Femoral shaft fracture fixation and chest injury after polytrauma

Impact of a Femoral Fracture on Outcome after Traumatic Brain Injury-A Matched-Pair Analysis of the TraumaRegister DGU®

Traumatic brain injury (TBI) is the leading cause of death and disability in polytrauma and is often accompanied by concomitant injuries. We conducted a retrospective matched-pair analysis of data from a 10-year period from the multicenter database TraumaRegister DGU^® to analyze the impact of a concomitant femoral fracture on the outcome of TBI patients. A total of 4508 patients with moderate to critical TBI were included and matched by severity of TBI, American Society of Anesthesiologists (ASA) risk classification, initial Glasgow Coma Scale (GCS), age, and sex. Patients who suffered combined TBI and femoral fracture showed increased mortality and worse outcome at the time of discharge, a higher chance of multi-organ failure, and a rate of neurosurgical intervention. Especially those with moderate TBI showed enhanced in-hospital mortality when presenting with a concomitant femoral fracture (p = 0.037). The choice of fracture treatment (damage control orthopedics vs. early total care) did not impact mortality. In summary, patients with combined TBI and femoral fracture have higher mortality, more in-hospital complications, an increased need for neurosurgical intervention, and inferior outcome compared to patients with TBI solely. More investigations are needed to decipher the pathophysiological consequences of a long-bone fracture on the outcome after TBI.

Factors influencing management of bilateral femur fractures: A multicenter retrospective cohort of early versus delayed definitive Fixation

INTRODUCTION

The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries.

METHODS

Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit.

RESULTS

Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p<0.01), higher admission lactate (4.4 and 3.0; p<0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p<0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (X² statistic: institution: 45.6, ISS: 8.83, lactate: 6.77, GCS: 0.94).

CONCLUSION

In this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries.

LEVEL OF EVIDENCE

Level III.

Surgical strategy for femoral shaft fractures in severely injured patients: A 13-year experience from a tertiary trauma centre

BACKGROUND

The treatment strategy of femoral shaft fractures in polytraumatised patients has evolved over the years and led to improved outcomes for these patients. However, there is still controversy regarding the optimal treatment strategy and surgical care can differ markedly from one country to another. We investigate the surgical treatment strategy (Early Definitive Care (EDC) or Damage Control Orthopaedics (DCO)) implemented in the care of severely injured patients with femoral shaft fractures treated at a single tertiary trauma centre in southern Finland and factors affecting decision making.

METHODS

The Helsinki Trauma Registry (HTR) was used retrospectively to identify severely injured patients (New Injury Severity Score [NISS] ≥ 16) treated from 2006 through to 2018 with concomitant femoral shaft fractures. Patients <16 years old, with isolated head injuries, dead on arrival and those admitted >24 h following the injury were excluded. Based on their initial surgical management strategy, femoral fracture patients were divided into EDC and DCO groups and compared.

RESULTS

Compared to other trauma-registry patients, those with femoral shaft fractures are younger (30.9 ± 15.9 vs. 47.0 ± 19.7, p<0.001) and more often injured in road traffic accidents (64.1% vs. 34.4%, p<0.001). The majority (78%) of included patients underwent EDC. Patients who underwent DCO were significantly more severely injured (NISS: 40.1 ± 11.5 vs. 27.8 ± 10.1, p<0.001) with longer lengths of stay in ICU (15.4 ± 9.8 vs. 7.5 ± 6.1 days, p<0.001) and in hospital (29.9 ± 29.6 vs. 13.7 ± 11.4 days, p<0.001) than patients treated with EDC. Decision making was based primarily on injury related factors, while non-injury related factors may have contributed to choosing a DCO approach in a small number of cases.

CONCLUSION

Early definitive care is the prevailing treatment strategy in severely injured femoral shaft fracture patients treated at a tertiary trauma centre. Patients treated with DCO strategy are more severely injured particularly having sustained worse intracranial and thoracic injuries. In addition to injury related factors, treatment strategy decision making was influenced by non-injury related factors in only a minority of cases.

