Fig. 13.1
Pathophysiology of the inflammatory cascade and iatrogenic “2nd hit” insults leading to secondary brain injury
Consequently, alternative strategies to provide early fracture stabilization of long bones, while avoiding the risk of “early total care,” have been proposed, including skeletal traction and “damage control” external fixation [61]. The concept of “damage control” surgery was extended beyond its initial applications in abdominal and thoracic trauma, to the acute management of major fractures in the severely injured, particularly in presence of associated head injuries [53, 62]. The principle is to provide early fracture stabilization by external fixation as a bridge to definitive fracture care once the patient is physiologically stable and the injured brain less vulnerable to iatrogenic “2nd hit” insults [13]. The delayed conversion from external fixation to intramedullary nailing of femur shaft fractures is considered safe once the ICP has normalized and/or patients are awake, oriented, and fully resuscitated [23]. In other words, the second procedure-related intramedullary reaming and nailing of long-bone fractures should be performed outside of the “priming” window, once the post-injury hyperinflammatory response has subsided (Fig. 13.1). When compared to early total care, the “damage control” approach with delayed conversion to definitive care has been shown to decrease the initial operative time and intraoperative blood loss without increasing the risk of procedure-related complications such as infection and nonunion [63, 64].
The pros and cons of the three main modalities for acute management of femur shaft fractures in head-injured patients, namely, (1) skeletal traction [61], (2) “damage control” external fixation [62, 63], and (3) “early total care” by reamed intramedullary nail fixation [60] are depicted in Fig. 13.2.
Fig. 13.2
Risks and benefits of different acute management strategies for immobilizing femoral shaft fractures in head-injured patients
Conclusion
Head-injured patients with associated long-bone fractures represent a very vulnerable patient population [49]. These patients have a high risk of sustaining secondary cerebral insults related to hypotension, increased ICP, and decreased CPP, all of which contribute to increased mortality and adverse neurological outcomes [56–60]. The involved specialties in the early management of multiply injured patients with head injuries and associated long-bone fractures, including ED physicians, trauma surgeons, neurosurgeons, and orthopedic surgeons, must “speak the same language” in terms of understanding the underlying pathophysiology of CHI and the time-dependent vulnerability of the injured brain to iatrogenic “2nd hit” insults [4, 13]. Despite recent advances from basic research and clinical studies, which improved our current understanding of the pathophysiology of CHI, the current literature remains conflicting in terms of identifying a clear-cut management strategy for timing and modality of fracture fixation in severely head-injured patients [13, 50, 51, 54, 58, 59]. This notion emphasizes the pressing need for well-designed, prospective, controlled multicenter trails aimed at comparing the standard treatment strategies for initial management of long-bone fractures in patients with severe head injuries (Fig. 13.2). Until higher-level evidence-based recommendations are available, the clinical approach for the management of this vulnerable cohort of patients must be based on the basic principle of do not further harm by applying simple measures of “damage control”—when in doubt—which respects the underlying pathophysiology of traumatic brain injury and the hyperinflammatory response of the combination of multiple critical injuries [10]. We recommend the following specific management strategy for associated long bone fractures in head-injured patients, based on a combination of empiric experience and review of the available pertinent literature in the field [13, 49]:
1.
Damage control orthopedics” by spanning external fixation in all patients with severe CHI (GCS ≤8 and intracranial pathology on CT scan, including cerebral edema, midline shift, sub/epidural bleeding, or open head injuries)
2.
Optional damage control orthopedics in all patients with moderate CHI (GCS 9–13) or patients with GCS of 14/15 with “minor” intracranial pathology on CT scan (e.g., traumatic subarachnoid hemorrhage that warrants observation only)
3.
Conversion from external to internal fixation in CHI patients who are awake and alert (GCS 13–15) or comatose patients with a stable ICP (<15 mmHg) and CPP in a normal range (>80 mmHg) for more than 48 consecutive hours
4.
Early total care for long-bone fractures all patients with mild CHI (GCS 14/15) and normal initial craniocerebral CT scan
5.
Temporary skeletal traction as a valid adjunct for patients “in extremis”, i.e., in severe protracted traumatic hemorrhagic shock and coagulopathy, who are unsafe to be taken to the operating room until adequately resuscitated
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