1. Kyle F. Dickson, M.D. M.B.A. Professor Baylor College of Medicine
Southwest Orthopaedic Group, Houston, Texas

2. Timing of Fracture Fixation in the Polytrauma Patient
Kyle Dickson MD, MBA
Professor Baylor College of Medicine
Southwest Orthopaedic Group, Houston, Texas

3. >5000 trauma admits with >1800 patients with ISS>15 (#1 ACS)

4. 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

5. 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

6. Topic Outline Occasional patients are hurt by long bone nailing
There is a systemic inflammatory response to major trauma

7. Topic Outline What is unknown?
How to predict bad consequences of long bone nailing
The optimal timing of fracture repair for all patients

8. Topic Outline The benefits of temporary external fixation
The effect of a head injury

10. 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

11. JA
BD = 6 meq/l
Temp = 33°

12. Primary survey Airway maintenance with cervical spine protection
Breathing and ventilation

13. Circulation with hemorrhage control
Disability: Neurologic status
Exposure/environment control: undress patient but prevent hypothemia

16. Morshed JBJS 2009
Relative risk of mortality treatment weighted analysis
Delay > 12 hours for femoral shaft stabilization ↓ mortality 50% (especially serious abdominal injury)

17. 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, h and > 120 h - ? Not h

18. Problems cont. Trauma registry – garbage in garbage out
? Ex fix until patient stabilized
Assumption is that delay is random not that the patient is being stabilized

19. Problems cont. Inclusion was same day transfers (? 11pm – 1am)
The weighting corrects for illness but not results of treatment and stabilization parameters

20. 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

21. 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

22. Coagulopathy Hypothermia  Ca2 (blood citrate) Acidotic
Lethal Triad – hemorrhage, coagulopathy, inflamatory/metabolic

23. 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)

24. INR vs Mortality 1st 24 hrs in STICU
P = 0.02, ROC = 0.71

25. Hemostatic Resuscitation

26. Blood/FFP/Cryo/Plts 1:1 ratio

27. 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

28. Emergent Extremity Issues
Neuro vascular exam
Splint extremities
Compartment syndrome and dysvascular limbs
Major dislocations
Basic wound management

29. Retrospective data from the 1980’s Early fracture fixation is good!

30. 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!!

31. 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

32. 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%)

33. 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!!

34. 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

35. 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?

36. 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
However severe inflammation my lead to organ injury
Good!!
Bad!!

37. 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

38. 1st hit (trauma)
FES
SIRS
2nd hit (Surgery, infection, more FES)
ARDS
MODS
MOF
MSOF

39. 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)

40. 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

41. 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 ….

42. The optimal timing of fracture repair for all patients
Is it within 48 hours or greater than five days?

43. “TOO SICK NOT TO FIX FRACTURES”

44. Damage Control Surgery
Philosophy
Stay out rather than get out of trouble
Restore normal physiology at the expense of normal anatomy

45. Bilateral femoral ex fix, tibial ex fix and I&D at the bedside
Damage Control
Bilateral femoral ex fix, tibial ex fix and I&D at the bedside

46. DCO external fixation
-Stabilizes orthopedic injuries while physiology improves
-Avoid a “second hit” by major orthopedic procedures
-Fracture stability without increased inflammatory response

47. 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

48. 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)

49. L > 6hrs Group S Group M Group L p ICU stay 13.2 10.9 18.5 n.s.
Ventilation
L > 6hrs
Group S Group M Group L p
ICU stay n.s.
Hosp. stay n.s.
Death: MOF
German Trauma Registry

50. 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

51. Exchange to an IM rod safe?
Bhandari et al JOT 2005
-Pooled data from level 4 studies
-Average infection rate 3.6%
Pin drainage

52. 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)

53. 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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64. 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

65. 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

66. Thank You