Timing of Surgery in Orthopaedic Patients with Brain Injury


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- Discussion:
    - assessment of perfusion: damage control orthopaedics
    - the most common situation is how to manage the femur fracture in the brain injured patient;    
    - some authors have expressed concern that intraoperative hypoxia and hypotension may commonly occur w/ early IM nail stabilization;
           - both hypoxia and hypotension may lead to aggravated brain injury;
           - w/ significant brain injury, there will often be enhanced frx healing and therefore, there may be increased efficacy of external fixation;
           - in addition, IM nailing in head injured patients may lead to hip heterotopic ossification;
           - as noted by Starr, et al (1998), early femoral shaft stabilization did not increase the prevalence of CNS complications in head injured patients;
           - mortality rate in these patients may approach 20% vs 4% mortality seen in the patient with an isolated femur fracture;
    - fat embolism:
           - note the high occurance of fat embolism (up to 15%) which occurs with concomitant femur frx and head injury;
                 - be aware that the mental status changes associated with fat embolism can confuse evaluation of head injury;
                 - petechial hemorrhages is the best diagnostic sign for diagnosis;
    - in the report by JM Smith and TJ Cunningham (15th Annual Meeting of the Orthopaedic Trauma Association, 1999) the authors retrospectively reviewed
          the risk of adverse neurologic or pulmonary complications in patients with coincident head injuries;
          - the authors were unable to demonstrate that early fracture fixation increases the likelihood or severity of CNS complications;
          - the authors felt that no firm conclusions should be made about this issue until prospective evidence becomes available;
    - in the literature review by Dunham CM, et al (2001), the authors note the following:
          - in patients with brain injury, there appears to be no advantage or disadvantage (from a neurologic standpoint), with early vs delayed 
                 orthopaedic stabilization;
                 - specific end points analyzed include mortality, ICU stay, hospital stay;
          - in the report by Mendelson SA, et al, the authors analyzed retrospectively pediatric femur fracture patients with concomitant head injury
                 to determine whether time to fracture fixation affects central nervous system, orthopaedic, or additional complications;
                 - 25 patients with a Head Abbreviated Injury Scale score of  3 and a femoral shaft fracture were reviewed;
                 - patients were divided by time to treatment for their femur fracture;
                 - average stay was 10.5 days for the early group and 18.5 days for the late group, the only statistically significant finding;
                 - orthopaedic and central nervous system complications were similar between the two groups;
                 - 16 additional complications were found in the late group versus three for the early group;
                 - femur fractures in the head-injured pediatric patient can be adequately addressed with early



Practice Management Guidelines for the Optimal Timing of Long-Bone Fracture Stabilization in Polytrauma Patients: The EAST Practice Management Guidelines Work Group 

Timing of osteosynthesis of major fractures in patients with severe brain injury.  

Multiple injuries: coma and fractures of the extremities

Treatment of femur fracture with associated head injury

Early fracture fixation may be deleterious after head injury

Head injuries coexistent with pelvic or lower extremity fractures--early or delayed osteosynthesis.

Lower extremity fracture fixation in head-injured patients.

Year Book: Timing of Osteosynthesis of Major Fractures in Patients With Severe Brain Injury.

Treatment of major skeletal injuries in patients with a severe head injury.

Early Versus Late Femoral Fracture Stabilization in Multiply Injured Pediatric Patients With Closed Head Injury 

Operative management of lower extremity fractures in patients with head injuries.

The role of secondary brain injury in determining outcome from severe head injury.

The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries.

Evidence for a humoral mechanism for enhanced osteogenesis after head injury.

Femur shaft fracture fixation in head-injured patients: when is the right time?

Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries

Fixation of femoral fractures in multiple-injury patients with combined chest and head injuries

Effects of a femoral shaft fracture on multiply injured patients with a head injury



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, June 19, 2012 3:42 pm