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Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review.

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Affiliations

  • 1. From the Department of Trauma Surgery (R.Pf., F.K.-L.K., Y.K., H.-C.P.), Harald-Tscherne Laboratory for Orthopaedic and Trauma Research (R.Pf., F.K.-L.K., Y.K., H.-C.P.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Traumatology (Z.J.B.), John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia; Department of Orthopaedic and Trauma Surgery (F.J.P.B.), Lucerne Cantonal Hospital, Lucerne, Switzerland; Riverside University Health System Medical Center and Loma Linda University School of Medicine (R.C.), Loma Linda, California; Department of Orthopaedics and Traumatology (C.F.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong; Academic Department of Trauma and Orthopaedics (P.V.G.), School of Medicine, University of Leeds; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom; Department of Trauma Surgery (F.Hie.), University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Orthopaedics (F.Hil.), Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany; Emergency Surgery Unit (H.K.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Trauma Surgery (T.L.), Aarau Cantonal Hospital, Aarau, Switzerland; Department of Trauma (I.M.), Hand, and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany; Department of Neurosurgery (M.F.O.), Clinical Neuroscience Center (M.F.O.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Surgery (R.Pe.), Trauma Surgery, Hamad Medical Corporation, Doha, Qatar; Department of Surgery (R.Pe.), Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic; Department of Orthopedics and Spine Surgery (S.R.), Ganga Hospital, Coimbatore, India; Department of Surgery, Division of Orthopaedic Surgery (E.H.S.), University of Western Ontario, London, Ontario, Canada; Department of Orthopaedic Surgery (H.A.V.), Case Western Reserve University, Cleveland, Ohio; and Department of Orthopaedics (B.A.Z.), UT Health San Antonio, San Antonio, Texas.
      Authors
    • Pfeifer R 1
    (1 author)

ORCIDs linked to this article

The Journal of Trauma and Acute Care Surgery, 01 Aug 2024, 97(4):639-650
https://doi.org/10.1097/ta.0000000000004428 PMID: 39085995 PMCID: PMC11446538

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This article is in the Europe PMC Open access subset. Refer to the copyright information in the article for licensing details.
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Abstract 

Background

The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures.

Methods

This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach.

Results

A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2).

Conclusion

A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room.

Level of evidence

Systematic Review/Meta-Analysis; Level IV.

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Logo of lwwopenLink to Publisher's site
J Trauma Acute Care Surg. 2024 Oct; 97(4): 639–650.
Published online 2024 Aug 1. https://doi.org/10.1097/TA.0000000000004428
PMCID: PMC11446538
PMID: 39085995

Early major fracture care in polytrauma—priorities in the context of concomitant injuries: A Delphi consensus process and systematic review

Reviewed by Roman Pfeifer, MD, Felix Karl-Ludwig Klingebiel, MD, Zsolt J. Balogh, MD, Frank J.P. Beeres, MD, PhD, Raul Coimbra, MD, PhD, Christian Fang, MD, Peter V. Giannoudis, MD, Falco Hietbrink, MD, PhD, Frank Hildebrand, MD, Hayato Kurihara, MD, Thomas Lustenberger, MD, Ingo Marzi, MD, Markus F. Oertel, MD, Ruben Peralta, MD, Shanmuganathan Rajasekaran, MD, Emil H. Schemitsch, MD, Heather A. Vallier, MD, Boris A. Zelle, MD, Yannik Kalbas, MD, Hans-Christoph Pape, MD, and for the IMPACT group—International MultidisciPlinAry Consensus Panel on PolyTrauma

Zurich, Switzerland

Author information Article notes Copyright and License information Disclaimer

Abstract

BACKGROUND

The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures.

METHODS

This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach.

RESULTS

A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2).

CONCLUSION

A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room.

LEVEL OF EVIDENCE

Systematic Review/Meta-Analysis; Level IV.

KEY WORDS: Polytrauma, timing of surgery, definitive fracture fixation, consensus statement, Delphi consensus

Timing of major fracture care in polytrauma patients constitutes one of the central questions in trauma research and several study groups have focused on identifying risk factors for adverse outcomes concerning timing and the extent of surgical procedures.1–4 Among the major determinants are alterations of clinical and physiological parameters and the time until their normalization.5,6 Various algorithms have been proposed to clear these patients for early fracture care based on their physiological stability. In addition, injury pattern and the severity of concomitant injuries play a crucial role in delaying early definitive fracture care.7

While several studies examine the effects of specific injury patterns on the timing of fracture care, the number of evidence-based treatment recommendations is low, and sometimes outdated.

Therefore, the International MultidisciPlinAry Consensus Panel on PolyTrauma (IMPACT) group was established to create universally acceptable and applicable recommendations for the timing of fracture care in polytrauma patients.

The main focus of these recommendations is the specific role of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as the role of multiple fractures.

METHODS

To create treatment recommendations for the timing of major fracture fixation in polytrauma patients with concomitant injuries, two scientific approaches were used and combined:

  1. A Delphi consensus process conducted by a group of international experts

  2. A systematic review of the literature

Delphi Consensus Process

The Delphi method was used according to recommended modifications.8 The consensus-based Checklist for Reporting Of Survey Studies (CROSS) was used (Supplemental Digital Content 1, http://links.lww.com/TA/D907).

Composition of the Consensus Group

A group of experts was selected by the scientific organizing committee according to the following criteria:

  1. Knowledge about the topic

  2. Previous publications and communications about the topic

  3. Representation of all disciplines involved in the decision-making of fracture care (general trauma, orthopedic surgery, neurosurgery)

  4. Global (geographic) representation

  5. Representation of multiple trauma systems

  6. Answer to the inquiries and the communications requested by the organizers (R.Pf. and H.-C.P.)

The detailed composition of the scientific organizing committee and the expert panel, along with their specialization and the country in which they practice, are presented in Table ​Table1.1. While the scientific organizing committee members created the initial statements, they were also part of the expert panel and participated in the voting process.

