0022-5282/00/4804-0613
The Journal of Trauma: Injury, Infection, and Critical Care
Copyright © 2000 by Lippincott Williams & Wilkins, Inc.
External Fixation as a Bridge to Intramedullary Nailing for
Patients with Multiple Injuries and with Femur Fractures:
Damage Control Orthopedics
Thomas M. Scalea, MD, Sharon A. Boswell, RN, CEN, Jane D. Scott, ScD, MSN, Kimberly A. Mitchell, MS,
Mary E. Kramer, RN, and Andrew N. Pollak, MD
Background: The advantages of early fracture fixation in
patients with multiple injuries have been challenged recently,
particularly in patients with head injury. External fixation (EF)
has been used to stabilize pelvic fractures after multiple injury.
It potentially offers similar benefits to intramedullary nail
(IMN) in long-bone fractures and may obviate some of the risks.
We report on the use of EF as a temporary fracture fixation in
a group of patients with multiple injuries and with femoral shaft
fractures.
Methods: Retrospective review of charts and registry data of
patients admitted to our Level 1 trauma center July of 1995 to
June of 1998. Forty-three patients initially treated with EF of the
femur were compared to 284 patients treated with primary IMN
of the femur.
Results: Patients treated with EF had more severe injuries
with significantly higher Injury Severity Scores (26.8 vs. 16.8)
and required significantly more fluid (11.9 vs. 6.2 liters) and
blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma
Scale score was lower ( p < 0.01) in those treated with EF (11 vs.
14.2). Twelve patients (28%) had head injuries severe enough to
require intracranial pressure monitoring. All 12 required ther-
apy for intracranial pressure control with mannitol (100%),
A
lthough the benefits of early fracture fixation are well
documented, questions remain concerning the optimal
timing of fracture fixation in adult trauma patients with
multiple injuries.1– 6 Early intramedullary nail (IMN) fixation
of long bone fractures in patients with multiple injuries has been
associated with a reduced risk of pulmonary complications.2,4,6
However, some recent reports have implicated fat embolization
associated with IMN worsening pulmonary complications for
patients with certain lung injury profiles.7 Additional studies
suggest that patients with severe traumatic head injury may
experience poorer outcomes if treatment of musculoskeletal in-
juries includes early surgical intervention.8,9 Substantial blood
Submitted for publication September 24, 1999.
Accepted for publication December 31, 1999.
From the R. Adams Cowley Shock Trauma Center (T.M.S., S.A.B.), Uni-
versity of Maryland Medical System, Program in Trauma (T.M.S.), Charles
McC. Mathias Jr. National Study Center for Trauma and EMS (J.D.S.,
K.A.M., M.E.K.), and Division of Orthopedics and Program in Trauma
(A.N.P.), University of Maryland School of Medicine, Baltimore, Maryland.
This study was not funded from corporate or other sources. The authors
contributed their time to the study.
Presented at the 59th Annual Meeting of the American Association of the
Surgery of Trauma, September 16 –18, 1999, Boston, Massachusetts.
Address for reprints: Thomas M. Scalea, MD, R. Adams Cowley Shock
Trauma Center, 22 South Greene Street, Room T3R35, Baltimore, MD
21201-1595.
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Vol. 48, No. 4
Printed in the U.S.A.
barbiturates (75%), and/or hyperventilation (75%). Most pa-
tients had more than one contraindication to IMN, including
head injury in 46% of cases, hemodynamic instability in 65%,
thoracoabdominal injuries in 51%, and/or other serious injuries
in 46%, most often multiple orthopedic injuries. Median oper-
ating room time for EF was 35 minutes with estimated blood loss
of 90 mL. IMN was performed in 35 of 43 patients at a mean of
4.8 days after EF. Median operating room time for IMN was 135
minutes with an estimated blood loss of 400 mL. One patient
died before IMN. One other patient with a mangled extremity
was treated with amputation after EF. There was one compli-
cation of EF, i.e., bleeding around a pin site, which was self-
limited. Four patients in the EF group died, three from head
injuries and one from acute organ failure. No death was second-
ary to the fracture treatment selected. One patient who had EF
followed by IMN had bone infection and another had acute
hardware failure.
Conclusion: EF is a viable alternative to attain temporary
rigid stabilization in patients with multiple injuries. It is rapid,
causes negligible blood loss, and can be followed by IMN when
the patient is stabilized. There were minimal orthopedic com-
plications.
loss associated with major operative procedures certainly com-
plicates optimal fluid resuscitation in the patient with a brain
injury, and general anesthesia interferes with the ability to seri-
ally assess neurologic function. Additional patient populations at
particular risk for complications from major operative proce-
dures include those who are hypothermic, coagulopathic, or
hemodynamically unstable.
External fixation (EF) plays an important role in primary
management of pelvic fractures in patients with multiple
injuries and with competing injuries in many centers.10,11 In
the past 3 years, we have largely adopted the use of EF for
femur fixation in unstable trauma patients with multiple in-
juries. We use EF as a “bridge” or “temporizing device” to
achieve the benefits of early fracture stabilization during
early resuscitation, and postpone the additional stresses posed
by IMN until the patient is stabilized.
The purpose of this study was to investigate the clinical
course and outcomes of all adult trauma patients admitted to
our center with femur fracture who were treated primarily
with EF versus IMN. We were specifically interested in
determining the characteristics of the EF and IMN popula-
tions, and outcomes of mortality, length of stay, and dis-
charge disposition. We were additionally interested in deter-
mining the reasons provided in the medical record for
The Journal of Trauma: Injury, Infection, and Critical Care April 2000

