The Polytrauma Patient
The multiply injured patient presents a major challenge to the orthopaedic surgeon. Treatment requires coordination and teamwork among any number of medical and surgical services, which can influence the timing of surgery or the choice of surgical approach. The systemic inflammatory response to trauma also presents a dilemma with a complex interplay between the additive effects of specific injuries and prioritizing the treatment of them. Damage control is a term frequently applied to the use of temporizing treatments to minimize the effects of independent injuries on systemic inflammation until the patient is sufficiently stable and ready for definitive treatment. The role of the orthopaedic surgeon in the treatment of the polytraumatized patient is (1) to determine the appropriate timing for surgical intervention; (2) to minimize further systemic insults from the orthopaedic injury or injuries and from surgery; and (3) to minimize the risk of orthopaedic complications, such as infection, malunion, and pulmonary embolism. Appropriate initial management of fractures in multiply injured patients has a profound influence on their overall recovery and prognosis, and reduces the rate of serious complications, such as adult respiratory distress syndrome, multiorgan failure, fat embolism, and thromboembolic disease. This chapter summarizes our rapidly advancing understanding of the physiological response to trauma, describes the systemic effects of musculoskeletal injury, and uses this information to describe a rational approach to prioritizing and managing musculoskeletal trauma in the multiply injured patient. Case histories are presented to illustrate these points.
Evaluation of the Polytraumatized Patient
The care and treatment of the polytraumatized patient requires a team approach and attention to detail in the emergency setting. Although the general surgery trauma service may typically coordinate the patient′s care, multiple services are often involved, including orthopaedic surgery, vascular surgery, neurosurgery, and anesthesia. The efforts and requirements of these service must be coordinated to provide the most efficient care for the patient.1
Evaluation begins with the principles of Advanced Trauma Life Support® (ATLS; American College of Surgeons, Chicago, IL). Thorough assessment of the patient includes an understanding of the patient′s medical history and the events leading to his or her injuries. Information about the mechanism of injury can alert the trauma team to look for specific types of injuries that may not be obvious on a primary or secondary survey. Prolonged extrication times may predispose the patient to hypothermia and may raise suspicion of soft tissue crush injuries despite a negative fracture workup. These patients as well as those with high-energy fractures or large transfusion requirements should be closely monitored for compartment syndrome. Transfusion requirements prior to arrival at the hospital, in addition to what is charted once in the hospital, may indicate a need for platelets or fresh frozen plasma prior to or during any immediate operative procedures.
Skin integrity and soft tissue injury should be assessed for all fractures. Closed injuries can still be associated with significant soft tissue injury or a closed degloving (Morel-Lavallée) lesion. Displaced or unstable pelvic ring injuries warrant rectal and vaginal examination for open injuries. Appropriate antibiotics should be given for open injuries, and the history, once again, becomes important. Wounds contaminated by soil should receive penicillin G and tetanus immunoglobulin if necessary. Wounds exposed to water sources may require coverage with ciprofloxacin for water-borne bacteria.
All fractures and dislocations need to be assessed for neurovascular abnormalities. When found, appropriate studies and consultations should ensue prior to surgical treatment. Vascular injuries may be identified on clinical exam alone or by diagnostic measures such as an ankle-brachial index (ABI) of less than 0.9.2,3 Computed tomography (CT) angiography may be used to further assess the need for vascular intervention. Communication with the vascular surgeon regarding timing of surgeries and placement of incisions is extremely important. Generally, bony stabilization should be performed prior to revascularization to enable the vascular surgeon to assess the length of the needed vessel repair and to prevent stresses on the repair. This stabilization can be done in rapid manner with external fixation in cases of limb-threatening injuries or with definitive fixation if the warm ischemia time is short. Incisions can usually be made in a manner that is not detrimental to the work of either service if they are planned cooperatively. Fasciotomy should be considered in cases of prolonged ischemia to prevent compartment syndrome secondary to reperfusion. Once again, incision placement for compartment release needs to be planned if further procedures are to be performed.
Angiography should be considered in patients with pelvic injuries requiring transfusion of more than four units of packed red blood cells (PRBCs) in less than 24 hours or more than six units of PRBCs in less than 48 hours despite temporary stabilization efforts or sheeting.4 Persistent hemodynamic instability in the face of a negative peritoneal lavage may indicate a possible retroperitoneal bleed where other sources (i.e., bilateral femur fractures) have been ruled out and may benefit from angiography and embolization of arterial bleeding in the pelvis. Alternatively, if suspicion for retroperitoneal bleeding is high, laparotomy and pelvic packing can be performed.
