Early fracture stabilisation in the presence of subclinical hypoperfusion

In polytrauma patients with an injury severity score (ISS)>16, early long bone and pelvic fracture fixation within 24h after injury has been shown to be beneficial. In contrast, surgery in the presence of subclinical hypoperfusion (SCH), defined as normal vital signs with a serum lactate≥2.5mmol/L may be detrimental. This study aimed to investigate the effect of fracture fixation in polytrauma patients with SCH.

We undertook a database review extracting 88 polytrauma patients with a new injury severity score (NISS)>16 with significant long bone or pelvic fractures (extremity NISS≥9) who underwent surgical fracture stabilisation within 48h of injury. In the group of patients with normal vital signs (mean arterial pressure≥60mmHg and heart rate≤110 beats/min) we compared outcomes between those with a normal preoperative lactate (<2.5mmol/L) and those with a raised lactate (≥2.5mmol/L).

Of the 36 patients with normal preoperative vital signs, 17 had normal lactates (control group) and 19 abnormal lactates (SCH group). There were no significant differences in the method of fixation or theatre time between the groups. The SCH group required more inotropic support in the first 24h post surgery (p=0.02) and had higher sequential organ failure assessment (SOFA) scores on day 3 (p=0.003). Although not reaching mathematical significance those with SCH required on average 10 days longer on mechanical ventilation.

Early fracture fixation in patients with SCH as defined by normal vital signs and a lactate≥2.5mmol/L is associated with significant postoperative morbidity. Consideration should be given to delaying surgery in this cohort.