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When should we operate on major fractures in patients with severe head injuries?
The American Journal of Surgery 183 (2002) 261–267
Review
When should we operate on major fractures in patients with severe head injuries? Peter V. Giannoudis, M.B., B.Sc., M.D.a,*, Veysi T. Veysi, M.B.Ch.B., B.Sc.a, Hans-Christoph Pape, M.B., M.D.b, Cristian Krettek, M.B., M.D.b, Malcolm R. Smith, M.B., M.D.a a
Department of Trauma and Orthopaedics, St. James’ University Hospital, Leeds, Beckett St., Leeds, LS9 7TF United Kingdom b Department of Trauma, Hannover Medical School, Hannover, Germany Manuscript received June 2, 2001; revised manuscript December 18, 2001
Abstract Background: The widely accepted practice of early fracture fixation (EFF) in multiply injured patients has recently been challenged in the presence of head injury. Data sources: English and German language articles on the subject were searched using Medline. Keywords included head trauma, intracranial trauma, brain injuries, fractures, fracture fixation, timing, femur fracture, and tibia fracture. Conclusions: 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. Treatment should therefore be tailored to the individual patient, with the assumption that full neurologic recovery will take place. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Head injury; Fracture fixation; Timing
Treatment of the multiply injured patient has evolved over the years to the now widely accepted state whereby patients are “too sick not to operate.” The prospective study by Bone et al [1] showed a reduction in mortality, pulmonary complications, and the length of intensive care unit (ICU) and hospital stay in patients who received early stabilization of their fractures. More studies followed confirming the beneficial effect of early operative fixation of long bone fractures and several protocols of treatment have been developed [2,3]. The widely accepted application of early fracture fixation (EFF) has recently been questioned in some selected groups of patients and in particular patients with significant head trauma [4]. It has been suggested that early fixation of a fracture in this group of patients may be deleterious to eventual neurologic outcome and therefore the operative procedure should be delayed [5]. Early fracture fixation reduces the noxious stimuli from the fracture site. This is advocated to have a positive effect * Corresponding author. Tel.: ⫹0044-113-2433144; fax: ⫹0044-1132065156. E-mail address: [email protected]
on the patient’s metabolism, muscle tone, body temperature, and thereby cerebral function. Furthermore, unstabilized fractures lead to deterioration of the general status of the patient by means of greater soft tissue damage and greater risk for fat embolism, and making nursing care less efficient. These can lead to respiratory insufficiency and pulmonary complications [6,7] and add to the length of hospital stay [8 –10]. Treatment and protection of the central nervous system is a priority in patients with a significant intracranial trauma. Secondary brain injury may exacerbate underlying head trauma and lead to further morbidity and disability (neurologic outcome) [11–14]. Several pathogenic mechanisms have been described for secondary brain injury [15,16]. All are known to have the common final pathway of hypoxia that can be local (further development of lesions visualized initially by head computed tomography [CT]) or systemic [17]. These factors can be exacerbated in the short term by the process of fracture fixation, where intraoperative blood loss and hypoxia can compound the effects of inadequate resuscitation [18,19,20]. Furthermore, the administration of fluids and monitoring of these patients may be a difficult task intraoperatively.
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In view of this ongoing debate we carried out a comprehensive review of the literature concerning the surgical management of these patients to address the question of whether early fracture fixation is safe for polytrauma patients with severe head injury.
Material and methods Manuscripts dealing with the management of fracture fixation in multiply injured patients with an associated head injury were identified from a Medline search including databases from 1960 to December 2000. The searches were made using the keywords head trauma, intracranial trauma, brain injuries, fractures, fracture fixation, timing, femur fracture, and tibia fracture, and MeSH subject headings. The Cochrane Controlled Trials Register and standard texts on trauma were also used. Articles referred to in the above sources were evaluated. Full articles were retrieved and methodological quality filters applied for their suitability for inclusion in a more detailed review. The criteria for inclusion of papers selected for detailed review included the presence of a head injury, the presence of polytrauma, timing of stabilization of the skeleton, neurological assessment of patients, and English or German language. Exclusion criteria included animal studies and, for a clinical study, inclusion of fewer than 10 patients. Data were extracted from these articles and methodology and outcome were analyzed. We analyzed the study type (randomized controlled trial, retrospective review, case series) and treatment methods described. The sample size in each study was extracted from the information available. Injury severity indicators as available were identified and analyzed. These included the Glasgow Coma Scale (GCS), Glasgow Outcome Score (GOS), Abbreviated Injury Scores (AIS) for the head and orthopedic injuries, and the overall Injury Severity Score (ISS). Any complications of treatment, the overall length of hospital stay, and mortality rates were considered.
Variations in the timing of surgery The commonest time limit for EFF was 24 hours [21– 24,28 –31,33]. However, Townsend et al [32] subdivided their patient group into those operated on in 0 to 2 hours, 2 to 12 hours, and 12 to 24 hours. Bone et al [27] chose 48 hours as the upper limit of the EFF group. It is of note that in two of the studies time limits are not clearly reported [25,26]. Variations in the control patients There is no uniformity in the control groups. In some studies the control group was made of patients operated on after 24 hours [21,22,28,30 –32]. Nutz and Katholnigg [25] subdivided the late fracture fixation group into secondary (second to seventh day) and tertiary (after the seventh day) groups. The control group in others were made of a combination of patients who either had late fracture fixation or were treated nonoperatively [23–26,33]. Bone et al [27] used 824 patients from the American College of Surgeons’ Multiple Trauma Outcome Study as the control group. The authors assumed that at the time of data collection for that study, no protocol was in place for early fracture fixation. Two studies used control groups consisting of patients with different injuries to the study group [26,29]. Variations in the ISS The ISS and AIS for the head and extremity injuries are given in Table 1 where available. Overall only 4 authors indicated the AIS values for the head and orthopedic injuries in the study and control groups [28,30,31,33]. Nutz and Katholnigg [25] use the Hannover polytrauma score as a measure of the injury severity. Some authors subdivided the patients according to the ISS and the GCS at the time of admission [27,33]. It is of note that in the study by Velmahos et al [30] the AIS of the orthopedic injuries were significantly different between the study and the control group. Indications on the preoperative clinical condition
Results Of the 24 manuscripts reviewed, 13 met the inclusion criteria. [21–33]. All 13 were designed as retrospective case reviews of hospital admissions. None used randomization. Two papers were written by neurosurgical units [21,22], two were by orthopedic units [25,29], and three by surgical units [28,30,31]. The remainder included collaboration of all the specialities mentioned above. In the 13 papers subjected to more detailed analysis, the outcomes for a total of 2,560 patients were described and the results in these 2,560 cases were analyzed further. Two of the studies included the vast majority (70%) of the patients [25,27].
