Early Fracture Stabilization Research Articles

Operative management of fracture distal femur with locking compression plate

Background: Fractures distal femur are one of the commonest fractures encountered in high velocity trauma which are associated with high morbidity and mortality. Isolated fracture can itself lead to complications such as ARDS and pulmonary embolism. This necessitates early stabilization of fractures. Internal fixation is the choice of treatment in fractures distal femur and Locking Condylar plate. Plate has shown to give one of the best results in terms of recovery, fracture union, return to work and the functional outcome.Objectives: To study the functional results of fracture distal femur treated by open reduction and internal fixation with locking condylar plate. Methods: 20 cases of fracture distal end femur were treated by open reduction and internal fixation by Locking Compression Plate at our institution. The patients were evaluated clinically and radio logically for outcomes. All patients were followed up for an average of 12 months. Outcome was assessed using NEER’S Score. Results: In our study 20 distal femoral fractures were treated. All cases were fresh, 13 patients were males and 7 patients were females. The median age was 47years ranging from 28-70 years.15 of the fractures were caused by road traffic accidents and 3 were due to fall, 2 were due to assault. 12 patients were with fracture on right side and 8 on left side. Using Neer’s scoring system excellent is 65%, good is 15%, fair is 15% and poor is 5%. Range of motion of knee & Hip was excellent to very good. Gait and weight bearing after complete union was satisfactory. Conclusion: open reduction and internal fixation of lower end femur using locking condylar plate. It is one of the best modalities of treatment especially in intra articular fractures where the maintenance of articular congruity is crucial. Fixation with locking condylar plate showed more effectiveness in severely osteoporotic bones, shorter post-operative stay, faster recovery, earlier union rates and excellent functional outcome compared to alternative procedures in other studies.

CT-based morphological analysis of spinal fractures in patients with diffuse idiopathic skeletal hyperostosis.

To clarify correlations between spinal fracture and delayed paralysis in patients with diffuse idiopathic skeletal hyperostosis (DISH) using computed tomography (CT) with multiplanar reformatting (CT-MPR). DISH increases susceptibility to unstable spinal fractures, leading to neurological deterioration. The pathomechanism of the neurological injury is unclear. This multicenter retrospective study included 42 DISH patients (32 male; 10 female) treated for 45 spinal fractures during a 5-year period. The mean age at the time of injury was 77.1±10.1 years. The cause of injury, delay in diagnosis, fracture location, and neurological status were recorded, and anterior- and posterior-column fractures, a fracture displacement over 3mm, and posterior-column ankylosis were assessed using CT-MPR. Most fractures (73.8%) resulted from trivial trauma, such as falling from a standing or sitting position. Diagnosis was delayed in 47.6% of the patients, primarily due to delays in seeking medical attention (65.0%). Although 78.6% of the patients were neurologically intact at the time of injury, 54.8% developed paralysis, defined by a change in one or more Frankel-score levels during short-term follow-up. Of the fractures, 39.1% were in the vertebral body, and 60.9% were at the disc level. Fractures with posterior-column ankylosis were significantly associated with delayed paralysis. CT-MPR was useful for evaluating spinal fractures and determining treatment in patients with DISH. Fractures associated with posterior-column ankylosis resulted in unstable three-column injuries that led to delayed neurological deterioration. Early surgical stabilization of such fractures is recommended to avoid delayed paralysis.

Polytrauma Followed by Hip and Vertebral Fracture in Elderly Patients after Traffic Accident

Elderly patients with multiple trauma are extremely fragile, hence early fracture stabilization provides an early mobility. The literature shows that early stabilization increases survival and reduces complications. We present a case report of a 79-year- old woman who was in a car accident and sustained unstable lumbar fracture L2 and sub trochanteric hip fracture.