TABLE 1

List of International Experts, Participating in the Consensus Process

NameSpecialtyCountryContinent
Z. BaloghTraumatology/OrthopedicsAustraliaAustralia
F. BeeresTraumatology/OrthopedicsSwitzerlandEurope
R. CoimbraTraumatologyUnited StatesNorth America
C. FangTraumatology/OrthopedicsChinaAsia
P. GiannoudisTraumatology/OrthopedicsUnited KingdomEurope
F. HietbrinkTraumatologyNetherlandsEurope
F. HildebrandTraumatology/OrthopedicsGermanyEurope
H. KuriharaTraumatologyItalyEurope
T. LustenbergerTraumatology/OrthopedicsSwitzerlandEurope
I. MarziTraumatology/OrthopedicsGermanyEurope
M. OertelNeurosurgerySwitzerlandEurope
HC. PapeTraumatology/OrthopedicsSwitzerlandEurope
R. PfeiferTraumatology/OrthopedicsSwitzerlandEurope
R. PeraltaTraumatologyQatarAsia
S. RajasekaranTraumatology/OrthopedicsIndiaAsia
E. SchemitschOrthopedics/TraumatologyCanadaNorth America
H. VallierOrthopedics/TraumatologyUnited StatesNorth America
B. ZelleOrthopedics/TraumatologyUnited StatesNorth America

Timeline

A timeline of the entire consensus process is provided in Figure ​Figure1.1. The scientific organizing committee (Z.J.B., H.-C.P., R.Pf., E.H.S., H.A.V.) initiated the process in May 2023, and a preamble was formulated (Supplemental Digital Content 4, http://links.lww.com/TA/D910). The first consensus discussion took part online on May 30, 2023. A second online meeting was held on August 31, 2023. A final meeting was held in person on September 13–14, 2023. Subsequently, the formulated consensus statement was circulated among the group members for final confirmation.

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Timeline of the Delphi process.

Generation of Consensus Statements

In preparation for the meeting, the organizing committee summarized the findings of the systematic literature search, which were arranged into 12 initial statements and circulated among the IMPACT group members. Statements were then adjusted based on the experts' feedback and additional statements were formulated. This process was repeated twice. The adjusted statements were then discussed and finalized during the in-person consensus meeting.

Consensus Meeting

A 2-day in-person meeting was held on September 13–14, 2023, at the University Hospital Zurich, Switzerland. The consensus statements were adjusted through critical discussion with the panel based on the evidence identified in the literature. Modifications were made until an agreement was reached. Anonymous voting was used to evaluate each statement using the PollEv application (Poll Everywhere, https://www.polleverywhere.com). An agreement of ≥75% was set as the threshold for consensus and approved by all participants.8

Systematic Review

The reporting of the systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (http://www.prisma-statement.org/) (Supplemental Digital Content 2, http://links.lww.com/TA/D908). We performed a systematic review to identify all relevant publications on the timing of fracture fixation in trauma patients with injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature.

Preliminary Screening

Several preliminary literature searches were conducted to prepare for the initiation of the Delphi process. These searches focused on the terminology for major fractures,9,10 the distinction between early surgery and damage control in isolated fractures with soft tissue injuries,5,7 the nomenclature of concepts,11 and the pathophysiology of polytrauma.12

Search Strategy

The final systematic literature search was performed on August 4, 2023, in the Medline and EMBASE databases. The time window was from January 1, 2000, to August 1, 2023. We used a combination of controlled vocabulary (MESH/Emtree-Terms) and regular search terms connected by Boolean operators. Truncation was used to account for plural forms and alternate spellings. Great care was taken to consider all relevant synonyms. Filters were applied to exclude inappropriate article types. The complete list of search terms is provided in the Supplemental Digital Content 3, http://links.lww.com/TA/D909. In addition, we screened the reference lists of selected studies and related reviews were screened (referred to as “additional sources”).

Extraction, Screening and Retrieval

Search results were extracted and organized in EndNote version 20 by Clarivate. Articles were de-duplicated and then screened (title and abstract) independently by F.K.-L.K. and F.K. R.Pf. performed a crosscheck of the extracted data. Any disagreement was resolved in a personal meeting. The remaining articles were retrieved from the respective publishers through access to our universitiy’s central library.

Inclusion and Exclusion Criteria

Original articles, reviews, systematic reviews/meta-analyses and guidelines in English or German were assessed for inclusion. Articles were included if they dealt with the timing of fracture care in multiply injured adult patients with concomitant brain, thoracic, abdominal, spinal, and/or vascular injuries.

Commentaries, conference abstracts, correspondences, expert opinions, editorials, letters, and experimental studies (in vitro/animal) were excluded. Further exclusion criteria were pediatric and combat trauma, an insufficient characterization of the injury patterns or injured body regions, or a missing concern with timing of fracture care.

Qualitative Synthesis and Evaluation of Scientific Evidence

After full-text assessment, all included articles were evaluated, and parameters of interest were extracted. These included general information (i.e., author, year, article type, number of patients) as well as the reported outcomes, the threshold for timing (hours) of surgery, and the recommended timing of surgery (early vs. late). The scientific evidence was also evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.8 This methodology was proposed by the Eastern Association for the Surgery of Trauma Practice Management Guidelines Ad Hoc Committee in a recent publication.13 The Grading was performed independently by two authors (F.K.-L.K. and Y.K.), and RP resolved any conflicts. The extracted data served as a foundation for creating the consensus statements in the expert panel. As the consensus statements are built on each other, the evidence was grouped according to the anatomic region of the concomitant injury. Furthermore, we assessed the agreement among the publications regarding the recommended timing of surgery (early vs. late) and the thresholds for the timing of surgery.

