RESUMO
Introduction: Orthopaedic aphorism teaches that fractures of long bones when associated with head injuries frequently heal with excessive callus and at a faster rate than normal. However, the evidence on this subject is flimsy and the aphorism remains unsubstantiated. Numerous studies have been conducted evaluating the possible humoral and other factors involved leading to excess callus formation in patients with a head injury. This study was designed to evaluate the effects of a traumatic head injury on bone healing in adults with a diaphyseal fracture of the lower limb. Methods: Fiveteen patients with a closed fracture of tibia or femur and associated head injury (cases) and 15 patients with a closed fracture of tibia or femur without an associated head injury (controls) were included in the study. All patients were evaluated in terms of various serum parameters, including IL-6, growth hormone, PTH, LDH, prolactin levels, and ALP. Head injuries were graded as mild, moderate, or severe. Ventilatory support if required was noted. Serum prolactin was repeated at 5 weeks. Patients were followed up with serial radiographs, and the volume of callus formed was calculated and compared. Results: The mean value of growth hormone, interleukin-6 levels, and prolactin levels at 5 weeks were found to be higher in patients with head injuries, and the difference was highly significant (p = 0.001). The severity of head injury also correlated proportionately with the spike in IL-6 levels. There was more pronounced callus formation in patients with head injury group when compared to the controls. This difference was significant at all intervals. Discussion: There was higher volume of callus noted at the end of 6 months in patients with severe head injury (GCS < 7) when compared to patients with moderate head injury (GCS > 7). The patients with severe head injury were naturally under ventilator support for a prolonged period compared to those with moderate head injury. It was thus indiscernible if the excess callus observed is due to the humoral cascade or as an effect of prolonged ventilation. Patients with head injuries show elevated parathyroid hormone levels, growth hormone levels at the time of injury, and elevated prolactin levels 5 weeks after the trauma-all of which might contribute to enhanced osteogenesis. Interleukin-6 levels are also elevated and the levels correlate to severity of head injury. Conclusion: Head injury triggers a humoral cascade invloving interleukin-6, parathyroid hormoe, growth hormone, and prolactin that contributes to enhanced fracture healing.
RESUMO
INTRODUCTION: Severe open injuries of limbs, especially of the femur and tibia when associated with vascular injuries, present major challenges in management. The decision to amputate or salvage can often be a difficult one even for experienced surgeons. Mangled lower extremity results due to high-energy trauma, especially due to motor vehicle accidents, and is defined as injury to three of the four systems in the extremity that is soft tissues, bone, vascular, and nerve. Open fractures are classified by Gustilo and Anderson's classification in which type 3B is an injury where soft-tissue loss and primary closure of the wound are not possible and type 3C is any open fracture with vascular compromise. CASE REPORT: We report a series of six ipsilateral fractures of the femur and the tibia treated at the Department of Orthopaedics, Sri Ramachandra Medical College and Hospital, Chennai, Tamil Nadu, over a 3-year period (2014-2017). The mean age of our patients was 30 years old, and there were five men and one woman. The right side lower limb was frequently involved (five cases), and the main etiology was road traffic accidents (six cases). Articular involvement was found in six cases. Skin wounds were noticed in all cases (type III C of the Gustilo classification). Urgent wound care, fluid replacement, and antibiotic therapy were undertaken for open fractures. According to modified Fraser classification, all six cases was classified under type II-C. Mangled extremity severity score for five cases was 7 and for one case it was 8. Ganga Hospital Open Injury Severity Score was also used which was found to be in borderline range of 16 score for three cases, 15 score for two cases, and 14 score for one case. All six cases were managed with serial wound debridement + Ilizarov fixator + soft-tissue repair with involvement of orthopedic, vascular, and plastic surgery team. Limb salvage was done for all six cases after considering all the factors. Postoperatively, rehabilitative care and physiotherapy in the form of non-weight-bearing mobilization with walker support was given to all patients. The patients were followed up for the period of 2 years and doing symptomatically better. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision-making in these situations. CONCLUSION: With great effort and good team work (like vascular and orthopedic surgeons), badly comminuted compound injuries (Type III C injury) can be managed well with Ilizarov fixation. Even though the decision of amputation versus salvage was based on more scientific/scoring system, patient's option should be taken, especially in borderline cases considering the present medicolegal scenario.