title: Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics.
abstract: BACKGROUND
  Femoral shaft fractures are associated with acute respiratory distress syndrome (ARDS). The idea that primary intramedullary nailing increases the incidence of ARDS has theoretical support. Our approach to treating femoral fractures in patients with multiple traumatic injuries is to perform reamed nailing after adequate resuscitation has been shown by normalizing lactate plus optimized ventilatory and hemodynamic parameters. Damage control orthopedics (DCO) with primary external fixation usually is reserved for those rare patients who do not respond to resuscitation. Our hypothesis was that this approach yields a low rate of ARDS.
  
  
  METHODS
  A prospective trauma database was searched for all femoral shaft fractures treated at a Level I trauma center during a 3-year period, yielding 582 patients. Exclusion criteria included death before treatment (n = 9), age younger than 16 years (n = 16), age older than 65 years (n = 35), fractures that were not amenable to nail fixation (n = 31), shaft fractures treated with a plate (n = 3), patients with bilateral femoral shaft fractures who had a primary nail placed in one femur and an external fixator on the other limb (n = 1), and patients with an Injury Severity Score (ISS) <or=17 (n = 260), leaving 227 patients in the final study group. We defined ARDS as a mean partial pressure of oxygen/fraction of inspired oxygen <200 for 5 or more consecutive days. We compared our results with the results of a similar design in the literature.
  
  
  RESULTS
  Of the 227 patients with ISS >17, only 12% were initially treated with DCO, and 88% were treated with primary reamed nailing. The 227 patients achieved successful early resuscitation as shown by lactate values that decreased significantly on the operative day compared with presenting values (p < 0.05). ARDS rates were low, including rates for the subgroup of patients with lung injury (thoracic Abbreviated Injury Scale score >2, n = 175) who were treated with nailing and had an ARDS rate of 2.0% and a death rate of 2.0%. The ARDS rate for the most severely injured patients who underwent nailing (ISS >28, thoracic Abbreviated Injury Scale score >2, n = 78) was only 3.3%, and 1.7% died.
  
  
  CONCLUSIONS
  In the context of resuscitation before reamed intramedullary nailing of femoral shaft fractures, our rate of ARDS was lower (p < 0.001) than that of a similar study reported in the literature in which the DCO approach was used in up to 36% of patients (p < 0.001) and was more in keeping with previously reported rates of ARDS. This remained true despite frequent use of early reamed femoral nailing and infrequent use of DCO. An explanation for the discrepancy between the centers might be differences in preoperative resuscitation or medical care provided to treat shock.
authors.affiliation: Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. rvo3@yahoo.com
authors.forename: Robert V
authors.initials: RV
authors.lastname: O'Toole
authors.forename: Michael
authors.initials: M
authors.lastname: O'Brien
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
authors.forename: Nader
authors.initials: N
authors.lastname: Habashi
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Pollak
authors.forename: Clifford H
authors.initials: CH
authors.lastname: Turen
mesh_terms: D000328:Adult; D002985:Clinical Protocols; D016267:External Fixators; D005264:Femoral Fractures / Q000097:blood / Q000601:surgery*; D005594:Fracture Fixation, Intramedullary / Q000379:methods / Q000639:trends*; D006801:Humans; D015601:Injury Severity Score; D007773:Lactates / Q000097:blood; D055370:Lung Injury / Q000628:therapy; D009104:Multiple Trauma / Q000601:surgery*; D011300:Preoperative Care; D012128:Respiratory Distress Syndrome / Q000453:epidemiology / Q000517:prevention & control*; D012151:Resuscitation / Q000379:methods*; D014193:Trauma Centers / Q000706:statistics & numerical data
chemical_list: D007773:Lactates