selecting EF as the primary repair procedure. Our central
premise is that, although patients with primary EF of the
femur should be more severely injured than patients with
primary IMN, survival would be comparable for EF and IMN
groups.
MATERIALS AND METHODS
The study was a retrospective analysis of prospectively col-
lected trauma registry data of patients admitted to the R.
Adams Cowley Shock Trauma Center (STC), the primary
adult resource center for trauma in the State of Maryland,
from July 1, 1995, to June 30, 1998. Patients were identified
through query of the STC trauma repository searching for all
cases of acute femur fracture. Trauma repository variables
concerning patient characteristics (i.e., age, sex), clinical
course, and outcomes (i.e., mortality, discharge destination)
were obtained for all identified cases. If primary repair of the
femur was designated as EF, medical records were then
abstracted to determine the indications for EF and subsequent
clinical course. For patients treated with EF, trauma reposi-
tory data and abstracted medical record data were linked to
create a comprehensive picture of clinical course and out-
comes.
Study inclusion criteria were acutely injured patients ad-
mitted to the STC with a femur fracture, who were treated
primarily with either EF or IMN. Cases were defined in terms
of femur fracture and repair only. Mechanism of injury in-
cluded blunt as well as penetrating trauma.
During the study period, a total of 324 patients met our
criteria (i.e., femur fracture and primary femur repair). Cases
were divided into EF (n ⫽ 43 [13%]) and IMN (n ⫽ 281
[87%]) groups. The decision regarding which fixation proce-
dure to use was based on the combined judgment of the
attending trauma surgeon, orthopedic surgeon, and any other
physician specialties consulting on the case.
The entire study population was characterized in terms of
patient attributes (i.e., age, sex, mechanism of injury), clinical
eters at admission, i.e., admission serum lactate, central
venous pressure, pulmonary wedge pressure, and ICP; and
rationale for use of EF as the primary method of fixation. In
addition, characteristics of the hospital course and surgical
procedures, i.e., operating room [OR] time, OR estimated
blood loss, and postoperative complications, were investi-
gated.
Outcome variables were obtained from the STC trauma
repository for all patients. Outcomes of interest included
intensive care unit length of stay (ICU-LOS), hospital LOS,
mortality, and discharge destination. Characteristics of the
clinical course and overall hospitalization were compared for
EF and IMN groups.
Data were analyzed by using the SAS statistical package.
Univariate and bivariate analyses were performed. The Sha-
piro-Wilk statistic was computed to determine whether data
were normally distributed. For normally distributed continu-
ous variables, the Student’s t test was used to determine
differences in means between EF and IMN groups. For con-
tinuous data that were not normally distributed within each of
the two treatment groups, and were unbounded in a positive
direction, e.g., intravenous fluids, length of hospital stay, a
nonparametric test (Wilcoxon rank-sum test) was used to
determine statistically significant differences between the EF
and IMN groups. Nonparametric tables include sample me-
dians and IQ range, i.e., the 25th and 75th percentiles of the
distribution of data. IQ range provides a measure of data
dispersion similar to standard data “range.” However, for
small populations that may include “outliers”, i.e., widely
divergent values due to rare or unusual cases, IQ is a more
stable and reliable estimate as to how data are distributed.
Pearson’s ␹2 square and Fisher’s exact tests were used to
assess levels of association for categorical data. The two-
tailed alpha was set at the 0.05 level.12
TABLE 1. Characteristics of all patients admitted with femur fracture
(N ⴝ 324) between July 1, 1995, and June 30, 1998

course, and discharge disposition. Multiple comparisons were Characteristic N n %

then made between EF and IMN groups to determine what Sex/male 324 229 71
systematic differences existed between groups. Groups were Race/white 202 63
compared by age, sex, race, mechanism of injury, Injury Mechanism of injury
Severity Score (ISS), and Glasgow Coma Scale (GCS) score. Motor vehicle 59
Pedestrian 6
The groups were also compared in terms of the proportion of
Motorcyclist 11
patients: admitted “in shock”, i.e., admission systolic blood Other 24
pressure [SBP] ⱕ 90 mm Hg; with Abbreviated Injury Scale Presenting in shocka 16 5
(AIS) score of the head of ⱖ3; and undergoing major non- AIS-Head ⱖ3 65 20
orthopedic operative procedures in the first 24 hours after ICU stay (if ⬎0) 129 40
N Mean Range
admission, i.e., thoracotomy, laparotomy, and craniotomy).
Groups were compared for the type and volume of blood Age (yr) 324 30.5 11–96
Admission GCS 13.8 3–15
products used in the first 24 hours (i.e., packed red cells, fresh
ISS 18.1 9–75
frozen plasma, and platelets). The proportion of patients re- N Median IQ Rangeb
quiring each product, and the median and interquartile range
ICU days (if ⬎0) 129 9.0 4–17
(IQ range) of volume per infused product were explored. Length of stay (days) 324 6.3 3.3–12.9
Additional data were collected through structured medical Fluids first 24 h (mL) 324 6900 4,800–10,750
record abstraction for all EF patients to identify use of inva- Shock is defined as an admission systolic blood pressure ⬍90
a

sive monitoring upon admission, i.e., pulmonary artery cath- mm Hg.

eter, intracranial pressure [ICP] monitor; physiologic param- b
Interquartile range (25th–75th percentile).

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Vol. 48, No. 4 Early External Fixation as a Bridge to Intramedullary Nailing

TABLE 2. Characteristics of patients admitted with femur fracture by initial procedure (EF vs. IMN)

EF (n ⫽ 43) IMN (n ⫽ 281)

Characteristic p Valuea
n % n %

Sex
Male 30 70 199 71 NS
Race
White 21 50 181 65 NS
Mechanism of injury
Motor vehicle 25 60 163 59 NS
Pedestrian 4 10 16 6
Motorcyclist 6 14 28 10
Other 7 17 70 25
Presenting in shockb 7 17 9 3 0.007
AIS Head ⱖ3 24 56 41 15 0.001
ICU stay (⬎0) 35 83 94 34 0.001
Mean Range Mean Range

Age (yr) 30.4 11–96 30.5 14–96 NS

Admission GCS 11.0 3–15 14.2 3–15 0.001
ISS 26.8 9–59 16.8 9–75 0.001
Median IQ Rangec Median IQ Rangec

Fluids first 24 h (mL) 11,975 6,650–22,300 6,213 4,737–9,534 0.001

a
p values are based on Fisher’s exact test for a comparison of proportions, Student’s t test for a comparison of group means, and Wilcoxon
rank-sum test for a comparison of group medians. NS, not significant.
b
Shock is defined as admission systolic blood pressure ⬍90 mm Hg.
c
Interquartile range (25th–75th percentile).

TABLE 3. Use of thoracotomy, laparotomy, and craniotomy within the first 24 h after admission for patients initially treated with EF or IMN for femur fracture

EF (n ⫽ 43) IMN (n ⫽ 281)

Procedure p Valuea
n % n %

Thoracotomy 0 — 1 0.36 —
Laparotomy 9 21 9 3 0.001
Craniotomy 0 — 0 — —
Total surgeriesb 9 21 10 3.6 0.001
a
Two-tailed Fisher’s exact test.
b
Thoracotomy, laparotomy, and craniotomy combined.

