Intramedullary nailing in polytrauma. Pro and contra early management

: The progress after multiple trauma is influenced by the extent of the initial injury and the resulting inflammatory response as well as by the severity of the thoracic trauma. Primary stabilisation of the femoral fracture is compulsory to ensure adequate intensive and respiratory care, e.g. changing between a supine and prone position. Intramedullary nailing in multiple trauma patients is still controversial. Because of retrospective studies concerning the time of operation in patients with multiple trauma of minor severity, primary intramedullary nailing is the method of choice in the Anglo-American section. In German-speaking areas, however, differentiated management has been established because of knowledge of the shock pathogenesis. Intramedullary nailing leads to an additive trauma in the sense of traumatic haemorrhagic shock. This is due to local pulmonary embolisation and systemic inflammatory reactions. Therefore, in severe injuries (ISS > 29 points) and/or severe thoracic trauma (AIS > 3), primary stabilisation by external fixation should be preferred, whereas intramedullary nailing, especially the less risk unreamed nailing, is to be recommended in patients with minor injuries. Definite fracture healing should be achieved by a change to intramedullary nailing in a secondary operation.