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Severe head trauma (BI) associated with long bone fractures is present in about 60% of polytraumatized patients admitted to hospital. However, there is no consensus regarding early fracture stabilization in such patients. In an experimental sheep study, the influence of intramedullary nailing of the femur (IMNF) on a cold-induced, vasogenic brain edema (method of Klatzo) in combination with traumatic hemorrhagic shock (THS) was investigated. Three animal groups (n = 6) were explored: group A, only BI; group B, BI and THS; group C, BI, THS and IMNF. The animals remained intubated, on controlled ventilation, sedated and received analgesia during the whole experiment. For a period of 6 h after the cold-induced brain injury the hemodynamic changes were measured and the intracranial pressure (ICP) was recorded in the left and the right hemisphere continuously. The hemorrhagic shock (MAP = 60 mm Hg) was maintained over 1.5 h. At the end of the reperfusion period (2 h) the nailing of the femur was performed. The animals were killed and the percentage water content of the brain was determined and compared with the brain water content of a control group (n = 6). There were no significant differences in ICP between groups A, B and C before or after IMNF, but in group C the ICP increased significantly after nailing. Brain water content in group C was significantly higher than in the control group and slightly significantly higher than in groups A and B. Brain edema and ICP are increased by IMNF.(ABSTRACT TRUNCATED AT 250 WORDS)

Early operative treatment of femur fractures is recommended in multiple trauma patients regardless of the pattern of injuries. However, in our clinical experience primary (< 24 h) reamed nailing of a femur shaft fracture in multiple trauma patients is associated with an unusually high number of pulmonary complications, especially in the presence of additional chest trauma. Based on these subjective observations, two clinical studies were done: (1) retrospectively (766 multiple traumatized patients), a higher ARDS incidence in patients with thoracic trauma and primary intramedullary nailing was found; (2) in a prospective clinical study patients submitted to femoral reaming showed a significant increase in pulmonary arterial pressure during the reaming phase, as well as transient worsening of pulmonary function (PaO2/FiO2). The changes were less pronounced in a group of patients undergoing femur nailing by an unreamed procedure. The presence of additional pulmonary trauma predisposes to the development of ARDS. Likewise, injuries associated with severe bleeding are known to predispose to capillary damage, resulting in pulmonary edema. In this group of patients, additional insults to the lung by operative procedures do not appear justified. Primary (< 24 h) reamed nailing has potentially negative effects on the lung and should be avoided if additional chest trauma is present in a polytrauma patient.

Osteomyelitis of long bones is a severe complication of fracture healing. If on-going infection occurs despite reoperation and if antibiotic treatment is of no benefit, reaming of the medullary canal has been considered beneficial. We investigated long-term follow-up (minimum 2 years) in patients submitted to reaming of the medullary canal to evaluate the efficacy of this method. Criteria for success were: no recurrence and no further antibiotic treatment necessary. Of 37 patients, 32 were followed up (mean duration after reaming, 3.7 years). The mean number of surgical operations for osteomyelitis prior to reaming was 3.2. In 88% of patients a full range of motion was observed upon reexamination, while in the others stiffness attributable to articular injuries that had been sustained preoperatively was still present. We found that 84.3% of patients were working in the same profession as prior to the fracture, 72% were involved in sport again, and 97% of patients were pain free. One otherwise healthy patient suffering from sclerosing osteitis (Garré) died of bone marrow embolism into the lung during reaming of the femur. Reaming of the medullary canal has a high cure rate in osteomyelitis even after several previous treatment attempts with surgical revision and/or antibiotic medication. The mechanism is most probably based on improvement of local perfusion. During surgery care must be taken not to provoke pulmonary embolization. Intraoperative monitoring by pulmonary artery catheter should be performed; reaming should be discontinued immediately, if a rise in of pulmonary artery pressure occurs.(ABSTRACT TRUNCATED AT 250 WORDS)

