Reynolds M A, Richardson J D, Spain D A, Seligson D, Wilson M A, Miller F B
Department of Surgery, University of Louisville School of Medicine, Kentucky, USA.
Ann Surg. 1995 Oct;222(4):470-8; discussion 478-81. doi: 10.1097/00000658-199522240-00005.
The effect of timing of femur fracture fixation for patients with multiple trauma was studied to determine the effect of operative timing on eventual outcome.
The relationship between timing of intramedullary rod (IMR) placement, degree of injury, and pulmonary complications was studied in 424 consecutive patients. The authors focused on 105 patients undergoing IMR placement with an Injury Severity score (ISS) of greater than or equal to 18. The effects of timing of IMR placement on various pulmonary complications, organ failure, intensive care unit (ICU) admission, and ventilatory assistance were studied for various time intervals.
Of the 424 patients, pulmonary complications increased slightly in the more seriously injured group (ISS > 18) but were not influenced by the timing of IMR placement. Of the 105 patients undergoing IMR placement with an ISS > or = 18, only 2 patients died. Both patients had an IMR placed in less than 24 hours and died later of head injury and delayed hemorrhage. The incidence of organ failure, number of ventilator days, and length of ICU stay did not differ between the groups based on timing of fracture fixation. The incidence of severe head injuries was higher in the group undergoing delayed IMR placement (> 48 hours).
Modest delays in IMR placement did not adversely affect patient outcome. Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation. In a well-integrated trauma system, clinical judgment regarding the timing of IMR placement was the most important determinant of outcome. Delays that were made to stabilize the patient, treat associated injuries, and plan orthopedic reconstruction did not adversely affect patient outcome.
研究多发伤患者股骨骨折固定时机对最终结局的影响，以确定手术时机对最终结果的作用。
对424例连续患者进行研究，分析髓内钉（IMR）置入时机、损伤程度与肺部并发症之间的关系。作者重点关注105例损伤严重度评分（ISS）大于或等于18且接受IMR置入的患者。针对不同时间间隔，研究IMR置入时机对各种肺部并发症、器官衰竭、重症监护病房（ICU）收治情况及通气辅助的影响。
在424例患者中，伤势较重组（ISS>18）的肺部并发症略有增加，但不受IMR置入时机的影响。在105例ISS>或=18且接受IMR置入的患者中，仅2例死亡。这2例患者均在24小时内置入IMR，随后死于头部损伤和延迟性出血。基于骨折固定时机分组，各器官衰竭发生率、呼吸机使用天数及ICU住院时间并无差异。延迟IMR置入组（>48小时）的严重颅脑损伤发生率较高。
适度延迟IMR置入对患者结局无不利影响。肺部并发症与损伤严重程度相关，而非骨折固定时机。在完善的创伤救治体系中，关于IMR置入时机的临床判断是结局的最重要决定因素。为稳定患者病情、治疗合并伤及规划骨科重建而延迟手术，对患者结局无不利影响。
