Review Question - QID 216480

The patient is presenting with multiple injuries following a motorcycle crash. Early definitive fixation of the femoral shaft fracture can be pursued to minimize pulmonary complications.

Polytraumatized patients treated with early appropriate care of their orthopedic injuries can minimize secondary inflammatory responses and pulmonary complications. Priority is given to spine, femur, pelvis, and acetabular fractures with the goal of definitive fixation within 36 hours of injury. However, this must be performed in the setting of adequate resuscitation which can be defined by hemodynamic stability, lactic acid < 4.0 mmol/L, pH >7.25, and base excess >-5.5.

Pape et al. performed a multicenter randomized trial of multiply injured patients presenting with femur fractures treated with either early intramedullary nailing (<24 hours) or external fixation followed definitive fixation. They reported medically borderline patients (increased risk for systemic complications) were 6.69 times more likely to sustain an acute lung injury if treated with early intramedullary nailing. They concluded external fixation followed by definitive fixation can reduce pulmonary complications in medically borderline patients.

O'Brien reviewed the treatment of femur fractures in multiply injured patients. Based on the reviewed literature the author concluded early fixation of long-bone fractures in multiply injured patients provided the patient is hemodynamically stable. Special consideration should be given to patients with severe chest injuries and head injuries.

Figure A is an AP radiograph of the left femur demonstrating a transverse fracture of the diaphysis. Figure B is an AP radiograph of the left humerus with a comminuted fracture of the diaphysis. Figure C is an AP radiograph of the right ankle demonstrating a pronation-abduction ankle fracture.

Incorrect answers
Answer 1: Damage control of the femur fracture is an option, but is more suitable in cases where there are severe chest injuries, head injuries, or hemodynamic instability.
Answer 2: The humerus fracture can be sufficiently immobilized with a splint, likely coaptation, until a more suitable time for fixation.
Answer 4: Temporizing the femur fracture with skeletal traction is not necessary for a hemodynamically stable patient.
Answer 5: Priority should be given to definitive fixation of the femoral shaft fracture to avoid potential pulmonary complications. Once this is stabilized, the ankle and humerus fractures can be addressed accordingly.