Not all the studies provide details on the preoperative clinical status of the patients. While Velmahos et al [30] reported that hypotension was present in 32% and hypoxia in 8.5% of patients overall, no distinction was made between the two groups. In the study by Jaicks et al [28], 16% of the early fixation group and 7% of the late fixation group were hypotensive whereas the incidence of hypoxia was 11% and 7%, respectively. Kalb et al [31] did not find any differences in the incidence of hypotension and hypoxia between the study and control groups. However, Kotwica et al [22] reported that 35.2% of the early fixation group and 24.4% of the late fracture fixation group were admitted in a state of hypovolemic shock.
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Table 1 Thirteen studies meeting inclusion criteria Study
ISS
GCS
Fractures stabilized
AIS head
AIS orthopedic
EFF
LFF
EFF
LFF
EFF
LFF
EFF
LFF
EFF
LFF
Martens 1988
37
35
8
8
N/A
N/A
N/A
N/A
N/A
Similar
Similar
N/A
N/A
N/A
N/A
Hofman 1991 Poole 1992
Higher 27.6
Lower 33.9
⬍7 12
⬍7 10
N/A N/A
N/A N/A
N/A N/A
N/A N/A
Riemer 1993 Nutz 1994 Bone 1994 Jaicks 1997 McKee 1997 Velmahos 1998 Kalb 1998 Townsend 1998 Starr 1998
23 26 18–60 25 33.2 25 33 Mean 35 23.3–32
22/26 14 18–60 27 34 23 31
N/A N/A 3–15 11.6 7.8 5.8 9.7 ⬍8 14.9–6.2
N/A N/A 3–15 10.8 8 5.7 9.9
Femur, tibia and pelvis Femur (10) Tibia (36) Pelvis (3) Any bone Femur Tibia Pelvis Femur Any bone Any bone No Femur Any bone Any bone Femur Femur
N/A
Kotwica 1990
Femur, tibia and pelvis Femur (17) Tibia (27) Pelvis (7) Any bone Femur Tibia Pelvis Femur Any bone Any bone Femur Any bone Any bone Femur Femur
N/A N/A N/A 3.3 N/A 3.8 4 N/A 3.2–4.2
N/A N/A N/A 3.1 N/A 3.4 3.9 N/A 3.8–4.1
N/A N/A N/A 3.0 N/A 2.9 2.9 3 3
N/A N/A N/A 2.9 N/A 2.4 2.6 3 3
29.8–34.3
13.3–5.6
N/A ⫽ not available; EFF ⫽ early fracture fixation; LFF ⫽ late fracture fixation; ISS ⫽ Injury Severity Score; GCS ⫽ Glasgow Coma Scale; AIS ⫽ Abbreviated Injury Score.
Indications on the perioperative conditions predisposing to secondary brain injury
perfusion pressures were significantly higher in the early fracture fixation group.
Only two studies give information both on hypoxic and hypotensive episodes (Table 1). Martens and Ectors [21] report that 60% of the patients in the two groups had episodes of hypoxia. Townsend et al [32] found that if patients who required a laparotomy or pelvic fixation were excluded, 88.8% of the patients whose femurs were fixed within 2 hours of admission had perioperative hypotension. They noted that these patients received less fluid replacement compared with the other groups studied in the prehospital phase of their treatment. Velmahos et al [30] found a significant difference in the number of patients who needed perioperative blood transfusions between the early and late fracture fixation groups (68% versus 36%, respectively). In the same study, the overall amount of blood transfused was significantly higher in the early fracture fixation group (2.4 versus 0.7 blood units) but there was no difference in the number of patients who needed a blood transfusion and the amount of blood transfused over the entire hospital stay. Jaicks et al found that the fluid requirements intraoperatively (4.71 versus 2.21 L), and over the subsequent 24 and 48 hours marks were significantly higher in the early fracture fixation group [28]. However, they found no difference in the blood transfusion requirements of the two groups. Kalb et al [31] also found a significant difference in the amount of intraoperative fluid and blood infused but no difference in the lowest and highest ICP measurements between the early and late fixation groups. However they observed that both the highest and lowest measured cerebral
Incidence of pulmonary complications All the authors have not also addressed the incidence of pulmonary complications between early and late fixation groups. Velmahos et al [30] report a 30% total incidence of pulmonary complications (pneumonia was the commonest followed by ARDS) but found no difference between the two groups. An incidence of 57.7% for the late and 42.2% for the early fixation groups was found by Poole et al [24] (pneumonia was again the commonest complication but there was no statistical difference in the two groups). Nutz and Katholnigg [26] found a higher incidence of pulmonary complications in the group operated between days 2 and 7 (35% versus 57%); and Starr et al [33] found a 45 times higher risk of pulmonary complications