English

BACKGROUND: Supracondylar fractures are one of the commonest fractures encountered in high velocity trauma which are associated with high morbidity and mortality.1 Isolated fracture can itself lead to complications such as ARDS and pulmonary embolism1. This necessitates early stabilization of fractures. Internal fixation is the choice of treatment in supracondylar fractures (AO type–A).2 Retrograde supracondylar nail has shown to give one of the best results in terms of recovery, fracture union, return to work and the functional outcome. METHODS: 20 patients with supracondylar fracture femur were studied (AO type-A). Supracondylar fractures femur were treated by closed or open reduction and internal fixation by Retrograde supracondylar nail inserted through inter-condylar notch between July 2012 to September 2014 at our institution. The patients were evaluated clinically and radiologically for outcomes. All patients were followed up for an average of 12 months. Outcome was assessed using NEER’S SCORE.3 RESULTS: Supracondylar femoral extra-articular fractures in 20 patients were treated in this study with retrograde intramedullary supracondylar nail after closed or open reduction. The AO-ASIF fracture classification was used. All extra-articular fractures were selected for study. Six were compound fractures according to the Gustilo-Anderson classification,4 the fracture was stabilized with the chosen system at an average of 6.9 days post-trauma, with an average operative time of 65. 9 minutes. In 15 cases closed reduction was possible while 5 required open reduction. Post-operatively all patients were shifted to continuous passive mobilization with early toe touch walking and gradually progressive weight bearing with appearance of clinical and radiological signs of union. Evaluation was done according to Neer’s rating system.3 65% excellent results were found. In the present study, road traffic accidents were observed to be the predominant cause of distal third femoral fractures in young patients. All fractures had a sound clinical and radiological union with an average radiological union time of 16.2 weeks and average full weight bearing time was 13.4 weeks. Average knee flexion was 108 degrees with an extensor lag of 4.15 degrees.

Operability in polytrauma

Trauma has been on the increase worldwide with significant morbidity and mortality, especially when it occurs in the form of polytrauma. The management of these patients has witnessed significant changes over the last decade with the better understanding of the pathophysiology of polytrauma and the recognition of the benefits of early fracture stabilization as part of the damage control orthopedics (DCO) surgical resuscitation of these patients. Inspite of these, the operability of the polytraumatized patients occasionally becomes contentious amongst the surgical trauma team. Available evidence, shows that the focus of polytrauma resuscitation in contemporary trauma surgical practice has now shifted to the operating room, to improve outcome in polytrauma management. An electronic search was done in the PubMed and EBSCO databases for relevant published articles on polytrauma. The terms Polytrauma OR Multiple trauma AND operability were entered. Only original articles on multiple trauma involving long bone(s) fractures and at least a thoracic injury not requiring intensive care treatment, or head injury with an initial Glasgow coma score ≥ 8 points or both, published in the last 2 decades were reviewed. In addition, the references from some of the retrieved articles were also reviewed to identify suitable articles.

Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma.

Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (<24 hours) versus late (>24 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50-1.08). The quality of evidence was rated as "low." No significant reduction in infection (RR, 0.4; 95% CI, 0.10-1.6) or VTE (RR, 0.63; 95% CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated "low." In trauma patients with open or closed femur fractures, we suggest early (<24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

Clinical results of early stabilization of spine fractures in polytrauma patients

PurposeThe purpose of study was to evaluate the clinical results of early stabilization of spine fractures in polytrauma patients. Materials and methodsBetween August 2003, and May 2012, 166 polytrauma patients with thoracolumbar spine fractures were included. Patients were divided into 2 groups according to injury-to-operation time (time cut-off, 72 hours). Patients were also subdivided into 4 groups according to injury severity score (ISS), and the clinical course was evaluated. ResultsGroup A showed shorter hospital length of stay, intensive care unit, and ventilator days than group B. For each of these categories, the differences between the 2 groups were statistically significant (P = .004, P = .044, and P = .043). Patients with moderate to severe injury (ISS, ≥26), those who were treated with early stabilization showed shorter hospital length of stay, intensive care unit, and ventilator days than the patients with mild to moderate injury (ISS, <26), and the differences were statistically significant (P = .004, P = .006, and P = .006). ConclusionPolytrauma patients whose spine fractures were stabilized within 72 hours had better clinical outcomes than those with late stabilization. In addition, more severely injured patients (ISS, ≥26) benefited more from early stabilization.

