O'Toole Robert V, O'Brien Michael, Scalea Thomas M, Habashi Nader, Pollak Andrew N, Turen Clifford H
Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
J Trauma. 2009 Nov;67(5):1013-21. doi: 10.1097/TA.0b013e3181b890be.
Femoral shaft fractures are associated with acute respiratory distress syndrome (ARDS). The idea that primary intramedullary nailing increases the incidence of ARDS has theoretical support. Our approach to treating femoral fractures in patients with multiple traumatic injuries is to perform reamed nailing after adequate resuscitation has been shown by normalizing lactate plus optimized ventilatory and hemodynamic parameters. Damage control orthopedics (DCO) with primary external fixation usually is reserved for those rare patients who do not respond to resuscitation. Our hypothesis was that this approach yields a low rate of ARDS.
A prospective trauma database was searched for all femoral shaft fractures treated at a Level I trauma center during a 3-year period, yielding 582 patients. Exclusion criteria included death before treatment (n = 9), age younger than 16 years (n = 16), age older than 65 years (n = 35), fractures that were not amenable to nail fixation (n = 31), shaft fractures treated with a plate (n = 3), patients with bilateral femoral shaft fractures who had a primary nail placed in one femur and an external fixator on the other limb (n = 1), and patients with an Injury Severity Score (ISS) <or=17 (n = 260), leaving 227 patients in the final study group. We defined ARDS as a mean partial pressure of oxygen/fraction of inspired oxygen <200 for 5 or more consecutive days. We compared our results with the results of a similar design in the literature.
Of the 227 patients with ISS >17, only 12% were initially treated with DCO, and 88% were treated with primary reamed nailing. The 227 patients achieved successful early resuscitation as shown by lactate values that decreased significantly on the operative day compared with presenting values (p < 0.05). ARDS rates were low, including rates for the subgroup of patients with lung injury (thoracic Abbreviated Injury Scale score >2, n = 175) who were treated with nailing and had an ARDS rate of 2.0% and a death rate of 2.0%. The ARDS rate for the most severely injured patients who underwent nailing (ISS >28, thoracic Abbreviated Injury Scale score >2, n = 78) was only 3.3%, and 1.7% died.
In the context of resuscitation before reamed intramedullary nailing of femoral shaft fractures, our rate of ARDS was lower (p < 0.001) than that of a similar study reported in the literature in which the DCO approach was used in up to 36% of patients (p < 0.001) and was more in keeping with previously reported rates of ARDS. This remained true despite frequent use of early reamed femoral nailing and infrequent use of DCO. An explanation for the discrepancy between the centers might be differences in preoperative resuscitation or medical care provided to treat shock.
股骨干骨折与急性呼吸窘迫综合征（ARDS）相关。髓内钉固定术会增加ARDS发生率这一观点有理论依据。我们对多发创伤患者股骨干骨折的治疗方法是，在乳酸水平恢复正常、通气和血流动力学参数优化，表明已进行充分复苏后，实施扩髓髓内钉固定术。损伤控制骨科（DCO）联合一期外固定通常仅用于那些对复苏无反应的罕见患者。我们的假设是，这种治疗方法导致ARDS发生率较低。
在一个前瞻性创伤数据库中，搜索了某一级创伤中心在3年期间治疗的所有股骨干骨折患者，共纳入582例。排除标准包括：治疗前死亡（9例）、年龄小于16岁（16例）、年龄大于65岁（35例）、不宜行髓内钉固定的骨折（31例）、采用钢板治疗的骨干骨折（3例）、双侧股骨干骨折患者中一侧股骨行一期髓内钉固定而另一侧肢体行外固定架固定（1例）以及损伤严重度评分（ISS）≤17分的患者（260例），最终研究组有227例患者。我们将ARDS定义为氧分压/吸入氧分数均值<200且持续5天或更长时间。我们将研究结果与文献中类似设计的结果进行了比较。
在227例ISS>17分的患者中，仅12%最初采用DCO治疗，88%采用一期扩髓髓内钉固定术治疗。与入院时相比，227例患者在手术日乳酸值显著下降，表明早期复苏成功（p<0.05）。ARDS发生率较低，包括肺损伤亚组（胸部简明损伤量表评分>2分，175例）患者，这些患者采用髓内钉固定术治疗，ARDS发生率为2.0%，死亡率为2.0%。接受髓内钉固定术的最严重受伤患者（ISS>28分，胸部简明损伤量表评分>2分，78例）的ARDS发生率仅为3.3%，1.7%的患者死亡。
在股骨干骨折扩髓髓内钉固定术前进行复苏的情况下，我们的ARDS发生率（p<0.001）低于文献中报道的类似研究，该研究中高达36%的患者采用DCO方法（p<0.001），且更符合先前报道的ARDS发生率。尽管频繁使用早期扩髓股骨钉固定术且很少使用DCO，但情况依然如此。两个中心之间存在差异的一个解释可能是术前复苏或治疗休克的医疗护理存在不同。