Retrograde femoral nails for emergency stabilization in multiply injured patients with haemodynamic instability

Introduction

The purpose of this study is to retrospectively evaluate the immediate effect of retrograde intramedullary femoral nail (RIMFN) fixation technique on patient's hemodynamic status as documented by vital signs (blood pressure and pulse) intraoperatively in all patients with femoral shaft fractures with multiple injuries and hemodynamic instability who were treated with RIMFN at our institution on emergency basis as part of damage control orthopaedics.

Patients and methods

A retrospective review of intra operative vital signs obtained from patient records was completed at a Level 1 trauma center in a university hospital.

In all, 11 multiply injured patients with (14) femur fractures with hemodynamic instability were identified. Of those, 3 had bilateral femur fractures. Closed reduction and retrograde femoral nailing without proximal locking was performed to achieve immediate skeletal and haemodynamic stability. Pulse rate and BP measurements were noted for all patients starting from the time patient would enter the operating room till the patient was shifted back to the recovery ward.

Results

The average cohort age was 28 years (20–36 years). The average Injury Severity Score was 28 (16–50). Statistically significant improvement in pulse rate and blood pressure was noted following femoral fracture fixation with intramedullary nail. No cases of infection or symptomatic fat or pulmonary embolism were encountered. One patient required exchange nailing for non-union and one femur underwent later lengthening.

Conclusions

Retrograde Intramedullary femoral nail can be an effective alternative to external fixator as damage control device and is associated with immediate improvement in vital signs (pulse and blood pressure) intra operatively.

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Reversal of shock is important determinant of outcome in multiply injured patients.

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Retrograde femoral nailing achieves immediate haemodynamic stability.

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Retrograde nailing as damage control device has low morbidity and mortality.

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Retrograde nailing without proximal locking is rapid, safe, effective procedure.

Early Surgical Stabilization of Complex Chest Wall Injuries Improves Short-Term Patient Outcomes

BACKGROUND

This study aimed to assess the outcome of patients undergoing internal fixation of complex rib fractures in a U.K. major trauma center.

METHODS

A retrospective analysis was performed on all patients undergoing operative fixation of rib fractures from March 2014 to May 2016. Outcome measures included hospital length of stay, intensive care unit (ICU) admission, mechanical ventilation, infection, and mortality.

RESULTS

One hundred and two patients (66 male patients and 36 female patients, with a median age of 62 years) underwent rib fracture fixation during the study period. The causes of trauma were road traffic accidents in 39 patients (38%), a fall from a substantial height in 38 patients (37%), and a fall down stairs in 21 patients (21%). Thirty-eight patients (37%) had isolated chest trauma, and 64 patients (63%) had additional injuries. Fifty-three patients (52%) required ICU admission with a mean ICU stay of 4.7 days (range, 1 to 34 days). The median hospital length of stay was 10.6 days (range, 3 to 51 days). Patients with additional injuries (p = 0.01) and those requiring mechanical ventilation (p < 0.0001) stayed significantly longer. Sixty-five patients (64%) underwent rib fixation within 48 hours of the injury, and 37 patients (36%) underwent the surgical procedure after 48 hours. A surgical procedure within 48 hours resulted in a shorter ICU stay (p = 0.01), fewer cases of pneumonia (p = 0.001), reduced duration of mechanical ventilation (p = 0.03) and fewer tracheostomies (p = 0.02), and shorter hospital length of stay (11.5 compared with 17.3 days; p = 0.008).

