Introduction: The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable patients with head, chest, abdomen or pelvic injuries with blood loss) followed by an immediate fracture fixation (“Early Total Care”) may be associated with a secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). We present our experience experience in the treatment strategy of polytraumatized patients with femoral shaft fracture.

Patients and Methods: From 1995 to 2008 there were 137 polytraumatized patients with femoral shaft fracture treated in our hospital. The outcomes of their treatment were retrospectively analyzed in this study. Patients were grouped according the treatment strategies for stabilization of the femoral shaft fracture: Group A – 99 patients treated with early total care (ETC) - intramedullary nailing (IMN) within 24 h of injury Group B- 38 patients treated with temporary external fixation as a bridge to IMN (DCO surgery starting at 2005).

Results: The groups were comparable regarding age, gender distribution and mechanism of injury. ISS was higher in group B (DCO) – 32,2 compared to group A (ETC) – 22,6. The patients in DCO group required significantly more fluids (14,2 L) then those in ETC (8,2 L) and blood (2,2 vs 1,3 L) in the initial 24 hours. Thoracic, abdominal or head injuries were accounted significantly higher number of patients submitted to DCO group from 2005 (24,2%) compared to ETC group (12,4%). Mean operative time for External Fixators was 40 minutes, 110 minutes for IMN. There was a significantly higher incidence of ARDS in ETC group −18,2% compared to DCO group – 8,6%. The incidence of multiple organ failure (MOF) was significantly lower in DCO group – 7,4% than in ETC group – 12,1 %. There were 3 unexpected deaths and 2 cases with conscious worsening in patients with head injury in ETC group. No significant differences in the incidence of local complications were found.

Conclusions: Based on this study it seems that a significant reduction in incidence of general systemic complications (ARDS, MOF) was found in DCO group in comparison with ETC group, Changing of the treatment protocol from ETC to DCO is not associated with increased rate of local complications (pin-tract infections, delayed unions or nonunions). There is a lower complication rate in DCO Group despite higher ISS compared with the ETC Group, DCO surgery appears to be an viable alternative for polytraumatized patients with femoral shaft fracture.

Anterior spinal pathology of the upper thoracic (T2–T4) segment is rare. The surgical approach is still controversial. Anterior week approach with partial osteotomy of the sternum or high latero-posterior thoracotomy are insufficient to approach this segment.

The purpose of this study is to present our experience with sternotomy as a approach in the surgical treatment of anterior spinal pathology to the upper thoracic (T2–T4) segment.

Material and methods: Between 2000–2004 nine patients with anterior spinal pathology in the upper thoracic segment were surgically treated. From all patients 5 were male and 4 female. The age ranged from 52 to 62 years. The anterior spinal pathology localisation was in 5 patients in T2; in 2 pt. in T2 and 2 pt. in both T2 and T3. The diagnosis in all patients was done by protocol wich included: careful neurological examination; standard radiographic films (AP and lateral view); CT; MRI; bone scan and other routine investigations. Neurologic status (deficit) was evaluated by modified Frankel Scale (M.F.S.). There were one patient grade A2; 4 patients with grade B; 3 pt. as a grade 3 and one grade D1. Sternotomy as a approach was used in all patients to expose the upper thoracic (T2–T4) segment. Corpectomy, extirpation of the local tumors mass; decompression of the spinal canal and neural elements was done.

The defect between T1-T3-4 was bridged with three-cortical iliac crest bone graft. In 7 cases fixation with anterior plate was done. Histologically in 2 pt. was found metastasis of carcinoma of thyroid grand foliculocellulare type; in 4 pt. solitary plasmocytoma; in two pt. giant cell tumor and in one patient invasive chondroma. All patients after surgery were transferred to the Oncology Center for other aditional treatment. Neurological recovery was registered in all patients expect one who died 2 months after surgery. The patient with grade A2 and one of grade B recovered to grade D1; one patient of grade B recovered to grade C and two of grade B and patients of grade C and D recovered to grade E. The solid fusion happened in all patient expect one who died.

Conclusion:

Sternotomy is a safe approach to the upper thoracic T2–T4 segment with possibility of direct visualisation of pathologic process and radical extirpation of the tumorous mass.