External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics

Background: The advantages of early fracture fixation in patients with mult iple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fract ures after multiple injury. It potentially offers similar benefits to intra medullary nail (IMN)in long-bone fractures and may obviate some of the risk s. We report on the use of EF as a temporary fracture fixation in a group o f patients with multiple injuries and with femoral shaft fractures, Methods: Retrospective review of charts and registry data of patients admit ted to our Level 1 trauma center July of 1995 to June of 1998, Forty-three patients initially treated with EF of the femur mere compared to 284 patien ts treated with primary IMN of the femur. Results: Patients treated with EF had more severe injuries with significant ly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the ini tial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treat ed with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe en ough to require intracranial pressure monitoring. All 12 required therapy f or intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindica tion to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time f or EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes,vith an estimated blood loss of 400 mL. One pa tient died before IMN. One other patient with a mangled extremity was treat ed with amputation after EF. There was one complication of EF, i.e., bleedi ng around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF fo llowed by IMN had bone infection and another had acute hardware failure. Conclusion: EF is a viable alternative to attain temporary rigid stabilizat ion in patients with multiple injuries. It is rapid, causes negligible bloo d loss, and can be followed by IMN when the patient is stabilized. There we re minimal orthopedic complications.