CONCLUSIONS

Surgical stabilization of multiple rib fractures may improve the outcome in patients with multiple injuries and isolated chest wall trauma. Early surgical fixation leads to shorter length of stay and better outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A new multiple trauma model of the mouse

Background

Blunt trauma is the most frequent mechanism of injury in multiple trauma, commonly resulting from road traffic collisions or falls. Two of the most frequent injuries in patients with multiple trauma are chest trauma and extremity fracture. Several trauma mouse models combine chest trauma and head injury, but no trauma mouse model to date includes the combination of long bone fractures and chest trauma. Outcome is essentially determined by the combination of these injuries. In this study, we attempted to establish a reproducible novel multiple trauma model in mice that combines blunt trauma, major injuries and simple practicability.

Methods

Ninety-six male C57BL/6 N mice (n = 8/group) were subjected to trauma for isolated femur fracture and a combination of femur fracture and chest injury. Serum samples of mice were obtained by heart puncture at defined time points of 0 h (hour), 6 h, 12 h, 24 h, 3 d (days), and 7 d.

Results

A tendency toward reduced weight and temperature was observed at 24 h after chest trauma and femur fracture. Blood analyses revealed a decrease in hemoglobin during the first 24 h after trauma. Some animals were killed by heart puncture immediately after chest contusion; these animals showed the most severe lung contusion and hemorrhage. The extent of structural lung injury varied in different mice but was evident in all animals. Representative H&E-stained (Haematoxylin and Eosin-stained) paraffin lung sections of mice with multiple trauma revealed hemorrhage and an inflammatory immune response. Plasma samples of mice with chest trauma and femur fracture showed an up-regulation of IL-1β (Interleukin-1β), IL-6, IL-10, IL-12p70 and TNF-α (Tumor necrosis factor- α) compared with the control group. Mice with femur fracture and chest trauma showed a significant up-regulation of IL-6 compared to group with isolated femur fracture.

Conclusions

The multiple trauma mouse model comprising chest trauma and femur fracture enables many analogies to clinical cases of multiple trauma in humans and demonstrates associated characteristic clinical and pathophysiological changes. This model is easy to perform, is economical and can be used for further research examining specific immunological questions.

Inflammatory response after nailing

Intramedullary nailing, as the gold standard stabilisation method of most long bones, has been tailed by its extensive use as the basic tool of investigating the immune response to trauma in many large and small animal models, as well as at the clinical setting. Over the last few decades a complex map of interactions between pro and anti-inflammatory pathways has been the result of these significant global research efforts. Parallel to the evolution of modern nailing and reaming techniques, significant developments at the fields of other disciplines relevant to trauma care, has improved the contemporary management of injured patients, challenging previous concepts and altering clinical barriers. The current article aims to summarise the current understanding of the effect of instrumenting the medullary canal after trauma, and hint on potential future directions.

Surgical Outcomes of Biologic Fixation for Subtrochanteric Fracture Using Locking Compression Plates

PURPOSE

This study aimed to evaluate the surgical outcomes of biologic plating using locking compression plate-distal femur (LCP-DF) in patients with subtrochanteric fracture of the femur.

MATERIALS AND METHODS

Between January 2010 and December 2013, 28 consecutive patients with subtrochanteric fractures of the femur, treated with biologic fixation using LCP-DF, were enrolled. Preoperative values, including patient age, sex, body mass index, fracture type, type of lung injury, and surgical timing from injury to surgery, were retrospectively evaluated. Radiologic assessments included time to union, coronal alignment, rotational alignment, and complications such as implant breakage and screw breakage. Adverse events, including postoperative fat embolism and adult respiratory distress syndrome, infection during the follow-up period, and walking ability at the last follow-up visit, were assessed.

RESULTS

Union was achieved in 27 patients (96.4%) after a mean duration of 5.4 months (range, 3-14 months). No patients developed fat embolism or adult respiratory distress syndrome during the hospitalization period of this study.

CONCLUSION

Biologic fixation using locking compression plates may represent a safe surgical option which can be utilized in patients with subtrochanteric fracture regardless of injury severity, surgical timing, fracture type, and presence of lung injury.