TABLE 4. Proportion of EF and IMN groups treated with blood products during the first 24 h and volumes (mL) of blood products infused

EF (n ⫽ 43) IMN (n ⫽ 281)

Parameter p Valuea
n % n %

Blood product infused

RBCs 29 67 75 27 0.001
Fresh frozen plasma 23 53 35 12 0.001
Platelets 14 33 17 6 0.001
Median IQ Rangeb Median IQ Rangeb

Volume of blood products (mL)

RBCs (if ⬎0) 1,500 750–2,250 1,000 500–1,500 0.007
Fresh frozen plasma (if ⬎0) 3,000 1,500–7,000 2,250 1,500–4,125 NS
Platelets (if ⬎0) 420 210–450 210 210–350 NS
a
Two-tailed Fisher’s exact test or Wilcoxon rank-sum test. NS, not significant.
b
Interquartile range (25th–75th percentile).

RESULTS
Between July of 1995 and June of 1998, a total of 324 trauma
patients, ages 11 to 96 years (mean age, 30.5 years) with femur
fracture, underwent EF or IMN as the primary fracture fixation
procedure (Figs. 1–3). The patients were predominantly male
(71%) and white (63%), and the mechanism of injury included
motor vehicle crashes (59%), pedestrians struck (6%), motorcy-
cle crashes (11%), and other mechanisms (24%; fall, assault,
other). Patients were moderately injured as evidenced by mean
admission ISS of 18.1, mean admission GCS score of 13.8, and
20% had AIS-Head scores of ⱖ3. Five percent of patients
presented in shock (defined as admission systolic blood pressure
of ⬍90 mm Hg) and 40% required an ICU stay. For patients
requiring ICU care, the median ICU-LOS was 9 days (Table 1).

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The Journal of Trauma: Injury, Infection, and Critical Care April 2000

TABLE 5. Indications for external fixation as noted on the medical recorda

Indication n %

Head injury 20 46
Shock/unstableb 28 65
Thoracoabdominal injury 21 51
Other injuries 20 46
a
Between one and three responses were noted on the medical
record for each patient; n ⫽ 43.
b
Hemodynamically unstable

TABLE 6. Admission and resuscitation markers for the external fixation

populationa

Admission During First 24 h

Parameter
Median IQ Range Median IQ Range

CVPb 8.5 4.0–17.0 12.0 11.0–16.0

PWPc 17.0 10.0–19.0 15.0 12.0–17.0
Cardiac indexd 4.6 3.7–6.1 5.9 5.8–9.2
ICPe 22.0 12.5–29.5 27.0 21.0–40.0
Serum lactate 4.3 3.3–7.0 — —
a
n ⫽ 43.
b
Central venous pressure (mm Hg).
c
Pulmonary wedge pressure (mm Hg).
d
Cardiac index (L/min per m2).
e
Intracranial pressure monitoring (mm Hg).

TABLE 7. OR time and blood loss among patients with femur fracture treated
with primary EF and secondary IMN

IMN Secondary
EF Primary Repair
Parameter Repair
Median IQ Range Median IQ Range

OR time (min) 35 30–45 135 105–180 FIG 1. A 19-year-old male presented with a serious blunt head injury, pulmonary
Estimated blood loss (mL) 90 25–100 400 250–600 contusions and bilateral femur fractures and a tibia fracture. In the resuscitation
unit, he had obvious compartment syndrome.

TABLE 8. Postoperative complications among patients with femur fractures

treated with EF or IMN EF versus IMN
EF IMN
Forty-three patients (13%) were treated with EF. The other
(%) (%) 281 patients (87%) underwent IMN as the primary procedure
Wound infection 3 6 for treatment of their femur fracture. No differences were
Osteomyelitis 3 3 found between EF and IMN groups in terms of patient age,
Hardware failure 3 0 sex, race, and mechanism of injury. However, the EF group
Other 5 0 was substantially more seriously injured. The EF group had a
No problems noted 86 91
mean admission ISS of 26.8 ( p ⫽ 0.001) and a mean admis-
sion GCS score of 11 ( p ⫽ 0.001). Seventeen percent pre-
TABLE 9. Clinical outcomes: LOS, discharge disposition, and discharge sented in shock ( p ⫽ 0.007), and 56% had an admission
destination among EF and IMN groups AIS-Head ⱖ 3 ( p ⫽ 0.001) (Table 2). The proportion of
EF (n ⫽ 43) IMN (n ⫽ 281) patients requiring major nonorthopedic operative procedures
Parameter p Value within the first 24 hours was 21% for EF patients versus 3.6%
Median IQ Range Median IQ Range
for IMN ( p ⫽ 0.001) (Table 3).
Length of stay (days)
ICU (if ⬎0) 11.0 6–19 8.0 4–16 0.06
Eighty-three percent of the EF group required an ICU stay
Hospital 17.5 8.8–26.5 5.7 3.0–10.1 0.001 ( p ⫽ 0.001). The proportion of EF patients requiring blood
EF IMN Total
products in the first 24 hours was also substantially higher
than the IMN group ( p ⫽ 0.001). This finding was true for
Discharge disposition
packed red cells, fresh frozen plasma, and platelets. The
Home 26% 51% 47% 0.001a
Rehabilitation/other 65% 49% 51% volume of packed red blood cells administered to the EF
Died 9% ⬍1% 2% group was significantly more than for IMN ( p ⫽ 0.007).
Total 13% 87% 100% However, among patients receiving blood products, there
a
Fisher’s exact test. However, estimate is unstable because of cell were no differences between groups in the volume of fresh
size ⬍5 in two cells (deaths). frozen plasma and platelets ( p ⫽ NS) (Table 4).