Although the orthopaedic focus is on care of the fracture(s), attention also needs to be given to injuries of other bodily systems to appropriately plan surgical approaches and patient positioning. Patients with intra-abdominal injuries requiring emergent/urgent laparotomy require special consideration if there are associated pelvic ring injuries. Incisions for laparotomy can be problematic if there is a pelvic ring injury that will require an anterior approach. Similarly, placement of suprapubic catheters in patients with bladder or urethral disruption should be coordinated among the involved services to prevent placement in the region of a future incision or within a pelvic hematoma Predisposing the patient to infection. Long intra-abdominal or thoracic procedures can also lead to hypothermia and coagulopathy, which may require a delay in orthopaedic intervention and consideration of damage-control techniques.5
Spine injuries can also affect the priority of orthopaedic intervention. Unstable injuries may require bracing or surgery prior to treatment of other fractures. Such injuries also need to be kept in mind when planning the operative approach and patient positioning in the operating room.
Assessment of the patient does not stop in the trauma bay. Ongoing survey of the patient should occur throughout the hospital course for missed injuries, evolution of compartment syndrome, early signs of infection, and other complications. The incidence of missed injuries in the first 24 hours of admission is as high as 12% in the multiply injured patient.6,7 Patients who are intubated and sedated are at particularly high risk, and surveillance must be vigilant.7
The Physiological Response to Trauma
Injuries, whether simple or complex, cause pain, bleeding, and activation of the systemic inflammatory response. Although inflammation has long been characterized as the first stage of healing, we are only beginning to gain an understanding of the diverse metabolic, physiological, and immunologic changes that occur after injury. For example, numerous investigators have documented changes in the levels of circulating proinflammatory and anti-inflamma-tory cytokines following injury.8–17 These alterations of the biochemical milieu cause widespread secondary changes in organ function, involving the immunologic, cardiovascular, pulmonary, and gastrointestinal systems, among others.8,9 Skeletal injuries, especially long-bone fractures, have been shown to contribute to such problems.13 In a murine model, closed femoral fractures were shown to cause immunosuppression and altered gastrointestinal permeability.18
Our current understanding of the pathophysiology of trauma divides injuries and their effects into so-called first hits and second hits. First hits are the initial injury and its immediate effects, including organ, skeletal, and soft tissue injury; hypotension; and hypoxemia. Second hits are subsequent complications or interventions that cause a reactivation or exaggeration of the initial response to injury, and by so doing, cause further morbidity and mortality.19 Examples of second hits are compartment syndrome, sepsis, hypotension, and invasive surgery. Femoral nailing is one of the best-characterized examples of a second hit.12,13 Avoiding iatrogenic exacerbation of the systemic inflammatory response is the primary focus of the concept of “damage-control orthopaedics,” discussed later in this chapter.
Systemic Inflammatory Response Syndrome
Both severe injury and major surgery (including orthopaedic surgery) cause the release of numerous cytokines, arachidonic acid metabolites, complement factors, acute-phase reactants, and hormones. Taken together, these changes represent the systemic inflammatory response. The clinical manifestations of these metabolic changes are multiple, and include fever, tachycardia, hyperventilation, and leukocytosis. Although these changes occur in predictable patterns, the magnitude of the response to a given level of injury is variable, and may be genetically determined.20 Coincidently, anti-inflammatory mediators are also produced; this is known as the compensatory anti-inflamma-tory response syndrome (CARS).10 Any imbalance between the normal systemic inflammatory and anti-inflammatory responses to injury can contribute to multiorgan dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and sepsis.10
In 1991, a consensus conference established specific criteria for the diagnosis of systemic inflammatory response syndrome (SIRS; see text box).21
Definition of SIRS and SIRS Score
Definition of SIRS, from the Consensus Conference of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM).21 At least two of the following four clinical criteria must be fulfilled to make the diagnosis of SIRS:
Heart rate > 90/min