Early intramedullary nailing of femoral shaft fracture on outcomes in patients with severe chest injury: A meta-analysis

Early intramedullary nailing (IMN) within the first 24 hours for multiply injured patients with femoral fracture and concomitant severe chest injury is still controversial. This review aimed to investigate the association between early IMN and pulmonary complications in such patients. We searched the literature up to Jan 2016 in the main electronic databases (PubMed, Web of Science, Cochrane library databases) to identify eligible studies. Data were extracted and analyzed using a Mantel-Haenszel method with random-effects model to estimate pooled odds ratio (OR) and 95% confidence intervals (CIs). Seven retrospective cohort studies were identified eventually. The pooled estimates demonstrated that the application of early IMN did not significantly increase the risk of adult respiratory distress syndrome (ARDS) (OR, 0.65; 95% CI: 0.38-1.13), mortality (OR, 0.79; 95% CI: 0.43-1.47), pneumonia (OR, 0.92; 95% CI: 0.55-1.54), multiple organ failure (MOF) (OR, 0.87; 95% CI: 0.45-1.71) and pulmonary embolism (OR, 1.81; 95% CI: 0.28-11.83). In subgroup analysis according to the type of IMN (reamed or undreamed), we did not find any significant difference either. Our results indicated that early IMN of femoral shaft fracture was not associated with increased rates of pulmonary complications in severe chest-injured patients.

Early intramedullary nailing for femoral fractures in patients with severe thoracic trauma: A systemic review and meta-analysis

PURPOSE

Early intramedullary nailing (IMN) within the first 24 h for multiply injured patients with femoral fracture and concomitant thoracic trauma is controversial. Previously published studies have been limited in size and their outcomes have been inconclusive. A meta-analysis was conducted to evaluate the available data in order to guide care and help improve the outcomes for these patients.

METHODS

We searched the literature up to December 2011 in the main medical search engines and identified 6 retrospective cohort studies that explored the safety of early IMN in patients with both femoral fracture and chest injury. Our primary outcome was the rates of pulmonary complication (pneumonia, adult respiratory distress syndrome, fat embolism syndrome), multiple organ failure (MOF) and mortality.

RESULTS

We found no statistically significant difference in the rate of pulmonary complications, MOF or mortality in the patients treated with early IMN.

CONCLUSION

Early IMN for femoral fractures does not increase the mortality and morbidity in chest- injured patients in the studies analyzed.

Development of a scoring system based on conventional parameters to assess polytrauma patients: PolyTrauma Grading Score (PTGS)

BACKGROUND

The impact of conventional laboratory data to identify polytrauma patients at risk of complications is established. However, it has not been assessed in terms of prognostic accuracy for systemic complications (ARDS, organ failure). We therefore assessed the most predictive parameters for systemic complications and developed a scoring system for early grading of polytrauma patients.

METHODS

A population based trauma registry was used.

INCLUSION CRITERIA

age >16 years, Abbreviated Injury Score (AIS) of the abdomen or chest ≥ 3 points and treatment in an intensive care unit, or Injury Severity Score (ISS) ≥ 16 points. The primary endpoint was hospital mortality. Patients were graded according their risk of death: low risk of death (5-14% mortality), intermediate risk patients (15-39% mortality) and high risk (>40%). Routine clinical and laboratory parameters on admission were assessed to determine their specific relevance to describe the risk profile of the patient. Based on these data, a scoring system for the description of the clinical status was developed. Statistical analysis included uniand multivariate analysis.

RESULTS

11.436 patients were included, the mean ISS was 22.7 ± 11.2 points, 73% were male, and 95.6% had blunt injuries. The most sensitive parameters were found to be the following ones: systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered. The multivariate analysis revealed the following threshold levels: BP 76-90 mmHg: r = 0.249, OR 1.283: Base deficit 8-10 r = 0.474, OR 1.606; INR 1.4-2 r = 0.160, OR 1.174; NISS 35-39 r = 0.9, OR 2.46; pBRC 3-14: r = 0.671, OR 1.957. The following ranges of score values were found to be associated with different patient status: <6 points: stable patients; 6-11 points: borderline condition; >11 points: unstable patients. When using this score, 80.6% were stable, 14.6% in a borderline condition and 4.8% unstable.