RESULTS

Expert Panel

The expert panel consisted of 17 experienced surgeons who were regularly involved in the management of and decision making in polytrauma patients. The scientific organizing committee was included in the expert panel and voting processes. The panel included trauma surgeons, orthopedic trauma surgeons, general surgeons, and neurosurgeons from 11 countries across four continents, as indicated by their affiliations. A detailed breakdown by country and specialty is provided in Table ​Table11.

Systematic Literature Review

The entire systematic literature review process is visualized in the modified PRISMA flowchart in Figure ​Figure2.2. The systematic literature search yielded an initial set of 12,476 publications. After initial screening and full-text assessment, 73 publications met inclusion criteria and were thus analyzed.2–5,14–82 Of these 73 publications, 47 recommended early definitive fracture care, and 10 recommended late definitive fracture care. Most publications set the cutoff between early and late surgery within 24 hours. Therefore, 24 hours was implemented as the threshold in the consensus statements. The domains of the publications are as follows: traumatic brain injury (n = 19), thoracic trauma (n = 13), abdominal trauma (n = 5), multiple fractures (n = 12), spinal trauma (n = 35), and vascular injury (n = 5). An overview of all included publications with a grading of their level of evidence is provided in Table ​Table22.

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Flowchart of the systematic review.

TABLE 2

Summary of the Included Literature in Regards to Which Treatment Strategy Is Favored

LoEOutcomes
AuthorYearArticle TypeNGRADEEarly/LateMortCompLOSVentFunOthRecommended Timing
Traumatic Brain Injury
Scalea et al.142004Retrospective3242B24 h+Late
Brundage et al.152002Retrospective20362A24 h++Early
Wang et al.162007Retrospective962B24 h+Neutral
Morshed et al.172009Retrospective30692A12 h+Late
Nahm et al.182011Retrospective1822B24 h++Early
Vallier et al.192013Retrospective1552B24 h++Early
Tan et al.202021Retrospective1032B96 h+++Early
Yu et al.212023Retrospective1222A24 h++Neutral
Ghneim et al.222023Prospective5202C24 h+Early
Lehmann et al.232001Review/2C24 h+Neutral
Grotz et al.242004Review/2C24 h++Neutral
Stahel et al.252005Review/2C5-10dLate
Flierl et al.262010Review/2C24 h+Neutral
Giannoudis et al.272002Sys. review132B24 h++Neutral
Velly et al.282010Sys. review122B24 h+++Neutral
Nahm et al.32012Sys. review131B24 h++Early
Pfeifer et al.52023Sys. review91B24 h++N/A
Lu et al.292020Metaanalysis14 (1046)2C24 h++Early
Carney et al.302017Guideline/1AN/AN/A
Thoracic Trauma
Kutscha-Lissberg et al.312001Retrospective552C24 h++Neutral
Pape et al.22002Retrospective5142A24 h+Late
Brundage et al.152002Retrospective20362A24 h++Early
Handolin et al.322004Retrospective612C24 h++Early
Schinkel et al.332006Retrospective2982B72 h++Early
Weninger et al.342007Retrospective1522B24 h++Neutral
O’Toole et al.352009Retrospective2272B24 h+Neutral
Nahm et al.182011Retrospective492B24 h++Early
Vallier et al.192013Retrospective4472B24 h++Early
Sewell et al.362018Retrospective952B24 h++Early
Nahm et al.32012Sys. review71B24 h++Early
Pfeifer et al.52023Sys. review121B24 h++N/A
Jiang et al.372016Metaanalysis7 (1170)1A24 h++Early
Abdominal Trauma
Morshed et al.172009Retrospective30692A12 h+Late
Nahm et al.182011Retrospective742B24 h++Early
Nahm et al.382013Retrospective1972BSequence+Neutral
Glass et al.392017Retrospective2942BSequence+++Fixation > abd. Closure
Roberts et al.402015Review/1AN/AN/A
Multiple Fractures
Connor et al.412003Retrospective1512B7d+++Early
Probst et al.42007Retrospective2902B24 h/72 h++Late
Morshed et al.192009Retrospective30692A12 h+Late
Vallier et al.422010Retrospective6452B24 h++Early
Nahm et al.182011Retrospective5762B24 h++Early
Vallier et al.192013Retrospective10052B24 h++Early
Vallier et al.432015Prospective3352B36 h++Early
Childs et al.442016Prospective3702BEAC/staged++Early
Byrne et al.452017Retrospective179932A24 h++Early
Tan et al.202021Retrospective1032B24 h++Early
Taylor et al.462022Retrospective2872B72 h+++Early
Nahm et al.32012Sys. review251B24 h++Early
Spinal Trauma
Croce et al.472001Retrospective2912B72 h++++Early
Chipman et al.482004Retrospective1462B72 h+++Early
Kerwin et al.492005Retrospective17422A72 h+++Early
McHenry et al.502006Retrospective10322A48 h+Early
Schinkel et al.332006Retrospective2982B72 h++Early
Kerwin et al.512007Retrospective3612B48 h++Late
Frangen et al.522010Retrospective1602B72 h+++Early
Pakzad et al.532011Retrospective832B24 h/72 h+Early
Vallier et al.192013Retrospective982B24 h++Early
Bliemel et al.542014Retrospective89942A72 h+++Early
Park et al.552014Retrospective1662B72 h++Early
Konieczny et al.562015Prospective382B72 h+Late
Vallier et al.432015Prospective3352B36 h++Early
Lubelski et al.572017Prospective462B36 hEarly
Kobbe et al.582020Retrospective1132B24 h++++Early
Sousa et al.592022Retrospective502C72 h++Early
Spinal Cord Injury
McKinley et al.602004Retrospective7792A24 h+Early
Fehlings et al.612012Prospective3132A24 h++Early
Rahimi-Movaghar et al.622014RCT352A24 h+++Early
Battistuzzo et al.632016Retrospective1922BMdn 21 h+Early
Grassner et al.642016Retrospective702B8 h+Early
Sewell et al.362018Retrospective952B24 h++Early
Nayak et al.652018Prospective542B24 h+Early
Du et al.662019Prospective4022A72 h+Early
Tanaka et al.672019Retrospective5142A24 h++Neutral
Nasi et al.682019Retrospective812B8 h+Early
Burke et al.692019Retrospective482B12 h+Early
Wutte et al.702020Retrospective432B8 h+Early
Badhiwala et al.712021Retrospective15482A24 h+Early
Balas et al.722022Retrospective41082A12 h+Early
Badhiwala et al.732018Review/1B24 hEarly
Ramakonar et al.742021Review/1B24 hEarly
Dimar et al.752010Sys. review111B24 h/72 h+++Early
Carreon et al.762011Sys. review111B24 h/72 h+++Early
Liu et al.772016Meta-analysis9 (734)1C24 h+++Early
Vascular Injury
McHenry et al.782002Retrospective272CSequence++Revasc. > OS
Teissier et al.792019Retrospective162CSequence++Revasc. > OS
Lewis et al.802022Retrospective1042BSequence++Revasc. > OS
Glass et al.812009Sys. review101CSequence++Shunt > OS > Repair
Fowler et al.822009Metaanalysis14 (210)1BSequence++Neutral