In multiple trauma patients with lung contusion, pulmonary complications have been reported that were attributed to intramedullary stabilization of the femur. The reaming procedure of the medullary canal is thought to play a major role. We investigated whether different types of reamers might exert different amounts of fat mobilization into the vascular system and different degrees of pulmonary dysfunction. Adult female Merino sheep were submitted to hemorrhagic shock (2 h, 50 mm Hg) and a unilateral lung contusion; in addition, a lung lymph fistula was created. Pulmonary capillary permeability, central venous triglyceride levels, 11-dehydro-thromboxane B2 (dh-TXB2) levels, and pulmonary artery pressure were determined. After recovery, animals were randomly assigned to intramedullary femoral nailing using several types of reamers: group A, AO reamer (n = 8); group B, Biomet reamer (n = 7); group H, Howmedica reamer (n = 6); group C, controls, no reaming (n = 4). Intramedullary reaming caused a significant (p < 0.05) increase in pulmonary artery pressure in groups A and B; dh-TXB2 levels increased in all groups. Statistically significant (p < 0.05) pulmonary capillary permeability damage was measured in group A only. Intramedullary femoral nailing can cause transient pulmonary hemodynamic and mediator effects as well as increased pulmonary capillary permeability. In the present study, this effect was evident in group A reamer systems only, which may be due to reamer construction.

A random group of multiple traumatized patients (n = 50) was compared from the aspects of physical rehabilitation and social reintegration with a group of multiple traumatized patients (n = 54) all of whom had serial fracture of the lower extremity. In both groups automobile accidents were the main reason for the injury (in 62%). Motorcycle accidents were responsible in 29% of cases but resulted in twice as many extremity injuries as car accidents, in addition to which the treatment of patients with serial extremity injury lasted twice as long as that of those patients with only single extremity injury. In 40% of the first group more than two secondary hospital treatments were necessary. Two years after trauma working capacity was reduced by less than 20% in only 28.8% of patients with serial injuries as against 69.2% in the randomized group. Reduction of working capacity by more than 80% was observed in only 9% of patients in both groups. In these cases reduction of working capacity was mainly due to severe head injuries and not to limb fractures. Return to work was achieved only after retraining in most such cases, while in others a transfer within the same company made it possible. When patients were asked for their own opinions on the final results of treatment, 75% said they were satisfied. Our results underscore the importance of reestablishing normal function and of reintegration after extremity injuries but also the problems involved.

We investigated the effects of primary (< or = 24 h) intramedullary femoral nailing on lung function and pulmonary hemodynamics in patients with multiple trauma. Two groups were separated: the group with primary femoral nailing with reaming (group RFN) was submitted to femoral nailing after reaming of the medullary canal; in the group with unreamed femoral nailing (group UFN) a small-diameter solid nail was inserted without reaming. Lung function was assessed by oxygenation ratio (PaO2/FIO2), and pulmonary hemodynamics by intraoperative pulmonary artery catheter measurements. Central venous blood concentrations of elastase and the platelet count were determined during and 3 days after surgery. Lung function was stable in UFN patients (n = 14), but deteriorated in RFN patients (n = 17) from 353 +/- 24 (PaO2/FIO2 preoperatively) to 260 +/- 28 (PaO2/FIO2 postoperatively) (p < 0.05) and improved only after 48 hours. Pulmonary artery pressure (PAP) did not change during surgery in UFN patients; in RFN patients PAP increased from 27.2 +/- 3.1 mm Hg (preoperatively) to 36.3 +/- 4.1 mm Hg (p < 0.05) upon reaming and normalized 1 hour after insertion of the nail. Femoral nailing after reaming represents a potential risk with respect to lung function disturbances. This might trigger the development of adult respiratory distress syndrome (ARDS), especially in patients at extra risk of this complication (additional lung contusion, "borderline patient"). In these cases unreamed femoral nailing might offer an alternative by allowing primary intramedullary stabilization without the risk of adverse effects to the lung.

