student research day - Case Western Reserve University School of ...

Nickolas J. Nahm
Early fixation of femoral shaft fractures in multiply injured patients
is associated with fewer complication
Nickolas J Nahm, Nichole Schafer and Heather A Vallier
Department of Orthopaedic Surgery
MetroHealth Medical Center
Introduction: In seminal work examining the effects of timing of treatment of femoral fractures in multiply
injured patients, Bone and colleagues concluded that early definitive stabilization is the optimal approach to
managing femoral shaft fractures. However, based on studies of thoracic trauma patients, Pape and colleagues
proposed an alternative tactic, known as damage control orthopaedics, in which femoral fractures are provisionally
stabilized with an external fixator, then treated on a delayed basis (several days to two weeks later), tailoring
treatment based on systemic injury of the patient. This study contributes to this ongoing discussion by exploring
the effects of timing of femoral fracture treatment on the incidence of complications in the multiply injured patient.
Methods: Data were collected retrospectively on 511 skeletally-mature multiply injured patients with a femoral
shaft fracture treated at a North American Level I Trauma Center between 1998 and 2006. Patient cohort groups
were established based on timing of treatment and accompanying injuries. Rates of pulmonary, renal, and
infectious complications were compared.
Results: Pneumonia and sepsis were less frequent in patients treated within 24 hours (9.7% and 0.9%,
respectively, n = 422) compared to patients treated after 24 hours (21.3% and 9.0%, respectively, n = 89, (p =
0.004 and 0.0002, respectively)). Furthermore, among patients with accompanying chest injuries (n = 227),
abdominal injuries (n = 141), or head injuries (n = 257), the rate of sepsis was lower in patients treated
definitively within 24 hours (1.8%, 4.0%, 1.9%, respectively) compared to patients treated after 24 hours (11.5%,
15.0%, 11.8%, respectively, (p = 0.005, 0.03, and 0.005, respectively)).
Conclusions: Despite differences in age and injury severity between patients treated within and after 24 hours of
injury, this study suggests that the majority of multiply injured patients may be definitively treated on an early
basis with few complications. Further study may help to define specific parameters where a damage control
strategy is warranted.
Supported by Orthopaedic Trauma Association
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