Kyle F. Dickson, M.D. M.B.A.
Professor Baylor College of Medicine
Southwest Orthopaedic Group, Houston, Texas
Timing of Fracture Fixation in
the Polytrauma Patient
Kyle Dickson MD, MBA
Professor Baylor College of Medicine
Southwest Orthopaedic Group, Houston, Texas
>5000 trauma admits with >1800
patients with ISS>15 (#1 ACS)
Lecture Goals
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Keep someone alive that would be
dead without you
Prioritize treatment to prevent killing
someone
Treat extremity injuries to return the
patient to a functional life
Topic Outline
What do we know?
The benefits of resuscitation
The vast majority of patients
benefit from early definitive long
bone stabilization
IM nailing of long bones has
systemic effects
Topic Outline
Occasional patients are hurt by
long bone nailing
There is a systemic inflammatory
response to major trauma
Topic Outline
What is unknown?
How to predict bad consequences
of long bone nailing
The optimal timing of fracture
repair for all patients
Topic Outline
The benefits of temporary
external fixation
The effect of a head injury
JA
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21 yo in MVA
Bilateral femur fractures, open tibia
L unstable pelvis, R T-type with pw
R rib fractures with a hemothorax
Splenic and liver laceration
SBP 88, HR 136, intubated
JA
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BD = 6 meq/l
Temp = 33°
Primary survey
A. Airway maintenance with
cervical spine protection
B. Breathing and ventilation
C.Circulation with hemorrhage
control
D.Disability: Neurologic status
E. Exposure/environment control:
undress patient but prevent
hypothemia
Morshed JBJS 2009
• Relative
risk of mortality treatment
weighted analysis
• Delay > 12 hours for femoral shaft
stabilization ↓ mortality 50%
(especially serious abdominal injury)
Problems
• Fixing
femur fractures may have
nothing to do with mortality – but
delay in fixation may be sicker
patients – selection bias
• Significant ↓ in mortality12-24h, 48120h and > 120 h - ? Not 24-48 h
Our Study
• Previous
mortality of bilateral femur
fractures 50% recently 25.9% (11.7%
for unilateral femur fracture)
• 6.7% (102/1519) mortality unilateral
• 20.0% (15/75) mortality bilateral
Our Study cont.
• Multivariate
logistic regression not
significant for femur fractures
• Highly significant for age group,
pedestrian accident, and ISS group
• ?fixed when stabilized and temporary
ex fix
Coagulopathy
Hypothermia
•  Ca2 (blood citrate)
• Acidotic
Lethal Triad – hemorrhage,
coagulopathy, inflamatory/metabolic
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Coagulopathy & Trauma
By the time of arrival at the ED, 28%
(2,994 of 10,790) of trauma patients
had a detectable coagulopathy that
was associated with poor outcome
(MacLeod et al., 2003)
INR vs Mortality
st
1 24 hrs in STICU
E a rly IC U IN R v s
P ro b a b ility o f D e a th
p ro b ab ility
1
p = 0 .0 2
0 .8
0 .6
0 .4
0 .2
0
1 .1
1 .3
1 .5
1 .7
1 .9
2 .1
2 .3
2 .5
2 .7
IN R
P = 0.02, ROC = 0.71
Hemostatic Resuscitation
Blood/FFP/Cryo/Plts 1:1 ratio
The benefits of resuscitation
Uncompensated shock gross signs of
circulatory deficiency (BP, HR, UO)
Compensated shock ongoing suboptimal
tissue perfusion
The heart and brain are protected while
the perfusion of other organs is
inadequate
Resuscitation - tissue acidosis eliminated
and aerobic metabolism restored
Emergent Extremity Issues
Neuro vascular exam
Splint extremities
Compartment syndrome
and dysvascular limbs
Major dislocations
Basic wound management
Retrospective data from the 1980’s
Early fracture fixation is good!
Bone and Johnson JBJS
1989
Parkland hospital – 178 patients with femur
fractures randomized to before 24 hours
or after 48 hours
Patients with ISS > 18 less pulmonary
complications (ARDS, FE, pneumonia)
Severely injured patients benefit the
most!!
Why does early fracture
stabilization help the lungs??
Reduce continued marrow emboli
Reduce pain and narcotic requirements
Eliminates traction and supine
positioning
Less atelectasis and decreased
pulmonary venous shunting
Primary IM femur fixation in MTP
with associated lung contusion –
a cause of ARDS
Pape et al JT 1993
106 pts with femur fracture and ISS > 18
In patients with chest trauma nailing
within 24 hours led to greater ARDS
(33% vs 7.7%) and mortality (21% vs
4%)
The vast majority of patients benefit
from early definitive long bone
stabilization
Retrospective studies
Prospective Bone and Johnson 1989
Early femoral fixation leads to:
Less complications
Less ICU
Less cost
Better outcome for the limb
There is no debate!!