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Vol. 48, No. 4
FIG 2. After stabilization, the patient was taken to the operating room for a
damage control orthopedic procedure. He underwent bilateral fasciotomies and
external fixation of all of his bony injuries. Bony reduction was deferred for
stabilization.
EF Clinical Course
Medical records were reviewed to determine the indications
for the use of EF as the primary method of femur fixation. As
many as three reasons were provided per case and included
shock/physiologically unstable (65%), major thoracoabdomi-
nal injuries requiring emergent therapy (51%), significant
head injury (46%), and other injuries severe enough to pre-
clude safe IMN (46%) (Table 5).
Admission serum lactate levels were obtained for all EF
patients. The median serum lactate level was 4.3, with an IQ
range of 3.3 to 7. A total of 91% of lactate levels “normal-
ized.” The median number of hours for lactate normalization
was 28, with IQ range of 20 to 39 hours (Table 6).
Twenty-five percent of those treated with EF had a pul-
monary artery catheter placed. Although the median initial
cardiac index was 4.6 L/min per m2 and filling pressures were
seemingly adequate, the elevated serum lactates suggest in-
adequate perfusion. Mean cardiac index was resuscitated to
5.9 L/min per m2 to clear lactate to normal.
ICP monitors were placed in 28% of EF cases. The median
opening ICP pressure was 22 mm Hg, with an IQ range was
12.5 to 29.5 mm Hg. Treatments used in treating elevated ICP
included mannitol (100%), barbiturates (75%), and/or hyper-
617
Early External Fixation as a Bridge to Intramedullary Nailing
FIG 3. Six days later, the patient was returned to the operating room for closed
intramedullary nailing. At that time, he also underwent a split thickness skin graft
of his fasciotomy. Staples were used to keep the skin graft in place.
ventilation (75%). ICP remained elevated during the first day,
increasing to a median of 27 mm Hg (IQ range, 21– 40 mm
Hg). None of the patients required craniotomy within the first
24 hours.
The median time between primary EF and secondary IMN
was 4 days (IQ range, 2.5– 6 days). The median time in the OR
for primary EF was 35 minutes. The median OR time for the
secondary IMN was 135 minutes (Table 7). No patient had
intraoperative hypotension or hypoxia during EF. Postoperative
complications occurred slightly more often in patients with EF
versus IMN. The only direct complication of EF was bleeding
around the pin sites, which was self-limited. One other patient
underwent amputation for a mangled extremity after initial EF.
He survived. One patient developed hardware failure, and an-
other developed acute osteomyelitis after initial EF. No compli-
cations occurred in 86% of patients treated with EF and 91% of
patients treated with IMN (Table 8).
Seven patients treated with EF never had IMN. One of
these patients had a severe closed head injury. The other
patient had a severe pelvic crush injury. He died early in his
hospital course. Five patients were young adults (ages, 11–16
years), and after further consideration, it was determined that
they were skeletally immature. EF was used as definitive
fixation in them.
The Journal of Trauma: Injury, Infection, and Critical Care
OUTCOMES
We compared clinical outcomes of LOS and discharge dis-
position for primary EF (n ⫽ 43) and primary IMN (n ⫽ 281)
groups. For patients admitted to the ICU, median ICU-LOS
was 11.0 days for EF patients (IQ range, 6 –19 days) com-
pared with 8.0 days (IQ range, 4 –16 days) for IMN patients
( p ⫽ 0.06). Overall hospital LOS was 17.5 days for the EF
group (IQ range, 8.8 –26.5 days), whereas the median hospital
LOS was 5.7 for IMN (IQ range, 3.0 –10.1days) ( p ⫽ 0.001)
(Table 9).
There were a total of five deaths among all study patients
(n ⫽ 324) with four deaths in the EF group (9% vs. ⬍ 1%,
p ⫽ 0.001). One patient died very early. He had a pelvic crush
injury and bilateral femur fractures. After application of ex-
ternal fixation to his pelvis and both femurs, he died from
organ failure. The three remaining deaths were due to severe
and irreversible brain injury and these deaths each occurred at
least 10 days after admission. One of these patients remained
in external fixation. The other two had an uneventful conver-
sion from EF to IMN, but succumbed later to their head
injury. No deaths in the EF group seemed to be secondary to
the fracture management selected.
For all patients discharged alive, 48% were discharged
directly home, whereas 52% were discharged either to a
“rehabilitation hospital” or to another “acute care” setting.
However, substantial differences were noted between groups.
Patients with primary EF were discharged to a “rehabilitation
hospital” or other “acute care” facility 72% of the time, while
this was required in only 49% of patients treated with IMN
( p ⫽ 0.008) (Table 9).
DISCUSSION
The optimal timing of fracture fixation continues to generate
considerable controversy. Decisions about the timing of fix-
ation requires balancing the risks of operative stress versus
any benefit that can be gained by early fixation. As early as
the mid-1970s, reports demonstrating the advantage of early
stabilization of long-bone fractures began to surface.13 In
1985, Seibel et al. defined the important role that bony inju-
ries play in the overall outcome of patients with multiple
injuries.2 In that study, injury severity did not correlate with
the magnitude nor the duration of pulmonary failure. Instead,
the authors found an association between respiratory failure
and the number of days patients spent in skeletal traction.
They proposed that the “pulmonary failure septic state” was
caused by a combination of factors, including fat embolism
syndrome, enforced supine positioning leading to atelectasis
with subsequent pneumonia, and an increased need for nar-
cotics to treat pain caused by continual motion at the fracture
site.
Seibel et al. also proposed that the fracture hematoma itself
served as a metabolic organ stimulating mediator release,
ultimately leading to multiple organ failure.2 They concluded
that early fracture fixation decreased many of the pulmonary
complications and resulted in better patient outcome. They
believed operative fixation performed on the night of admis-
sion was technically easier and exposed patients to the oper-
618
April 2000
ative stress when nutritional and immunologic reserves were
at their highest level. Patients in the early fixation group had
a lower risk of infection as well as systemic and orthopedic
complication rate when compared with the group of patients
undergoing delayed fixation.
Other authors have demonstrated very similar results. Bone
et al. found increased pulmonary complications, including
acute respiratory failure, fat embolism, and pneumonia in
patients who had delayed stabilization of fractures.3 In addi-
tion, these patients had longer hospital and ICU stays and
increased costs. Early fracture fixation has been shown to
decrease the incidence of respiratory failure in patients with
major fractures and patients with multiple orthopedic
injuries.6 The salutory effect of early fracture fixation was
seen primarily in the most severely injured (ISS ⬎ 40). Early
fracture fixation may do more than simply prevent acute
respiratory failure. Lozman et al. demonstrated better cardiac
function in patients undergoing immediate fracture fixation,