A methodological systematic review of early versus late stabilization of thoracolumbar spine fractures

The optimal timing of stabilization in patients with traumatic thoracolumbar fractures remains controversial. There is currently a lack of consensus on the timing of surgical stabilization, which is limited by the reality that a randomized controlled trial to evaluate early versus late stabilization is difficult to perform. Therefore, the objective of this study was to determine the benefits, safety and costs of early stabilization compared with late stabilization using data available in the current literature. An electronic literature search was performed in Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials for relevant studies evaluating the timing of surgery in patients with thoracolumbar fractures. Two reviewers independently analyzed and selected each study on the basis of the eligibility criteria. The quality of the included studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE). Any disagreements were resolved by consensus. Ten studies involving 2,512 subjects were identified. These studies demonstrated that early stabilization shortened the hospital length of stay, intensive care unit length of stay, ventilator days and reduced morbidity and hospital expenses for patients with thoracic fractures. However, reduced morbidity and hospital expenses were not observed with stabilization of lumbar fractures. Owing to the very low level of evidence, no conclusion could be made regarding the effect of early stabilization on mortality. We could adhere to the recommendation that patients with traumatic thoracolumbar fractures should undergo early stabilization, which may reduce the hospital length of stay, intensive care unit length of stay, ventilator days, morbidity and hospital expenses, particularly when the thoracic spine is involved. Individual patient characteristics should be concerned carefully. However, the definite conclusion cannot be made due to the heterogeneity of the included studies and low level of evidence. Further prospective studies are required to confirm whether there are benefits to early stabilization compared with late stabilization.

Early fracture stabilisation in the presence of subclinical hypoperfusion

IntroductionIn polytrauma patients with an injury severity score (ISS)>16, early long bone and pelvic fracture fixation within 24h after injury has been shown to be beneficial. In contrast, surgery in the presence of subclinical hypoperfusion (SCH), defined as normal vital signs with a serum lactate≥2.5mmol/L may be detrimental. This study aimed to investigate the effect of fracture fixation in polytrauma patients with SCH. MethodsWe undertook a database review extracting 88 polytrauma patients with a new injury severity score (NISS)>16 with significant long bone or pelvic fractures (extremity NISS≥9) who underwent surgical fracture stabilisation within 48h of injury. In the group of patients with normal vital signs (mean arterial pressure≥60mmHg and heart rate≤110 beats/min) we compared outcomes between those with a normal preoperative lactate (<2.5mmol/L) and those with a raised lactate (≥2.5mmol/L). ResultsOf the 36 patients with normal preoperative vital signs, 17 had normal lactates (control group) and 19 abnormal lactates (SCH group). There were no significant differences in the method of fixation or theatre time between the groups. The SCH group required more inotropic support in the first 24h post surgery (p=0.02) and had higher sequential organ failure assessment (SOFA) scores on day 3 (p=0.003). Although not reaching mathematical significance those with SCH required on average 10 days longer on mechanical ventilation. ConclusionEarly fracture fixation in patients with SCH as defined by normal vital signs and a lactate≥2.5mmol/L is associated with significant postoperative morbidity. Consideration should be given to delaying surgery in this cohort.