Leukocytes < 4000/mm3, > 12,000/mm3, or 10% juvenile neutrophil granulocytes
Breathing rate > 20/min, with PaCO2 < 32 mmHg
Temperature < 36°C or > 38°C
SIRS score: Four clinical criteria are used, scored at 0 (absent) or 1 (present), to give a total score ranging from 0 to 4. A SIRS score ≥ 2, in the absence of systemic sepsis, is evidence of a systemic inflammatory response.17 The criteria are as follows:
Pulse greater than 90 beats/min
Leukocyte count above 12 or below 4 (× 1,000/mm3)
Respiratory rate above 20 breaths/min (or PCO2 < 33 mmHg)
Core temperature below 34°C or above 38°C
The presence of SIRS can be easily quantified by the SIRS score,17 and is predictive of a number of complications, including ARDS, disseminated intravascular coagulation, acute renal failure, and shock.14
The systemic inflammatory response is mediated by the release of numerous cytokines from injured tissues or in response to tissue or end-organ hypoxia and hypoper-fusion. Cytokines are polypeptides that act in an autocrine or paracrine manner to induce changes in cellular function. Proinflammatory cytokines are numerous and include tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6), and interleukin-8 (IL-8, also known as neutrophil activating peptide [NAP]). Increased serum levels of these cytokines are found in patients with evidence of systemic inflammation, as well as in the bronchoalveolar lavage of patients with thoracic trauma or ARDS.9 Serum levels of IL-6 correlate with the amount of overall soft tissue trauma and chest trauma,16 and with the Injury Severity Score (ISS); the incidence of MODS, ARDS, and sepsis; as well as with outcome.8
High levels of circulating proinflammatory cytokines induce many physiological changes. Polymorphonuclear leukocytes (PMNs) are recruited to the site of injury and are stimulated to release proteases and oxygen free radicals. The coagulation and complement cascades are activated as well as the kallikrein-kinin system. The liver is stimulated to produce acute-phase reactants such as C-reactive protein (CRP), α1-antitrypsin, α2-macroglobulin, ceruloplasmin, lipopolysaccharide (LPS)-binding protein (LBP), fibrinogen, and prothrombin. A more thorough review of this topic can be found elsewhere.10,22
As mentioned above, the accumulation and stimulation of PMNs at the site of injury is one of the first events of the host response to injury. Although the recruitment and activation of PMNs at the site of injury is crucial for the killing and phagocytosis of bacteria and the removal of dead tissue, this same early host response has a paradoxically detrimental effect as well, both locally and systemically. Activated PMNs, in the presence of proinflammatory cytokines and toxins such as LPS, upregulate adhesion molecules (adhesins) and adhere to endothelial tissue. Increased levels of adhesins can be measured in trauma patients and are predictive of complications.11
The accumulation of activated PMNs at the site of injury is thought to be one of the primary causes of secondary tissue injury.23 When stimulated, activated PMNs and macrophages released proteolytic enzymes such as elastase and metalloproteinase, as well as generate reactive oxygen species.23,24 These enzymes degrade most proteins in the extracellular matrix as well as important plasma proteins. In addition, neutrophil elastase induces the further release of proinflammatory cytokines, potentially exacerbating the problem. Increased levels of elastase and elastase-α1-protease-inhibitor complex are detectable in trauma patients depending on the injury severity and the post-traumatic course.15
Multiorgan Dysfunction Syndrome
Occasionally, multiply injured patients develop progressive failure of their host-defense mechanisms, manifested by sepsis and progressive cerebral, cardiovascular, pulmonary, hepatic, gastrointestinal, renal, and circulatory dys-function and collapse.25 This clinical phenomenon has been called by many names, including MODS and multi-organ failure. Although MODS was initially thought to be the end result of sepsis, it is now known to occur in nonseptic patients as well (although sepsis may develop later). Current thinking attributes delayed-onset MODS to an imbalance between the pro- and anti-inflammatory mechanisms.17,26 There are many proposed theories about the etiology of MODS. At the most basic cellular level, many different abnormalities occur as a part of MODS, including endothelial cell damage, increased vascular permeability with capillary leakage, and microcirculatory failure with cellular hypoxia and apoptosis of parenchymal cells.25 Virtually all major organ systems can be affected individually or in combination (Table 1.1 ), and patients who develop MODS often succumb despite intensive care unit support.
