Traumatic brain injury and stabilisation of

long bone fractures

Dr.Ahmed AzmyTeam A–Orthopaedic department

Khoula Hospital

In the era of ‘‘damage control orthopaedics’’, the timing and type of stabilisation of long bone fractures in patients with associated severe traumatic brain injury has been a topic of lively debate

•Traumatic brain injury and stabilisation of long bone fractures: an update M.R.W. Grotz, H.C. Pape, M.K. Allami. injury, Int. J. Care Injured (2004) 35, 1077—1086

Incidence

In 20% of all trauma patients and are the most common cause of death

Multiple trauma with head injuries

mortality rates can reach over 40%

On The One Handearly definitive fracture stabilisation could be beneficial in the head injured patient By:-reducing persistent pain at the fracture site,minimising involuntary movements of the unconscious.

Fracture stabilisation has a positive effect on thepatient’s metabolism, muscle tone, body temperature and therefore cerebral function.

unstabilised fractures may cause deterioration in the patient’s condition by means of exacerbating soft tissue damagedevelopment of fat embolism respiratory insufficiency.

ON THE OTHER HANDseveral authors have suggested that early fixation of fractures in

patients with traumatic brain injury may be deleterious to the

eventual neurological outcome and be associated with secondary

brain injury.

•Lehmann U, Reif W, Hobbensiefken G, Seekamp A, Regel G, Sturm JA, et al. Effect of primary fracture management on craniocerebral trauma in polytrauma. An animal experiment study. Unfallchirurg 1995;98:437—41

•Chestnut RM. Secondary brain insults after head injury: clinical perspectives. New Horizons 1995;3:366—9

Primary and secondary brain damage

Primary brain inuryoccurs at the time of the accident

The main causes:

1. angular acceleration, or

deceleration forces

2. direct forces

Secondary brain inuryOccurs subsequently to the accident

The main causes:-

Are hypotension and hypoxia,

hyperthermia, hypo- or hyperglycaemia,

hyponatraemia and sepsis.

pathological changes of the endogenic

neurochemical system, resulting in an

increased liberation of mediators, toxic

amino acids, proteolytic enzymes, or

oxygen radicals, can result in secondary

brain damage.

In the polytrauma setting avoidance of secondary brain damage is of particular importance.

FRACTURE FIXATIONEarly fracture fixation(EFF)

EFF brings the benefit of reducing fracture pain.

Brundage et al. demonstrated an improved outcome length of hospital and ICU stay was lower

Poole et al. demonstrated a significant decrease in peri-operative neurological complications

Starr et al. demonstrated significantly lower pulmonary complications

•Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV. Timing of femur fracturefixation: effect on outcome in patients with thoracic and head injuries. J Trauma2002;52:299—307•Poole GV, Miller JM, Agnew SG, Grisworld JA. Lower extremity fracture fixation in head injured patients. J Trauma 1992;32:654—9•Starr AJ, Hunt JL, Chason DP, Reinert CM, Walker J. Treatment of femur fracture with associated head injury. J Orthop Trauma 1998;12:38—45.

Late fracture fixation [LFF]Jaicks et al. reported lower rates of intraoperative, hypovolaemic, or hypoxic, events in the late fixation group compared with the early fixation group.

•Jaicks RR, Cohn SM, Moller BA. Early fixation may be deleterious after head injury. J Trauma 1997;42:1—5.

Martens et al. reported an incidence of 38% early neurological deterioration following early fixation and none in the late fixation group

•Martens F, Ectors P. Priorities in the management of polytraumatised patients with head injury: partially resolved problems. Acta Neurochir (Wien) 1988;94:70—3.

EFF VS. LFFSeveral other authors looked at mortality rates, length of hospital stay and peri-, or post-operative complications in multiple trauma patients with severe head injury, comparing early versus delayed fracture treatment. However, none of these clinical trials showed any statistical difference.

The current recommendation is to proceed with early skeletal stabilisation, providing haemodynamic stability has been achieved.by means of cavity decompression and temporary skeletal stabilisation, without compromising optimal oxygenation and regulation of cerebral blood flow.

•Scalea TM, Scott JD, Brumback RJ, Burgess AR, Mitchell KA, Kufera JA, et al. Early fracture fixation may be ‘‘just fine’’ after head injury: no difference in central nervoussystems outcomes. J Trauma 1999;46:839—46.

Type of fracture stabilisationIMN VS. PLATES

IMN:- There is a theoretical risk of potentiating additional central nervous system injury by The intravasation of medullary fat, increase in brain Oedema and increase in intracranial pressure.

•Lehmann U, Reif W, Hobbensiefken G, Seekamp A, Regel G, Sturm JA, et al. Effect of primary fracture management on craniocerebral trauma in polytrauma. An animal experiment study. Unfallchirurg 1995;98:437—41.

PLATES :-On the other hand, plating of lower extremity fractures carries the risk of a more extensive surgical approach, with its consequent danger of increased blood loss leading to hypotension, in turn resulting in secondary brain injury.

•Pietropaoli JA, Rodgers FB, Shackford SM, et al. The deleterious effect of intraoperative hypotension on outcome in patients with severe head injuries. J Trauma 1992;33:403—7.:

RECOMMENDATIONS1. The initial management should be the rapid control of haemorrhage, and

the restoration of vital signs and tissue perfusion.

2. Initially, the severity of the head injury should be assessed by the Glasgow Coma Scale prior to administration of analgesia and sedation

3. In physiologically unstable patients the ‘Damage Control’ approach should be considered.

4. Maintenance of cerebral perfusion/oxygenation is essential for preventing secondary brain damage in the multiply injured patient. The difference between the MAP and the intracranial pressure (ICP) determines the cerebral perfusion pressure (CPP), which should be at least 60—70 mmHg in head injury patients.

5. ICP levels below 20 mmHg are favourable.