Niloofar Dehghan

Flail chest injuries: A review of outcomes and treatment practices from the National Trauma Data Bank

BACKGROUND Flail chest injuries are associated with severe pulmonary restriction, a requirement for intubation and mechanical ventilation, and high rates of morbidity and mortality. Our goals were to investigate the prevalence, current treatment practices, and outcomes of flail chest injuries in polytrauma patients. METHODS The National Trauma Data Bank was used for a retrospective analysis of the injury patterns, management, and clinical outcomes associated with flail chest injuries. Patients with a flail chest injury admitted from 2007 to 2009 were included in the analysis. Outcomes included the number of days on mechanical ventilation, days in the intensive care unit (ICU), days in the hospital, and rates of pneumonia, sepsis, tracheostomy, chest tube placement, and death. RESULTS Flail chest injury was identified in 3,467 patients; the mean age was 52.5 years, and 77% of the patients were male. Significant head injury was present in 15%, while 54% had lung contusions. Treatment practices included epidural catheters in 8% and surgical fixation of the chest wall in 0.7% of the patients. Mechanical ventilation was required in 59%, for a mean of 12.1 days. ICU admission was required in 82%, for a mean of 11.7 days. Chest tubes were used in 44%, and 21% required a tracheostomy. Complications included pneumonia in 21%, adult respiratory distress syndrome in 14%, sepsis in 7%, and death in 16%. Patients with concurrent severe head injury had higher rates of ventilatory support and ICU stay and had worse outcomes in every category compared with those without a head injury. CONCLUSION Patients who have sustained a flail chest have significant morbidity and mortality. More than 99% of these patients were treated nonoperatively, and only a small proportion (8%) received aggressive pain management with epidural catheters. Given the high rates of morbidity and mortality in patients with a flail chest injury, alternate methods of treatment including more consistent use of epidural catheters for pain or surgical fixation need to be investigated with large randomized controlled trials. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level IV.

Surgical fixation of Vancouver type B1 periprosthetic femur fractures: a systematic review.

Objectives: Vancouver type B1 periprosthetic femur fractures occur around a stable implant and are typically treated with open reduction and internal fixation (ORIF). Different fixation techniques are described in the literature, and there is a lack of consensus regarding the best operative fixation strategy. The purpose of this investigation was to systematically review and compare the most commonly used fixation strategies for these fractures. Data Sources: A database search was performed using PubMed, MEDLINE, and Cochrane databases to identify studies published in English language from 1985 to 2013. Study Selection: Articles with a minimum of 5 patients with type B1 periprosthetic femur fractures and containing outcome data regarding nonunion, malunion, infection, and reoperation rate were included. Data Extraction: Studies were analyzed and categorized into 4 groups: group 1: ORIF with cortical strut allografts alone, group 2: ORIF with cable plate/compression plates alone, group 3: ORIF with cable plate/compression plates and cortical strut allograft, group 4: ORIF with locking plates alone. Individual patient outcomes were extracted for each study and pooled for each of the 4 groups. Data analysis was performed comparing rates of nonunion, malunion, hardware failure, infection, and reoperation. Data Synthesis: Data were analyzed using Review Manager and SAS 9.3. Conclusions: In total, 333 patients identified with an overall rate of 5% nonunion, 6% malunion, 5% infection, 4% hardware failure, 9% reoperation, and 15% total complications. When comparing outcomes for different modes of fixation, compared with cable plate/compression plate systems, locking plates had a significantly higher rate of nonunion (3% vs. 9% P = 0.02) and a trend toward a higher rate of hardware failure (2% vs. 7%, P = 0.07). There are limitations to this study, and further investigation with high-quality randomized controlled trials is needed to effectively compare treatment strategies.

Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial.

Objectives: The aim of this study was to compare early weightbearing and range of motion (ROM) to nonweightbearing and immobilization in a cast after surgical fixation of unstable ankle fractures. Design: Multicentre randomized controlled trial. Setting: Two-level one trauma centers. Patients: One hundred ten patients who underwent open reduction and internal fixation of an unstable ankle fracture were recruited and randomized. Intervention: One of 2 rehabilitation protocols: (1) Early weightbearing (weightbearing and ROM at 2 weeks, Early WB) or (2) Late weightbearing (nonweightbearing and cast immobilization for 6 weeks, Late WB). Main Outcome Measurements: The primary outcome measure was time to return to work (RTW). Secondary outcome measures included: ankle ROM, SF-36 heath outcome scores, Olerud/Molander ankle function score, and rates of complications. Results: There was no difference in RTW. At 6 weeks postoperatively, patients in the Early WB group had significantly improved ankle ROM (41 vs. 29, P < 0.0001); Olerud/Molander ankle function scores (45 vs. 32, P = 0.0007), and SF-36 scores on both the physical (51 vs. 42, P = 0.008) and mental (66 vs. 54, P = 0.0008) components. There were no differences with regard to wound complications or infections and no cases of fixation failure or loss of reduction. Patients in the Late WB group had higher rates of planned/performed hardware removal due to plate irritation (19% vs. 2%, P = 0.005). Conclusions: Given the convenience for the patient, early improved functional outcome, and the lack of an increased complication rate, we recommend early postoperative weightbearing and ROM in patients with surgically treated ankle fractures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nail fixation of non-traditional fractures: Clavicle, forearm, fibula