with delays in fracture fixation (the delayed fixation was a stronger predictor of pulmonary complications than chest injury). Indications on neurologic outcome The effect of early or late fracture fixation on perioperative neurological complications also has not been investigated in all the selected studies. Martens and Ectors [21] reported 5 cases (38%) of early neurologic deterioration in the early fixation group and none in the delayed group. The average ISS and GCS for those with deterioration of neurologic status in the early group were 49 and 6 points whereas for those without deterioration of neurologic status they were 29 and 10 points, respectively. Poole et al [24] used changes in intracranial pressure (ICP), GCS, new le-
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Table 2 Studies with information on neurologic outcome Study
Martens 1988 Kotwica 1990
Hofman 1991
Intraoperative hypovolemia
Intraoperative hypoxia (no)
GOS or GCS
EFF
LFF
EFF
LFF
EFF
LFF
EFF
LFF
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A GOS 1–2 ⫽ 3–5 ⫽ GOS 1–2 ⫽ 3–5 ⫽ N/A N/A N/A N/A N/A GOS 3–5 ⫽ GCS GCS N/A GCS
N/A GOS 1–2 ⫽ 3–5 ⫽ GOS 1–2 ⫽ 3–5 ⫽ N/A N/A N/A N/A N/A GOS 3–5 ⫽ GCS GCS N/A GCS
N/A 14
N/A 22
N/A 3 months
13.3*
46.5*
6 months
2 7* N/A 11.6 11 28
0 34.4* N/A 17.7 0 27
N/A N/A N/A N/A Hospital discharge 32 months
5 10 ?/49 0
8 8 ?/12 11.1
Hospital discharge 20 months Hospital discharge Hospital discharge
N/A
N/A
N/A
N/A
Poole 1992 Riemer 1993 Nutz 1994 Bone 1994 Jaicks 1997 McKee 1997
N/A N/A N/A N/A 16% N/A
N/A N/A N/A N/A 7% N/A
N/A N/A N/A N/A 11% N/A
N/A N/A N/A N/A 7% N/A
Velmahos 1998 Kalb 1998 Townsend 1998 Starr 1998
41% 8.3% 89% N/A
24% 0.5% 8.3% N/A
14% N/A N/A N/A
4% N/A N/A N/A
32 19 4 11
14
Mortality (%)
Time to follow-up
30 19 23 20
28
* Statistically significant. EFF ⫽ early fracture fixation; LFF ⫽ late fracture fixation; GOS ⫽ Glasgow Outcome Score; GCS ⫽ Glasgow Coma Scale; N/A ⫽ not available.
sions on CT scan, and late onset seizures as measures of perioperative neurological complications; they found 23.1% of the late fixation and 6.7% of the early fixation group had an adverse neurological event and this was statistically significant. They also found that all but one of the neurological complications occurred in patients with an admission GCS of 7 or less. McKee et al [27] found 3 patients in the early fixation group (closed head injury and femur fracture) who developed neurological complications in the postoperative period but did not attribute any of these to the femur fracture or its fixation. Both Jaicks et al [28] and Starr et al [33] found no difference in neurological complications between the two groups. Where such data were available, McKee et al [29] found that there was no difference in the long-term neurological outcome between the early and late fixation groups.The outcome measures used in this study were the GOS, the category test score, and the Trails A and B tests. Kalb et al [31] found that 12% of the early fixation group and 8%of the late fixation group had long-term cognitive problems and 8% of the late fixation group also were found to be emotionally labile. Formally recognized neuropsychological tests were not used. The authors also reported that 26% of the early and 20% of the late fixation groups had longterm orthopedic problems [31]. Hofman and Goris [23] found that the GOS was better in the early fixation group compared with the late fixation group but the difference did not reach significance. Kotwica et al [22] observed that the relative incidence of GOS was similar for both the early and late fixation groups. Townsend
et al [32] provide the GOS for all the patients, but separate data are not available for each of the study groups. There were no other long-term neurological outcome data from any other available study (Table 2). It is of note, however, that in four studies the mean follow-up of the patients for assessment of the long-term neurologic outcome ranges from 3 months to 32 months [22,23,29,31] and in five studies there was no reference to the time of follow-up [21,24 –27]. Mortality rates Mortality rates are given in Table 2. Only in two studies mortality did reach significance with the early fixation groups having the lowest rates [23,25]. It is also of note that in the study by Bone et al [27] the difference in mortality becomes significant in severe head injuries (GCS on admission 5-4; EFF mortality 3 of 22 patients [13.6%] versus LFF 19 of 39 patients [51.3%]).
