Changes in the Management of Femoral Shaft Fractures in Polytrauma Patients : From Early Total Care to Damage Control Orthopedic Surgery (2004)

major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of poly- trauma patients treated at a Level I trauma cen- ter within the last two decades regarding the ef- fect of changes in the management of their femoral shaft fracture. Methods: In a retrospective cohort study performed at a Level I trauma center, the pa- tient's injuries and clinical outcomes were stud- ied. Adult blunt polytrauma patients were in- cluded if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (in- cluding external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the Results: The patient groups were com- parable regarding age, gender distribution, and the mechanism of injury. Primary external fixa- tion was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups com- pared with the ETC group (16.6%) (p 0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I°EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I°IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdom- inal injuries accounted for significantly higher numbers of patients submitted to I°EF in the INT (13.6%, p 0.03) and DCO (17.3%, p 0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of mul- tiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I°IMN (15.1%) and I°EF (9.1%) in the DCO subgroup were compared. Conclusion: A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an in- creased awareness toward thoracic and abdom- inal injuries may have played a role. Even dur- ing the DCO era, IMN was associated with a higher rate of ARDS than I°EF. In view of a lower complication rate despite higher injury severity compared with the ETC period, the introduction of DCO appears to be an adequate alternative for patients at high risk of develop- ing posttraumatic systemic complications such as ARDS and multiple organ failure.