Bilateral femoral shaft fracture in polytrauma patients: Can intramedullary nailing be done on an emergency basis?

Abstract

IntroductionWhether damage control orthopedics (DCO) or early total care (ETC) is the best way to treat polytrauma patients who have suffered a bilateral femoral shaft fracture remains unanswered. The aim of this study was to evaluate the morbidity of bilateral femur fractures treated by simultaneous intramedullary (IM) nailing according to ETC principles. Materials and methodsThis retrospective single-centre study included all polytrauma patients who had suffered a femoral shaft fracture and were treated at our level I trauma centre. Demographic data, associated lesions, injury severity score (ISS) and occurrence of acute respiratory distress syndrome (ARDS) were collected prospectively in our trauma database. Unilateral fractures (UF) were compared to bilateral fractures (BF). The risk of ARDS was evaluated by multivariate logistic regression. ResultsBetween 2010 and 2019, 176 UF (88%) and 25 BF (12%) were included. Patients with BF had a higher ISS (36 vs. 25, p<0.001) and more brain injuries (44% vs. 15%, p=0.001) than patients with a UF. More blood transfusions were done in BF than UF (4.0 vs. 1.6 units, p=0.002). The incidence of ARDS was higher in BF patients than UF (36% vs. 4%) with longer stay in intensive care (18 vs. 12 days, p=0.02) and in the hospital (32 vs. 23 days, p=0.006). There were no deaths in either group. The risk of ARDS was correlated to ISS, but not to bilaterality. DiscussionStudies on DCO and ETC report similar mortality and ARDS rates for BF. ISS appears to determine the postoperative morbidity irrespective of how the patients are managed. In contrast with DCO, perioperative intensive care has a predominant role in ETC, allowing early definitive fixation of fractures, even in severely injured patients. ConclusionBilateral femoral shaft fractures are a sign of severe trauma leading to high postoperative morbidity. The patient is likely to have concomitant severe injuries. Simultaneous ECM can be done emergently providing appropriate perioperative intensive care management. Level of evidenceIV; retrospective study.