Comments In patients with multiple trauma the usual cause of traumatic brain injury is the result of angular acceleration or deceleration forces applied to the head. Traumatic brain injury is classified as either primary or secondary [34]. Primary injury occurs at the time of the accident whereas secondary injury occurs subsequently and is the result of other factors [15,16]. Head injury is evaluated clinically by the Glasgow Coma Score, which is also predictive of the
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patient’s outcome [35–37]. A score of less than 9 points indicates severe injury whereas a score of 13 to 14 points is indicative of a mild injury. Neurologic outcome after head injury is graded by the Glasgow Outcome Scale consisting of 5 levels of result: level 1 is death, level 2 is persistent vegetative state, level 3 severe disability, level 4 moderate disability (disabled by independent), and level 5 normal or near normal life [38]. During the 1960s some sporadic reports are found in the literature about the management of head injured patients with skeletal injuries. In general, conservative management prevailed in the management of long bone fractures. Gibson [39] reported 59 patients with head injuries and femur fractures and recommended traction in a Thomas’ splint as the best form of fracture care. On the contrary, other authors observed that traction with or without spica cast rendered the poorest results and even stated that they could not recommend this method of treatment in the population as had been advocated by Gibson [40]. Bellamy and Brower [41] also reported 142 patients with skeletal trauma and head injury. They found difficult to manage head injured patients in traction and recommended a more aggressive surgical approach. They also emphasized that the orthopedist must proceed as though full neurologic recovery would occur to avoid later functional deficits. Wray and Davis [42] considered early operative treatment imperative for open fractures, fractures with vascular injury, and major joint dislocations. Other authors [39] felt that a period of observation was necessary before operating on open fractures to indicate whether the patient was improving and could be considered a justifiable surgical risk while some others suggested that after the acute phase of head injury (usually 7 to 10 days) the risks associated with general anesthesia are minimized and that this was the safest period for open reduction and internal fixation of fractures [40]. The current recommendation of the treatment of long bone fractures in patients with polytrauma is to proceed with early (within 24 hours) skeletal stabilization if the patient is in a stable condition. Although this recommendation has been derived from a series of studies during the past 30 years [43– 45], the disadvantages of extremely early or poorly timed orthopedic operations include stimulation of the systemic inflammatory response syndrome and the potential to induce secondary brain injury [46 –51]. In the unstable patient, however, immediate intervention is necessitated for the rapid control of hemorrhage and restoration of vital signs and tissue perfusion by means of cavity decompression and temporarily skeletal stabilization without compromising optimal oxygenation and regulation of brain blood flow. Early fixation of long bone fractures has been advocated as it avoids the enforced crucifix position of skeletal traction and reducing its complications (thromboembolus, loss of joint motion, muscle wasting). It also reduces pulmonary insufficiency (ARDS, fat embolism,
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pneumonia), persistent pain at the fracture site and health care costs [1,2]. Although most authors would agree with this general policy of early fracture fixation, in polytrauma patients concerns have been raised about patients with associated head trauma. It has been suggested that prolonged operations could cause intraoperative hypotension, hypoxia, and coagulopathy in combination with increased blood loss and fluid requirements during and after the orthopedic operation; and this will be detrimental to cerebral perfusion and would be an additional insult to the already injured brain, thus outweighing the benefits of early fracture stabilization. The widely accepted recommendation of maintaining of cerebral perfusion pressure (CPP) greater than 70 mm Hg, by keeping ICP less than 20 mm Hg and mean arterial pressure greater than 90 mm Hg may be difficult to achieve in these patients [52]. The adverse relationship between intraoperative hypotension and neurologic outcome has been well documented in the literature. Pietrapaoli et al [53] observed 53 patients who required surgery within 72 hours of their head injury. Despite all patients being normotensive before surgery, 32% developed a systolic pressure less than 90 mm Hg during surgery and the mortality rate was 82%. Moreover, Marion et al [53] have shown that critically low cerebral blood flow and possibly regional cerebral ischemia is most common during the first 12 to 24 hours after a severe head injuryx. The prevention of secondary brain damage is thus the major concern among physicians responsible for the treatment of the traumatic brain injury. The majority of the previously cited reviews have not studied extensively the effect of head injury in the polytrauma, and it appears from the literature that the most effective treatment for patients with multiple trauma and associated head injuries remains unclear. Although it seems the trend is for better results to be obtained in the early fixation group, the studies are too dissimilar in the inclusion criteria and all are of retrospective nature. This review convincingly demonstrates that the available literature has made various efforts to investigate this important topic. However, it becomes evident that despite these numerous investigations, we are left with an even greater number of questions in the management of head injured patients. What is the effect of the prehospital treatment in these patients (fluid management, ventilation, duration until admission and temperature regulation)? Is the type of inhospital treatment relevant? By which means should the relevant head injury lesion be defined—radiographic imaging (CT), clinical findings (GCS), or physiologic parameters (CPP, ICP)—and what is the relevance of it? What should be the definition of long-term outcome and what should be the minimal follow-up? Furthermore, in order to be able to interpret the evidence from published manuscripts consistency in reporting is essential. It is imperative that authors describe in detail the inclusion and exclusion criteria, the injuries treated, the method of treatment, the method of assessment of patients,
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the complications encountered, and the results of management and follow-up after a widely accepted period of time using standardized assessment methods. Although it is not possible to use the current available literature in the context of evidence based medicine to derive a definitive conclusion about the management of the polytrauma with severe head injury we can make the following recommendations: 1. The initial management of the head injured should be similar to the polytrauma without head injury focusing on the rapid control of hemorrhage and restoration of vital signs and tissue perfusion. 2. Cavity decompression may be necessitated as well as temporarily skeletal stabilization. 3. Maintenance of CPP ⬎70 mm Hg should be mandatory before, during, and after operation. 4. Sophisticated monitoring of local blood flow and tissue oxygen delivery will provide more information about the course of the patients. 5. Brain injury can be made worse if resuscitation is inadequate or if intervention such as long bone fixation allows hypotension or low CPP to occur. 6. The treatment protocol should be based on the individual patient’s clinical assessment and treatment requirements rather than mandatory time policies in respect to fixation of long bone fractures. 7. Orthopedic injuries should be managed aggressively with the assumption that full neurologic recovery will occur. In conclusion, it appears that the current literature is not clear regarding the timing of fixation of skeletal injuries in the head-injured patient. No standardization of the previously mentioned factors in a single study can be achieved. Only a large multicenter prospective randomized trial could be helpful, although such a study might not be ethical. Also it might be difficult to recruit patients after such severe injuries. Finally, it should not be forgotten that head injury predisposes the patient with polytrauma to complications that early or late fixation may not overcome.
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[44] Seibel R, LaDuca J, Hassett JM, et al. Blunt multiple trauma (ISS 36) femur traction and the pulmonary failure—septic state. Ann Surg 1985;202:283–95. [45] Riska EB, von Bonsdorff H, Hakkinen S, et al. Prevention of fat embolism by early internal fixation of fractures in patients with multiple injuries. Injury 1976;8:110 –16. [46] Giannoudis PV, Smith RM, Banks RE, et al. Stimulation of inflammatory markers after blunt trauma. Br J Surg 1998;85:986 –90. [47] Giannoudis PV, Abbott C, Stone M, et al. Fatal systemic inflammatory response syndrome following early bilateral femoral nailing. Intens Care Med 1998;24:641–2. [48] Giannoudis PV, Smith RM, Bellamy MC, et al. Stimulation of the inflammatory system by reamed and undreamed nailing of femoral fractures: an analysis of the second hit. J Bone Joint Surg (Br) 1999;81:356 – 61. [49] Pape HC, Auf’m Kolk M, Paffrath T, et al. Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion: a cause of post-traumatic ARDS? J Trauma 1993;34:540 – 8. [50] Pape HC, Schmidt RE, Rice J, et al. Biochemical changes after trauma and skeletal injury of the lower extremity: quantification of the operative burden. Crit Care Med 2000;28:3441– 8. [51] Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg 2000; 82A:781– 8. [52] Shackford SR, Zhuang J, Schmoker J. Intravenous fluid toxicity: effect on intracranial pressure, CSF and cerebral oxygen delivery in focal brain injury. J Neurosurg 1992;76:91– 8. [53] Pietrapaoli JA, Rogers FB, Shackford SR, et al. The deleterious effects of intraoperative hypotension on outcome in patients with severe head injures. J Trauma 1992;33:403–7. [54] Marion DW, Darby J, Yonas H. Acute regional cerebral blood flow changes caused by severe head injuries. J Neurosurg 1991; 74:404 –7.