Femoral Shaft Fracture Fixation and Chest Injury After Polytrauma

Thirty years ago, the standard of care for the multiply injured patient with fractures was placement of the fractured limb in a splint or skeletal traction, until the patient was considered stable enough to undergo surgery for fracture fixation1. This led to a number of complications2, such as adult respiratory distress syndrome (ARDS), infection, pneumonia, malunion, nonunion, and death, particularly when the patient had a high Injury Severity Score (ISS)3. Retrospective studies showed that the incidence of fat embolism syndrome could be reduced with stabilization of long-bone fractures in a multiply injured patient. Riska et al. noted a decrease in fat embolism syndrome from 22% (twenty-one of ninety-five) with traction treatment to 1% (one of ninety-five) with early operative fracture stabilization4. This finding led to greater use of early surgical stabilization of femoral fractures in the multiply injured patient. Subsequent follow-up studies demonstrated decreases in mortality and morbidity with early surgical stabilization of long-bone fractures in the multiply injured patient5-9. Moreover, retrospective noncontrolled studies showed that the patients with the highest ISS or greatest number of injuries derived more benefit from surgical stabilization of a femoral fracture shortly after the injury than from treatment with skeletal traction for seven to ten days prior to operative femoral fixation. Border et al.5 and Johnson et al.6 showed a decrease in pulmonary failure, time on a ventilator, time in the intensive care unit, septic complications, and death with early surgical stabilization. Because of the lack of control of these retrospective studies, and skepticism by both general surgeons and orthopaedic surgeons about the importance of early fracture stabilization, one of us (L.B.B.) and others performed a prospective randomized study to compare femoral fractures treated within twenty-four hours after injury with …

Early Definitive Stabilization of Unstable Pelvis and Acetabulum Fractures Reduces Morbidity

Although the benefits of acute stabilization of long bone fractures are recognized, the role of early fixation of unstable pelvis and acetabular fractures is not well-defined. The purpose of this study was to review complications and hospital course of patients treated surgically for pelvis and acetabulum fractures. We hypothesized that early definitive fixation would reduce morbidity and decrease length of stay. Six hundred forty-five patients were treated surgically at a level I trauma center for unstable fractures of the pelvic ring (n = 251), acetabulum (n = 359), or both (n = 40). Mean age was 40.5 years, and mean Injury Severity Score (ISS) was 25.6 (range 9-66). They were retrospectively reviewed to determine complications including acute respiratory distress syndrome (ARDS), pneumonia, deep vein thrombosis, pulmonary embolism, multiple organ failure (MOF), infections, and reperations. Definitive fixation was within 24 hours of injury in 233 patients (early, mean 13.4 hours) and >24 hours in 412 (late, mean 99.2 hours). Twenty-nine patients (12.4%) had complications after early fixation versus 81 (19.7%) after late, p = 0.006. Length of stay and intensive care unit days were 10.7 days versus 11.6 days (p = 0.26) and 8.1 days versus 9.9 days (p = 0.03) for early and late groups, respectively. With ISS >18 (n = 165 early [ISS 32.7]; n = 253 late [ISS 33.1]), early fixation resulted in fewer pulmonary complications (12.7% versus 25%, p = 0.0002), less ARDS (4.8% versus 12.6%, p = 0.019), and less MOF (1.8% versus 4.3%, p = 0.40). Rates of complications, pulmonary complications, deep vein thrombosis, and MOF were no different for patients with pelvis versus acetabulum fractures. In patients receiving ≥ 10U packed red blood cells (n = 41 early, n = 56 late) early fixation led to fewer pulmonary complications (24% versus 55%, p = 0.002), less ARDS (12% versus 25%, p = 0.09), and MOF (7.3% versus 14%, p = 0.23). Two hundred ten patients had some chest injury (32.6%). Chest injury with Abbreviated Injury Scores ≥ 3 was present in 46 (19.7%) of early and 78 (18.9%) of late patients (p = 0.44) and was associated with pulmonary complications in 26.1% versus 35.9%; ARDS in 15.2% versus 23.1%; and MOF in 6.5% versus 6.4%, respectively (all p > 0.20). However, chest injury with Abbreviated Injury Scores ≥ 3 was independently associated with more complications including ARDS (20.2% versus 3.3%, p < 0.0001), other pulmonary complications (32.3% versus 10.4%, p < 0.0001), and MOF (6.5% versus 1.2%, p = 0.0016), regardless of timing of fixation. Early fixation of unstable pelvis and acetabular fractures in multiply injured patients reduces morbidity and length of intensive care unit stay, which may decrease treatment costs. Further study to ascertain the effects of associated systemic injuries and the utility of physiologic and laboratory parameters during resuscitation may delineate recommendations for optimal surgical timing in specific patient groups.

