Abstract
Introduction: Road side accidents resulting in polytrauma with an associated fracture of femur is a common pattern of injury in asian countries. We hypothesised that the use of unreamed nailing in the management of such fractures has better outcome than reamed nailing.
Material and Methods: We retrospectively reviewed 116 cases of polytrauma with associated fracture of shaft of femur admitted in our tertiary teaching hospital in North India bewteen Jan 1996 to Dec 2001. The patients were initially resuscitated according to the advanced trauma life support protocol. They were randomally managed by interlocking nail using reamed (n=48) and unreamed (n=68) technique after being haemodynamically stabilized. Five intraoperative parameters were recorded – the surgical time, fluoroscopy time, the intraoperative blood loss, intraoperative oxygen saturation, and any intraoperative complications. The patients were assessed postoperatively for ninety six hours for features of adult respiratory distress syndrome. All patients were clinically and radiologically assessed at 6 weekly intervals till union. The follow-up reassessments were performed by a single surgeon (AG).
Results: There were 80 males, 30 females (6 were bilateral), with an average age of 26 years (range 19 to 64 years). The fractures were closed in 74 and open in 42 (Gustillo Grade 1;n=28, Grade 2;n=9, Grade 3;n=5). 48 were managed by reamed interlock nailing (Group 1) and 68 by unreamed interlock nailing (Group 2). 58 patients had an associated blunt trauma chest, 36 had blunt trauma abdomen, 18 had an associated head injury and 12 had spine injuries. The average surgical time for Group 1 was 118 minutes and for Group 2 was 94 minutes (p=0.014). The average fluorscopy time for Group 1 was 4.30 minutes and for Group 2 was 4.06 minutes. The average intra-operative blood loss for Group 1 was 254 millilitres and for Group 2 was 202 millilitres. The average intraoperative oxygen saturation fall as measured at the time of reaming and nail insertion was 2% in Group 1 and 6% in Group 2. The intraoperative complications were 11 (22.91%) in Group 1 and 18 (26.47%) in Group 2. The features of ARDS were observed in 6 patients in Group 1 (12.5%) and 4 patients in Group 2 (5.88%). The average union time was 25 weeks in Group 1 as compared to 19.4 weeks in Group 2 (p=0.012). The reoperation rate was 6.25% in Group 1 and 11.76% in Group 2.
Discussion: The unreamed interlock nailing is the definitive management of fractures of femur in patients with polytrauma or blunt trauma chest as it requires lesser operative time (and thus exposing the patient to shorter period of anaesthesia), lesser blood loss and lesser fluoroscopy exposure. The incidence of ARDS is significantly lower with unreamed nailing in polytrauma patients. However the union time was significantly longer in unreamed nailing as compared to reamed nailing.
Correspondence should be addressed to Mr Carlos Wigderowitz, Honorary Secretary BORS, University Dept of Orthopaedic & Trauma Surgery, Ninewells Hospital & Medical School, Dundee DD1 9SY.