Review
When should we operate on major fractures in patients with severe head injuries? Peter V. Giannoudis, M.B., B.Sc., M.D.a,*, Veysi T. Veysi, M.B.Ch.B., B.Sc.a, Hans-Christoph Pape, M.B., M.D.b, Cristian Krettek, M.B., M.D.b, Malcolm R. Smith, M.B., M.D.a a
Department of Trauma and Orthopaedics, St. James’ University Hospital, Leeds, Beckett St., Leeds, LS9 7TF United Kingdom b Department of Trauma, Hannover Medical School, Hannover, Germany Manuscript received June 2, 2001; revised manuscript December 18, 2001
Abstract Background: The widely accepted practice of early fracture fixation (EFF) in multiply injured patients has recently been challenged in the presence of head injury. Data sources: English and German language articles on the subject were searched using Medline. Keywords included head trauma, intracranial trauma, brain injuries, fractures, fracture fixation, timing, femur fracture, and tibia fracture. Conclusions: 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. Treatment should therefore be tailored to the individual patient, with the assumption that full neurologic recovery will take place. © 2002 Excerpta Medica, Inc. All rights reserved. Keywords: Head injury; Fracture fixation; Timing
Treatment of the multiply injured patient has evolved over the years to the now widely accepted state whereby patients are “too sick not to operate.” The prospective study by Bone et al [1] showed a reduction in mortality, pulmonary complications, and the length of intensive care unit (ICU) and hospital stay in patients who received early stabilization of their fractures. More studies followed confirming the beneficial effect of early operative fixation of long bone fractures and several protocols of treatment have been developed [2,3]. The widely accepted application of early fracture fixation (EFF) has recently been questioned in some selected groups of patients and in particular patients with significant head trauma [4]. It has been suggested that early fixation of a fracture in this group of patients may be deleterious to eventual neurologic outcome and therefore the operative procedure should be delayed [5]. Early fracture fixation reduces the noxious stimuli from the fracture site. This is advocated to have a positive effect * Corresponding author. Tel.: ⫹0044-113-2433144; fax: ⫹0044-1132065156. E-mail address: [email protected]
on the patient’s metabolism, muscle tone, body temperature, and thereby cerebral function. Furthermore, unstabilized fractures lead to deterioration of the general status of the patient by means of greater soft tissue damage and greater risk for fat embolism, and making nursing care less efficient. These can lead to respiratory insufficiency and pulmonary complications [6,7] and add to the length of hospital stay [8 –10]. Treatment and protection of the central nervous system is a priority in patients with a significant intracranial trauma. Secondary brain injury may exacerbate underlying head trauma and lead to further morbidity and disability (neurologic outcome) [11–14]. Several pathogenic mechanisms have been described for secondary brain injury [15,16]. All are known to have the common final pathway of hypoxia that can be local (further development of lesions visualized initially by head computed tomography [CT]) or systemic [17]. These factors can be exacerbated in the short term by the process of fracture fixation, where intraoperative blood loss and hypoxia can compound the effects of inadequate resuscitation [18,19,20]. Furthermore, the administration of fluids and monitoring of these patients may be a difficult task intraoperatively.
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 2 ) 0 0 7 8 3 - 3
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In view of this ongoing debate we carried out a comprehensive review of the literature concerning the surgical management of these patients to address the question of whether early fracture fixation is safe for polytrauma patients with severe head injury.
Material and methods Manuscripts dealing with the management of fracture fixation in multiply injured patients with an associated head injury were identified from a Medline search including databases from 1960 to December 2000. The searches were made using the keywords head trauma, intracranial trauma, brain injuries, fractures, fracture fixation, timing, femur fracture, and tibia fracture, and MeSH subject headings. The Cochrane Controlled Trials Register and standard texts on trauma were also used. Articles referred to in the above sources were evaluated. Full articles were retrieved and methodological quality filters applied for their suitability for inclusion in a more detailed review. The criteria for inclusion of papers selected for detailed review included the presence of a head injury, the presence of polytrauma, timing of stabilization of the skeleton, neurological assessment of patients, and English or German language. Exclusion criteria included animal studies and, for a clinical study, inclusion of fewer than 10 patients. Data were extracted from these articles and methodology and outcome were analyzed. We analyzed the study type (randomized controlled trial, retrospective review, case series) and treatment methods described. The sample size in each study was extracted from the information available. Injury severity indicators as available were identified and analyzed. These included the Glasgow Coma Scale (GCS), Glasgow Outcome Score (GOS), Abbreviated Injury Scores (AIS) for the head and orthopedic injuries, and the overall Injury Severity Score (ISS). Any complications of treatment, the overall length of hospital stay, and mortality rates were considered.
