ADULT-RESPIRATORY-DISTRESS-SYNDROME, PNEUMONIA, AND MORTALITY FOLLOWING THORACIC INJURY AND A FEMORAL FRACTURE TREATED EITHER WITH INTRAMEDULLARY NAILING WITH REAMING OR WITH A PLATE - A COMPARATIVE STUDY

Multiply injured patients (an Injury Severity Score of 17 points or mo re) who were admitted to one of two level-I regional trauma centers be tween 1983 and 1994 because of a fracture of the femoral shaft with a thoracic injury (an Abbreviated Injury Scale score of 2 points or more ) or without a thoracic injury were studied retrospectively. The patie nt populations and the protocols for the treatment of trauma were simi lar at the two centers; however, the centers differed with regard to t he technique that was used for acute stabilization of the fracture of the femoral shaft, At Center I intramedullary nailing with reaming was used in 217 (95 per cent) of the 229 patients, whereas at Center II a plate was used in 206 (92 per cent) of the 224 patients, This differe nce was used to investigate the effect of acute femoral reaming on the occurrence of adult respiratory distress syndrome in multiply injured patients who had a chest injury, Three groups of patients were evalua ted: those who had both a fracture of the femur and a thoracic injury, those who had a fracture of the femur but no thoracic injury, and tho se who had a thoracic injury without a fracture of the femur or the ti bia, The third group was studied at each center to determine if there was a difference between the institutions,vith regard to the rate of a dult respiratory distress syndrome, Patients who had diabetes, chronic obstructive pulmonary disease, asthma, hepatic or renal failure, or a n immunosuppressive condition were excluded from the study. The record s were abstracted to determine the Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Score for each patient, Requireme nts for fluid resuscitation were calculated for the first twenty-four: hours; these included the number of units of packed red blood cells, f resh-frozen plasma, and platelets that were transfused and the volume of crystalloid that was used, The duration of intubation, the duration of hospitalization, and the occurence of adverse outcomes (death, mul tiple organ failure, adult respiratory distress syndrome, pneumonia, a nd pulmonary embolism) were determined for each patient, The groups of patients were analyzed as a whole and then were stratified into subgr oups (according to whether or not they had a thoracic injury and wheth er the Injury Severity Score was less than 30 points or 30 points or m ore) to determine if the type of fixation of the femoral fracture affe cted the rate of adult respiratory distress syndrome or mortality Logi stic regression models were used to analyze the data, The over-all occ urrence of adult respiratory distress syndrome in the 453 patients who had a femoral fracture was only 2 per cent (ten patients), The rates of adult respiratory distress syndrome for the patients who had a thor acic injury but no femoral fracture (eight [6 per cent] of 129 patient s at Center I, compared with ten [8 per cent] of 125 patients at Cente r II) did not differ between centers, suggesting that the institutions were comparable in their treatment of multiply injured patients, The occurrence of adult respiratory distress syndrome in the patients who had a femoral fracture without a thoracic injury did not differ substa ntially according to whether the fracture had been treated with a nail (118 patients) or a plate (114 patients), Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, fa ilure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar regardless of whether naili ng with reaming (117 patients) or a plate (104 patients) had been used , The use of intramedullary nailing with reaming for acute stabilizati on of fractures of the femur in multiply injured patients who have a t horacic injury without a major comorbid disease does not appear to inc rease the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.