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Mortality after reamed intramedullary nailing of bilateral femur fractures.

To the Editor: We read with interest the article in the October 2003 issue by Nork et al entitled “Mortality after reamed intramedullary nailing of bilateral femur fractures.” We share the same experience as the authors regarding increased morbidity and mortality that patients with these injuries have, especially the higher risk for development of adult respiratory distress syndrome (ARDS), compared with patients with unilateral fractures. However, there are certain points we would like the authors to clarify. One of the critical points in dealing with patients with polytrauma who have long bone fractures is the timing of definitive treatment. Although Bone et al reported that early definitive treatment of long bone fractures of the lower extremities is consistent with a favorable outcome, early treatment also could lead to the development of serious complications, such as ARDS and multiple organ failure, particularly in trauma victims with serious chest injury or hemodynamic shock. However, multiple intramedullary nailing procedures for bilateral femoral fractures seem to comprise a risk factor for respiratory complications. In the study by Nork et al, did the patients who died have a higher prevalence of chest trauma or head injuries compared with the survivors? Furthermore, although the mortality rates are discussed, the timing of mortality is not discussed. Additionally, several patients from the unilateral group and two from the bilateral group had surgery at least 4 days after initial presentation to the trauma room. What was the reason for this delay? How were these patients treated initially such that delayed stabilization was required? Was the femoral fracture stabilized temporarily by a Thomas splint, or traction? These data are of paramount importance to be able to draw any meaningful conclusions. We think that early fracture stabilization tailored to each patient, after accounting for associated injuries, seems appropriate in the current climate of damage control orthopaedic surgery.