Locked intramedullary fixation is a well-established technique for managing long-bone fractures. While intramedullary nail fixation of diaphyseal fractures in the femur, tibia, and humerus is well established, the same is not true for other fractures. Surgical fixations of clavicle, forearm and ankle are traditionally treated with plate and screw fixation. In some cases, fixation with an intramedullary device is possible, and may be advantageous. However, there is however a concern regarding a lack of rotational stability and fracture shortening. While new generation of locked intramedullary devices for fractures of clavicle, forearm and fibula are recently available, the outcomes are not as reliable as fixation with plates and screws. Further research in this area is warranted with high quality comparative studies, to investigate the outcomes and indication of these fractures treated with intramedullary nail devices compared to intramedullary nail fixation.

Prospective Randomized Clinical Trial Investigating the Effect of the Reamer-irrigator-aspirator on the Volume of Embolic Load and Respiratory Function During Intramedullary Nailing of Femoral Shaft Fractures

Objectives: We sought to determine whether the use of the Reamer-Irrigator-Aspirator (RIA) device resulted in a decreased amount of fat emboli compared with standard reaming (SR) when performing intramedullary (IM) nailing of femoral shaft fractures. Design: Prospective randomized clinical trial. Setting: Multi-centered trial, level I trauma centers. Patients/Participants: All eligible patients who presented to participating institutions with an isolated femoral shaft fracture amenable to fixation with antegrade IM nailing. Thirty-one patients were enrolled: nine were excluded because of technical difficulties with the transesophageal echocardiogram (TEE) recording. Therefore, the study comprised 22 patients: 11 patients randomized to the SR group and eleven patients randomized to the RIA group. Intervention: Antegrade IM nailing of a femoral shaft fracture with standard reamers or the RIA device. All patients were monitored intraoperatively with a continuous TEE to assess embolic events in the right atrium. A radial arterial line was used to monitor blood gases and potential systemic effects of emboli. Main Outcome Measure: Duration, size, and severity of emboli as measured by TEE. The operative procedure was divided into 6 distinct stages: preoperative, reduction, guidewire passage, reaming, nail insertion, and postoperative. Results: There was no significant difference in emboli between the RIA and SR groups preoperatively, during fracture reduction, guidewire insertion, or postoperatively. Measured with a standardized scoring system, there was a modest reduction in total emboli score in the RIA group during reaming (SR 5.30 [SD; 1.81] vs. RIA 4.05 [SD; 2.19], P = 0.005) and during nail insertion (SR 5.09 [SD; 1.74] vs. RIA 4.25 [SD; 1.89], P = 0.03). We were unable to correlate this reduction with any improvement in physiologic parameters (mean arterial pressure, end-tidal CO2, O2 saturation, pH, paO2, and paCO2). Conclusions: This study showed a modest reduction of embolic debris during the reaming and nail insertion segments of the operative procedure. We were unable to correlate this with any change in physiologic parameters. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Outcome Following Flail Chest Injuries

While prior studies have focused on the acute or short-term benefits of surgical intervention for flail chest injuries (i.e., decreased time of mechanical ventilation), it is important to remember that of equal or greater significance to the patient is their long-term outcome. A number of negative chronic sequelae have been described following crushing injuries to the chest. These include chronic chest wall pain and deformity, dyspnea, abnormal pulmonary dysfunction, and impaired general health status. Two separate studies have reported that fewer than half of patients with flail chest injuries treated nonoperatively have been able to return to gainful employment. There is obviously room for improvement in this area: to do so, the rate and severity of long-term complications need to be carefully defined so that the results of intervention (i.e., surgical stabilization) can be properly analyzed. While it is reasonable to postulate that surgery may improve certain aspects of these injuries (such as chest wall deformity), higher-level prospective, comparative, or randomized trials, with long-term follow-up, are required for definitive information on this topic. Additionally, certain concomitant injuries (such as a pulmonary contusion or head injury) can have a major effect on outcome. This chapter will discuss the most up-to-date information available on this topic of long-term outcome following a flail chest injury.