Early Fracture Fixation May Be Deleterious After Head Injury
ABSTRACT & COMMENTARY
Synopsis: In this retrospective case series, multiple trauma patients with both cerebral and long-bone injuries who underwent fracture fixation within 24 hours had lower mean Glascow Coma Scale scores at discharge than those in whom the operation was delayed for a mean of three days.
Source: Jaicks RR, et al. J Trauma 1997;42:1-5.
The authors of this report from yale reviewed the records of 33 patients admitted to their Level I trauma center with both head and skeletal injuries (Injury Severity Score ³ 12, plus Abbreviated Injury Scale score ³ 3 for each injury) who had undergone operative fracture fixation (FF) during a period of 4.3 years. Nineteen of these patients had FF within 24 hours of admission and were compared with the 14 patients whose FF was delayed, in terms of injury severity, operative management, and several outcome measures. The only statistically significant differences between the two groups of patients were that those undergoing early FF (mean, 6.8 vs 84.3 hrs following admission) received more fluid, both during the operation (mean, 4.7 vs 2.2 L) and postoperatively at 24 (11.1 vs 5.4 L) and 48 hours (14.0 vs 8.7 L). More of the early FF patients experienced intraoperative hypotension (3 vs 1) and oxyhemoglobin desaturation (2 vs 1). There were no significant differences in the incidence of neurologic complications in the two groups; however, three of 19 patients undergoing early FF had Glascow Coma Scale (GCS) scores less than 15 on discharge while all 14 patients whose FF was delayed had discharge GCS scores of 15 (the maximum value).
Jaicks et al acknowledge the small study population and lack of information on why some patients had early FF and others did not. However, they postulate that the increased volume of fluid administration intraoperatively, and the tendency of the early FF patients to experience intraoperative instability, may have been related to the poorer neurologic outcome observed in several of these patients.
COMMENT BY DAVID J. PIERSON, MD
Early operative FF became the standard of care at leading trauma centers during the last 20 years. Supporting this approach were a number of studies showing improvements in blood gas values and lower rates of subsequent development of pneumonia and the acute respiratory distress syndrome (ARDS) when patients with multiple trauma underwent early operative FF. These studies, like that of Jaicks et al, tended to be retrospective chart reviews that tacitly assumed no differences to be present in injury severity or other aspects of management other than the timing of FF in their patients. In the present article, the authors’ literature review found only two prospective randomized trials of early vs. delayed FF (or, in one case, no FF): One of these reported decreased lengths of stay with early FF, and both of them found a lower incidence of pulmonary dysfunction. Neither study looked specifically at outcomes in head-injured patients.
Avoidance of secondary brain injury, principally by maintaining cerebral perfusion pressure and preventing even brief periods of ischemia, is a main focus of management of patients with closed head trauma. This creates a potential conflict with the current approach to managing skeletal trauma, which seeks to stabilize fractures as soon after injury as possible and thus to decrease the release of fat and mediators of inflammation into the circulation. Although the present study’s retrospective design and small sample size preclude the confident drawing of conclusions based on its findings, those findings are in keeping with the thinking and experience of many trauma surgeons that the stresses and potential for even momentary cerebral ischemia in patients with both head injury and fractures are not worth the possible advantages of early operative fracture fixation.
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