Is damage control orthopedics essential for the management of bilateral femoral fractures associated or complicated with shock? An animal study.

Background: The maximum score of a single anatomic system, the Injury Severity Score, may not reflect the overall damage inflicted by bilateral femoral fractures and justify the strategy of damage control orthopedics (DCO). It is necessary to investigate effects of various therapeutic procedures on such fractures with or without shock to facilitate correct decision making on DCO.

Methods: A model of bilateral femoral fractures was made in 36 of 48 male New Zealand White rabbits. A model of bilateral femoral shaft fractures associated with shock was made. After resuscitation, a reamed intramedullary nailing fixation was performed in the first group (IM group), and an external fixation device applied in the second group (EF group), and the fractures in the third group (control group) were supported with splints only. They were divided into four groups: shock with IM nailing (shock-IM), shock with external fixation (shock-EF), shock with conservative method (shock-Cons), and intramedullary nailing without shock (nonshock-IM). Vital signs and inflammatory reactions were recorded. Thirty-six hours after the therapeutic procedures in four groups, the animals were killed for histologic evaluation.

Results: The changes of vital signs were most significant in shock-IM group (p < 0.05). The exaggerated levels of interleukin-6, Interleukin-10, and tumor necrosis factor alpha concentrations demonstrated a significant difference between all the groups-shock-IM and other groups (p < 0.05). As to histologic appearances, the statistical difference varies from organ to organ. There is highly significant difference when the IM group is compared with the other two groups as far as lungs are concerned. As to the liver, there is only significant difference between the IM group and the control group. In terms of kidney and heart, there is no significant difference cross the groups. As to histologic appearances, there is highly significant difference in lungs between shock-IM group and other three groups. There is significant difference in liver between the shock-IM group and the shock-Cons group (p < 0.05). Kidneys and heart were less affected cross the groups.

Conclusions: In this study, an early reamed intramedullary nailing fixation procedure resulted in more adverse effects on system stress, inflammatory response, and multiple organs. The injuries also cause histologic damages to lungs and liver. Therefore, early reamed intramedullary nailing fixation may pose a potential risk of developing complications and adopting the DCO strategy may be more preferable. Shock and IM combined cause most severe damages, followed by IM without shock, shock plus EF, and shock plus conservative procedure in that order. If IM must be used for some reasons, it is desirable be delayed until shock has been fully controlled and vasculorespiratory stability restored.