Fracture Care and the Systemic Inflammatory Response: The Second Hit
The treatment of musculoskeletal trauma can influence the development of SIRS and MODS. For many trauma victims, appropriate resuscitation restores homeostasis, the SIRS scores remain low, and the patient benefits from early fracture care, which prevents the complications that follow from prolonged immobilization (Fig. 1.1). Fixation of long-bone fractures in particular, however, has been shown to represent a second hit to the patient, and may exacerbate the systemic inflammatory response and precipitate the development of any or all of the components of SIRS and MODS (Fig. 1.2).12,13,19 Giannoudis et al19 studied the level of inflammatory markers IL-6 and elastase in femoral shaft fractures treated with reamed and unreamed nailing. Both markers were significantly elevated compared with controls at the time of admission. Intramedullary nailing caused a further elevation in both markers, demonstrating a systemic inflammatory response to nailing. Although there was a trend toward a greater response in patients treated with reamed nailing, the data did not reach statistical significance. It has been proposed that extensive surgery should be avoided in the “borderline” patient.5
Currently, research efforts are being directed at characterizing the biochemical and physiological parameters that define a borderline patient, so that treatment may be better individualized and matched to what the patient is capable of physiologically withstanding (see text box).
Parameters Used to Define the “Borderline” Patient
Multiple injuries (ISS > 20) and chest trauma (chest Abbreviated Injury Scale [AIS] score > 2)
Multiple injuries including abdominal/pelvic trauma and shock (initial blood pressure [BP] < 90 mmHg)
Severe polytrauma (ISS > 40), without chest trauma
Bilateral pulmonary contusion
Initial mean pulmonary arterial pressure > 24 mmHg
Increase of pulmonary artery pressure during femoral nailing > 6 mmHg
(Adapted from Pape HC, Tscherne H. Early definitive fracture fixation with polytrauma: advantages versus systemic/pulmonary consequences. In: Baue AE, Faist E, Fry M, eds. Multiple Organ Failure. New York: Springer-Verlag; 2000:279–290.)
For example, Hans-Christoph Pape and colleagues13 looked at multiply injured but clinically stable patients with femur fractures and divided them into three groups based on management of their femur fracture: primary femoral nailing, primary external fixation, and delayed femoral nailing. Both clinical parameters and serum levels of IL-1, IL-6, and IL-8 were followed. These investigators found that levels of IL-6 and IL-8 were higher after primary femoral nailing than after primary external fixation or after secondary (delayed) intramedullary nailing, although no significant clinical differences were found. In a later study from the same center, a similar population of patients was studied27; however the SIRS score and the Marshall multiorgan dysfunction score28 were used as outcome parameters. Once again, patients undergoing immediate femoral nailing were compared with a second group of patients undergoing primary external fixation and later conversion to a femoral nail. Despite having lower injury severity scores, the mean SIRS score was significantly higher in the primary nailing group from 12 hours until 72 hours postoperatively compared with the external fixation group. When the patients initially undergoing external fixation later underwent intramedullary nailing, the SIRS scores remained lower than those in the primary nailing group.28 These studies provide strong evidence that choices made during the clinical management of femur fractures in multiply injured patients may influence the risk of SIRS and MODS.
Prioritization of Injury Treatment
In the 1970s, acute fracture treatment was rarely performed due to the commonly held belief that trauma patients were “too sick for surgery.” These patients were typically kept in traction for prolonged periods of time and underwent definitive fixation (if fixation was performed at all) on a delayed basis. In the late 1980s, with improvements in clinical care and monitoring, many clinicians decided to begin treating fractures on a more urgent basis, with the understanding that doing so could decrease the incidence of fat embolism syndrome and allow more rapid mobilization of the patient. Early retrospective studies demonstrated the benefits of such an approach, showing a decrease in the incidence of ARDS and pneumonia and in the length of hospital stay.29 Bone et al30 performed a prospective randomized study examining delayed (> 48 hours) versus early (< 24 hours) fixation of femoral shaft fractures, and found that early stabilization had a decreased rate of ARDS, a shorter period of assisted ventilation, and a shorter hospital stay.
As early stabilization became more common, it was found that some patients with multiple injuries had a higher incidence of complications with early intramedullary nailing of femoral shaft fractures.31 This was particularly concerning in patients who had preoperative evidence of pulmonary trauma, in whom immediate femoral nailing appeared to be associated with the development of ARDS postoperatively.31 Although femoral nailing has demonstrable effects on pulmonary physiology,32 other work has shown that the incidence of ARDS and other pulmonary complications is more likely to be the result of the severity of chest trauma than the method of fracture fixation.33
Surviving the Night
Adequate resuscitation is critical in the early care of the polytraumatized patient. In multiple limb injuries, central lines give appropriate access without encroaching on surgical sites.
