Study
Fracture type
Follow-up
Patientb
Pain
Functional disability
RTW
Neurologic impairments
Pohlemann (1994)
Unstable fractures
2.2 years
58
11–66 %
No data
No data
21–60 %
Miranda (1996)
Pelvic ring fracture
5 years
80
16–35 %
8–21 %
75–81 %
No data
Tornetta (1996)
Unstable fracture
3.7 years
48
37 %
37 %
67 %
35 %
Brenneman (1997)
Open fracture
4 years
27
No data
No data
64 %
18 %
Kabak (2003)
Unstable fracture
3.8 years
36
31 %
No data
72 %
16–31 %a
Suzuki (2007)
Unstable fracture
3.9 years
57
No data
No data
84 %
28 %
The evaluation of the Hannover Rehab Study database [14–16] with regard to acetabular and proximal femoral fractures has demonstrated the following long-term outcomes (Table 30.2): A significant percentage of patients (45–50 %) with hip fractures experienced posttraumatic pain and approximately (20–35 %) reported an abnormal gait. High rates of gait abnormality were observed in patients who had sustained acetabular fractures. Moreover, outcome scores, as measured by HASPOC and SF-12, were poor in patients with acetabular fractures and proximal femur injuries. In general, patients with shaft fractures demonstrated significantly more favorable scores than patients with an articular fracture. This might be explained by the degeneration of the affected joint following articular fractures which may lead to functional disabilities and chronic pain [49–53]. The observed rates of arthroplasty were 7.5 % for hip joint.
Table 30.2
Functional status of the lower extremities following polytrauma with fractures at different localizations
Acetabulum N = 20 | Proximal femur N = 20 | |
|---|---|---|
Persistant pain | 50.0 % | 45.0 % |
Abnormal gait | 35.0 % | 20.0 % |
Work disability | 27.8 %a | 10.0 % |
Successful rehabilitation | 70.0 % | 60.0 % |
HASPOC-total | 78.78 | 70.07 |
SF-12 PCU | 40.91 | 40.95 |
When analyzing the outcome of pelvic ring fractures in the same study population, patients with combined anterior and posterior pelvic ring injuries had significantly worse physical SF-12 and HASPOC subjective scores in comparison to patients with isolated anterior or posterior pelvic fractures (Table 30.3) [54]. In addition, patient group with anterior and posterior pelvic ring injuries more frequently reported negative subjective health status. The number of patients reporting failing or bad health status was significantly higher in patients with combined anterior and posterior pelvic injuries than patients with isolated fractures. This might be related to constant pain that has been reported by 32.6 % of patients with combined pelvic injured. Moreover, this patient group reported limping and use of crutches more frequently [54].
Table 30.3
Long-term results of severely injured patients with: A, isolated anterior pelvic ring injuries; P, posterior pelvic ring injuries; A/P, combined anterior and posterior pelvic ring fractures
Group A | Group P | Group A/P | p value* | |
|---|---|---|---|---|
Patients (N) | 33 | 33 | 43 | |
Male (n, %) | 22 (66.6) | 21 (63.6) | 35 (81.4) | p < 0.001 |
Mean age at follow-up (years) | 43 | 43 | 46 | 0.505 |
ISS (mean) | 24 (16–41) | 24 (16–43) | 22 (16–45) | 0.216 |
SF-12 (mean) | ||||
Physical score | 44.4 | 45.87 | 38.71 | 0.004 |
Mental score | 48.68 | 50.97 | 48.35 | 0.476 |
HASPOC (mean) | ||||
Subjective | 47.89 | 48.7 | 67.27 | 0.024 |
Objective | 17.00 | 25.18 | 27.78 | 0.217 |
Vallier and colleagues analyzed the outcome after pelvic ring injury in women and reported substantial residual dysfunctions [55]. In this study, isolated pelvic ring trauma without concomitant injuries of the lower extremity was associated with a significantly better outcome [55]. On the other hand, patient sustained antero-posterior compression injuries and bladder ruptures showed negative results. Dyspareunia was more frequently reported in women with antero-posterior compression fractures, B-type injuries, bladder ruptures, and symphyseal plate fixation [56]. At follow-up, the caesarean delivery among woman with pelvic injuries was significantly higher performed than in woman without pelvic injuries [57]. However, uncomplicated pregnancy and deliveries are possible even with retained fixation material, [57].
30.3 Spinal Fractures
There are few studies highlighting health-related quality of life in polytrauma patients with spinal fractures. In a retrospective review of 915 polytrauma patients, Tee et al. demonstrated that on arrival, as well as tachycardia, hyperglycemia, and multiple chronic comorbidities; the presence of thoracic spine injuries were early predictive factors for poor outcome [58]. This was substantiated by Reinhold et al. analyzing data from the Spine Study Group of the German Association of Trauma Surgery comparing 733 patients with a 2-year follow-up. They demonstrated that thoracic spine injuries showed less potential for neurological recovery compared to injuries located at other heights [59]. Hofbauer et al. confirmed these findings also for a pediatric cohort [60].
Spinal cord injury in severely injured patients was one of the significant determinants for a decreased health-related quality of life measured with the EuroQol-Score [61]. These findings ware mainly based on decreased autonomous mobility.
In patients with traumatic spinal cord injuries, an initial poor neurological status is among well-known predictors such as traumatic brain injury, high injury severity score and comorbidities that are significantly associated with early mortality [62].
In a 5-year follow-up of 70 patients (38 % polytraumatized) with spinal fractures McLain found a high significance of the neurological injury for unsatisfying recovery. The regained work status also correlated highly with the neurological impairment [63]. The total rate of patients able to return to full-time work was 70 %, but only 12 % in patients with persistent neurological impairment. Holtslag et al. substantiated these findings in a large cohort of severely injured patients, by finding a 21 % return to full-time work rate [64].
It seems natural that outcome of severely injured patients with spinal fractures is mostly determined by the neurological recovery. However, Putz et al. compared two cohorts of multiply injured paraplegic patients with and without neurological recovery after 1 year. Their study was one of the first to look after influence factors of successful recovery other than the initial neurological damage. They could show that functional improvement was independent from neurological improvement [65]. Additionally they suggested that severity of accompanying thoracic trauma is one key factor of successful rehabilitation. None of the patients with a thoracic C-type fracture and an AIS (Impairment scale) type A could show a neurological improvement during the first year. Early decompression and stabilization of spine injuries seems to be beneficial especially in incomplete neurological defects. Length of stay at intensive care unit and days of ventilation seem to be reduced and lower pulmonary complications are seen [66, 67]. However, good prospective clinical trials are still missing on this topic.
Conclusion
Due to improved mortality rates of severely injured patients, long-term follow-up observation studies have gained more attention. Studies emphasized the importance of psychosocial variables on the long-term functional outcome. Early psychological intervention for polytrauma patients has been suggested to address this issue. Large outcome studies have demonstrated that acetabular fractures, anterior and posterior pelvic ring injuries, especially those with concomitant injuries are associated with poor long-term functional results and unfavorable outcome scores. Persisting neurological impairment leads to a decreased health-related quality in spinal injuries. Patients with severe injuries that are associated with poor outcome should be identified earlier in order to improve their rehabilitation results. Social reintegration of patients and return to work were defined as main long-term goals in the treatment of polytrauma patients.
References
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Nast-Kolb D, Aufmkolk M, Rucholtz S, Obertacke U, Waydhas C. Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma. J Trauma. 2001;51:835–42.CrossRefPubMed
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