Year Book: Timing of Osteosynthesis of Major Fractures in Patients

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With Severe Brain Injury. Hofman-PAM. Goris-RJA. 1992 Year Book of Orthopedics. Article 9-10. Original Article: J Trauma. 1991. 31. pp 261-263. COMMENTARY BY S.T. HANSEN, M.D. Even though it is retrospective and nonrandomized, this paper offers very important and interesting information. It addresses a problem common to all major trauma centers--whether to anesthetize brain-injured patients for prolonged surgery to perform osteosynthesis. This institution has a long history of recommending early osteosynthesis in polytrauma and emphasizing the need for assisted respiration and full oxygenation of patients under anesthesia. Their protocols for brain-injured patients also include administering high doses of barbiturates and performing intracranial pressure monitoring. Prospective randomized studies may be needed before this practice can be confidently recommended, but strong evidence is presented that early osteosynthesis in brain-injured patients improves both survival and the final neurologic outcomes. More important, the authors indicate that major fractures can produce a lower rating on the Glasgow Coma Scale on initial evaluation than the severity of brain injury actually warrants, a situation that can lead to undue pessimism regarding eventual recovery and to possibly withholding treatment from patients who, in fact, have a reasonably good prognosis with aggressive treatment.--S.T. Hansen, M.D.