Thirty years ago, the standard of care for the multiply injured patient with fractures was placement of the fractured limb in a splint or skeletal traction, until the patient was considered stable enough to undergo surgery for fracture fixation1. This led to a number of complications2, such as adult respiratory distress syndrome (ARDS), infection, pneumonia, malunion, nonunion, and death, particularly when the patient had a high Injury Severity Score (ISS)3. Retrospective studies showed that the incidence of fat embolism syndrome could be reduced with stabilization of long-bone fractures in a multiply injured patient. Riska et al. noted a decrease in fat embolism syndrome from 22% (twenty-one of ninety-five) with traction treatment to 1% (one of ninety-five) with early operative fracture stabilization4. This finding led to greater use of early surgical stabilization of femoral fractures in the multiply injured patient. Subsequent follow-up studies demonstrated decreases in mortality and morbidity with early surgical stabilization of long-bone fractures in the multiply injured patient5-9. Moreover, retrospective noncontrolled studies showed that the patients with the highest ISS or greatest number of injuries derived more benefit from surgical stabilization of a femoral fracture shortly after the injury than from treatment with skeletal traction for seven to ten days prior to operative femoral fixation. Border et al.5 and Johnson et al.6 showed a decrease in pulmonary failure, time on a ventilator, time in the intensive care unit, septic complications, and death with early surgical stabilization.
Because of the lack of control of these retrospective studies, and skepticism by both general surgeons and orthopaedic surgeons about the importance of early fracture stabilization, one of us (L.B.B.) and others performed a prospective randomized study to compare femoral fractures treated within twenty-four hours after injury with those treated more than forty-eight hours after injury10. The investigators randomized all femoral fractures of patients admitted acutely to Parkland Hospital in Dallas, Texas, over a two-year period, from 1984 to 1986. One hundred and seventy-seven patients were randomized: eighty-seven to the early fixation group and ninety to the late fixation group. Each group was then subdivided into patients with multiple injuries, defined as an ISS of =18, and patients with essentially an isolated femoral fracture and an ISS of <18. Pulmonary complications consisting of ARDS, pulmonary dysfunction, fat emboli, pulmonary emboli, and pneumonia were present in 38% (fourteen) of thirty-seven patients in the late fixation/multiple injuries group and 4% (two) of forty-six in the early fixation/multiple injuries group; pulmonary dysfunction developed only in the late fixation/multiple injuries group (5%; two of thirty-seven). The average age and ISS were very similar in both multiply injured groups. However, the numbers of days on assisted ventilation, in the intensive care unit, and in the hospital as well as the cost of treatment were significantly increased in the late fixation group. This prospective and randomized study impacted the care of musculoskeletal injuries in the multiply injured patient and became the foundation for the dogma of early total care10.
Misuse of early total care, however, led to early surgical fracture fixation in some patients whose physiologic state did not tolerate the additional trauma of fracture fixation in the first twenty-four hours11-14. Patients considered borderline for tolerating fracture surgery, or more appropriately "at risk," include those who are hemodynamically unstable or hypothermic, have coagulation abnormalities, or have poor oxygenation due to traumatic lung injury (Table I). Early stabilization of fractures in "patients at risk" was never advocated by authors of early total care studies1,15. Early fracture fixation in these "patients at risk" (Table I) is associated with a potential for higher complication rates. The need for fracture stabilization in these patients combined with the need for less physiologic stress when stabilizing the skeleton led to the introduction of damage control orthopaedics, in which external fixators are placed across long-bone fractures for temporary stabilization (Fig. 1)16-19. These "patients at risk" could be treated in a temporizing fashion while still maintaining stability of the fracture, allowing potential mobilization of the patient. Pape et al. popularized and prospectively studied the use of damage control orthopaedics with temporary external fixation for stabilization of the musculoskeletal injuries in "patients at risk" or patients in extremis ("at the point of death")20,21. These "patients at risk" require aggressive resuscitation with hemorrhage control and need to be reevaluated and monitored closely as their physiologic state can rapidly change. If they are stabilized with good oxygenation and good urinary output and the end points of resuscitation have been achieved, it is safe to proceed with definitive stabilization of the long-bone fractures in the operating room1,19. If, however, the patient remains unstable or has fluctuation of the vital signs (i.e., is a transient responder to shock treatment), then damage control orthopaedics should be performed.