Pelvic ring injuries can cause massive bleeding. If there is any concern, err on the side of placing a pelvic binder.
Furthermore, as described above (see The Physiological Response to Trauma), we now have a better understanding of the inflammatory response to severe injury, and recent evidence suggests that urgent provisional stabilization of fractures with delayed definitive fixation may improve patient outcomes. This method has been termed damage-control orthopaedics (DCO).
Timing of Surgical Interventions
Prolonged operative treatment in the acute setting can lead to hypothermia and coagulopathy. A core body temperature of 34°C is associated with increased mortality, decreased platelet activity, and altered fibrinolysis. Traumatized patients often receive large volumes of intravenous fluids at ambient temperature and may undergo abdominal or thoracic surgical procedures, predisposing them to hypothermia. Patients requiring blood transfusion will be depleted of platelets, factor V, and factor VIII. These factors add to the systemic stressors of the initial traumatic event and need to be considered in the timing of surgical treatment of orthopaedic injuries.
Guidelines for the Timing of Operative Intervention in the Trauma Patient
Emergent (within 1 to 2 hours maximum)
Compartment syndrome
Closed or open reduction of dislocation or fracture/dislocation where vascularity of limb, vascularity/integrity of overlying skin, or nerves are compromised due to the deformity of the dislocation or fracture (e.g., lateral subtalar joint dislocation that is not reducible and where the patient has numbness on the plantar aspect of the foot with blanching over the medial skin of the ankle; tongue-type calcaneus fracture where the tuber is blanching the skin in the Achilles tendon region)
Stabilization of fractures associated with vascular injuries
Closed reduction of joint dislocations (e.g., hip, knee)
Mechanical stabilization of unstable pelvic injuries in hemodynamically unstable patients
Urgent (within 6 to 12 hours maximum)
Stabilization of long bone (e.g., femur, tibia) fractures in the polytrauma patient
Open reduction and internal fixation of a femoral neck fracture in a young adult
Open reduction and internal fixation of a displaced talar neck fracture
Debridement and stabilization of open fractures
Reduction and stabilization of unstable spine injuries with evolving neurologic deficits
Expedient (within 24 hours maximum)
Stabilization of femur fractures in the non-polytraumatized patient (i.e., isolated injury)
Stabilization (e.g., external fixation) across axially unstable articular injuries (e.g., tibial plateau and pilon fractures)
Hip fractures (e.g., high-energy intertrochanteric femur fractures)
Semi-elective (in 1 to 7 days maximum)
Foot and ankle fractures excluding pilon and calcaneus fractures
Acetabular fractures
Definitive management of unstable pelvic ring injuries
Closed upper extremity trauma (e.g., supracondylar-intercondylar distal humerus fracture, both bone forearm fracture)
Reduction and stabilization of unstable spine injuries with complete neurologic deficit or without neurologic deficit
Elective (in 1 to 4 weeks)
Articular fractures about the lower extremity where the condition of the soft tissues affects the timing of surgery (e.g., calcaneus, pilon, tibial plateau fractures)
A key role that the orthopaedic surgeon plays in the management of the polytrauma patient is to assess the musculoskeletal injuries and decide which injuries need to be treated emergently (i.e., within 1 to 2 hours), urgently (within 6 to 12 hours), expediently (within 24 hours), semi-electively (in 1 to 7 days), and electively (in 1 to 4 weeks). Thus, a schema for the timing of orthopaedic injuries in the trauma patient was outlined (see text box). Clearly, this schema is not meant to be a strict mandate, because the exact timing of treatment of injuries should be determined by the particular characteristics of the injuries themselves, the stability of the patient, and the availability of an appropriate surgical team.
Damage-Control Orthopaedics
Video 1.1 Unreamed Femoral Nailing
Damage-control orthopaedics (DCO) entails staged treatment of fractures in patients with multiple injuries requiring resuscitation efforts. The first stage is temporary stabilization and includes control of hemorrhage, debridement of open wounds, and external fixation. In the patient who is in extremis, these procedures may need to be performed in the trauma room or the intensive care unit (ICU). The second stage is resuscitation, during which the patient returns to the ICU for close monitoring, repletion of blood products, and further hemodynamic stabilization. Stage three consists of definitive fixation of the fracture once the patient is optimized for orthopaedic intervention.
