TREATMENT TACTICS FOR PATIENTS WITH MULTIPLE UNILATERAL SHAFT FRACTURES OF THE HIP AND THE LEG ASSOCIATED WITH ABDOMINAL AND RETROPERITONEAL INJURIES

Azerbaidzhan State Institute of Postgraduate Medicine named after A. Aliev,

Baku, Azerbaidzhan

Associated closed injury to the abdomen and various segments of the locomotor system relate to the category of complex injuries, which require emergency aid.

There many literature works which are dedicated to the issue of treatment of unilateral fractures of the femoral bone and the leg bones [1, 3, 5, 8]. However up to the present time there is not any uniform opinion about the most appropriate tactics of treatment of such fractures. The treatment tactics for associated injuries to the abdominal cavity and the retroperitoneal space and for unilateral fractures of the lower extremity is characterized with higher diversity. Some authors prefer conservative treatment, others resort to surgical management, if conservative treatment is ineffective [2, 6]. However surgical treatment is a method of choice for most authors [4].

The severity of patients’ condition is determined by the combination of injuries of bones in different locations and abdominal organs, as well as by traumatic shock. The symptoms of developing traumatic shock often disguise the clinical picture of abdominal injuries that leads to diagnostic errors. Sometimes the severity of abdominal cavity injuries in combination with injuries to the extremities and other organs and tissues is so high that even correct diagnostics and timely surgical treatment do not produce desirable effects.

Diagnostics of internal organ injuries as a part of closed abdominal injury in combination with locomotor injuries is quite difficult. The typical picture of intraperitoneal bleeding is easily differentiated with manifestations of traumatic or spinal shock. The well-known clinical symptoms of acute abdomen in patients with polytrauma are characterized with utmost inconstancy. The X-ray examination is not versatile, because of specific severity of patient’s condition, is not realizable in all cases, and it cannot solve the whole problem of diagnostics. Ultrasonic examination does not give absolute identification of traumatic pathology of the abdominal organs. In such cases, the crucial importance relates to emergent diagnostic laparoscopy, which sometimes prevents needless laparotomy.

The objective of the study – to make the comparative analysis of osteosynthesis techniques and time of its carrying out in patients with multiple unilateral shaft fractures of the hip and the leg associated with abdominal and retroperitoneal injuries.

MATERIALS AND METHODS

During 2006-2012 we observed 93 patients with multiple unilateral shaft fractures of the femur and the leg in combination with abdominal and retroperitoneal injuries. The patients were treated in the multidisciplinary City Clinical Hospital #3. The opened fractures were classified according to Gustilo R. B. and Anderson J.T. (1976) [7]. 36 patients received conservative treatment. 57 patients received surgical osteosynthesis. For estimation of characteristics of fractures we used AO/ASIF classification. The long term results of treatment were estimated with the classification by Jonner R. and Wruhs O. (1983) [9]. The patients were distributed into two groups: the group A with conservative treatment, the group B – with surgical osteosynthesis. The patients were admitted to the intensive care unit, where they received necessary examinations and appropriate assistance. The physicians of various profiles (surgeons, traumatologists, neurosurgeons, urologists, otolaryngologists, otolaryngologists etc.) were involved.

The results were analyzed with SPSS for Windows (the version 17.0; SPSS, Chicago, Illinois) and in some cases with MS Excel. The methods of descriptive statistics (the frequency of the studied signs) were used for the comparative analysis of the osteosynthesis techniques and time of carrying out in the patients with multiple unilateral shaft fractures of the femoral and leg bones in combination with abdominal and retroperitoneal injuries.

All conducted procedures corresponded to the ethical standards of the bioethical legislation of Azerbaidzhan, Helsinki declare 1975 (the edition 2008) and the Rules for Clinical Practice in Russian Federation confirmed by the Order of Health Ministry of Russian Federation, June, 19, 2003, #266. The study was approved by the ethical committee of Azerbaidzhan State Institute of Postgraduate Medicine named after A. Aliev, Baku, Azerbaidzhan (the protocol #7, November, 12, 2015). All studies were conducted after receiving written consents from all patients.

RESULTS

There were 93 patients including 79 men (84.9 %) and 14 women (15.1 %). Most patients (76.3 %) were of employable age (age of 21-60). The main cause of the injuries was road traffic accidents in 88 (94.6 %).

61 patients (65.6 %) were admitted within an hour after the injury, 16 patients (17.2 %) – within 12 hours, 9 patients (9.7 %) – within 24 hours. 7 patients (7.5 %) were transferred from the regional hospitals within a week after the injury.

Right-side injuries were found in 51 patients (54.8 %), left-side injuries – in 42 (45.2 %). Closed fractures were noted in 32 patients (34.4 %), femoral fractures – in 11 (11.8 %), leg fractures – in 21 (22.6 %). Opened fractures were identified in 61 patients (65.6 %) including 19 patients (31.2 %) with femoral bone fractures and 42 patients (68.8 %) with leg fractures.

The opened injuries (according to the classification by Gustilo R. B. and Anderson J. T.) were distributed in the following way: the type 1 – 26 (42.62 % of all opened fractures), the type 2 – 19 (31.14 %), the type 3a – 10 (16.39 %), the type 3b – 6 (9.83 %). Therefore, upon of expiry of 2 months, 2 patients received recurrent osteosynthesis with the pin device, because of the fracture of the plate in AO system. Pin osteomyelitis developed in 8 patients (5 femurs, 3 legs). Slow union of the leg bones was in 9 patients, mixed contracture of the knee joint was in 12 patients (7 operated patients, 5 non-operated patients).