Chirurgie périphérique chez le traumatisé crânien grave : précoce ou retardée ?

Head injuries are present in up to 65 % of multiple trauma patients with a frequent association with orthopaedic injuries. The concept of early surgical stabilization of long-bone fractures in patients with multiple injuries became firmly established in the 1980s. However, optimal timing of long bone fracture fixation in trauma patients with associated severe traumatic brain injury has been a lively topic. The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. In recent years, some studies reported a worse outcome, with secondary brain damage, resulting from hypotension, hypoxia and increased intraoperative fluid administration. This review summarises the current evidence available regarding the management of these patients in particular the recent concept of early temporary surgical stabilization in the era of “damage control orthopaedic surgery”.

The Beneficial Effects of Early Stabilization of Thoracic Spine Fractures Depend on Trauma Severity

The timing of stabilization for thoracic spine injuries is discussed controversial. Although early repair of long bone fractures is known to reduce complications, few studies investigate this issue in spine trauma. We retrospectively investigated 160 patients (January 2000 to March 2003) with spine fractures from Th1 to L1, which were stabilized. Patients were divided into two groups: early stabilization within 72 hours or later. Other subgroups were analyzed for the relationship of neurologic status, injury severity, and incidence of preoperative lung failure. : Severely injured patients (Injury Severity Score >or=38 pts) with early stabilization had a significantly shorter intensive care unit-stay (14 days [1-34 days] vs. 20 days [1-39 days]; p < 0.05) and overall shorter hospital stay (56 days [9-147 days] vs. 108 days [11-198 days]; p < 0.05). Similar patterns were seen for patients with Frankel A deficits (Frankel Score) and preoperative lung failure. The clinical course of less severe-injured patients was not influenced at all. Our data provide further evidence that early stabilization of spine injuries is safe. In severely injured patients, it does not impair perioperative lung function and results in a reduced overall intensive care unit and hospital stay.

Does Early Fracture Fixation of Thoracolumbar Spine Fractures Decrease Morbidity or Mortality?

Systematic Review. To determine whether early spinal stabilization in thoracolumbar spine trauma decreases morbidity and mortality. The role of early spinal stabilization through surgical means may have a number of benefits. These include reduced morbidity and mortality because of more rapid mobilization afforded by spinal column stabilization and a reduction in the incidence and severity of sepsis and respiratory failure. There are several potential disadvantages of early surgery. The most strongly debated is the potential that the additional physiologic injury may result in an unintended increase in morbidity and mortality caused by worsening of existing injuries, such as with pulmonary or intracranial trauma. This problem may be compounded by increased hemorrhage and resulting hypotension. Operating in the presence of missed or underestimated associated injuries or under less-than-ideal conditions relative to the complexity of the surgery and resources required is also a potential disadvantage. A systematic review of the English-language literature was undertaken for articles published between January 1990 and December 2008. Electronic databases and reference lists of key articles were searched to identify published studies examining the timing of thoracolumbar fracture fixation. Two independent reviewers assessed the strength of literature using the Grading of Recommendations Assessment, Development, and Evaluation criteria, assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus. A total of 68 articles were initially screened, and 9 ultimately met the predetermined inclusion criteria. These studies demonstrated that early stabilization of thoracic fractures reduced the mean number of days on a ventilator, the number of days in intensive care unit and in hospital, and reduced respiratory morbidity compared with late stabilization. This effect, other than the length of hospital stay, was not seen with stabilization of lumbar fractures. There is not enough evidence to determine the effect of the timing of stabilization on mortality in thoracolumbar fractures. Ideally, patients with unstable thoracic fractures should undergo early (<72 hours) stabilization of their injury to reduce morbidity and, possibly, mortality.