N, number (original article: patients, review: publications, metaanalysis: publications (patients)); LoE, Level of Evidence (according to the GRADE method); Early/Late defines the threshold applied in the respective article in hours (h) or days (d) (in case of multiple thresholds, those are presented as X/X); Outcomes: Mortality, Complications (esp. respiratory complications); LOS, length of stay (ICU and/or hospital), Ventilator days, Functional outcomes (in articles with spinal cord injury this refers to neurological recovery), and other (e.g., blood transfusions, amputation, etc.); RCT, randomized controlled trial; EAC, early appropriate care.

Consensus Statements and Level of Agreement

The initial 12 statements, formed during the preparation phase (online meeting 1/2), were extended by an additional eight statements. A total of 20 statements were voted on during the in-person meeting in Zurich. Among these 20 statements, 15 statements (75%) reached full consensus (100% agreement), and 5 statements (25%) reached a level of 92% to 95% agreement. These statements are presented in Table ​Table3,3, along with the agreement within the expert panel, the level of evidence in the literature, and the overall agreement in the literature.

TABLE 3

Consensus Statements, Agreement in the Panel, Evidence Level and Congruency in Literature

NoStatementAgreement in Expert Panel (%)Evidence Level of LiteratureAgreement in Literature
Traumatic brain injury
1In patients with mild TBI (GCS ≥ 13) and initial head CT without evidence of acute intracranial trauma sequelae with adequate respiratory and hemodynamic parameters, early (<24 h) definitive fracture fixation of isolated major fractures is recommended.94N = 19
GRADE (n):
1A = 1
1B = 5
1C = 6
2A = 3
2B = 4		Early: n = 7
Neutral: n = 9
Late: n = 3
Thresholds:
24 h: n = 15
72 h: n = 0
Other: n = 4
2In patients with mild TBI (GCS ≥ 13) and initial head CT without evidence of acute intracranial trauma sequelae with adequate respiratory and hemodynamic parameters, early (<24 h) definitive fracture fixation of multiple major fractures is permissible as long as the patient remains physiologically stable during serial reassessment. If the patient becomes unstable, consider DCO.100
3In mild TBI patients (GCS ≥ 13) with acute intracranial trauma sequelae findings on initial head CT, early (<24 h) definitive fixation of major fractures is permissible after exclusion of significant intracranial pathologies and lack of further progression on follow-up head CT.100
4TBI patients should NOT undergo definitive fixation of major fractures in the presence of intracranial hypertension (ICP > 20 mmHg), deterioration of neurological status, progression of the initial trauma sequelae findings on head CT, hemodynamic and/or respiratory instability, and coagulopathy.100
5In patients with significant TBI, delayed definitive fracture fixation of major fractures is acceptable in patients with stable GCS, without deterioration of neurological status and findings in the follow-up head CT, or stable ICP (ICP ≤ 20 mmHg) and CPP (>60–70 mmHg) in patients with invasive neuromonitoring.100
Thoracic trauma
6In patients with chest injuries and adequate oxygenation/ventilation and stable lung function (with or without ventilator support), early (<24 h) definitive fracture fixation of isolated major fractures is recommended.100N = 13
1A = 1
1B = 3
1C = 0
2A = 2
2B = 5
2C = 2		Early: n = 8
Neutral: n = 4
Late: n = 1
Thresholds:
24 h: n = 12
72 h: n = 1
Other: n = 0
7In patients with bilateral severe chest injury, early (<24 h) fixation by external fixation according to DCO principles should be considered. In cases of inadequate oxygenation and unstable lung function on ventilatory support, fracture stabilization according to DCO principles, usually by external fixation, is recommended.94
8In patients with chest injuries, early (<24 h) definitive fracture fixation of multiple major fractures is permissible as long as the patient remains physiologically stable. Continuous perioperative monitoring is recommended in these patients according to the previously selected parameters.100
Abdominal Trauma
9In patients with blunt abdominal injuries that do not require surgery and the patient is physiologically stable as previously defined, early (<24 h) definitive fracture fixation of isolated major fractures is recommended.100N = 5
1A = 1
1B = 0
1C = 0
2A = 1
2B = 3
2C = 0		Early: n = 2
Neutral: n = 2
Late: n = 1
Thresholds:
24 h: n = 1
72 h: n = 0
Other: n = 4
10In patients with blunt and penetrating abdominal injuries who respond to resuscitation and in whom hemorrhage control has been achieved, definitive fixation of isolated fractures is recommended as long as the patient remains physiologically stable.94
11For patients mentioned in recommendations 9 and 10 who have multiple major fractures, serial intraoperative monitoring is recommended to determine the feasibility of the fixation of several fractures in one operation.100
12In patients with blunt and penetrating abdominal injuries that require surgical intervention, early (<24 h) stabilization based on DCO principles is recommended in the presence of major visceral organ injury, major soft tissue injury, prolonged surgery, or major intraoperative blood loss.94
Multiple Fractures
13In patients with multiple major fractures, the sequence of fracture fixation should be based on the risk of:
• Loss of life (such as severe bleeding e.g. from extremity injury)
• Catastrophic disability (e.g. incomplete spinal cord injury or deteriorating neurological status in unstable spinal injuries)
• Limb loss (e.g. compartment syndrome, vascular injury, open fracture)
• Loss of function (e.g., peripheral neurological compromise)		100N = 12
1A = 0
1B = 1
1C = 0
2A = 2
2B = 9
2C = 0		Early: n = 10
Neutral: n = 0
Late: n = 2
Thresholds:
24 h: n = 7
72 h: n = 1
Other: n = 4
14In patients with multiple major fractures and stable physiology, the prioritization should take into account:
• The location of the fracture
• The complexity of the fracture (e.g. open, highly comminuted)
• The duration of the surgical procedure
• The anticipated associated hemorrhage
• The expertise of the surgical team
• The availability of resources		100
15In patients with multiple major fractures (including bilateral injuries) and stable physiology, serial perioperative assessments are required to consider and allow for sequential fixation of fractures100
Spinal (Cord) Injury
16Early (<24 h) reduction, decompression, and spinal fixation are required in patients with potentially complete spinal cord injury and have priority over definitive fixation of other fractures. Before initiating this surgical procedure, other life-threatening conditions must be addressed ensuring a stable physiological condition has been established.100N = 35
1A = 0
1B = 4
1C = 1
2A = 10
2B = 19
2C = 1		Early: n = 32
Neutral: n = 1
Late: n = 2
Thresholds:
24 h: n = 16
72 h: n = 10
Other: n = 9
17Patients with spinal cord injury with partial neurological deficit and deteriorating neurological function in the presence of severe spinal instability (type B or C injuries) are considered a special cohort, and emergent surgery is recommended. In this situation, spine fixation is required and takes priority. Before initiating this surgical procedure, other life-threatening conditions must be addressed ensuring a stable physiological condition has been established.100
18In patients with spinal cord injury and multiple major fractures, serial assessments of physiologic fitness are required to allow for the sequential fixation of other fractures.92
Vascular Injury
19In patients with extremity arterial injury and brief ischemia time with expected rapid fracture fixation, skeletal stabilization or otherwise temporary stabilization (damage control for the extremity) should be attempted before vascular repair if achievable in a short timeframe. In addition, prophylactic fasciotomies should be considered.100N = 5
1A = 0
1B = 1
1C = 1
2A = 0
2B = 1
2C = 2		OS first: n = 1
Neutral: n = 1
Revasc. first: n = 3
Thresholds:
Sequence Revasc./osteosynthesis
20In patients with extremity arterial injury who are approaching 6 h of critical ischemia time, restoring distal arterial flow has priority over fracture fixation. Intra-arterial shunts followed by temporary fracture stabilization or definite fixation and then definitive vascular repair versus definitive vascular repair followed by fracture stabilization should be decided on a case-by-case basis. In these cases, fasciotomies are required.100

CPP, cerebral perfusion pressure; CT, computed tomography; DCO, damage-control orthopedics; GCS, Glasgow Coma Scale.

As there are always multiple studies that provide evidence to support each statement, we did not assign a level of evidence to each individual statement but rather subsumed them according to the anatomic location.

Regarding the agreement within the literature, we noted the highest agreement regarding spinal (cord) injuries, in which 32 of 35 publications recommended early definitive fracture care. The lowest agreement and the lowest number of identified publications were noted regarding vascular injury (3 of 5 publications recommended revascularization before fracture care). All further levels of evidence and the agreement within the literature can be seen in Table ​Table22.

DISCUSSION

Fracture management constitutes a major part of the treatment of polytrauma patients, as shown by large trauma registries. In the German Trauma Registry, for instance, ~30% of patients suffered a severe injury (Abbreviated Injury Scale ≥ 3) to the extremities, pelvis, and spine. Sixty-five percent of these patients required an average of 2.9 surgeries.83 From the patient's perspective, timely fracture care is advisable to facilitate rapid recovery. Nevertheless, objective criteria to delay fracture fixation have been defined.84

Multiple improvements have been demonstrated to have enabled more expeditious and safe surgical treatment within the first 24 hours after injury.85 Even under physiological conditions and with adequate hemodynamics in the early stages after injury, associated trauma or specific injury patterns may cause a delay in fracture fixation.

In this international expert panel by the IMPACT group, consensus on the timing of fracture fixation in patients with associated traumatic brain, thorax, abdomen, spine/spinal cord, and extremity vascular injuries was reached using the Delphi method. All statements formulated by the expert panel were critically analyzed based on a systematic literature review and their level of evidence. Overall, 73 publications were reviewed, and 20 statements were approved (Tables ​(Tables2,2, ​,3).3). These are discussed below based on the type of associated injury.

Traumatic Brain Injury

Avoiding secondary brain damage is crucial, and several publications support our recommendations.25,30 Currently, early definitive treatment of major fractures is only recommended for patients with mild traumatic brain injury.5,21 In cases of more severe intracranial injuries, the concern for cerebral complications is great, and their prevention is of utmost importance.27,28

Several publications have investigated the effects of delayed fracture fixation after mild traumatic brain injury but have failed to prove an effect on complication rates or neurological outcomes.16,21 While the second-hit phenomenon is well described, some authors have raised doubts about its relevance in patients with mild traumatic brain injury.21 The brain versus bone multicenter trial involved 520 patients with lower extremity fractures and mild to severe traumatic brain injury. They examined the effect of the timing of lower extremity fracture fixation on neurological outcomes.22 The results suggest that neurological outcomes are largely dependent on the severity of the initial brain injury rather than the surgical care provided to treat associated injuries.