and Goldstein et al. demonstrated a better overall pulmonary
performance in patients undergoing early fixation of pelvic
fractures.14,15 Early fracture fixation may be especially im-
portant in femur fractures. They are high-energy injuries and
patients often have multiple associated injuries often in the
thorax. Charash et al. described a 50% incidence of pulmo-
nary contusions in their study on patients with femur
fractures.4 That group as well as Behrman et al. demonstrated
improved outcome with early femoral fixation.5
More recently, however, the absolute necessity of early
fracture fixation has been called into question. In 1995, Reyn-
olds et al. demonstrated that delaying femoral fixation for
several days did not seem to effect the patient’s outcome.16
They postulated that this delay allowed the patients to stabi-
lize. Any deleterious affects that may result from delaying the
fixation were offset by increased hemodynamic stability.
Similarly, Rogers et al. have shown that stabilization of
isolated femur fractures can be delayed up to 72 hours with-
out an increase in complications.17 In their rural trauma
center, emergent fracture fixation increased the number of
emergency operations, increased time of surgery, and did not
seem to be a wise use of resources.
Patients with long-bone fractures and significant head in-
juries may require a different treatment algorithm. In 1992,
Poole et al. demonstrated no reduction in pulmonary compli-
cations when early fracture fixation was used in patients with
closed head injuries.18 Instead, pulmonary complications
seemed more closely related to the severity of the head injury
and chest injury (if present). In 1997, Jaicks et al. demon-
strated poorer central nervous system outcomes in patients
with head injuries when the concomitant long-bone fractures
were stabilized early.9 Early fracture fixation was associated
with significantly higher intraoperative fluid requirements,
and a higher rate of both intraoperative hypotension and
hypoxia. They postulated that this led to lower GCS score at
the time of discharge, relative to the patients whose fracture
fixation was delayed. However, recently Scalea et al. found
no difference in discharge GCS score when patients with
closed head injuries underwent early fracture fixation.1 In
addition, they found no difference in ICU or hospital LOS or
Vol. 48, No. 4
the need for vasopressors, inotropes, or fluid resuscitation
when fractures stabilized early.
It would seem reasonable that the risks of early fracture
fixation may be most pronounced in patients who are the
most severely injured, particularly if they require other life-
saving measures during their course. Damage control is a
term coined by Rotondo et al. in 1993 and has been most
often used for devastating abdominal injury.19 By using this
philosophy, only major injuries resulting in significant blood
loss are addressed at the time of initial laparotomy. Intestinal
injuries are stapled, and packing is often used as an adjunct to
hemostasis. The patient is then transferred as quickly as
possible to the ICU for rewarming, monitoring, and ongoing
resuscitation. Generally 24 to 48 hours later, when the patient
is adequately resuscitated, warm, and has a normal coagula-
tion profile, he or she is taken back to the OR and unpacked.
Gastrointestinal reconstruction can be performed at that time.
This pattern of care can be used for injuries outside of the
abdomen as well. These techniques can be adapted for use in
the thorax, central vascular system, and even in the extrem-
ities for peripheral vascular injuries.20 –22 Applying this tech-
nique to the badly injured patient with bony injury would
involve stabilizing fractures soon after injury, minimizing the
operative time, and preventing heat and blood loss. For pa-
tients with closed head injuries, this protocol would poten-
tially prevent secondary brain injury. Patients should then be
taken to the ICU. Once resuscitated, they are returned to the
OR for more elective definitive fracture fixation. Presumably,
patients would better tolerate definitive fracture fixation
when they were more stable, particularly if it required pro-
longed operative time, significant soft-tissue dissection,
and/or blood loss.
EF is a technique that has been well established in the care
of patients with multiple injuries. Early use of EF can reduce
pelvic volume and limit blood loss in patients with significant
pelvic fractures.10,11 In addition, the use of EF on the upper
extremities and tibia is commonplace. There are little data
about the use of EF for femur fractures. The treatment of
femoral shaft fractures with EF has been reported in pediatric
patients with good results.23 In adults, EF of femoral shaft
fractures has been shown to have a high rate of complication.
Nonunion and deep pin tract infection approach 20%.24 –26 In
addition, 45% of patients treated with EF develop knee stiff-
ness. However, in these series’ EF was used only for complex
and/or open femoral shaft fractures. External fixation as an
initial treatment with later conversion to IMN has been stud-
ied extensively in tibial fractures. Two early reports con-
demned this treatment with infection rates as high as
44%.27,28 However, both these series used an extended period
of EF with high rates of pin tract infection before IMN. By
limiting the duration of EF and associated pin tract infection,
other authors achieved a high union rate and infection rate of
under 6%.29
In our institution, we use EF as a method of initial stabi-
lization for fractured femurs in patients with multiple injuries.
We include all types of femoral shaft fractures and converted
these to IMN relatively early. The mean time to definitive
fracture fixation after EF was approximately 4 days. Al-
619
Early External Fixation as a Bridge to Intramedullary Nailing
though the current study addresses the use of EF for stabili-
zation of only femoral fractures, we routinely use temporary
EF for stabilization of fractures of the humerus, forearm, and
tibia in victims of multi-system trauma who demonstrate
relative or absolute contraindications to early open reduction
and internal fixation or IMN. The choice and timing of
definitive fixation procedures in these instances varies, de-
pending on the specific bone and soft-tissue injuries. Further
study is necessary to define better the results and feasibility of
this staged fixation technique for long bones other than the
femur, but many similarities between these patients and those
included in the present study are evident.
The patients treated with external fixation were more se-
riously injured and less physiologically stable than those
treated with standard intramedullary nailing. Patients treated
with EF had a significantly higher ISS and were much more
likely to present in shock. In addition, they were more likely
to have serious closed head injuries. They had a significantly
lower admitting GCS score and were more likely to have an
AIS head score ⱖ 3. Not surprisingly, resuscitation needs
were much higher for patients treated with EF.
Our practice has been to aggressively fix femur fractures as
soon as possible after admission. We routinely perform IMN
of closed femoral shaft fractures as soon as initial work-up is
completed. External fixation was selected only when the care
of other injuries precluded definitive fixation or if the patient
