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Early stabilization of the patient's femur fracture places him at risk for increased pulmonary complications
3%
71/2398
Surgical intervention should be delayed due to the patient's head injury
74/2398
Damage control orthopaedics (DCO) using external fixation is indicated for this patient
12%
282/2398
Early stabilization of the patient's femur fracture does not place the patient at increased risk for worsening neurologic outcomes
79%
1888/2398
A concomitant chest injury would always be a contraindication to early fixation of the patient's femur fracture
68/2398
Select Answer to see Preferred Response
Early stabilization of femur fractures in patients with concomitant head injuries has been found to have no increased risk of worsening neurologic outcomes. Treatment of patients with a closed head injury and a femoral fracture remains controversial but recent data suggests that intramedullary nails done acutely leads to decreased pulmonary complications, decreased thromboembolic events, improved rehabilitation, decreased length of stay and cost of hospitalization, and improved GCS scores on discharge. However, it is important to note that intraoperative hypotension should be avoided in these patients, as it has been associated with worsening outcomes following acute intramedullary nailing of the femur. Starr et al. performed a retrospective study to determine if the timing of treatment of femur fractures in patients with an associated head injury had an effect on the risk of pulmonary and CNS complications. They found that delaying fracture stabilization (> 24 hours) made pulmonary complications 45 times more likely, while early fracture stabilization had no effect on the risk of CNS complications. McKee et al. performed a retrospective case-control study to determine the effect of early intramedullary nailing of femoral shaft fractures on the neurologic outcome of patients with multiple injuries and a concomitant head injury. They found no significant differences between the two groups in terms of early mortality, length of hospital/ICU stay, level of neurologic disability, or results of cognitive testing. Their results support the continued early intramedullary nailing of femoral fractures for patients with a concomitant head injury. Richards et al. performed a retrospective study evaluating lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation (< 24 hours) and its effects on pulmonary complications (defined as mechanical ventilation lasting ≥ 5 days). They found that a median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥ 5 days, whereas a median preoperative lactate of 2.8 mmol/L was not. Figures A and B are radiographs demonstrating a transverse femoral shaft fracture. Incorrect Answers: Answer 1: Early stabilization of the patient's femur fracture places him at decreased risk of pulmonary complications. Answer 2: A concomitant head injury is not a contraindication to early fixation of the patient's femur fracture. Answer 3: Damage control orthopaedics using external fixation is not indicated in this patient. Intramedullary nailing should be performed instead. Answer 5: A concomitant chest injury is not a contraindication to early fixation of the patient's femur fracture.
2.4
(8)
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