In general, in the presence of significant intracranial pathologies, delayed definitive fracture fixation is recommended if further progression is observed on follow-up head CT.27,28 An increase in intracranial pressure (ICP >20 mm Hg) and a decrease in cerebral perfusion pressure (CPP < 60/70 mm Hg) is associated with a significant increase in mortality.5 These thresholds are also recommended in the recent Guidelines for the Management of Severe Traumatic Brain Injury.30 Accordingly, secondary reconstructions of fractures are justified in patients with stable Glasgow Coma Scale, no deterioration seen on follow-up head CT, or improvements of the parameters mentioned above (ICP, CPP).

Thoracic Trauma

The primary goal in the management of patients with chest trauma is to maintain oxygenation and ventilation and to prevent secondary complications, such as pneumonia, acute lung injury, and acute respiratory distress syndrome.86 Recent systematic reviews of prospective and retrospective studies suggest that early definitive treatment of fractures may be used safely for most patients with chest injuries, depending on the criteria mentioned previously84 and refined later.87 It is unclear whether certain surgical techniques affect pulmonary function, as the only studies available were on reamed versus unreamed femoral nailing and studies comparing different reamer types.2,88,89

A meta-analysis did not show significantly increased rates of pulmonary complications such as pneumonia and mortality in patients with thoracic trauma.37 However, patients with bilateral chest injuries require special attention as they have a higher rate of complications, especially in the presence of bilateral pulmonary contusions and/or hemothoraces and pneumothoraces.90 In those patients, it is recommended that temporary external fixation of fractures be performed.

Abdominal Trauma

The primary aim of abdominal trauma management is to control bleeding and contamination from enteral injuries.40 Information about the timing of fracture fixation in patients with abdominal trauma is limited. Roberts et al. published physiological parameters and rated indications for the use of damage-control surgery.40 According to their study, difficult-to-access major venous injuries, major liver or combined pancreaticoduodenal injuries, as well as devascularization or massive disruptions of the duodenum or pancreas, require damage-control interventions.40 If hemorrhage control can be achieved, or if nonoperative management is possible, it is recommended to perform definitive fixation of isolated fractures as long as the patient remains physiologically stable. For patients with multiple major fractures, it is recommended to conduct serial monitoring of the patient's physiologic response (hemodynamic, respiratory, renal, coagulation, and metabolic). It has been found that definitive fracture fixation is safe regarding surgical site infection, even in the presence of an open abdomen.39 As an exception, patients with pelvic ring injuries and associated abdominal trauma require special care to avoid gross contamination from enteric injuries.91 Still, even in this group, internal fixation helps heal soft tissue and control infection.

Multiple Fractures

The primary goal in treating patients with multiple fractures is early and safe bone reconstruction and patient mobilization. The sequence of fracture fixation is challenging, and clinical studies are difficult to perform in this patient population.18 However, multiple aspects must be considered when determining the surgical sequencing and timing for these complex patients. For instance, an international survey of 196 trauma surgeons from 61 countries found that assessing the surgical load (a physiological burden to the patient incurred by the surgical procedure) is very important.92 Factors to consider include the avoidance of shock, lung dysfunction, coagulopathy, hypothermia, soft tissue injuries, as well as potential intraoperative blood loss.92 It is crucial to prioritize life over limb when sequencing the fixation of major fractures after polytrauma. In addition, the management of major fractures is dictated by the prevention of severe disability (e.g., from spinal cord injury), followed by the risk of limb loss (e.g., compartment syndrome, arterial injury, or thrombosis). Should the patients' clinical status not improve after resuscitative efforts, damage-control orthopedics are a valid and important alternative for long bone fracture stabilization.35 In some situations, a staged procedure in the musculoskeletal system is performed mainly due to local factors (contaminated wounds, bone defects, etc.) and has been named “musculoskeletal temporary surgery.”7 These complex injuries also affect the sequence of fracture fixation.

Spinal Injuries

In polytrauma patients, the spine is affected in up to 30% of cases.93 Unstable fractures often require invasive procedures, which may be impossible in polytrauma patients due to the high surgical load, including long operative time, invasive approach, and risk of bleeding. Most publications recommend early fixation and treatment of unstable spinal fractures, regardless of the presence of neurologic deficit.62,75,76 Our literature review indicates that injuries to the thoracic spine, especially those with neurological deficits, should be stabilized early.48,94 A recent publication clearly showed that spinal injury requires early definitive surgery within 24 hours after admission, especially in patients with neurological deficits.85 Early surgery in the form of posterior spinal stabilization performed within 24 hours improves outcomes by avoiding immobilization, improving lung function, and shortening hospital and intensive care stays.77,94

Vascular Injuries

The timing of fracture fixation in patients with associated major vascular injury remains a topic of debate. Some authors suggest temporary fixation of the fracture before final vascular repair to avoid potential graft complications.82 Conversely, others recommend immediate revascularization to decrease ischemia time.78–80 In studies dealing with fracture repair and associated vascular trauma, the emphasis is mostly not on the timing but on the sequence of fracture fixation or revascularization.81 Our systematic review indicates that prolonged fracture fixation before revascularization increases vascular morbidity.80 Furthermore, the time taken to restore distal arterial flow has been consistently identified as the only modifiable risk factor for both graft failure and limb amputation in patients with a combined fracture of a long bone and severe arterial injury.80 Therefore, in cases of extremity fractures with arterial injuries, approaching the critical ischemia time of 6 hours, restoration of distal arterial flow takes priority over fracture fixation. This can be accomplished by the use of temporary intravascular shunts or definitive repair (primary repair, interposition graft), depending on the duration of ischemia and the complexity of the fractures.

