Trauma case from down under

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Dear Fiona,

There is no existing data in the literature not to perform reamed intramedullary nailing on this patient.

1. Unreamed nailing causes actually more fat intavasations due to the significantly higher pressures banging the unreamed nail than incremental nailing. There is no role for unreamed femoral nailing for trauma patients.
If you can oxygenate this patient and no haemodynamic instability (metabolic acidosis) you have better to nail straight away with reaming to chatter (~12mm) with 0.5mmm increments with sharp reamers with deep flutes. Reaming Irrigation Aspiration (RIA) system can be used but still to be proven its significance.

2. PA dissection is highly likely to be a VOMIT.

Best Regards, 

Zsolt


Professor Zsolt J. Balogh, MD, PhD, FRACS
Director of Trauma, John Hunter Hospital and Hunter New England Area Health Service
Discipline Head of Traumatology, University of Newcastle
Newcastle, NSW
AUSTRALIA
Tel: +61 2 49214259
Fax: +61 2 49214274
E-mail: zsolt.balogh at hnehealth.nsw.gov.au



-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Mathias Kalkum
Sent: Saturday, 11 September 2010 5:02 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Trauma case from down under

Fiona,


from my humble rural view:

> - snip -  1. This man is obviously very high risk for developing ARDS. Is there
> any alternative to nailing his femur and the resultant fat emboli
> accelerating the damage to his lungs? Does delaying femoral nailing
> simply add other, greater risks?

unreamed femur nail, now. This can be done in 30 minutes. Reason for
that is you want this guy as stable and painfree as can be, so can bed
him whatever seems appropriate to you. And you don't want to do so in
about 4-6 days, you want to do it now - so fix his femur now. Don't
bother to much about fat emboli. A stable fracture, *un*reamed nail,
good oxygenisation is your best bet!


> 2. What is the relevance of the PA dissection (assuming it is not a
> VOMIT) other than as a marker of significant chest injury? Given his
> other injuries, should he be anticoagulated, and if so, when? Our trauma
> referral centre didn't seem to be able to help much with advice on this,
> though they agreed to take him when he developed ARDS and required
> invasive ventilation.

sorry - no idea


> 3. Anaesthetic question - For definitive management of his femur, what
> would be the best anaesthetic option? My personal choice would probably
> be ketamine/spinal or opiate/spinal, avoiding a chest drain unless his
> pneumothorax worsens. We wanted to avoid IPPV also, but were prepared to
> convert to GA if required.

Being just a surgeon allow me one remark: our anesthetists would
probably insist on a chest tube *if* they would intubate in this case.

My 2 cents


Mathias
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