Pulmonary aspects of treatment of long bone fractures in the polytrauma patient

Distal Radius Fractures and the Dorsal Spanning Plate in the Management of the Polytraumatized Patient

Distal radius fractures are some of the most common fractures treated by the orthopaedic surgeon. There are a variety of methods of fixation to treat these fractures; however, in patients with polytrauma and in high-energy fracture patterns, fixation options can be limited. In the past, these fractures were treated with plaster, Kirschner wires, or external fixators that were fraught with complications. The dorsal spanning plate is an excellent option in the treatment of high-energy fractures and patients with polytrauma, fractures with dorsal or volar comminution, fracture dislocations, and shear injuries, and in geriatric patients with poor bone quality. The dorsal spanning plate not only allows for fixation of these complex fractures but also allows for weight-bearing through the wrist, an advantage for patients with concomitant lower extremity fractures and geriatric patients who need mobility aides. Understanding the risks and benefits of dorsal spanning plates and their use for the treatment of polytraumatized patient is a vital base of knowledge for the orthopaedic traumatologist.

Fat Embolism Syndrome

Fat embolisms are fat globules that enter the circulatory system, typically through trauma, that may or may not lead to the development of fat embolism syndrome (FES), a rare and ill-defined diagnosis that can cause multiorgan failure and death. The exact mechanism of FES remains unknown, although several theories support the involvement of inflammatory response activation that contributes to characteristic clinical findings. There is no gold standard for diagnosis of FES, and treatment at this time remains primarily supportive. Early recognition of FES symptoms is the most beneficial nursing intervention for combating this serious disorder.

Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics

BACKGROUND

Femoral shaft fractures are associated with acute respiratory distress syndrome (ARDS). The idea that primary intramedullary nailing increases the incidence of ARDS has theoretical support. Our approach to treating femoral fractures in patients with multiple traumatic injuries is to perform reamed nailing after adequate resuscitation has been shown by normalizing lactate plus optimized ventilatory and hemodynamic parameters. Damage control orthopedics (DCO) with primary external fixation usually is reserved for those rare patients who do not respond to resuscitation. Our hypothesis was that this approach yields a low rate of ARDS.

METHODS

A prospective trauma database was searched for all femoral shaft fractures treated at a Level I trauma center during a 3-year period, yielding 582 patients. Exclusion criteria included death before treatment (n = 9), age younger than 16 years (n = 16), age older than 65 years (n = 35), fractures that were not amenable to nail fixation (n = 31), shaft fractures treated with a plate (n = 3), patients with bilateral femoral shaft fractures who had a primary nail placed in one femur and an external fixator on the other limb (n = 1), and patients with an Injury Severity Score (ISS) <or=17 (n = 260), leaving 227 patients in the final study group. We defined ARDS as a mean partial pressure of oxygen/fraction of inspired oxygen <200 for 5 or more consecutive days. We compared our results with the results of a similar design in the literature.

RESULTS

Of the 227 patients with ISS >17, only 12% were initially treated with DCO, and 88% were treated with primary reamed nailing. The 227 patients achieved successful early resuscitation as shown by lactate values that decreased significantly on the operative day compared with presenting values (p < 0.05). ARDS rates were low, including rates for the subgroup of patients with lung injury (thoracic Abbreviated Injury Scale score >2, n = 175) who were treated with nailing and had an ARDS rate of 2.0% and a death rate of 2.0%. The ARDS rate for the most severely injured patients who underwent nailing (ISS >28, thoracic Abbreviated Injury Scale score >2, n = 78) was only 3.3%, and 1.7% died.

CONCLUSIONS

In the context of resuscitation before reamed intramedullary nailing of femoral shaft fractures, our rate of ARDS was lower (p < 0.001) than that of a similar study reported in the literature in which the DCO approach was used in up to 36% of patients (p < 0.001) and was more in keeping with previously reported rates of ARDS. This remained true despite frequent use of early reamed femoral nailing and infrequent use of DCO. An explanation for the discrepancy between the centers might be differences in preoperative resuscitation or medical care provided to treat shock.

Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery

In the treatment of polytrauma patients, multiple studies have shown how the timing and the type of the initial surgery of long bone fractures influence the incidence of systemic complications. Database analyses documented that unduly long surgical procedures undertaken early after trauma increase the risk of acute respiratory distress syndrome (ARDS), especially when femoral shaft fractures are stabilized. Animal research and prospective clinical studies also support the fact that the type of stabilization of a femoral shaft fracture may influence the systemic response to trauma. Reamed intramedullary reaming and nailing for a femoral shaft fracture is associated with an increased risk of pulmonary fat embolization from the medullary canal. This can result in pulmonary compromise if certain cofactors are also present. Modified reamers have been developed to reduce this side effect. The mediating effects are immunologic changes, varying according to the magnitude of the surgical procedure. Pro-inflammatory markers (e.g., Interleukins) may be used to assess the inflammatory response to injury as well as the magnitude of surgery and the systemic impact induced by surgery. Serum levels of such markers can be used clinically to tailor the amount of surgery that is performed to the clinical condition of the patient. The potentially negative impact of excessive surgery in high-risk patients can be avoided by using a new grading system for the assessment of the clinical status of the injured patient. Most recently, a large prospective randomized multicenter study has documented that this grading system is effective for identifying these borderline patients, and that in the borderline patient a staged surgical approach, such as temporary femoral stabilization with an external fixator, reduces the incidence of systemic complications. This work has changed the surgical management of multiply injured patients toward an approach that is tailored to the clinical condition of the patient, as indicated by well-defined clinical parameters as well as objective measurements of serum cytokine levels.