We investigated whether primary (< 24 hours) intramedullary stabilization of femoral shaft fractures in multiple trauma patients with severe thoracic injury might be associated with an increased incidence of adult respiratory distress syndrome (ARDS). A total of 766 patients with multiple trauma admitted to Hannover Medical School between January 1, 1982, and December 31, 1991, were investigated retrospectively. Of these, 106 patients met the inclusion criteria: Injury Severity Score > 18, femoral midshaft fracture treated by intramedullary nailing, primary admission or referral within 8 hours after injury, and no death from head injury or hemorrhagic shock. Two groups were differentiated according to the presence or absence of chest trauma (severe chest trauma = AIS thorax > or =, group T; no severe chest trauma = AIS thorax < 2, group N). Selection of subgroups according to the time of femur stabilization was group I < 24 hours after trauma, group II > 24 hours after trauma. Injury Severity Scores in the four groups were TI: 29.4 (n = 24); TII 31.4 (n = 26); NI 20.1 (n = 33); NII 25.4 (n = 23). In patients without thoracic trauma the ICU time (NI: 7.3 days; NII: 18.0 days) and intubation time (NI: 5.5 days; NII: 11.0 days) were lower in the patients treated primarily (p < 0.05). In patients with severe chest trauma there was a higher incidence of posttraumatic ARDS (33% versus 7.7%) and mortality (21% versus 4%) when early intramedullary femoral nailing was done. In the absence of severe chest trauma primary intramedullary femoral nailing is beneficial.(ABSTRACT TRUNCATED AT 250 WORDS)

We investigated the effects of primary (< 24 h) intramedullary femoral nailing on lung function and pulmonary hemodynamics in multiple trauma patients. The standard procedure following reaming of the medullary canal (AFN) was compared with a new procedure using a small, solid nail without prior reaming (UFN). Pulmonary hemodynamics were determined using a pulmonary artery catheter. Global lung function was assessed by means of the oxygenation ratio (PaO2/FiO2). Concentrations of elastase and the platelet count as a general parameter of the clinical course were determined from central venous blood during and 3 days after surgery. The lung function was stable in UFN patients (n = 6), but decreased significantly in AFN patients (n = 10) from 353 +/- 24 (PaO2/FiO2 preoperative) to 260 +/- 28 (PaO2/FiO2 postoperative) and did not improve until 48 h later. Pulmonary artery pressure (Pap) remained within normal limits in UFN patients, whereas in AFN patients Pap increased from 27.4 +/- 3 mm Hg (preoperative) to 37 +/- 3 mm Hg during reaming and did not normalize until 1 h after insertion of the nail. The platelet count remained unchanged in UFN patients and dropped in AFN patients from 143 +/- 25 x 1000 cells/ml blood (preoperative) to 87.5 +/- 15 x 1000 cells/ml blood 2 days after surgery. Our measurements did not show an increase in central venous triglycerides in the AFN group, probably because bone marrow does not become immediately soluble. There was no significant difference between the increase of elactase levels in the two groups. The femoral nailing procedure with reaming in multiple trauma patients involves a potential risk to the lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Stabilization of femoral shaft fractures is a controversial issue in the management of patients with multiple trauma. Intramedullary nailing usually is preferred primarily; in recent years, however, pulmonary complications (e.g., ARDS) have been reported that were attributed to the reaming procedure. To study the effects of different nailing methods in a model of severe trauma, hemorrhagic shock and lung contusion were created at day 1 in sheep prepared by the method described by Staub. After recuperation (day 3) the animals in the study group (group 1) underwent intramedullary nailing of a closed femur without prior reaming; group 2 was treated with reaming and nailing according to AO standards. The reaming procedure led to an acute increase of pulmonary arterial pressure only in group 2 (19.8 +/- 2.1 to 31.0 +/- 4.6 mm Hg). Pulmonary triglyceride levels increased at parallel time points from 18.27 +/- 2.3 to 33.04 +/- 7.37 mg/dL only in group 2. Stimulatory capacity of polymorphonuclear leukocytes (PMNL) increased in the study group and decreased in controls (group 1: 2.652 +/- 0.23 x 10(6) cpm to 3.387 +/- 1.34 x 10(6) cpm; group 2: 2.699 +/- 0.34 x 10(6) cpm to 2.460 +/- 0.187 x 10(6) cpm). Intramedullary nailing caused an increase of lung capillary permeability in both groups; in the study group less damage was seen (group 1: 0.390 +/- 0.0006 to 0.354 +/- 0.011; group 2: 0.391 +/- 0.0004 to 0.336 +/- 0.015; p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)