Can the Severity of a Femoral Fracture be a Marker for the Occurrence of Respiratory Distress Syndrome in Polytrauma Patients?

Introduction: Acute Respiratory Distress Syndrome(ARDS) is a frequent and serious early complication of polytrauma. The literature is contradictory on the technique of fixation in emergency : external fixation or intramedullary nailing(IN). Some suggest ISS(Injury-Severity-Score) to decide. Our emergency strategy is IN for any ISS.

The objective is to evaluate incidence of ARDS in polytrauma after IN according to the severity of femoral diaphyseal fracture and ISS. We also assess rate of early(infection,pulmonary embolism,leg syndrom(LS)) and late complications(nonunion).

Methods: We analyzed a retrospective consecutive cohort of 191patients with an average follow-up of 18months. IN was performed first day. Group A(n=85), consisting of severe fractures in case of vascular or nerve complications or associated lesion on bone segment(bilateral femoral fractures,neck fracture,floating-knee,hip-dislocation). Group B(n=128), consisting of non-severe fractures.

Results: ISS was higher in Group A(23.6vs19.2,p<0.05). Open fractures and smoking subjects were identical. Operating times were longer in Group A(135vs107min,p<0.05). Positive correlation was found between ISS and occurrence of ARDS(p<0.007). ARDS was higher in Group A(11.8%(n=10)vs3.1%(n=4),p<0.007). Rate of infection was higher in Group A(11.8%(n=10)vs3.1%(n=4),p <0.007). LS were more important in Group A(6vs1,p<0.007). There were more nonunions in Group A(11.8%(n=10)vs3.1%(n=4),p<0.007). No difference was found for the other complication.

Conclusion: Occurrence of ARDS is significantly increased in severe femoral fractures treated with IN in polytrauma patient. They attest higher energy trauma as attested by higher ISS. The use of fracture severity as a predictive factor for ARDS and complications may be interesting, associated with ISS, to decide the treatment of femoral fractures in polytrauma patients.