Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial.

OBJECTIVE: This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients. METHODS: A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R). RESULTS: Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge. CONCLUSION: Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Blunt cerebrovascular injury of cervical and petrous ICA with stroke: A case study.

This case report documents treatment of a 32-year-old male patient after being extricated from an extensively damaged motor vehicle after a collision. On first presentation, the patient had a Glascow Coma Score of 14 and a pan-scan revealed a severely comminuted fracture of the proximal left femoral shaft, a fracture of the left patella, and multiple rib fractures. A neurological exam on a later evaluation showed global aphasia and sharp decline in movements of the right upper and lower extremities even with painful stimuli. A CT Angiography of the head and neck was obtained and revealed evidence of occlusion in the upper cervical segment and proximal petrous segment of the left internal carotid artery (ICA). Two 6x40mm precise stents were placed restoring normal intracranial flow to the patient's left ICA. The patient was discharged having sensation and motor function in all extremities and with resolved aphasia and no neurologic deficits.

Blunt traumatic coronary artery dissection: A case study.

BACKGROUND: Coronary artery dissection is an extremely rare but lethal complication of blunt chest trauma. Dissection may cause thrombus formation or vasospasm, leading to the clinical presentation of acute myocardial infarction. Diagnosis can be difficult as traumatic chest pain has several etiologies; therefore, an electrocardiogram (ECG) is necessary in all cases of thoracic trauma [1-3]. CASE REPORT: Thirty-eight-year old female, with no significant past medical history, presented to a freestanding emergency department with complaints of severe chest pain and right shoulder pain after a blunt trauma water sport accident. Upon selective angiography of left and right coronary artery and left heart catheterization, the patient was found to have an occluded distal left anterior descending artery (LAD). The patient underwent aspiration thrombectomy of the proximal LAD artery and percutaneous transluminal coronary angioplasty (PTCA) of distal LAD artery, which decreased the stenosis from 100% to less than 10%. The patient was discharged home on hospital day three with follow up in one month.Coronary artery dissection should be considered in blunt thoracic trauma particularly in cases of unexplained chest pain, regardless of the mechanism of injury, age of patient or comorbidities. Patients should be evaluated with an ECG, troponin, and possibly an echocardiogram to rule out this type of injury.