Application of clinical proteomics in diagnosis and management of trauma patients

Poly-trauma remains a medical entity with major implications, for patient's morbidity, mortality and healthcare economics. Advances in molecular medicine have improved diagnostic techniques in detecting devastating complication after major trauma. Patients at high risk of multiple organ dysfunction syndrome (MODS) or adult respiratory distress syndrome (ARDS), could be identified early, monitored and treated. Proteomics is the systematic evaluation of proteins produced by the cell under normal or pathological circumstances. Investigating protein production will allow us to identify and modify disease natural history and treatment. In this review, we summarise the proteomic methods currently applied in trauma research.

Surgical stress response

Recent advances in molecular medicine have allowed the characterization and quantification of inflammatory cascades following surgery and trauma. Activation of immune cells is followed by the release of various cytokines as well as by migration of leukocytes into inflamed tissues. Various methods have been developed in order to modulate the immune-inflammatory system and at the same time to prevent overreaction and unexpected complications. In this context, the magnitude of surgical stress exerted on the patient is of paramount importance. Several factors, either controllable or not, are known to contribute to the development and amplification of the 'surgical stress response'. Therefore, they should be taken into consideration by both surgical practitioners and other medical specialties involved in the management of the traumatised patient.

Compartment Pressures, Limb Length Changes and The Ideal Spherical Shape: A Case Report and In Vitro Study

BACKGROUND

Changes in compartment pressures have been noted during traction, reduction, and intramedullary fixation of fractures. Changes in limb length and compartment volumes are suspected contributing factors. Pressure and volume changes are known to be related in animal models. If an acute increase in limb length can adversely affect compartment pressures, reversal or delay of such an increase in length may be of value in the treatment and prevention of compartment syndromes.

METHODS

A clinical example is presented in which a documented anterior compartment syndrome was successfully treated by deliberate loss of fracture reduction, without fasciotomy. Fracture reduction was later restored when swelling subsided. Anterior compartment pressures were recorded in response to limb length changes in osteotomized cadaver limbs stabilized with external fixation.

RESULTS

The pressure in the anterior compartment varies directly with acute changes in the length of the leg, in an experimental model. Mathematical analysis indicates that available volume within a compartment varies inversely with acute changes in its length.

CONCLUSIONS

Fracture reduction that restores the length of an acutely injured extremity may increase pressure in the compartments by decreasing available volume. Deliberate loss of reduction can decrease pressure in the compartments, offering a potential alternative to fasciotomy in the care of compartment syndrome in cautiously selected, monitored patients. Early stabilization without reduction, followed by delayed reduction, may be preferable during treatment of fractures prone to compartment syndrome. Decreased available compartment volume may contribute to compartment syndrome after distraction with intramedullary rods or skeletal traction.

Evolving trends in the care of polytrauma patients

Management of polytrauma patients has changed considerably in recent years. This is in keeping with the developments that have occurred in the fields of fracture fixation techniques and intensive care. Prior to the 1970s, patients with multiple injuries were treated non-operatively, as it was believed that they were too ill to withstand surgery. Around this time, literature appeared to suggest that these patients had high rates of complications as a result of prolonged recumbency. Fracture fixation techniques were also developing rapidly, and these events led to the advent of early fracture stabilisation of multiply injured patients, known as early total care. In the following decade, the surgical world came to recognise that early stabilisation of skeletal injuries produced poor results in certain patients. The concept of 'damage control' surgery was introduced for multiply injured patients. The current era may give way to new methods as our understanding of the pathophysiology of polytrauma improves.

The immuno-inflammatory response to trauma

The systemic inflammatory response syndrome is a well recognized physiological entity being part of our homeostatic mechanisms. It represents the cascade of inflammatory reactions initiated in the immediate aftermath following trauma reflecting the state of alertness that our body undergoes in order to fight for survival. A variety of inflammatory mediators and cellular elements are involved during this process interacting amongst each other. This allows communication between the different organ systems and thus regulating local and systemic responses. We have just begun to characterize and quantify the immuno-inflammatory response to trauma and this has opened new horizons in the way we understand the pathophysiological response to injury. As our knowledge evolves new therapeutic agents and innovative treatment plans will be developed contributing to increased survival rates in patients with multiple injuries.

Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making

Grading of the clinical status in patients with multiple trauma is important regarding the treatment plan. In recent years, 4 different clinical conditions have been described: stable, borderline, unstable, in extremis. Clinical parameters have been widely used in patients with penetrating injuries, and 3 categories were found to be important: shock, hypothermia, coagulopathy. However, in blunt trauma patients, the role of conventional parameters for decision making regarding the timing of fracture treatment is poorly described. After blunt trauma, additional factors seem to play a role, because the injuries affect multiple body regions. These additional factors are summarized under the term, "soft-tissue injuries," which may include the soft tissues of the extremities, lung, abdomen, and pelvis. The study describes four pathophysiologic cascades that are relevant to the clinical conditions listed above. Threshold values for separation of the patient conditions are documented, leading to a staged surgical strategy.