Early definitive stabilization versus damage control orthopaedics for femur shaft fractures in the multiply injured patient

Background

The optimal timing and treatment of patients with femoral shaft fractures and associated head, thoracic, or abdominal injury remains controversial. This study examines the acute patient outcomes associated with the evolution of early total care to damage control orthopaedics for multiply injured patients with femoral shaft fractures.

Methods

This study was a retrospective comparison of two sequential protocols for the care of multiply injured patients with femoral shaft fractures. From 1993 to 1998 our institutional protocol for these patients consisted of early total care (ETC) with intramuscular nailing or femoral traction within 24 hours. From 1998 to 2003 we placed femoral external fixation on all polytrauma patients meeting specific injury criteria. Study inclusion criteria included severely injured skeletally mature patients (closed physes) with femoral shaft fractures. Patients were determined to be severely injured if they presented with an ISS ≥ 25, AIS of the head ≥ 3, or hypotension. All included patients received fracture stabilization within 24 hours of presentation. The cohort population was compared with respect to age, sex, and ISS. Primary outcome measures for comparison between these groups included mortality, pulmonary complications (ARDS score), and multiple organ failure (MOF score). The groups were also compared regarding operative time, ICU length of stay, and hospital length of stay.

Results

During the ETC treatment period 102 patients with femur shaft fractures were identified, 27 of which met the inclusion criteria. During the DCO period 202 patients were identified, 38 of which met the inclusion criteria. The patient groups were comparable regarding age, gender, and injury severity score. There was no difference between the groups in terms of ARDS incidence, lung scores, MOF incidence, MOF score, ICU LOS, or hospital LOS. The DCO group had a significantly shorter OR time.

Conclusion

In our experience the method of fracture fixation (DCO vs ETC) did not appear to impact the incidence of systemic complications (ARDS and MOF) in the polytrauma patient with an associated femoral shaft fracture. However, we feel that multi-disciplinary care is facilitated with DCO and that the decreased initial operative exposure appears to benefit specific subsets of patients. The debate over the optimal timing and method of femur fixation will continue until a treatment protocol can be validated based on a high-quality study with a large number of patients. This study provides the basis for a prospective, randomized, multicenter trail of DCO versus ETC for femur shaft fractures in multiply injured patients.