Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Hans-Christoph Pape, MD*,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Posted January 2009
The standard of care for major fractures of the extremities
in patients with multiple injuries is still under debate1-7. Usually,
early definitive fixation for major fractures is advisable. Exceptions include certain
patient subgroups that may have unexpectedly high complication rates if early
definitive stabilization is performed. These groups include patients who have
additional severe injuries (such as chest trauma), patients who underwent a
prolonged operation; and patients whose preoperative status was poor8.
Many previous studies were limited by a number of factors: they were observational;
they did not focus on the cofactors addressed above; they included patients
with isolated fractures and patients with polytrauma; or they had differences
in treatment definition. Moreover, different types of fixation were used in
some studies and many studies had small sample sizes1-7. The study by
Morshed et al. addresses many of these shortcomings by taking into account how additional
severe injuries and hypoperfusion may confound our understanding of the impact
of treatment time on the clinical course of these polytrauma patients.
Morshed et al. made use of data from the U.S. National
Trauma Databank9 and summarized incident trauma cases that occurred
between January 1, 2000, and December 31, 200410. The inclusion
criteria were the presence of a closed or open fracture(s) of the femoral shaft,
an Injury Severity Score of ≥15, an age
of sixteen years or older, and internal fixation of the femur. This study is
different from many other studies because it tried to provide clinically
relevant categories for treatment beyond a simple dichotomy at twelve or twenty-four
hours. Five time periods were selected a priori, based on commonly used intervals
cited in the literature11-13: treatment given within twelve hours
or less after the injury; treatment given more than twelve hours to as much as
twenty-four hours after the injury; treatment given more than twenty-four hours
to as much as forty-eight hours after the injury; treatment given more than
forty-eight hours to as much as 120 hours after the injury; and treatment given
more than 120 hours after the injury. The authors hypothesize that an
additional physiologic stress from definitive fracture surgery could activate
an adverse systemic response leading to end-organ injury and a higher mortality
rate in patients who were most likely to have been inadequately resuscitated
and in a state of occult hypoperfusion (i.e., patients who received early
treatment within the first twelve hours). They used an inverse probability of
treatment-weighted analysis to estimate the risk of mortality for a defined
treatment time. Their results document that definitive fixation in all but one
(the twenty-four to forty-eight-hour time frame) of the four delayed treatment
categories was associated with a substantially lower risk of mortality to about
50% of that expected with early treatment (within twelve hours). Also, patients
with serious associated injuries demonstrated greater risk reductions from
delayed fixation when compared with those with less serious or no abdominal
injury. The authors conclude from this study that a cautious approach to early
definitive femoral shaft fracture fixation among multisystem trauma patients
should be performed, and they reinforce this conclusion for patients who
present with serious associated abdominal injuries.
This study presents strong evidence in favor of a graduated
approach toward the multiply injured patient. The authors document that a close
relationship exists among the type of surgery, the degree of initial injuries
and the state of resuscitation, and the general condition. The results agree
with those of a prospective randomized study that compared definitive and temporary stabilization of fractures of the femoral shaft14.
Both studies are in agreement that the preoperative condition is important to
the postoperative course following a definitive fixation14.
One of the strengths of the current study is that it uses
mortality as an end point, which is unbiased and unaffected by more subtle
treatment conditions, as are ventilatory parameters or clinical scores of organ
failure.
For decades, the clinical status of multiply injured
patients has been graded with use of only cardiovascular parameters. General
surgeons have then considered several other factors as important in describing
changes observed in exsanguinating injuries (i.e., those caused by penetrating
trauma), which include hypothermia, acidosis, and coagulopathy induced by
hemorrhagic shock, known as the triad of death15.
Orthopaedic surgeons have then tried to adapt these factors to the population
of patients with blunt trauma whose injuries are ones predominantly affecting
the extremities. As a fourth element, surgeons also have added soft-tissue
injuries, thus implicating all muscular and subcutaneous injuries of the
extremities, lung, abdomen, and pelvis. It should be noted that this fourth
entity summarizes a number of clinical diagnoses16. While to date it
appears that routine parameters can adequately reflect some of the underlying
pathophysiology, more sensitive measures of tissue oxygenation will hopefully
be available in the future.
In summary, the authors rightfully reinforce the fact that
current end points used to guide resuscitation, such as blood pressure, urine
output, heart rate, base deficit, and serum lactate, may underestimate occult
tissue hypoperfusion. Therefore, either a combination of parameters or more
sensitive measurements for hypoxemia should be available in order to separate
stable patients from those in an uncertain condition.
Another important conclusion to be drawn from this study is
that orthopaedic surgeons should be actively involved in the process of
evaluating the patient's condition. This is especially true since the
responsibility for the patient, initially the job of the general
surgeon both preoperatively and during the clearing process, is subsequently assumed
by the orthopaedic surgeon.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
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