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When Should Head-Injured Patients with Long-Bon Fractures Undergo Surgical Treatment of Their Fractures

Alex B. Valadka

BRIEF ANSWER

Background

As recently as the middle of the 20th century, patients who sustained femur fractures had a good chance of never returning to gainful employment.¹ These injuries were generally managed by skeletal traction or plaster immobilization, with frequently poor results. Prolonged, forced immobilization in the supine position predisposes patients to the complications of immobility: deep vein thrombosis, pulmonary embolism, decubitus ulcers, generalized deconditioning, atelectasis, pneumonia, etc.² Moreover, continued motion of the ends of a fracture causes pain that may contribute to enforced immobility.¹ Persistent soft tissue injury from ongoing motion at the fracture site can also lead to the liberation of multiple inflammatory mediators.^1,2 Fat emboli syndrome was also said to be a frequent occurrence, partly because of entry of fat droplets and tissue thromboplastins into the bloodstream through torn marrow veins that remain open after injury because their walls remain adherent to bone.³

The development of effective methods of fracture fixation in the 1940s allowed for immediate anatomic reduction, with reduced pain and increased patient mobility.^1,2 By the late 1970s, the superiority of prompt operative fixation over traditional nonoperative management of femur fractures had become accepted.^1,2,4

In some older studies, ” early“ surgery was defined as fixation within several weeks of injury. The time period that is considered ” early“ has become progressively shorter, with some studies extolling the virtues of fixation within 48 or even 24 hours of injury or of hospital admission.5–7 Reported benefits include improved pulmonary function and shorter hospital and intensive care unit (ICU) stays. The acceptance of the concept of a trauma-activated systemic inflammatory response that may peak several days after injury has likely contributed to the shortening of the interval between injury and fixation because it has been suggested that fixation of fractures is of most benefit if performed early in the inflammatory cascade, perhaps because early fixation may help prevent or minimize the inflammatory response.

At about the same time that prompt fixation of these fractures became established as the preferred method of treatment, the concept of potential secondary brain injury from such insults as hypotension and hypoxia became firmly established. Impairment of cerebral autoregulation after even relatively minor injury may persist for some time after a patient has been stabilized, with a corresponding potential for heightened susceptibility to secondary cerebral insults (class II and class III data).^8–10

For these reasons, aggressive resuscitation of patients with traumatic brain injury (TBI) and the need for meticulous monitoring in the ICU to prevent and promptly treat secondary cerebral insults often conflict with plans to take these patients to early surgery for repair of long bone fractures. Confounding this issue further is the fact that different studies of the effects of timing of fracture fixation have used different surgical techniques for fixation and different methods of assessing the effect of timing of surgery. Orthopedic and systemic injuries of different types and severities have often been lumped together, as have injuries to different bones.

This chapter evaluates the published literature in an attempt to formulate a recommendation about the optimal timing of surgical fixation of long bone fractures in TBI patients. All studies cited in this chapter report class III data unless otherwise specified.

Literature Review

Benefits of Early Fixation

In 1977, Riska et al¹¹ retrospectively reviewed 47 multiply injured patients with at least two long bone fractures that were treated by ” early“ fixation, defined as fixation within 2 weeks of injury. They concluded that surgery was preferable to conservative treatment.

In a report of a larger series published in 1982, Riska and Myllynen³ concluded that early surgery is helpful in reducing the frequency of clinical fat embolism syndrome. However, the time period of ” early“ operation was not specified.

Seibel et al¹² analyzed the effects of early versus delayed internal fixation of femur or acetabular fractures in retrospective analyses of prospectively collected data from 56 severely injured multiple trauma patients (class II data). Patients who underwent immediate surgery (time not specified) were compared with two groups who had surgery either 10 or 30 days after injury. Immediate fixation was more beneficial than delayed surgery in terms of a constellation of findings associated with what the authors call the pulmonary failure-septic state: pulmonary function, white blood cell counts, fevers, positive blood cultures, etc.

Lozman et al¹³ prospectively randomized 18 multiply injured patients with tibia or femur fractures to either immediate fixation (time not specified) or conservative treatment with plaster casts or skeletal traction (class II data). During the 4 days of the study period, cardiac index was higher and pulmonary shunt was lower in the immediate fixation group. The frequency of detection of fat macroglobules in pulmonary blood did not differ between groups.

Bone et al¹⁴ prospectively randomized 178 patients with femur fractures to either early (within 24 hours) or late (beyond 48 hours) stabilization of their fractures. The number of patients with severe TBI is not specified but is apparently small. Among patients with isolated femur fractures, late stabilization was associated with a longer and more expensive hospital stay, but pulmonary complications were infrequent in both groups. In multiply injured patients, delayed stabilization was associated with a higher incidence of pulmonary complications [adult respiratory distress syndrome (ARDS), fat embolism, and pneumonia] and with longer and more expensive hospital stays than early stabilization. Statistical significance of the results is not reported. Long-term functional assessments were not performed. The retrospective nature of the data analyses and group assignments makes this a class II study.

Drawbacks of Early Fixation

Some reviews have suggested that early fracture fixation may have some drawbacks. Pape et al¹⁵ reported that intramedullary femoral nailing within 24 hours of trauma in patients with preexisting pulmonary injury was associated with a higher mortality rate (21% versus 4%) and a higher incidence of ARDS (33% versus 7.7%) than delayed nailing, but in patients without pulmonary injury, duration of intubation and ICU stay were lower when early surgery was performed. Along the same lines, Poole et al1 concluded that the risk of pulmonary complications was not related to the timing of fracture fixation but was strongly related to the severity of head and chest injuries.

Fakhry et al¹⁶ reviewed 2805 patients with femoral shaft fractures in a statewide hospital discharge database. Although the mortality rate was higher for the 31% of patients treated nonsurgically, reasons for the choice of nonoperative management were not specified and may reflect overall worse prognoses in these patients. Among the more severely injured patients (Injury Severity Scale scores ≥15), surgery between 2 and 4 days was associated with the lowest mortality rates and shortest hospitalizations. A trend toward higher mortality and longer hospitalizations was seen when these patients underwent surgery within 1 day. The authors suggested that further study and individualized management were warranted in the more severely injured patients.

Early Fixation in Traumatic Brain Injury Patients

BENEFITS

Many reports that attempt to demonstrate the benefits (or lack of harm) of early fracture fixation in TBI patients suffer from major methodologic flaws.^17–20 For example, these reports are often based on retrospective reviews of patient charts or hospital trauma registries. In many of these studies, severity of head injury is assessed not on a functional scale like the Glasgow Coma Scale (GCS), but rather on an anatomic scale like the Abbreviated Injury Scale. These studies often include a large number of patients with mild TBI who might be more physiologically capable of undergoing major orthopedic surgery and who might also be able to ” conceal“ any subtle but still important deficits suffered as a result of surgery. Another common weakness of these retrospective studies is that long-term functional outcomes—both neurologic and orthopedic—are not determined at standardized time points (if even reported at all); instead, GCS scores at discharge are reported, perhaps because such information is often the only data available to the retrospective reviewer. An important drawback to the use of GCS scores as an outcome tool is that patients who are severely disabled or even vegetative (who would be regarded as having unfavorable outcomes by most investigators) can have relatively high GCS scores. Furthermore, the number of days postinjury at which patients are discharged can vary widely, as can their neurologic status at hospital discharge. Thus, use of time of hospital discharge as a standard reference point is not nearly as valid as use of a fixed number of weeks or months after injury.