Treatment of patients with lower extremity fractures and concomitant
head injury is controversial. The authors compared reamed
intramedullary nailing versus plating of femoral and
tibial fractures in patients with
polytrauma and concomitant
head injury. One thousand five hundred twenty-five patients with
head injuries were identified from a prospective
trauma database. Of those, 1211 patients sustained severe
head injuries (Abbreviated Injury Score >/= 3). One hundred nineteen patients with severe
head injuries and lower extremity long
bone fractures met the inclusion criteria. Ultimately, four patient groups were identified: Group A, reamed femoral nail (n = 21); Group B, femoral plate (n = 29); Group C, reamed tibial nail (n = 23); and Group D, tibial plate (n = 46). Reamed intramedullary nails did not significantly alter the risk of mortality when compared with plates in femoral (relative risk 0.46; 95% confidence interval, 0.04-4.6) and tibial (relative risk 1.18; 95% confidence interval, 0.05-11.9) fractures. The severity of the initial
head injury (Glasgow Coma Scale score) was the strongest predictor of mortality. Functional independence scores between patients with reamed nails and patients with plates were similar at 1 year.
Head injury does not seem to be a
contraindication to reamed
intramedullary nailing in patients with lower extremity fractures. The severity of
head injury alone is an important predictor of outcome. A large, randomized trial with sufficient study power is needed to clarify this issue.