Over this past decade, it has been shown that stable, multiply injured patients with musculoskeletal injuries can safely receive definitive treatment of long-bone fractures very soon after their injury (early total care)22. In contrast, a patient in extremis, or who is hemodynamically unstable or has impaired oxygenation, should have temporizing early stabilization with external fixators (damage control orthopaedics). Prospective and randomized studies have shown that the "patient at risk" who can be stabilized can also be safely treated with definitive intramedullary nailing of femoral fractures or be treated with external fixation (the damage control approach)20,21. However, one must be careful not to apply the damage control concept to stable patients or to "patients at risk" who could be potentially treated with early total care. It has been shown that stable patients who undergo external fixation instead of definitive treatment of a femoral fracture have an unnecessary delay in definitive treatment, with a longer stay in the intensive care unit, a longer duration of ventilator use, longer hospitalization, and an increase in the cost of care23. It therefore is advantageous to the patient to undergo definitive treatment whenever it can be safely performed.
Despite these advances in our understanding of patient management, it is still unclear how to best treat a patient with multiple injuries and pulmonary contusion or one with bilateral femoral fracture.
On the basis of all of the clinical evidence and findings from animal experiments, it appears that bilateral femoral fracture in a hemodynamically stable patient can be safely managed with intramedullary nailing, but it is critical that the oxygenation and hydration of the patient be closely monitored during the initial nailing to be sure that the patient is still stable enough to undergo the second nailing in the same operative setting. Individual management is needed for those rare patients who have bilateral femoral fracture and pulmonary contusion. When patients are well oxygenated, even if they have a pulmonary contusion, either bilateral external fixation or, preferentially, intramedullary nailing of one of the femora and external fixation or plate fixation of the other may be performed. External fixation should be performed instead of intramedullary nailing for any patient who is not well oxygenated, regardless of whether he or she has an isolated or bilateral femoral fracture (Fig. 3).
In conclusion, the vast majority of patients with a femoral fracture who have an ISS of =18 are stable and can undergo immediate intramedullary nailing of the femoral fracture without undue risk. Patients who are unstable after resuscitation or who are in extremis should undergo temporary stabilization of the long-bone fracture with external fixation. A patient with a femoral fracture, an ISS of =18, and substantial lung injury who is hemodynamically stable, does not have hypothermia, and is well oxygenated and whose lactate level can be brought down to the 2.2 mmol/L range can also be safely treated with acute intramedullary femoral nailing45.
The advantage of definitive stabilization is that the patient can be mobilized more quickly. This has been shown to improve lung function because an upright position is better for ventilation and oxygenation. The disadvantage is that this surgery may be poorly tolerated by an unstable patient. A certain percentage of multiply injured patients should not have acute intramedullary fixation of a femoral fracture. Temporary stabilization with external fixation can greatly reduce the second surgery insult in these patients. Those patients who are stable enough for intramedullary nailing should have definitive treatment within the first twenty-four hours. This reduces the time in the intensive care unit, time on ventilation support, days of hospitalization, and necessity for a second operative procedure. However, patients who are unstable need to be closely evaluated and closely monitored to be sure that they can safely undergo definitive fixation. Any patient who is hemodynamically unstable, has coagulation abnormalities, is hypothermic, or is oxygenating or ventilating poorly should not undergo definitive intramedullary fixation until his or her general condition is stabilized. Instead, he or she should have temporary fracture fixation, followed by definitive fixation once their condition has been optimized.