We used AO/ASIF classification for estimation of patterns of the fractures (the table 1).

Table 1
The features and location of the fractures (according to AO/ASIF)

The long term results of the treatment were estimated with the classification by Jonner R. and Wruhs O. (1983) (the table 2).

Table 2
The long term results of treatment of the observed patients

The table 3 demonstrates the conducted surgical interventions according to vital indications. The data by Pape H.C. and Agadzhanyan V.V. (2005) [13, 14] were used for the examination of dependence of injury severity and surgical interventions for the abdominal cavity and the retroperitoneum according to vital indications in the patients with multiple unilateral shaft fractures of the femur and the leg.

Table 3

Dependence of injury severity on location of an injury and emergency surgical abdominal and retroperitoneal interventions in the patients with multiple unilateral shaft fractures of the hip and the leg

According to vital indications or the patient’s condition, concurrently or consecutively, the traumatologists conducted wound toilet (the type 1) or primary surgical preparation (the type 2) during the surgical interventions for the abdominal cavity and the retroperitoneum.

As the table 4 shows, there is not any uniform opinion about timing of osteosynthesis for patients with associated injuries of the abdomen and the locomotor system.

Table 4
Time intervals for conducting osteosynthesis

Choice of a method of osteosynthesis was based on general condition of the patients, presence of concurrent injuries and shock, age of the patients, patterns of the fractures and the extensiveness of soft tissue injuries (the table 5).

Table 5

Treatment of patients with multiple unilateral shaft fractures of the hip and the leg in combination with abdominal and retroperitoneal injuries

The patients were distributed into 2 groups: the group A received conservative treatment, the group B – surgical fixation.

Skeletal traction was conducted for 36 patients among 93 patients with the associated abdominal injuries and the fractures of the femur and the leg. The main indications for conservative treatment were young age with good and satisfactory relationship of fragments, older age at the background of cardiovascular insufficiency, severe concurrent injuries to the internal organs. 24 patients were treated with double traction from the femoral condyles and the calcaneal bone. 12 patients received skeletal traction from the femur; the leg was fixed with plaster split, because of insignificant displacement of fragments. Skeletal traction was realized with the damper method [5] with Beler splint or the author’s device (the patent # 990161 “The device for treatment of fractures and dislocations of bones of lower extremities and for development of motions in the joints”, 1999). The device gives the possibility of development of motions in the knee and hip joints without removal of skeletal traction. Plaster fixation was applied without removal of skeletal traction in 1.5-2 months after full recovery of the abdominal wound and appearance of clinical union.

57 patients received osteosynthesis after correction of shock, after surgical interventions for the abdominal cavity and the retroperitoneum, and stabilizing general condition. Also 3 patients (3.2 %) with opened shaft fractures of the leg and the femur in combination with renal rupture (1 patient) and intestinal and liver rupture (2 patients) received emergent fixation of both segments with use of the rod devices. Other 54 patients (58.1 %) received late interventions (on the days 10-14 after the injury). The indications for surgical treatment were absent contraindications and the consent of the patient for conduction of surgical osteosynthesis.

Plate osteosynthesis of the femur and the leg was conducted for the patients with the fractures of the types A and B. The fractures with the transverse line in the middle one-third of the femoral shaft were fixed with the intramedullary nail (retrograde introduction) and the rod device. Ilizarov device and the hybrid pin-rod construction (on the basis of Ilizarov device) were used for the opened fractures or the patients with contraindications to plaster split because of abdominal wounds (the table 6).

Table 6

A type of osteosynthesis in patients with multiple unilateral shaft fractures of the hip and the leg in combination with abdominal and retroperitoneal injuries

The dynamic compression screws (DCS) were used for the fractures of the proximal and distal shafts of the femur: maple leaf shaped screws for the leg in 6 patients, T-shaped ones for 7 patients for the purpose of persistent and stable osteosynthesis with the possibility of refusal from plaster fixation in the postsurgical period. The dynamic compression plates (DCP) were used for the fractures of the middle one-third in 4 patients. The author’s device (the patent #980094 “The device for external fixation, 1998) was used for 4 patients. As for the leg, DCP were used for 8 patients, the author’s plate – for 7.

DISCUSSION

Therefore, there is no uniform opinion about the most appropriate tactics of treatment for such fractures. Many authors prefer conservative treatment, others – surgical or combinations of surgical and conservative techniques [2, 6].

The clinical study allowed realization of the comparative analysis of various techniques of osteosynthesis and its timing for patients with multiple unilateral shaft fractures of the leg and the femur in combination with abdominal and retroperitoneal injuries.

CONCLUSION

1. Patients with multiple unilateral fractures of the femur and the leg in combination with abdominal and retroperitoneal injuries should be treated and observed in the multidisciplinary hospitals or the departments of associated injury with reserved personnel.

2. After admission of patients with the above mentioned injuries, along with anti-shock treatment and surgical interventions according to vital indications, it is necessary to use skeletal traction, which is one of the factors of anti-shock treatment and is the preparation of the patient for further surgical osteosynthesis.

3. Pin-rod osteosynthesis is indicated in case of emergent fixation.

4. According to our observations, surgical osteosynthesis for patients with multiple unilateral fractures of the leg and the femur in combination with abdominal and retroperitoneal injuries is conducted after surgical interventions and stabilizing general condition.

5. The indication for surgical osteosynthesis is absence of contraindications and the patient’s consent.

6. As for surgical fixation techniques, the preferred options are metal constructs providing persistent and stable osteosynthesis, early activity and early development of motions in both segments in patients with multiple unilateral shaft fractures of the femur and the leg.