Limitations

One limitation is the composition of the expert panel itself. Although it was important to control for an even distribution of experts in terms of geographical location, representation of different surgical specialties, and individual professional focus, slight imbalances had to be accepted regarding feasibility and coordination of the expert panel. The statements were synthesized from the expertise of the participants and the existing literature. Depending on the specific topic, the amount and quality/evidence of published literature varied greatly, resulting in a greater weighting of the expert opinions. Although most of the central issues of surgical care and trauma patterns were included in the statements, the recommendations may not cover rare or uncommon cases.

CONCLUSION

This international expert panel reached an overwhelming consensus that early definitive fracture fixation (within 24 hours) should be attempted even in polytrauma patients if the posttraumatic clinical condition allows. Our 20 statements provide clear indications and contraindications for the most relevant associated injuries and are supported by the literature.

The following order of priorities should be respected: (1) life, (2) central nervous system, (3) limb, and (4) functionality. While the physiological responses (hemodynamic, respiratory, renal, coagulation, metabolic) remain important, emphasis should also be put on the neurological status and injury-specific factors when deciding on the timing of fracture fixation in polytrauma patients. Serial assessments are mandatory to reflect the dynamics early on and to adapt the treatment strategy accordingly.

AUTHORSHIP

R.Pf., F.-K.L.K., Z.J.B., R.C., E.H.S., H.A.V., Y.K., H.-C.P. participated in the conceptualization. R.Pf., F.-K.L.K., Z.J.B., R.C., E.H.S., H.A.V., Y.K., H.-C.P. participated in the methodology. R.Pf., F.-K.L.K., Z.J.B., F.J.P.B., R.C., C.F., P.V.G., F.Hie., F.Hil., H.K., T.L., I.M., M.F.O., R.Pe., S.R., E.H.S., H.A.V., B.A.Z., Y.K., H.-C.P. participated in the investigation. F.-K.L.K., Y.K. participated in the visualization. R.Pf., H.-C.P. participated in the project administration. R.Pf., H.-C.P. participated in the supervision. R.Pf., F.-K.L.K., Y.K., H.-C.P. participated in the writing—original draft. R.Pf., F.-K.L.K., Z.J.B., F.J.P.B., R.C., C.F., P.V.G., F.Hie., F.Hil., H.K., T.L., I.M., M.F.O., R.Pe., S.R., E.H.S., H.A.V., B.A.Z., Y.K., H.-C.P. participated in the writing—review and editing.

ACKNOWLEDGMENTS

This study was performed by the consortium of the IMPACT group, an international expert group on polytrauma management:

DISCLOSURE

Conflict of interest: All JTACS Disclosure forms have been supplied and are provided as supplemental digital content (http://links.lww.com/TA/D911).

Footnotes

Published online: August 1, 2024.

