 1, 21 patients (< 12-hour surgical delay); and Group 2, 33 patients (> 12-hour surgical delay). Both groups were similar for baseline characteristics. Group 2 patients remained an extra 4.6 days in the hospital. A Kaplan-Meier analysis revealed that by the eighth postoperative day, all Group 1 patients were discharged from the hospital, whereas 47.8% of Group 2 patients remained in the hospital. Plate fixation was associated with a greater incidence of complications when compared with intramedullary nail internal fixation. Complication rates were significantly greater in the delayed surgical group. A multiple regression analysis revealed that surgical delay and postoperative complications accounted for 35% of the total variance in postoperative hospital stay. Time to surgical treatment was not prognostic of long term quality of life. Surgical delay results in longer postoperative hospital stays, greater complication rates, and increased total cost to the health care system.     

Comparison of dynamic versus static external fixation for pediatric femur fractures

External fixation of pediatric femoral shaft fractures has the advantages of minimal dissection and early weight bearing. However, it is associated with slow healing and potential for refracture. Some surgeons have proposed that axial dynamization may improve the speed and strength of callus formation. to test this hypothesis, we performed a randomized controlled trial using 53 femur fractures in 52 patients between 1995 and 1999. Patients were randomized to receive dynamic or static fixation. Average time until early callus formation was 23.2 days for dynamic fixation and 24.9 days for static fixation (P = 0.627). Average time until complete radiographic healing was 70.1 days for dynamic fixation and 63.1 days for static fixation (P = 0.370). Similarly, the differences in time to fixator removal and to full weight bearing did not reach statistical significance. The conclusion was that axial dynamization of external fixation for pediatric femur fractures has no significant effect on time to healing or frequency of complications.     

踝部骨折内固定术后踝部早期活动与延迟活动的比较

四项小样本随机或半随机对照试验的证据显示:①与延迟至术后12周活动踝部相比,早期活动有利于踝部功能的恢复,但仅有一项研究提示二者存在统计学差异.②术后早期活动踝部的患者可以更早地返回工作岗位.③在早期活动踝部的患者中,感染更常见,但是与延迟活动的患者相比,前者发生静脉血栓的几率更低.     

踝部骨折内固定术后早期和晚期活动的比较

三个小型、近似随机对照实验的中度证据表明：①踝部骨折内固定术后，早期和晚期活动组间比较，踝关节功能评分无差异。②在晚期活动组中，静脉血栓发生率轻度增加，但差异无显统计学意义。③早期活动感染和其它并发症发生率轻度增加。[第一段]     

Early versus delayed surgery for ankle fractures: a comparison of results

A retrospective review of closed ankle fractures treated using open reduction and internal fixation (ORIF) was undertaken. The aim was to investigate if the timing of surgery had any influence upon soft tissue complications and hospital stay. Sixty-two patients, 31 men and 31 women, were reviewed. Twenty-four (39%) underwent the surgery within 24 h (average 17.5 h) of injury, while the other 38 (61%) were operated at an average of 3.1 (2–9) days. The average length of stay (LOS) was 7.1 (range 2–15) days in patients who had the surgery within 24 h of injury as compared to 10.6 (range 4–64) days in those who had their surgery after 24 h of injury. The post-operative stay was 6.3 days as compared to 7.5 days in the two groups respectively. Fourteen complications were seen, including six infections all of which occurred in patients who underwent surgery after 24 h of injury. Three cases with delayed wound healing were also noted. A significantly higher complication rate was noted in patients aged 70 years or older (6/11). We conclude that delay in ORIF of ankle fractures is associated with increased complication, increased morbidity and increased hospital stay. These fractures should be surgically fixed within 24 h.     

Clinical outcomes following invasive versus noninvasive preoperative stabilization of closed diaphyseal femur fractures

Background

The use of invasive traction (INV-T) to stabilize femur fractures prior to fixation (open reduction and internal fixation, ORIF) remains controversial. Some centers have utilized noninvasive traction (NINV-T) or splinting preoperatively. It is possible that INV-T decreases hemorrhage. However, the use of INV-T in pediatric patients and for femoral neck fractures in adults is associated with worsened outcomes. We hypothesized that there is no difference in the need for transfusion between those who receive INV-T and NINV-T.

Methods

A retrospective study was performed at two level I and one level II trauma center from January 2006 to December 2009. Patients ??18?years with a closed diaphyseal femur fracture who underwent ORIF within 48?h of arrival were included. Patients were grouped by method of preoperative fracture stabilization. Primary endpoint was need for transfusion. A power analysis found that 94 patients were needed to detect a 25?% difference with 80?% power.

Results

Fifty-six (22?%) received INV-T and 199 (78?%) received NINV-T stabilization. No significant differences were found between groups in terms of age, injury severity score, or ORIF method. There was no significant difference between the two groups in the hemoglobin value on arrival, preoperative hemoglobin value, or the difference between admission and preoperative hemoglobin values. We did not find a significant difference in the need for red blood cell transfusion between the two groups. There was no difference in length of stay or discharge destination.