The goal of DCO is to provide enough fracture stabilization to allow the patient to be mobilized, and to decrease local inflammation that can contribute to systemic changes, while at the same time avoiding major surgery that would constitute a so-called second hit to the patient after the initial trauma. Although external fixation is the primary method used during damage control, unreamed femoral nailing may also fall into this category because studies have shown that it may cause less additional operative burden than reamed nailing,19 and potentially less embolic burden on the lungs, although this remains somewhat controversial.34 Furthermore, at least for some patients who are in the operating room already, unreamed femoral nailing may be expeditiously performed.
Pape et al35 categorized the polytraumatized patient based on four potential conditions: stable, borderline, unstable, and in extremis. Stable patients are hemodynamically stable, normothermic, with a lactate measurement less than 2.0 mmol/L and no respiratory difficulties or coagulopathy (Table 1.2). Stable patients can have definitive management of their injuries in the early time period (< 24 hours), but this is not imperative. Borderline patients require resuscitation before going to the operating room, and potentially may have definitive early management of their orthopaedic injuries, but they remain at high risk for rapid deterioration. These patients are defined as those with an ISS greater than 40, or greater than 20 if there is an associated thoracic injury; hypothermic (colder than 35°C); have multiple injuries associated with severe abdominal/pelvic injury and systolic blood pressure less than 90 mmHg; evidence of pulmonary contusion; bilateral femur fractures; or moderate/severe head injuries (see box, Parameters Used to Define the “Borderline” Patient, above). These patients fall into a “gray zone” and can be considered for early total care, but with caution and a low threshold for conversion to DCO if the patient worsens or proves unstable during the first operative intervention. The unstable patient should undergo damage control stabilization with further resuscitation. Patients who are in extremis are those who are failing resuscitative measures and may need to have external fixation placed at the bedside in the ICU setting.35,36
Factor | Criterion |
Systolic blood pressure | > 90 mmHg |
Core temperature | > 34°C |
Urine output | > 150 mL/h |
Cerebral perfusion pressure | > 70 mmHg |
SIRS score | < 2 |
PaO2/FiO2 ratio | > 280 |
Lactate | < 2.5 |
Platelet count | > 100,000/µL |
C-reactive protein | < 11 mg/dL |
Interleukin-6 | < 500 pg/dL |
Abbreviation: SIRS, systemic inflammatory response syndrome.
Although monitoring IL-6 levels may be clinically relevant to assess patient readiness for surgery, it is not a standard laboratory procedure and thus may be difficult to use in the hospital setting. Serum lactate levels are routinely used because of ease and speed of obtaining the information. Lactate is a measure of tissue perfusion. In cases of trauma, inadequate tissue perfusion secondary to hypoxia, blood loss, or cardiogenic shock results in elevated blood lactate levels. Normal values range from 0.8 to 2.0 mmol/L. Studies have shown that the degree of elevated lactate on admission and the number of days of elevation above normal correlate with multiorgan dysfunction.37,38 Other markers used are platelet counts greater than 100,000 per microliter, C-reactive protein (CRP) less than 11 mg/dL, and the Po2/Fio2 ratio greater than 280.39 The SIRS score as described earlier in this chapter has been shown to be predictive of mortality and infection risk and may also be used as a marker for adequate resuscitation for surgery (Table 1.2).40–42
Techniques of Damage-Control Orthopaedics
Video 1.2 Reamer Irrigator Aspirator for Patients with Pulmonary Injury
The primary surgical interventions in DCO are irrigation and debridement of open wounds, reduction of dislocations, and external fixation of the lower extremities and/or pelvis. External fixators may be applied to individual bones, such as the tibia or femur, or applied across joints such as the knee or ankle. The concept is very similar to the techniques of spanning external fixation discussed for the management of tibial plateau fractures in Chapter 32 and tibial plafond fractures in Chapter 33. External fixation can be performed rapidly and occasionally in conjunction with other emergent procedures. In one study, the average surgical time for external fixation was 35 minutes compared with the 135 minutes for intramedullary nailing as a secondary procedure.43
Newer reaming techniques that decrease the intramedullary pressure can also be employed if intramedullary nailing is to be performed on a borderline patient or on a patient with multiple long-bone fractures. This technique involves use of a specialized reamer that irrigates and suctions the medullary canal throughout reaming. Animal model studies have demonstrated significantly reduced intramedullary pressure and degree of fat embolization with the use of this technique.44,45 This may reduce the incidence of fat embolism and help prevent pulmonary complications, although clinical studies are pending.
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