CONCLUSION

We developed a scoring system to discriminate polytrauma patients on admission that are at risk of systemic complications. Systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered are able to provide a prognosis of patients at risk of posttraumatic complications. Further prospective studies should be performed to verify this new scoring system.

Emergency department evaluation and treatment of acute hip and thigh pain

Although the incidence of hip fractures is decreasing, the overall prevalence continues to increase because of an aging population. People older than 65 suffer fractures at a rate of 0.6% per year--2% per year for persons older than 85. One in 5 patients suffering a hip fracture will die within a year. Additionally, the emergency physician must consider entities such as avascular necrosis, compartment syndrome, and muscular disruption. This article reviews patterns and complications of acute hip and thigh injuries and clinically relevant diagnostic, anesthetic, and treatment options that facilitate timely, appropriate, and effective emergency department management.

Role of Damage Control Orthopedics and Early Total Care in the Multiple Injured Trauma Patients

The care of multiply injured patients with orthopedic injuries has evolved from prolonged periods in traction to early total care (ETC). ETC is advantageous in ease of nursing care and aiding patient recovery. However, concerns have been raised that this ‘second hit’ of surgery places these severely injured patients at risk of excessive inflammatory responses that can lead to systemic inflammatory response syndrome (SIRS). Damage control was initially used in abdominal trauma but has been adapted for use in orthopedics. The mainstay of treatment involves external fixation of long bone and pelvic fractures which acts to defer definitive fixation until physiologic stability is restored. The indications for implementing each approach are not clear and this article provides a narrative review of the topic.

Mitochondrial DNA induces inflammation and increases TLR9/NF-κB expression in lung tissue

Mitochondrial DNA (mtDNA) contains unmethylated CpG motifs that exhibit immune stimulatory capacities. The aim of this study was to investigate whether mtDNA activates the Toll-like receptor 9 (TLR9)/nuclear factor-κB (NF-κB) pathway, thereby contributing to post-traumatic systemic inflammatory response syndrome (SIRS) and lung injury in rats. The effects of mtDNA on macrophage culture were examined in order to elucidate the putative cellular mechanisms. Rats and macrophage cultures were treated with phosphate-buffered saline, nuclear DNA, or mtDNA for 2, 4, 8 and 24 h. Histological analysis of lung tissue was undertaken following hematoxylin and eosin staining, and cytokine levels were assessed by ELISA. NF-κB and IκB-α phosphorylation levels, as well as TLR9 protein expression were determined by western blot analysis; NF-κB, IκB-α and TLR9 mRNA levels were analyzed by RT-PCR. A greater degree of inflammation and lung injury was observed in response to mtDNA. In addition, mtDNA increased serum tumor necrosis factor-α, interleukin (IL)-6 and IL-10 levels in vivo and increased their secretion by cultured macrophages (p<0.05). In lung tissue, mtDNA increased NF-κB, IκB-α and TLR9 mRNA levels (p<0.05); it also increased phosphorylated NF-κB p65 and TLR9 protein levels in the macrophage cultures. Thus, mtDNA may be part of the danger-associated molecular patterns, contributing to the initiation of sterile SIRS through the activation of the TLR9/NF-κB pathway and the induction of pro-inflammatory cytokine production.

The evolution of damage control orthopedics: current evidence and practical applications of early appropriate care

This article summarizes the evolution of literature and practice related to fracture care in polytrauma patients. Particular emphasis is given to the management of femoral shaft fractures and the concept of damage control in these complex patients. The application of these guidelines in common clinical practice is also discussed.

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.