Variations in the timing of surgery The commonest time limit for EFF was 24 hours [21– 24,28 –31,33]. However, Townsend et al [32] subdivided their patient group into those operated on in 0 to 2 hours, 2 to 12 hours, and 12 to 24 hours. Bone et al [27] chose 48 hours as the upper limit of the EFF group. It is of note that in two of the studies time limits are not clearly reported [25,26]. Variations in the control patients There is no uniformity in the control groups. In some studies the control group was made of patients operated on after 24 hours [21,22,28,30 –32]. Nutz and Katholnigg [25] subdivided the late fracture fixation group into secondary (second to seventh day) and tertiary (after the seventh day) groups. The control group in others were made of a combination of patients who either had late fracture fixation or were treated nonoperatively [23–26,33]. Bone et al [27] used 824 patients from the American College of Surgeons’ Multiple Trauma Outcome Study as the control group. The authors assumed that at the time of data collection for that study, no protocol was in place for early fracture fixation. Two studies used control groups consisting of patients with different injuries to the study group [26,29]. Variations in the ISS The ISS and AIS for the head and extremity injuries are given in Table 1 where available. Overall only 4 authors indicated the AIS values for the head and orthopedic injuries in the study and control groups [28,30,31,33]. Nutz and Katholnigg [25] use the Hannover polytrauma score as a measure of the injury severity. Some authors subdivided the patients according to the ISS and the GCS at the time of admission [27,33]. It is of note that in the study by Velmahos et al [30] the AIS of the orthopedic injuries were significantly different between the study and the control group. Indications on the preoperative clinical condition
Results Of the 24 manuscripts reviewed, 13 met the inclusion criteria. [21–33]. All 13 were designed as retrospective case reviews of hospital admissions. None used randomization. Two papers were written by neurosurgical units [21,22], two were by orthopedic units [25,29], and three by surgical units [28,30,31]. The remainder included collaboration of all the specialities mentioned above. In the 13 papers subjected to more detailed analysis, the outcomes for a total of 2,560 patients were described and the results in these 2,560 cases were analyzed further. Two of the studies included the vast majority (70%) of the patients [25,27].
Not all the studies provide details on the preoperative clinical status of the patients. While Velmahos et al [30] reported that hypotension was present in 32% and hypoxia in 8.5% of patients overall, no distinction was made between the two groups. In the study by Jaicks et al [28], 16% of the early fixation group and 7% of the late fixation group were hypotensive whereas the incidence of hypoxia was 11% and 7%, respectively. Kalb et al [31] did not find any differences in the incidence of hypotension and hypoxia between the study and control groups. However, Kotwica et al [22] reported that 35.2% of the early fixation group and 24.4% of the late fracture fixation group were admitted in a state of hypovolemic shock.
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Table 1 Thirteen studies meeting inclusion criteria Study
ISS
GCS
Fractures stabilized
AIS head
AIS orthopedic
EFF
LFF
EFF
LFF
EFF
LFF
EFF
LFF
EFF
LFF
Martens 1988
37
35
8
8
N/A
N/A
N/A
N/A
N/A
Similar
Similar
N/A
N/A
N/A
N/A
Hofman 1991 Poole 1992
Higher 27.6
Lower 33.9
⬍7 12
⬍7 10
N/A N/A
N/A N/A
N/A N/A
N/A N/A
Riemer 1993 Nutz 1994 Bone 1994 Jaicks 1997 McKee 1997 Velmahos 1998 Kalb 1998 Townsend 1998 Starr 1998
23 26 18–60 25 33.2 25 33 Mean 35 23.3–32
22/26 14 18–60 27 34 23 31
N/A N/A 3–15 11.6 7.8 5.8 9.7 ⬍8 14.9–6.2
N/A N/A 3–15 10.8 8 5.7 9.9
Femur, tibia and pelvis Femur (10) Tibia (36) Pelvis (3) Any bone Femur Tibia Pelvis Femur Any bone Any bone No Femur Any bone Any bone Femur Femur
N/A
Kotwica 1990
Femur, tibia and pelvis Femur (17) Tibia (27) Pelvis (7) Any bone Femur Tibia Pelvis Femur Any bone Any bone Femur Any bone Any bone Femur Femur
N/A N/A N/A 3.3 N/A 3.8 4 N/A 3.2–4.2
N/A N/A N/A 3.1 N/A 3.4 3.9 N/A 3.8–4.1
N/A N/A N/A 3.0 N/A 2.9 2.9 3 3
N/A N/A N/A 2.9 N/A 2.4 2.6 3 3
29.8–34.3
13.3–5.6
N/A ⫽ not available; EFF ⫽ early fracture fixation; LFF ⫽ late fracture fixation; ISS ⫽ Injury Severity Score; GCS ⫽ Glasgow Coma Scale; AIS ⫽ Abbreviated Injury Score.
Indications on the perioperative conditions predisposing to secondary brain injury
perfusion pressures were significantly higher in the early fracture fixation group.