Floating Knee Injuries: A High Complication Rate

Floating knee injuries are usually associated with complications and mortality, regardless of the treatment regimen. Orthopedic surgeons typically recommend various treatment regimens, especially aggressive and early stabilization of both femoral and tibial fractures. Some authors have reported that the complication and mortality rates remain high regardless of the treatment regimen used. The purpose of this retrospective study was to review the long-term results of treatments for floating knee injuries performed at our institution, and also to calculate the distribution of fracture types within patient age groups and the association with complications related to floating knee injury. We retrospectively reviewed medical records and radiographs of 419 floating knee injuries treated for postoperative complications from November 1987 to April 2003. Of the 419 patients with floating knee injuries, 104 (24.8%) developed complications. The result showed that the complication rate was associated with fracture type (open fracture [32.2%; P<.001], Fraser type IIc [36.8%; P<.001], tibial plateau [28.6%; P=.037], and distal tibia [28.6%; P=.035]). This study revealed that the complication rate associated with floating knee injuries remained high, regardless of the treatment regimen used. Surgeons should focus on reducing complications while treating floating knee injuries.

A Lethal Case of Fat Embolism Syndrome in a Nine-Year-Old Child: Options for Prevention.

We report a lethal case of fat embolism syndrome in a nine-year-old child after a direct blunt trauma leading to a pelvic fracture. On the second day, signs of bowel perforation and septic shock led to an acute aggravation of the pulmonary symptoms, cardiac arrest and death. Fat embolism is seldom thought to occur in pediatric trauma patients; however, this case illustrates it can lead to disastrous sequela. Since there is no specific treatment for it, prevention by early fracture stabilization is the only option.

The floating knee: retrospective review of 15 cases treated over a 5-year period

Purpose The purpose of this study is to conduct a retrospective analysis of the floating knee cases managed in our center between 2000 and 2005, as well as the results achieved by treatment, comparing them with the cases reported in the literature. Materials and methods A retrospective review was carried out of all patients with ipsilateral femoral and tibial fractures treated in our hospital between 2000 y 2005. Seventeen patients were included in the study, of which 15 could be followed up clinically after a mean 4-year period. Data related to demography, fracture-type, associated injuries, treatment type and complications were recorded. Finally, patients were assessed on the Karlström and Olerud scale. Results Results were good for five patients, fair for four and poor for six. As regards complications, there were two cases of infection, one of fat embolism, three pseudoarthroses and five lateral popliteal sciatic nerve palsies. One of the patients required a supracondylar amputation and another died. Conclusions Floating knee is an extremely severe lesion, with significant associated injuries and frequent complications and sequelae. In our series, results have been poor in 6 patients according to the Karlström and Olerud scale, which confirms the severity of the lesion. We believe that currently the best treatment is early stabilization of both fractures by means of a combined (retrograde femoral and antegrade tibial) nailing procedure. Finally, we suggest a modified evaluation scale (based on the Karlström and Olerud scale), which might prove more accurate in classifying results. Using this suggested classification, our series would have obtained a mean of 59 points, with a total of 6 excellent results, 1 good, 3 fair and 5 poor.

Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study

Optimal timing of stabilization for spinal injuries is discussed controversially. The goal of this study is to investigate the neurological recovery and its influencing factors in thoracolumbar spine fractures after surgical decompression and stabilization within 8 h of spinal cord injury versus surgery which is performed between 3 and 15 days. Twenty-seven patients undergoing thoracolumbar stabilization with neurological deficit for an acute thoracolumbar spinal injury at the level of Th8-L2 vertebra at Selcuk University between March 2004 and December 2006 were recorded. Patients with neurological deficit and medically stable for surgery underwent immediate stabilization within 8 h defined as group I (n = 12) and patients underwent operation in 3-15 days after thoracolumbar injury were defined as group II (n = 15). Patients were assessed for neurologic deficit and improvement as defined by the scoring system of American spinal injury association (ASIA). In spite of comparable demographic data, patients in group I had a significantly shorter overall hospital and intensive care unit stay and had lesser systemic complications such as pneumonia and also exhibited better neurological improvement than group II (p < 0.05). Early surgery may improve neurological recovery and decrease hospitalization time and also additional systemic complications in patients with thoracolumbar spinal cord injuries. Thus early stabilization of thoracolumbar spine fractures within 8 h after trauma appears to be favorable.