IM nailing of long bones has
systemic effects
Robinson et al JBJS b 2001
Trans esophageal echo and invasive monitoring
during
IM nailing
Increase in PA pressure
Decrease in arterial oxygen partial pressure
Systemic change in markers of coagulation
Systemic Effects of Nailing
Brundage et al JT 2002
1362 patients over 12 years
Femur fixation < 24 hours - improved outcome even
with severe chest and head injuries
“Resuscitation and hemodynamic normalization are
essential parts of our protocol”
Only 65% of patients were physiologically ready
within 24H
Highest incidence of ARDS in group fixed between 2
and 5 days - a time of heightened inflammatory
response?
There is a systemic inflammatory
response to major trauma
Injury activates cell defense mechanisms, producing
mediators of coagulation and inflammation
Protect against infection
Remove damaged tissue
Initiate repair
Good!!
However severe inflammation my lead to organ
injury
Bad!!
The pro inflammatory response is
increased by primary IM nailing
Pape et al JT 2003
Prospective study - 35 patients
The systemic inflammatory response measured
by IL-6 was increased (55pg/ml-254pg/ml)
by immediate IM nailing but not by ex fx and
secondary nailing
No difference in clinical outcomes
1st hit (trauma)
FES
SIRS
2nd hit (Surgery, infection, more FES)
ARDS
MODS
MOF
MSOF
Occasional patients are hurt
by long bone nailing
Robinson et al JBJS b 2001
8/84 patients develop post op
pulmonary compromise (7
were prophylactic for
metastatic disease)
Can we detect a patient at risk??
Injury factors - High ISS, pulmonary injury,
severe abdominal injury, bilateral femur or
other multiple long bone injuries
Physiologic factors – Slow difficult
resuscitation, high transfusion
requirement, prolonged surgical time,
hypothermia, coagulopathy
Can we detect a patient at risk??
Genetic and biochemical markers –
Currently not practical or reliable
IL-6 (> 800 pg/ml) - most studied and
best correlates with outcome but
….
The optimal timing of fracture
repair for all patients
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Is it within 48 hours or greater
than five days?
“TOO SICK NOT TO FIX
FRACTURES”
Damage Control Surgery
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Philosophy
Stay out rather than get out of trouble
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Restore normal physiology at the
expense of normal anatomy
Damage Control
Bilateral femoral ex fix, tibial ex fix and
I&D at the bedside
DCO external fixation
-Stabilizes orthopedic injuries while
physiology improves
-Avoid a “second hit” by major
orthopedic procedures
-Fracture stability without
increased inflammatory response
The benefits of temporary
external fixation
DCO - Retrospective cohort studies
(Pape et al J Trauma 2002)
-Significant reduction in systemic
complications
-No increase in local
complications
Damage Control Orthopaedics
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Prevent 2nd hit (MOF, MSOF, SIRS,
ARDs)
Hgb < 8
Base Deficit > 5 mEq/l
Body temperature < 33º
INR > 1.5 (2.0 – 50% mortality)
Fix the femurs and the tibia within 48 hours
(lung)
L > 6hrs
Group S Group M Group L p
Ventilation
9.5
ICU stay
13.2
Hosp. stay 35.5
Death: MOF 36.4
11.0
15.7 0.04
10.9
28.6
31.8
18.5 n.s.
44.6 n.s.
46.6 0.04
German Trauma Registry
Timing
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Within 24-48 hours injuries most
mobile
2-5 days may be worst time to
operate
Soft tissue good (includes lung)
Positive fluid balance
Exchange to an IM rod safe?
Bhandari et al JOT 2005
-Pooled data from level 4 studies
-Average infection rate 3.6%
Pin drainage
The effect of a head injury
-Severity
of the head injury is the
greatest predictor of outcome
-ICP monitoring – Keep ICP below 20
-Systemic BP control – avoid
hypotension
-Put the two together! - CPP should be
> than 70 mm hg (mean arterial
minus ICP)
-No
Head injury and fracture
fixation
clear evidence that timing/type
of fracture fixation is an important
predictor of outcome
-Assume full neurologic recovery will
occur
-Who is doing your anesthesia and
judging resuscitation?
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Damage Control Orthopaedics
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Prevent
hit (MOF, MSOF, SIRS,
ARDs)
Hgb < 8
Base Deficit > 5 mEq/l
(pH<7.2,lactate>2)
Body temperature < 33º
INR > 1.5
Timing
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Within 24-48 hours injuries most
mobile
3-5 days may be worst time to
operate
Soft tissue good (includes
lung)(plafond – 28 days)
Positive fluid balance
Thank You