Only two studies give information both on hypoxic and hypotensive episodes (Table 1). Martens and Ectors [21] report that 60% of the patients in the two groups had episodes of hypoxia. Townsend et al [32] found that if patients who required a laparotomy or pelvic fixation were excluded, 88.8% of the patients whose femurs were fixed within 2 hours of admission had perioperative hypotension. They noted that these patients received less fluid replacement compared with the other groups studied in the prehospital phase of their treatment. Velmahos et al [30] found a significant difference in the number of patients who needed perioperative blood transfusions between the early and late fracture fixation groups (68% versus 36%, respectively). In the same study, the overall amount of blood transfused was significantly higher in the early fracture fixation group (2.4 versus 0.7 blood units) but there was no difference in the number of patients who needed a blood transfusion and the amount of blood transfused over the entire hospital stay. Jaicks et al found that the fluid requirements intraoperatively (4.71 versus 2.21 L), and over the subsequent 24 and 48 hours marks were significantly higher in the early fracture fixation group [28]. However, they found no difference in the blood transfusion requirements of the two groups. Kalb et al [31] also found a significant difference in the amount of intraoperative fluid and blood infused but no difference in the lowest and highest ICP measurements between the early and late fixation groups. However they observed that both the highest and lowest measured cerebral
Incidence of pulmonary complications All the authors have not also addressed the incidence of pulmonary complications between early and late fixation groups. Velmahos et al [30] report a 30% total incidence of pulmonary complications (pneumonia was the commonest followed by ARDS) but found no difference between the two groups. An incidence of 57.7% for the late and 42.2% for the early fixation groups was found by Poole et al [24] (pneumonia was again the commonest complication but there was no statistical difference in the two groups). Nutz and Katholnigg [26] found a higher incidence of pulmonary complications in the group operated between days 2 and 7 (35% versus 57%); and Starr et al [33] found a 45 times higher risk of pulmonary complications with delays in fracture fixation (the delayed fixation was a stronger predictor of pulmonary complications than chest injury). Indications on neurologic outcome The effect of early or late fracture fixation on perioperative neurological complications also has not been investigated in all the selected studies. Martens and Ectors [21] reported 5 cases (38%) of early neurologic deterioration in the early fixation group and none in the delayed group. The average ISS and GCS for those with deterioration of neurologic status in the early group were 49 and 6 points whereas for those without deterioration of neurologic status they were 29 and 10 points, respectively. Poole et al [24] used changes in intracranial pressure (ICP), GCS, new le-
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Table 2 Studies with information on neurologic outcome Study
Martens 1988 Kotwica 1990
Hofman 1991
Intraoperative hypovolemia
Intraoperative hypoxia (no)
GOS or GCS
EFF
LFF
EFF
LFF
EFF
LFF
EFF
LFF
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A GOS 1–2 ⫽ 3–5 ⫽ GOS 1–2 ⫽ 3–5 ⫽ N/A N/A N/A N/A N/A GOS 3–5 ⫽ GCS GCS N/A GCS
N/A GOS 1–2 ⫽ 3–5 ⫽ GOS 1–2 ⫽ 3–5 ⫽ N/A N/A N/A N/A N/A GOS 3–5 ⫽ GCS GCS N/A GCS
N/A 14
N/A 22
N/A 3 months
13.3*
46.5*
6 months
2 7* N/A 11.6 11 28
0 34.4* N/A 17.7 0 27
N/A N/A N/A N/A Hospital discharge 32 months
5 10 ?/49 0
8 8 ?/12 11.1
Hospital discharge 20 months Hospital discharge Hospital discharge
N/A
N/A
N/A
N/A
Poole 1992 Riemer 1993 Nutz 1994 Bone 1994 Jaicks 1997 McKee 1997
N/A N/A N/A N/A 16% N/A
N/A N/A N/A N/A 7% N/A
N/A N/A N/A N/A 11% N/A
N/A N/A N/A N/A 7% N/A
Velmahos 1998 Kalb 1998 Townsend 1998 Starr 1998
41% 8.3% 89% N/A
24% 0.5% 8.3% N/A
14% N/A N/A N/A
4% N/A N/A N/A
32 19 4 11
14
Mortality (%)
Time to follow-up
30 19 23 20
28
* Statistically significant. EFF ⫽ early fracture fixation; LFF ⫽ late fracture fixation; GOS ⫽ Glasgow Outcome Score; GCS ⫽ Glasgow Coma Scale; N/A ⫽ not available.
sions on CT scan, and late onset seizures as measures of perioperative neurological complications; they found 23.1% of the late fixation and 6.7% of the early fixation group had an adverse neurological event and this was statistically significant. They also found that all but one of the neurological complications occurred in patients with an admission GCS of 7 or less. McKee et al [27] found 3 patients in the early fixation group (closed head injury and femur fracture) who developed neurological complications in the postoperative period but did not attribute any of these to the femur fracture or its fixation. Both Jaicks et al [28] and Starr et al [33] found no difference in neurological complications between the two groups. Where such data were available, McKee et al [29] found that there was no difference in the long-term neurological outcome between the early and late fixation groups.The outcome measures used in this study were the GOS, the category test score, and the Trails A and B tests. Kalb et al [31] found that 12% of the early fixation group and 8%of the late fixation group had long-term cognitive problems and 8% of the late fixation group also were found to be emotionally labile. Formally recognized neuropsychological tests were not used. The authors also reported that 26% of the early and 20% of the late fixation groups had longterm orthopedic problems [31]. Hofman and Goris [23] found that the GOS was better in the early fixation group compared with the late fixation group but the difference did not reach significance. Kotwica et al [22] observed that the relative incidence of GOS was similar for both the early and late fixation groups. Townsend
et al [32] provide the GOS for all the patients, but separate data are not available for each of the study groups. There were no other long-term neurological outcome data from any other available study (Table 2). It is of note, however, that in four studies the mean follow-up of the patients for assessment of the long-term neurologic outcome ranges from 3 months to 32 months [22,23,29,31] and in five studies there was no reference to the time of follow-up [21,24 –27]. Mortality rates Mortality rates are given in Table 2. Only in two studies mortality did reach significance with the early fixation groups having the lowest rates [23,25]. It is also of note that in the study by Bone et al [27] the difference in mortality becomes significant in severe head injuries (GCS on admission 5-4; EFF mortality 3 of 22 patients [13.6%] versus LFF 19 of 39 patients [51.3%]).
