Kyle F. Dickson, M.D. M.B.A.

Professor Baylor College of MedicineSouthwest Orthopaedic Group, Houston, Texas

Timing of Fracture Fixation in the

Polytrauma Patient

Kyle Dickson MD, MBAProfessor Baylor College of Medicine

Southwest Orthopaedic Group, Houston, Texas

>5000 trauma admits with >1800 patients with ISS>15 (#1 ACS)

Lecture Goals• 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 OutlineWhat 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 OutlineOccasional patients are hurt by

long bone nailing

There is a systemic inflammatory response to major trauma

Topic OutlineWhat 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 fixationThe effect of a head injury

JA• 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

• 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, 48-120h 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

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 1st 24 hrs in STICU

Early ICU INR vsProbability of Death

0

0.2

0.4

0.6

0.8

1

1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.5 2.7

INR

pro

ba

bilit

y

p=0.02

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 perfusionThe 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’sEarly 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 emboliReduce 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 ARDSPape 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

stabilizationRetrospective studiesProspective Bone and Johnson 1989Early 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 NailingBrundage et al JT 2002

1362 patients over 12 yearsFemur 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 24HHighest 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 traumaInjury activates cell defense mechanisms,

producing mediators of coagulation and inflammationProtect against infectionRemove damaged tissueInitiate repair

However severe inflammation my lead to organ injury

Good!!

Bad!!

The pro inflammatory response is increased by primary IM nailing

Pape et al JT 2003Prospective study - 35 patientsThe 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

• Is it within 48 hours or greater than five days?

“TOO SICK NOT TO FIX FRACTURES”

Damage Control Surgery

• PhilosophyStay out rather than get out of trouble

• 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

• 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)

Ventilation 9.5 11.0 15.7 0.04

L > 6hrs

Group S Group M Group L p

ICU stay 13.2 10.9 18.5 n.s.

Hosp. stay 35.5 28.6 44.6 n.s.

Death: MOF 36.4 31.8 46.6 0.04

German Trauma Registry

Timing• 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)

Head injury and fracture fixation

-No 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• Prevent 2nd hit (MOF, MSOF, SIRS,

ARDs)• Hgb < 8• Base Deficit > 5 mEq/l

(pH<7.2,lactate>2)• Body temperature < 33º• INR > 1.5

Timing• 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