Patients with long-bone fractures and blunt chest trauma with pulmonary contusion have a higher incidence of pulmonary morbidity and death than patients with the same injury severity score but without long-bone fractures. Concern has been expressed about the potential detrimental effects on pulmonary function of early osteosynthesis in these patients, particularly with intramedullary reaming and nailing. Increased stress at a time when inflammatory mediators are maximally activated may indeed result in increased pulmonary inflammation (Waydh§s ®t§.l; 1994).
However, in a retrospective study of patients stratified according to the severity of pulmonary contusion, the ratio of PaO2 to FiO2 showed no significant difference between those with and without early osteosynthesis of major fractures. Neither was there a difference in the incidence of acute respiratory distress syndrome, the duration of artificial ventilation, or the length of ICU stay between the two groups ( vanO$.eL§L 1994).
Temporary deterioration of lung function with a rise in pulmonary artery pressure, as seen during reaming and nailing of femur fractures, can be largely prevented by the use of unreamed nails. Secondary pulmonary damage can also be circumvented by using a two-stage procedure, with an external fixator applied first, followed later by internal fixation.
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