was thought not to be physiologically suitable for early IMN.
The reasons for this were numerous and they included ana-
tomic as well as physiologic parameters. Patients with con-
traindications to primary IMN are paradoxically the same
patients least likely to tolerate the complications of skeletal
traction. These relatively sophisticated decisions were made
in concert by the trauma attending surgeon, orthopedic at-
tending surgeon, and the other consulting services.
It would seem that patients with multiple injuries and with
a closed head injury are ideally suited for this type of therapy.
This was the case in 40% of our patients. The short operative
time of 30 minutes allows patients to be followed up with
serial neurologic examinations. The minimal blood loss with
EF and short anesthetic time limits the incidence of hypoxia
and hypotension and minimizes secondary brain injury.
Jaicks et al. reported a 62% incidence of intraoperative hy-
potension and an 11% incidence of intraoperative hypoxia
during early definitive fracture fixation in patients with head
injuries.9 They postulated that these intraoperative problems
explained the lower discharge GCS score in patients who
underwent early fracture fixation. Townsend et al. have ech-
oed this concern.8 In a recent report, they demonstrated an
inverse relationship between timing of fracture fixation and
intraoperative hypotension. Patients with femur fractures and
moderate or severe head injuries had a 68% incidence of
hypotension when definitive fracture fixation was performed
within 2 hours of admission. This rate fell to 8% if fracture
fixation was delayed more than 24 hours. We believe that the
use of external fixation as a temporizing measure should
allow for the advantages of rigid fracture fixation without the
aforementioned intraoperative complications. None of our
patients developed intraoperative hypotension or hypoxia.
The Journal of Trauma: Injury, Infection, and Critical Care
We were able to accomplish external fixation quickly. Mean
OR time was 35 minutes for external fixation, and blood loss
was under l00 mL. This finding was in contradistinction to a
time for IMN of over 2 hours and a blood loss over four times
larger than for EF.
Our approach to “damage control orthopedics” mirrors that
of torso injury. After EF is completed, patients are taken to
the ICU for ongoing resuscitation. When they are deemed
physiologically stable, they return to the OR for conversion to
IMN. At the very least, intracranial hypertension must be
controlled. In general, we repeat the head computed tomo-
graphic scan and use those results in addition to serial neu-
rologic examinations to determine neurologic stability. Hy-
pothermia must be corrected, and the patient must have a
normal coagulation profile. We use volume, red blood cells,
and inotropes to support cardiovascular function to clear
lactate to normal. We attempt to optimize ventilatory me-
chanics, weaning FIO2 to the minimum level necessary. When
all of these factors have been controlled, we deem the patient
a candidate for IMN. In general, this is performed in the next
available elective time slot.
The complication rate in patients treated with EF compares
very favorably to those treated with primary IMN. Compli-
cations were relatively rare and were for the most part of little
physiologic consequences. We only followed patients to the
time of hospital discharge. However, Nowotarski et al. re-
ported on 54 patients treated earlier at our institution where
initial femoral EF was converted to IMN.30 They had 11-
month follow-up. Major fracture-related complications oc-
curred only in two patients.
Nine percent of the patients treated with EF died. Although
this rate is statistically significantly higher than those treated
with IMN, the small cell size precludes conclusions. Three of
the deaths were from closed head injury. One patient was
treated with EF alone. The other two had an uneventful
conversion to IMN. It seems difficult to implicate the choice
to use EF as causative. The last death was a 17-year-old boy
who sustained a high-energy crush injury. He underwent
external fixation of his pelvis and both femurs after bilateral
hypogastric embolization. He could not be resuscitated and
died within 24 hours of admission.
There is substantial literature demonstrating the salutory
effects of early operative fixation in patients with long-bone
fractures. Although this has been questioned, it seems unwise
to abandon this practice. There are some clear advantages to
early stabilization of fractures. It is important to remember
that fracture fixation is an operation of magnitude and has
physiologic consequences. Blood loss can be substantial, and
this potential, combined with prolonged anesthesia and the
soft-tissue injury that can accompany fracture fixation, may
be the difference between compensated and uncompensated
shock in patients with multiple injuries. Certainly, patients
who have their immune system primed by injury may have
precipitous release of mediators by a second insult such as
early fracture fixation, especially if it is combined with sig-
nificant blood loss.31 Over the past few years, our practice
has gravitated to an increased use of temporary EF followed
by IMN. In the earlier study at the STC, EF was used in 4%
620
April 2000
of the total femoral shaft fractures seen. In the current study,
EF was used in 13% of patients.
EF has the potential to deliver all of the beneficial effects
of early fracture fixation with virtually none of the potential
complications. Immediate EF followed by early closed med-
ullary nailing is a safe method for treating femoral shaft
fractures in badly injured patients. It is a valuable addition to
the armamentarium of those caring for severe injury. This
technique follows all of the principles of damage control, a
treatment philosophy that has been adopted by virtually every
trauma center in this country.
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1. Scalea TM, Scott JD, Brumback RJ, et al. Early fracture
fixation may be “just fine” after head injury: no difference
in central nervous system outcomes J Trauma. 1999;
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2. Seibel R, LaDuca J, Hassett JM, et al. Blunt multiple trauma
(ISS 36), femur traction, and the pulmonary failure-septic
state. Ann Surg. 1985;202:283–295.
3. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early
versus delayed stabilization of femoral fractures: a
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4. Charash WE, Fabian TC, Croce MA. Delayed surgical
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5. Behrman SW, Fabian TC, Kudsk KA, et al. Improved
outcome with femur fractures: early versus delayed fixation.
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6. Johnson KD, Cadambi A, Seibert B. Incidence of adult
respiratory distress syndrome in patients with multiple
musculoskeletal injuries: effect of early operative
stabilization of fractures. J Trauma. 1985;25:375–384.
7. Pape HC, Auf’m’Kolk M, Paffrath T, Regel G, Sturm JA,
Tscherne H. Primary intramedullary femur fixation in
multiple trauma patients with associated lung contusion: a
cause of posttraumatic ARDS? J Trauma. 1993;34:540 –548.
8. Townsend RN, Lheureau T, Protetch J, et al. Timing
fracture repair in patients with severe brain injuries.
J Trauma. 1998;44:977–981.
9. Jaicks RR, Cohn SM, Moller BA. Early fracture fixation
