Brundage Susan I, McGhan Ryan, Jurkovich Gregory J, Mack Chris D, Maier Ronald V
Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.
J Trauma. 2002 Feb;52(2):299-307. doi: 10.1097/00005373-200202000-00016.
Optimal timing of femur fracture fixation remains controversial. This study examines the association between the timing of femur fracture fixation and outcome in patients with concomitant chest and head injuries.
A retrospective review of registry data from a Level I trauma center identified 1362 patients with a femoral shaft fracture over a 12-year period. Patients were categorized into five groups by timing of femur fracture fixation: Group 1, within 24 hours; Group 2, 24 to 48 hours; Group 3, 48 to 120 hours; Group 4, > 120 hours; and Group 5, patients with no operative fixation. Primary outcome measures included morbidity (specifically, pulmonary complications) and mortality. Secondary outcome measures were hospital length of stay, intensive care unit length of stay, and discharge Glasgow Coma Scale score. Subsets of patients were examined including all patients with multiple injuries (Injury Severity Score > 15), chest trauma (Chest Abbreviated Injury Scale score > or = 2), and head trauma (Head Abbreviated Injury Scale score > or = 2).
Acute respiratory distress syndrome, pneumonia, hospital length of stay, and intensive care unit length of stay were lowest in the group fixed within 24 hours, even in patients with concomitant head or chest trauma. Fixation between 2 and 5 days was associated with a significantly increased incidence of acute respiratory distress syndrome, pneumonia, and fat embolization syndrome in patients with concurrent chest trauma (p < 0.0001). In head-injured patients, discharge Glasgow Coma Scale score was highest in the group fixed within 24 hours. Timing of operative fixation did not affect mortality.
Our data show that early femur fracture fixation (< 24 hours) is associated with an improved outcome, even in patients with coexistent head and/or chest trauma. Fixation of femur fractures at 2 to 5 days was associated with a significant increase in pulmonary complications, particularly with concomitant head or chest trauma, and length of stay. Chest and head trauma are not contraindications to early fixation with reamed intramedullary nailing.
股骨干骨折固定的最佳时机仍存在争议。本研究探讨股骨干骨折固定时机与合并胸部和头部损伤患者预后之间的关联。
对一家一级创伤中心登记数据进行回顾性分析，确定了12年间1362例股骨干骨折患者。根据股骨干骨折固定时机将患者分为五组：第1组，在24小时内；第2组，24至48小时；第3组，48至120小时；第4组，>120小时；第5组，未进行手术固定的患者。主要结局指标包括发病率（特别是肺部并发症）和死亡率。次要结局指标为住院时间、重症监护病房住院时间及出院时格拉斯哥昏迷量表评分。对患者亚组进行了检查，包括所有多发伤患者（损伤严重度评分>15）、胸部创伤患者（胸部简明损伤量表评分>或=2）及头部创伤患者（头部简明损伤量表评分>或=2）。
在24小时内进行固定的组中，急性呼吸窘迫综合征、肺炎、住院时间及重症监护病房住院时间均为最低，即使是合并头部或胸部创伤的患者。对于合并胸部创伤的患者，在2至5天进行固定与急性呼吸窘迫综合征、肺炎及脂肪栓塞综合征的发生率显著增加相关（p<0.0001）。在头部受伤患者中，在24小时内进行固定的组出院时格拉斯哥昏迷量表评分最高。手术固定时机不影响死亡率。
我们的数据表明，早期股骨干骨折固定（<24小时）与改善预后相关，即使是合并头部和/或胸部创伤的患者。在2至5天进行股骨干骨折固定与肺部并发症显著增加相关，尤其是合并头部或胸部创伤时，以及住院时间延长。胸部和头部创伤并非早期扩髓髓内钉固定的禁忌证。