Conclusion

INV-T is not associated with improved outcomes in adult patients with closed mid-shaft femoral fractures who are operated upon within 48?h of arrival.     

Improved outcome with femur fractures: early vs. delayed fixation

Prior studies documented that early fixation of femur fractures results in a decreased incidence of adult respiratory distress syndrome (ARDS), fat embolism syndrome, and pneumonia. This study evaluates the impact of magnitude of injury on pulmonary complications and length of ICU and hospital stays in 339 trauma patients with femur fracture undergoing early (n = 121) vs. late (n = 218) operative fixation. Groups were similar with respect to transfusions, hypotension, and associated injuries, but more patients over age 50 years underwent early fixation. Patients were categorized according to Injury Severity Score (ISS): 1) less than 15 (n = 202), 2) 16-35 (n = 104), and 3) greater than 36 (n = 33). Delayed fixation significantly increased the incidence of pulmonary shunt in ISS (3) patients and of pneumonia in patients older than 50. Late fixation resulted in significantly longer hospital stays in all groups and more ICU days in the ISS (3) group. We believe that early femur fixation should be performed on all patients. Pulmonary complications were decreased and health care costs reduced.     

Early versus delayed repair of facial fractures in the multiply injured patient.

The management of facial fractures in the polytrauma patient requires the coordination of multiple surgical disciplines to optimize the functional and cosmetic outcome while minimizing overall morbidity and mortality. Although the plastic surgery literature historically advocates the early repair of facial fractures, the risk of general anesthesia in patients with associated injuries sometimes makes early repair unsafe. We compared early operative repair versus delayed operative repair of facial fractures in multitrauma patients. We specifically examined wound infection, overall complication rate, total length of hospital stay, days in the Intensive Care Unit (ICU), and days on the ventilator in the two groups. A 5-year (1991-1996) retrospective study of multitrauma patients with associated facial fractures was undertaken at an urban community hospital. We had a total of 82 patients, who were divided into three groups. Thirty-three patients did not have operative repair of the facial fractures during the initial admission and were followed by the plastic surgery service on an outpatient basis. These patients will not be discussed further. Seven patients underwent early operative repair, which was defined as repair within 48 hours of admission (group I). Forty-two patients had delayed operative repair, defined as repair more than 48 hours after admission (group II). The reasons for delayed repair included: excessive soft tissue swelling (16), intracranial injuries (12), unstable medical condition (8), and coordination of procedures with other services (6). Of the 49 patients who underwent operative repair, 43 were involved in motor vehicle accidents, 3 were injured by a fall from a height, 2 were involved in auto-pedestrian accidents, and 1 was a victim of assault. Forty-eight of the 49 patients were initially admitted to the ICU. Cumulative associated injuries were as follows: closed head injury (38), extremity fracture (21), blunt chest injuries (11), intra-abdominal injuries (5), vertebral column injuries (7), and ocular injuries (2). The average Injury Severity Score for Group I was 17.3 and for Group II, 18.1. In group I, there were no deaths, there were no wound infections, and the complication rate was 14.3 per cent. The average total number of days spent on the ventilator was 3.0, the average total number of days spent in the ICU was 5.0, and the average total hospital stay was 16.0 days. In group II, there were no deaths, the wound infection rate was 5 per cent, and the overall complication rate was 21 per cent. The average total number of days spent on the ventilator was 3.3, the average total number of days spent in the ICU was 5.8, and the average total days in the hospital was 14.8. Our results indicate that in a similar cohort of multitrauma patients, delayed repair did not increase length of ICU stay or hospital stay. The wound infection rate was negligible, and the complication rate was similar in the two groups. We conclude that a delay in repair of facial fractures in the critically ill patient has an acceptably low complication rate and may be advantageous in decreasing operative risk and minimizing cost by coordinating multiple procedures with various surgical subspecialties.     

Secondary fractures associated with external fixation in pediatric femur fractures.

Sixty-six femur fractures sustained by children ages 4-14 years and treated with external fixation were reviewed retrospectively to assess factors influencing the incidence of refracture. The total rate of secondary fracture was 12% (eight patients) including five recurrent fractures at the original fracture site and three fractures through the pin sites. After removal of the external fixator, five patients refractured at the original fracture site and one patient fractured through a pin tract. Two patients fractured at pin sites while the fixator was still in place. Multivariate linear-regression analysis showed no correlation between the incidence of refracture and fracture pattern, percentage of bone fragment contact after fixator application, type of external fixator, or dynamization. A statistically significant association (p < 0.05) was found between the number of cortices demonstrating bridging callus [on both anteroposterior (AP) and lateral views] at the time of fixator removal and the rate of refracture. Fractures showing fewer than three cortices of bridging callus had a three (33%) in nine rate of refracture, whereas fractures with three or four cortices of bridging callus had a two (4%) of 57 rate of refracture.