Comments In patients with multiple trauma the usual cause of traumatic brain injury is the result of angular acceleration or deceleration forces applied to the head. Traumatic brain injury is classified as either primary or secondary [34]. Primary injury occurs at the time of the accident whereas secondary injury occurs subsequently and is the result of other factors [15,16]. Head injury is evaluated clinically by the Glasgow Coma Score, which is also predictive of the
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patient’s outcome [35–37]. A score of less than 9 points indicates severe injury whereas a score of 13 to 14 points is indicative of a mild injury. Neurologic outcome after head injury is graded by the Glasgow Outcome Scale consisting of 5 levels of result: level 1 is death, level 2 is persistent vegetative state, level 3 severe disability, level 4 moderate disability (disabled by independent), and level 5 normal or near normal life [38]. During the 1960s some sporadic reports are found in the literature about the management of head injured patients with skeletal injuries. In general, conservative management prevailed in the management of long bone fractures. Gibson [39] reported 59 patients with head injuries and femur fractures and recommended traction in a Thomas’ splint as the best form of fracture care. On the contrary, other authors observed that traction with or without spica cast rendered the poorest results and even stated that they could not recommend this method of treatment in the population as had been advocated by Gibson [40]. Bellamy and Brower [41] also reported 142 patients with skeletal trauma and head injury. They found difficult to manage head injured patients in traction and recommended a more aggressive surgical approach. They also emphasized that the orthopedist must proceed as though full neurologic recovery would occur to avoid later functional deficits. Wray and Davis [42] considered early operative treatment imperative for open fractures, fractures with vascular injury, and major joint dislocations. Other authors [39] felt that a period of observation was necessary before operating on open fractures to indicate whether the patient was improving and could be considered a justifiable surgical risk while some others suggested that after the acute phase of head injury (usually 7 to 10 days) the risks associated with general anesthesia are minimized and that this was the safest period for open reduction and internal fixation of fractures [40]. The current recommendation of the treatment of long bone fractures in patients with polytrauma is to proceed with early (within 24 hours) skeletal stabilization if the patient is in a stable condition. Although this recommendation has been derived from a series of studies during the past 30 years [43– 45], the disadvantages of extremely early or poorly timed orthopedic operations include stimulation of the systemic inflammatory response syndrome and the potential to induce secondary brain injury [46 –51]. In the unstable patient, however, immediate intervention is necessitated for the rapid control of hemorrhage and restoration of vital signs and tissue perfusion by means of cavity decompression and temporarily skeletal stabilization without compromising optimal oxygenation and regulation of brain blood flow. Early fixation of long bone fractures has been advocated as it avoids the enforced crucifix position of skeletal traction and reducing its complications (thromboembolus, loss of joint motion, muscle wasting). It also reduces pulmonary insufficiency (ARDS, fat embolism,
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pneumonia), persistent pain at the fracture site and health care costs [1,2]. Although most authors would agree with this general policy of early fracture fixation, in polytrauma patients concerns have been raised about patients with associated head trauma. It has been suggested that prolonged operations could cause intraoperative hypotension, hypoxia, and coagulopathy in combination with increased blood loss and fluid requirements during and after the orthopedic operation; and this will be detrimental to cerebral perfusion and would be an additional insult to the already injured brain, thus outweighing the benefits of early fracture stabilization. The widely accepted recommendation of maintaining of cerebral perfusion pressure (CPP) greater than 70 mm Hg, by keeping ICP less than 20 mm Hg and mean arterial pressure greater than 90 mm Hg may be difficult to achieve in these patients [52]. The adverse relationship between intraoperative hypotension and neurologic outcome has been well documented in the literature. Pietrapaoli et al [53] observed 53 patients who required surgery within 72 hours of their head injury. Despite all patients being normotensive before surgery, 32% developed a systolic pressure less than 90 mm Hg during surgery and the mortality rate was 82%. Moreover, Marion et al [53] have shown that critically low cerebral blood flow and possibly regional cerebral ischemia is most common during the first 12 to 24 hours after a severe head injuryx. The prevention of secondary brain damage is thus the major concern among physicians responsible for the treatment of the traumatic brain injury. The majority of the previously cited reviews have not studied extensively the effect of head injury in the polytrauma, and it appears from the literature that the most effective treatment for patients with multiple trauma and associated head injuries remains unclear. Although it seems the trend is for better results to be obtained in the early fixation group, the studies are too dissimilar in the inclusion criteria and all are of retrospective nature. This review convincingly demonstrates that the available literature has made various efforts to investigate this important topic. However, it becomes evident that despite these numerous investigations, we are left with an even greater number of questions in the management of head injured patients. What is the effect of the prehospital treatment in these patients (fluid management, ventilation, duration until admission and temperature regulation)? Is the type of inhospital treatment relevant? By which means should the relevant head injury lesion be defined—radiographic imaging (CT), clinical findings (GCS), or physiologic parameters (CPP, ICP)—and what is the relevance of it? What should be the definition of long-term outcome and what should be the minimal follow-up? Furthermore, in order to be able to interpret the evidence from published manuscripts consistency in reporting is essential. It is imperative that authors describe in detail the inclusion and exclusion criteria, the injuries treated, the method of treatment, the method of assessment of patients,
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the complications encountered, and the results of management and follow-up after a widely accepted period of time using standardized assessment methods. Although it is not possible to use the current available literature in the context of evidence based medicine to derive a definitive conclusion about the management of the polytrauma with severe head injury we can make the following recommendations: 1. The initial management of the head injured should be similar to the polytrauma without head injury focusing on the rapid control of hemorrhage and restoration of vital signs and tissue perfusion. 2. Cavity decompression may be necessitated as well as temporarily skeletal stabilization. 3. Maintenance of CPP ⬎70 mm Hg should be mandatory before, during, and after operation. 4. Sophisticated monitoring of local blood flow and tissue oxygen delivery will provide more information about the course of the patients. 5. Brain injury can be made worse if resuscitation is inadequate or if intervention such as long bone fixation allows hypotension or low CPP to occur. 6. The treatment protocol should be based on the individual patient’s clinical assessment and treatment requirements rather than mandatory time policies in respect to fixation of long bone fractures. 7. Orthopedic injuries should be managed aggressively with the assumption that full neurologic recovery will occur. In conclusion, it appears that the current literature is not clear regarding the timing of fixation of skeletal injuries in the head-injured patient. No standardization of the previously mentioned factors in a single study can be achieved. Only a large multicenter prospective randomized trial could be helpful, although such a study might not be ethical. Also it might be difficult to recruit patients after such severe injuries. Finally, it should not be forgotten that head injury predisposes the patient with polytrauma to complications that early or late fixation may not overcome.
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