DELAYED SURGICAL FIXATION OF FEMUR FRACTURES IS A RISK FACTOR FOR PULMONARY FAILURE INDEPENDENT OF THORACIC TRAUMA

A recent retrospective analysis of femur fractures concluded that early surgical fixation in patients who have sustained blunt thoracic trauma (AIS score for Thorax greater-than-or-equal-to 2) was a risk factor for postoperative pulmonary failure. We conducted a review of all femur fractures admitted to a level I trauma center from November, 1988 to May, 1993. Inclusion criteria were ISS greater-than-or-equal-to 18, mid-shaft femur fractures treated with reamed intramedullary fixation, and no mortalities secondary to head trauma or hemorrhagic shock. One hundred thirty-eight patients met these criteria. Four patient groups were created: N1-no thoracic trauma (AIS score for thorax < 2), and early surgical fixation (<24 hours after injury, n = 49); N2-no thoracic trauma and delayed fixation (greater-than-or-equal-to24 hours, n = 8); T1-thoracic trauma (AIS score for Thorax greater-than-or-equal-to 2) and early fixation (n = 56); T2-thoracic trauma and delayed fixation (n = 25). There were no significant differences in age, Injury Severity Score, or Glasgow Coma Scale score between the four groups. Mortality rate, length of stay (LOS), LOS in the TICU, and duration of mechanical ventilation tended to be greater in patients with delayed fracture fixation, however, this was not statistically significant. The N2 patients had a pneumonia rate of 38% compared with 10% in group N1 (p = 0.07). The T2 patients had a pneumonia rate of 48% compared with 14% in group T1 (p = 0.002). The overall pulmonary complication rate (pneumonia, adult respiratory distress syndrome, fat embolism syndrome, and pulmonary embolus) was 56% in group T2 compared with 16% in group T1 (p = 0.007). We conclude that delayed surgical fixation is associated with a higher pulmonary complication rate, independent of blunt thoracic trauma.