may be deleterious after head injury. J Trauma. 1997;42:1–
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10. Burgess AR. The management of hemorrhage associated
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11. Henry SM, Tornetta P, Scalea TM. Damage control for
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12. Seigel S, Castellan NJ Jr, eds. Nonparametric Statistics for
the Behavioral Sciences. New York: McGraw-Hill; 1998.
13. Riska E, Von Bonsdorf H, Hakkinen S. Prevention of fat
embolism by early internal fixation of fractures in patient
with multiple injuries. Injury. 1976;8:110 –116.
14. Lozman J, Deno DC, Feustel PJ, et al. Pulmonary and
cardiovascular consequences of immediate fixation or
conservative management of long-bone fractures. Arch Surg.
1986;121:992–999.
15. Goldstein A, Phillips T, Sclafani SJA, et al. Early open
reduction and internal fixation of the disrupted pelvic ring.
J Trauma. 1986;26:325–333.
16. Reynolds MA, Richardson JD, Spain DA, et al. Is the
timing of fracture fixation important for the patient with
multiple trauma? Ann Surg. 1995;222:470 – 481.
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17. Rogers FB, Shackford SR, Vane DW, et al. Prompt fixation
of isolated femur fractures in a rural trauma center: a study
examining the timing of fixation and resource allocation.
J Trauma. 1994;36:774 –777.
18. Poole GV, Miller JD, Agnew SG, et al. Lower extremity
fracture fixation in head-injured patients. J Trauma. 1992;
32:654 – 659.
19. Rotondo M, Schwab CW, McGonigal M, et al. Damage
control: an approach for improved survival in exsanguinating
penetrating abdominal injury. J Trauma. 1993;35:375–382.
20. Wall MJ, Soltero E. Damage control for thoracic injury.
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21. Reilly PM, Rotondo MR, Carpenter JP, et al. Temporary
vascular continuity during damage control: intraluminal
shunting for proximal superior mesenteric artery injury.
J Trauma. 1995;37:757–759.
22. Scalea TM, Mann R, Austin R, et al. Staged operation for
exsanguinating lower extremity trauma: an extension of a
technique. J Trauma. 1994;36:291–293.
23. Schneider J, Crosby LA. Treatment of pediatric femur
fracture with external fixation. Nebr Med J. 1996;8:432–
435.
24. Mohr VD, Eickhoff U, Haaker R, et al. External fixation of
open femoral shaft fractures. J Trauma. 1995;39:648 – 652.
25. Murphy CP, D’Abrosia RD, Dabezies EJ, et al. Complete
femur fractures: treatment with Wagner external fixation
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1988;32:1553–1561.
26. Alonso J, Geissler W, Hughes JL. External fixation of
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27. Maurer DJ, Merkow RL, Gustilo RB. Infection after
intramedullary nailing of severe open tibial fractures initially
treated with external fixation. J Bone Joint Surg Am. 1989;
71:835– 838.
28. McGraw JM, Lim EV. Treatment of open tibial shaft
fractures: external fixation and secondary intramedullary
nailing. J Bone Joint Surg Am. 1988;70:900 –911.
29. Antich-Adrover P, Marti-Garin D, Murias-Alvarez J, Puente-
Alonso C. External fixation and secondary intramedullary
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30. Nowotarski PJ, Turen CH, Brumback RJ, et al. Conversion
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DISCUSSION
Dr. John A. Morris Jr. (Nashville, Tennessee): Dr. Scalea
and his colleagues have described the concept of orthopedic
damage control. They have looked at 321 femur fractures
admitted to Maryland Shock Trauma over a 3-year period,
and 280 of those received early fixation using intermedullary
nails.
Forty-three patients received initial orthopedic damage
control, which consisted of placement of external fixation
followed about 4 days later by standard placement of an IM
nail. It is clear that the 43 patients who received orthopedic
damage control were sicker based on ISS, GCS, lactate, units
of blood transfused, and associated injuries.
The long-term outcome between the two groups favored
the patients who had relatively isolated femur fractures as
opposed to the patients who had orthopedic damage control,
621
Early External Fixation as a Bridge to Intramedullary Nailing
as would be expected. Complications attributed directly to
external fixation were minimal.
To put this study in perspective, Dr. Scalea and his col-
leagues have provided us with a Phase 2 study which says
orthopedic damage control can be done safely, safely in a
population of very sick patients. What they have not done,
nor have they intended to do, is to demonstrate the efficacy of
external fixation as a bridge to intermedullary nailing of
femur fractures.
The efficacy study would require a multi-institutional trial
with a study group all requiring orthopedic damage control.
The patients would then be randomized to our current therapy
or to orthopedic damage control. It is only in this fashion that
we can answer the question, Is the additional time and ex-
pense spent in the process of external fixation on a temporary
basis a benefit to both the patient and the patient’s payer?
I have two questions for the authors. First, how would you
define the entry criteria for such a study on orthopedic dam-
age control? Would it be based purely on the presence of head
injury or would there be a series of hemodynamic ventilatory
and metabolic parameters such as exist for patients undergo-
ing thoracoabdominal damage control?
I encourage the authors to continue this exciting work. I
especially encourage them to form a multi-institutional trial
to validate the efficacy of this procedure.
And that brings me to my second question. How do I sign
up for that study?
I thank the Association and the members for the privilege
of the floor.
Dr. Hans-Christoph Pape (Hannover, Germany): I first
would like to congratulate Dr. Scalea for his data that are very
interesting and challenging.
The bottom line seems to be that you precluded patients in
a critical condition from primary nailing, and you found a
comparably good outcome. This matches precisely the expe-
rience that we have had in Hannover. We have previously
identified similarly subgroups of patients that we named
borderline in our 1993 publication. Probably, the consider-
ation of an additional subgroup of patients with severe head
trauma may make sense.
Also, your paper is in line with three presentations which
were given last year at the meeting of the Orthopedic Trauma
Association in fall and several papers are also due this fall.
They advocate the conversion of early fixation into IM nail-
ing, and all of them say it is safe.
And now, in contrast, there is a paper from 1997 which is
also from the Shock Trauma Center, from some authors from
the Shock Trauma Center, Michael Bussey and Andrew Bur-
gess. They also looked at severely injured patients they had in
one of their groups with thoracic trauma and ISS of 30. Yet,
the ARDS incidence was only 2%. They concluded that
primary fracture fixation is not harmful. One of their conclu-
sions was this.
Now, when I first read your abstract, I figured that maybe
there is a contradiction between the findings published by the
Orthopedic Department and your department, but then I
looked a little more closely and it turned out that in the
Bussey paper, patients were included from 1983 until
The Journal of Trauma: Injury, Infection, and Critical Care
1994, whereas you included patients from July 1995 to
