Early fracture stabilization has been shown to reduce morbidity and mortality in the patient who is multiply injured. Controversy exists in terms of managing multiple trauma patients who sustain thoracic injuries along with femoral shaft fractures. The purpose of the present study was to determine whether the presence and treatment of femoral shaft fractures increases morbidity in patients with pulmonary contusions and to determine the effect of patient and surgical factors on outcome.

Patients that suffered chest injuries between January 1987 and April 2006 were identified from the prospectively collected trauma databases at two hospitals. Patient records were reviewed to verify all data. The diagnosis of pulmonary contusion was confirmed with radiologic or post-mortem investigations. All relevant patient and surgical data was collected. Exclusion criteria included severely injured patients (head/abdomen AIS> 3), age sixty years, death twenty-four hours after injuries occurred.

A total of 1190 patients with confirmed pulmonary contusions met inclusion criteria; there were 113 femoral shaft fractures (five bilateral). Patients in both the isolated pulmonary contusion and pulmonary contusion with femoral fracture had similar injury severity scores (ISS) and demographic information. Fractures were reduced with intramedullary nailing in 88% of cases. Mean age was thirty-five years. There were significantly more incidences of fat embolism syndrome and acute lung injury (ALI) in patients with femoral factures (twenty-four hours following the injury had significantly greater risk of developing ARDS (p< 0.05).

The presence of femoral shaft fractures in patients with pulmonary contusions increases the duration of admittance to hospital and can lead to higher rates of fat embolism syndrome and ALI, however it does not appear to impact overall mortality or contribute to the development of other common respiratory complications. Early reduction of shaft fractures is encouraged to further decrease complications.

Health utilities indicate the value of a given health state. They are essential components of decision analyses, and economic evaluations. In the area of total shoulder arthroplasty (TSA) we were unable to find literature estimating changes in utilities or the effect of method of obtaining utilities. The purpose of this pilot study was to describe the trajectory of utility scores before and after TSA using three approaches: the EQ-5D and the Health Utilities Index (HUI2 and HUI3) self-report format.

Twenty-four patients undergoing TSA at two teaching hospitals (Boston and Toronto) were assessed twice preoperatively, as well as at four and twelve weeks follow-up by self report mailed survey. At each survey all three utility estimates were obtained. Demographic and functional status was also gathered. The EQ-5D is a five item questionnaire which scores into a profile to which utility weights obtained from the developers were applied. The HUI self-report is a fifteen item scale obtaining a score on eight domains. A multiplicative formula is used to assign utility weights to these responses. Descriptive analysis of the sample, baseline characteristics and change in utility were completed. Intra-class correlation coefficients were used to calculate test-retest reliability between the two preoperative visits. Standardised response means (SRM) (mean change/SD of change) and relative efficiency (RE=ratio of SRM2) were calculated. Individual trajectories of change were graphed and examined for trends.

Twenty-four patients participated with average age of sixty-seven years, 58% were female and experienced large improvements in disability and pain (mean change DASH = 18.9/100, SPADI Pain = 30.3/100). Utility scores had low to moderate correlations with each other (0.26–0.68). Mean baseline scores were low (EQ5D=0.44, HUI2=0.68, HUI3 = 0.50). The average change in utility is shown in the following table along with effect size estimations and test-retest reliability.

Patients experience clinically important and statistically significant changes in their utility values even in the early stages of recovery after TSA (three months). The HUI3 and EQ-5D were most responsive to changes experienced in this sample.