Operative Timing and Management of Spinal Injuries in Multiply Injured Patients

Spinal injuries occurring in polytrauma patients are caused by high impact trauma. Due to high velocity mechanism, trauma of the vertebral column may be accompanied by injuries of adjacent body cavities such as thorax, abdomen, and pelvis. Neurologic examination is mandatory and has to be documented preferably using the ASIA/IMSOP-classification. Clinical symptoms may point towards spinal injury. However, absence of clinical symptoms is not sufficient to rule out spinal injuries. Two diagnostic pathways may be followed to assess the spine: (1) Conventional X-ray diagnostics of the entire spine followed by selective CT scanning of suspected lesions and CT scanning of the upper cervical spine region C0-C3 in unconscious patients. (2) Whole body polytrauma-multislice-spiral-CT scanning from head to pelvis without conventional Xray playing the key role in the algorithm of modern ER management. In this study, 287 polytrauma patients with associated spinal injuries were analyzed prospectively from a cohort group of 731 polytrauma patients treated from 2002 to 2004 in our institution. Indications for surgery include neurologic deficit, instability, as well as malalignment and dislocation. In polytraumatized patients, indication for primary surgery is given in complex spinal injuries with associated vascular, neurologic, or organ injuries as well as multilevel spinal fractures or unstable spinal injuries. In patients with unstable spinal injuries cardio-pulmonary instability and life threatening intracranial pressure are contra - indications for immediate spinal surgery. On the day of injury ventral spondylodesis of unstable cervical spine fractures of C3-C7 and dorsal spondylodesis of unstable thoraco-lumbar fractures using internal fixator are the standard procedures. Polytrauma patients benefit from early stabilization of spinal fractures including reduction of ventilation and ICU treatment, pneumonia rate, general complications, as well as hospital stay. However, it is controversial if mortality rate and neurologic outcome are affected by the time point of operative stabilization.

Timing and Duration of the Initial Pelvic Stabilization After Multiple Trauma in Patients From the German Trauma Registry: Is There an Influence on Outcome?

There is an ongoing debate about the systemic burden of early definitive fracture stabilization in multiply injured patients. In patients with extremity fractures, the benefit of limited initial surgery has been examined. In this retrospective analysis, we assessed whether differences in outcome can be attributed to the degree of initial surgery in polytrauma patients with pelvic-ring fractures. Multiply injured patients of the German Trauma Registry (Injury Severity Score [ISS] > or =16) with pelvic-ring fractures in need of surgery were analyzed for independent effects of the duration and the timing of the initial surgical stabilization of the pelvis. We compared three subgroups according to duration (D) [short (S): <1 hour; intermediate (I): 1-3 hours; and long (L): >3 hours] and timing (T) [early (E): day 0; intermediate (I): days 1-3; and late (L): day >3]. In addition, a subgroup analysis dependent on injury severity was performed. Statistics included analysis of variance, post-hoc Tukey test, chi test, Student's t test, with significance at p < 0.05. Demographic data and injury severity were comparable between the groups. The duration of surgery was associated with a higher rate of liver failure (group D-S: 6%; D-I: 17%; D-L: 28%; p = 0.028). The timing of surgery was associated with a higher rate of renal failure (T-E: 17%; T-I: 3%; T-L: 5%; p = 0.021), multiorgan failure (T-E: 27%; T-I: 23%; T-L: 13%; p = 0.024) and mortality (T-E: 18%; T-I: 19%; T-L: 4%; p = 0.019). There was improved mortality, lower rates of multiorgan failure, and sepsis in patients with higher ISS for procedures less than 3 hours. In our retrospective analysis, both initial short as well as delayed surgery were associated with a lower rate of organ failure and mortality in multiply injured patients (ISS > or =16). This is especially supported for patients with high ISS.