June 1998.
So I have two questions. First of all, did you change your
management protocol within the recent years? If so, based on
which findings?
Second, in your paper, you indicated that there was a
difference in blood loss, 90 mL for external fixation group
and 400 for the IM nailing group. How did you assess that the
400 mL in the IM nailing was only due to IM nailing but not
due to other orthopedic surgery that might have been done
simultaneously?
Dr. Stephen M. Cohn (Miami, Florida): It seems that
there is a little bit of irony here. Last year you published a
paper saying that it was okay to treat all head-injured patients
with internal fixation early. But at the same time, 15% of your
population was being excluded from internal fixation by the
external fixation group.
I had the opportunity to talk to Andy Burgess about 3 years
ago, and he told me you were doing this, and I do think it is
an innovative way to stabilize the fracture and minimize
bleeding, etcetera. But, on the other hand, it seems to support
the view that not every patient, particularly those with head
injury, can safely undergo—at least, it seems like you have
changed your philosophy and now you feel that early fracture
fixation in head injury is potentially harmful. Maybe you
could comment on that.
Dr. Lawrence H. Pitts (San Francisco, California): The
idea of a quick procedure with little blood loss sounds very
attractive to the neurosurgeon treating a critically ill patient.
Alex Valadka—I am sorry he is not here—I think just out
of interest in the topic reviewed—and I think he said he
presented at EAST; I may have remembered that wrong—
anyway, reviewed a hundred just IM nailings and found on
the anesthetic record hypertension to below 90 for two suc-
cessive tick marks in a third of the patients and blood loss
routinely about 500 cc, which is not far off from the 400 you
reported here. So anything other than that sounds attractive to
a neurosurgeon.
A question that I have is if you do external fixation in one
of these critically ill patients and they remain critically ill for
a period of time, intracranial hypertension and so forth, how
long can you delay before you feel it necessary to go on to a
more definitive management? How much time can you buy
with this technique? Thanks.
Dr. Clayton H. Shatney (San Jose, California): Dr. Sca-
lea, one question. If your orthopods are like mine, they would
like probably antibiotics in these people prior to going ahead
and doing the definitive procedure. Is that the case? Do you
treat these folks with antibiotics prior to the ORIF, and if so,
what is the current antibiotic de jour?
Dr. Thomas M. Scalea (closing): Thank you. I am grati-
fied to see this degree of interest at this late hour. Instead of
answering individual questions, let me make some summary
comments. This is a process that is continuing to evolve. Ten
years ago we thought we had answered the question. Every-
body had early IM nailing for long-bone fractures. Now we
are not so sure. It is not yet clear which patients ought to have
early IM nailing and which patients should not. I absolutely
622
April 2000
agree with Dr. Morris this is going to require a significant
amount of work and it almost certainly will need to be
multi-institutional in nature in order to answer the question.
Rather than say that we are changing, I prefer to think that
we are increasing the sophistication of our decision-making.
Decisions about the timing of fracture fixation should be
based on physiologic principles. This should involve an as-
sessment of the cardiovascular, pulmonary, and neurologic
stability in concert with associated injuries. The nature of the
fracture, the magnitude of operation needed to definitively fix
this fracture are also important components of the decision-
making. It is only a global assessment like this that allows for
the development of a rational plan.
In general, this is the way we decide. We gauge the initial
depth of shock by a combination of vital signs, but more im-
portantly, the initial base deficit. Ongoing cardiovascular stabil-
ity is best gauged in our opinion by supporting oxygen delivery
to clear lactate to normal. We examine pulmonary mechanics to
identify rapidly worsening respiratory failure from conditions
such as contusion and/or aspiration and if so, what we can do to
optimize pulmonary performance. We examine the nature of
their head injury. In general, we repeat CT scans about 6 hours
after admission. Neurologic performance is gauged by clinical
exam plus the evolution of the head CT. Lastly, we take factors
such as age and chronic medical conditions in an attempt to
gauge physiologic reserve.
As many of you know, we are quite liberal with invasive
monitoring such as intracranial pressuring monitoring and
invasive hemodynamic monitoring. We place these monitors
in the resuscitation unit to guide our resuscitation. Some
patients are best served by us being able to watch them
closely and address minute-to-minute neurologic and cardio-
vascular performance. If so, we are going to opt for the
30-minute 90-cc blood loss procedure. On the other hand, if
the patient is stable and safe for a prolonged period of anes-
thesia, we would just as soon go ahead and perform IM
nailing on the night of admission.
The Shock Trauma Center reported its early experience
with this technique in the early 1990s. In that series, 4% of
patients with femur fractures had external fixation performed
as a bridge to more definitive fixation. In our current series,
it is 15% of these patients. Thus, it seems quite clear that
more and more of the time we believe that the 30-minute,
90-cc blood loss procedure without physiologic insult is a
better idea. This is particularly in contradistinction to our
practice 10 years ago.
Though not in this series, we have treated some patients
definitively with external fixation alone. Some of them sim-
ply never achieved adequate physiologic parameters to un-
dergo more definitive fixation. Their fractures started to heal,
and we deemed that this would be acceptable long-term
therapy. It is clearly not our first choice. In general, we can
stabilize almost everybody within 6 or 7 days. They then go
back to the operating room. We do not generally keep people
on antibiotics for any period of time and the presence of an
external fixator by itself is not an indication for antibiotics in
our institution. When they return to the operating room for
their IM nailing, they get a pre-op dose of antibiotics to cover
Vol. 48, No. 4
whatever bugs with which they have become colonized in the
ICU. They then get their surgery. In general, we would treat
with one additional day of antibiotics post-op and then they
are stopped.
I would close by saying that this is the type of project that
really defines the role of the general surgeon in caring for
patients with multiple injuries. It seems odd even to me that
I am up here talking about external fixation and IM nails.
623
Early External Fixation as a Bridge to Intramedullary Nailing
However, it is only by practicing in a truly collaborative,
multidisciplinary way that we would be able to get at some of
these fundamental issues. We need to define the question and
then put together a multi-institutional trial to at least begin to
scratch the surface.
I would like to thank all of my co-authors, the Shock
Trauma Center, and the Association for the privilege of the
floor. Thank you.