R.Pf., F.K.-L.K., Y.K., H.-C.P. contributed equally

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

REFERENCES

1. Dunham CM Bosse MJ Clancy TV Cole FJ Jr. Coles MJ Knuth T, et al. . Practice management guidelines for the optimal timing of long-bone fracture stabilization in polytrauma patients: the EAST Practice Management Guidelines Work Group. J Trauma. 2001;50(5):958–967. [Abstract] [Google Scholar]
2. Pape HC Hildebrand F Pertschy S Zelle B Garapati R Grimme K, et al. . Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma. 2002;53(3):452–461; discussion 61-2. [Abstract] [Google Scholar]
3. Nahm NJ, Vallier HA. Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: a systematic review of randomized and nonrandomized trials. J Trauma Acute Care Surg. 2012;73(5):1046–1063. [Abstract] [Google Scholar]
4. Probst C, Probst T, Gaensslen A, Krettek C, Pape HC. Timing and duration of the initial pelvic stabilization after multiple trauma in patients from the German Trauma Registry: is there an influence on outcome? J Trauma. 2007;62(2):370–377; discussion 6-7. [Abstract] [Google Scholar]
5. Pfeifer R, Klingebiel FK, Halvachizadeh S, Kalbas Y, Pape HC. How to clear polytrauma patients for fracture fixation: results of a systematic review of the literature. Injury. 2023;54(2):292–317. [Abstract] [Google Scholar]
6. Scherer J Coimbra R Mariani D Leenen L Komadina R Peralta R, et al. . Standards of fracture care in polytrauma: results of a Europe-wide survey by the ESTES polytrauma section. Eur J Trauma Emerg Surg. 2022. [Europe PMC free article] [Abstract] [Google Scholar]
7. Pfeifer R Kalbas Y Coimbra R Leenen L Komadina R Hildebrand F, et al. . Indications and interventions of damage control orthopedic surgeries: an expert opinion survey. Eur J Trauma Emerg Surg. 2021;47(6):2081–2092. [Abstract] [Google Scholar]
8. Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, Wales PW. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401–409. [Abstract] [Google Scholar]
9. Kalbas Y, Pape HC. What factors determine a "major fracture"? Injury. 2022;53(8):2701–2703. [Abstract] [Google Scholar]
10. Kalbas Y Klingebiel FK-L Halvachizadeh S Kumabe Y Scherer J Teuben M, et al. . Developments in the understanding of staging a “major fracture” in polytrauma: results from an initiative by the polytrauma section of ESTES. Eur J Trauma Emerg Surg. 2023. [Europe PMC free article] [Abstract] [Google Scholar]
11. Pfeifer R, Pape HC. Trends in nomenclature to describe concepts in trauma patients: time for standardization. Injury. 2020;51(11):2353–2355. [Abstract] [Google Scholar]
12. Pape HC, Moore EE, McKinley T, Sauaia A. Pathophysiology in patients with polytrauma. Injury. 2022;53(7):2400–2412. [Abstract] [Google Scholar]
13. Kerwin AJ Haut ER Burns JB Como JJ Haider A Stassen N Dahm P, Eastern Association for the Surgery of Trauma Practice Management Guidelines Ad Hoc Committee .. The Eastern Association of the Surgery of Trauma approach to practice management guideline development using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S283–S287. [Abstract] [Google Scholar]
14. Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48(4):613–621 discussion 21-3. [Abstract] [Google Scholar]
15. Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma. 2002;52(2):299–307. [Abstract] [Google Scholar]
16. Wang MC, Temkin NR, Deyo RA, Jurkovich GJ, Barber J, Dikmen S. Timing of surgery after multisystem injury with traumatic brain injury: effect on neuropsychological and functional outcome. J Trauma. 2007;62(5):1250–1258. [Abstract] [Google Scholar]
17. Morshed S, Miclau T, 3rd, Bembom O, Cohen M, Knudson MM, Colford JM, Jr. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am. 2009;91(1):3–13. [Europe PMC free article] [Abstract] [Google Scholar]
18. Nahm NJ, Como JJ, Wilber JH, Vallier HA. Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma. 2011;71(1):175–185. [Abstract] [Google Scholar]
19. Vallier HA, Super DM, Moore TA, Wilber JH. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course. J Orthop Trauma. 2013;27(7):405–412. [Abstract] [Google Scholar]
20. Tan JH Wu TY Tan JYH Sharon Tan SH Hong CC Shen L, et al. . Definitive surgery is safe in borderline patients who respond to resuscitation. J Orthop Trauma. 2021;35(7):e234–e240. [Abstract] [Google Scholar]
21. Yu TP Chen YT Ko PY Wu CH Yang TH Hung KS, et al. . Is delayed fixation worthwhile in patients with long bone fracture concomitant with mild traumatic brain injury? A propensity score-matched study. Injury. 2023;54(7):110804. [Abstract] [Google Scholar]
22. Ghneim M Kufera J Zhang A Penaloza-Villalobos L Swentek L Watras J, et al. . Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial. J Trauma Acute Care Surg. 2023;95(4):516–523. [Abstract] [Google Scholar]
23. Lehmann U, Rickels E, Krettek C. Multiple trauma with craniocerebral trauma. Early definitive surgical management of long bone fractures? Unfallchirurg. 2001;104(3):196–209. [Abstract] [Google Scholar]
24. Grotz MRW, Giannoudis PV, Pape HC, Allami MK, Dinopoulos H, Krettek C. Traumatic brain injury and stabilisation of long bone fractures: an update. Injury. 2004;35(11):1077–1086. [Abstract] [Google Scholar]
25. Stahel PF, Ertel W, Heyde CE. Traumatic brain injury: impact on timing and modality of fracture care. Orthopade. 2005;34(9):852–864. [Abstract] [Google Scholar]
26. Flierl MA, Stoneback JW, Beauchamp KM, Hak DJ, Morgan SJ, Smith WR, Stahel PF. Femur shaft fracture fixation in head-injured patients: when is the right time? J Orthop Trauma. 2010;24(2):107–114. [Abstract] [Google Scholar]
27. Giannoudis PV, Veysi VT, Pape HC, Krettek C, Smith MR. When should we operate on major fractures in patients with severe head injuries? Am J Surg. 2002;183(3):261–267. [Abstract] [Google Scholar]
28. Velly L, Pellegrini L, Bruder N. Early or delayed peripheral surgery in patients with severe head injury? Ann Fr Anesth Reanim. 2010;29(9):e183–e188. [Abstract] [Google Scholar]
29. Lu S, Du T, Sun Z, Xu L, Tong X, Yan H. Timing of extremity fracture fixation in patients with traumatic brain injury: a meta-analysis of prognosis. World Neurosurg. 2020;133:227–236. [Abstract] [Google Scholar]
30. Carney N Totten AM O'Reilly C Ullman JS Hawryluk GW Bell MJ, et al. . Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017;80(1):6–15. [Abstract] [Google Scholar]
31. Kutscha-Lissberg F, Hopf FK, Kollig E, Muhr G. How risky is early intramedullary nailing of femoral fractures in polytraumatized patients? Injury. 2001;32(4):289–293. [Abstract] [Google Scholar]
32. Handolin L, Pajarinen J, Lassus J, Tulikoura I. Early intramedullary nailing of lower extremity fracture and respiratory function in polytraumatized patients with a chest injury: a retrospective study of 61 patients. Acta Orthop Scand. 2004;75(4):477–480. [Abstract] [Google Scholar]
33. Schinkel C Frangen TM Kmetic A Andress HJ Muhr G, German Trauma Registry .. Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome. J Trauma. 2006;61(1):156–160 discussion 60. [Abstract] [Google Scholar]
34. Weninger P, Figl M, Spitaler R, Mauritz W, Hertz H. Early unreamed intramedullary nailing of femoral fractures is safe in patients with severe thoracic trauma. J Trauma. 2007;62(3):692–696. [Abstract] [Google Scholar]
35. O'Toole RV, O'Brien M, Scalea TM, Habashi N, Pollak AN, Turen CH. Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics. J Trauma. 2009;67(5):1013–1021. [Abstract] [Google Scholar]
36. Sewell MD, Vachhani K, Alrawi A, Williams R. Results of early and late surgical decompression and stabilization for acute traumatic cervical spinal cord injury in patients with concomitant chest injuries. World Neurosurg. 2018;118:e161–e165. [Abstract] [Google Scholar]
37. Jiang M, Li C, Yi C, Tang S. Early intramedullary nailing of femoral shaft fracture on outcomes in patients with severe chest injury: a meta-analysis. Sci Rep. 2016;6:30566. [Europe PMC free article] [Abstract] [Google Scholar]
38. Nahm NJ, Como JJ, Vallier HA. The impact of major operative fractures in blunt abdominal injury. J Trauma Acute Care Surg. 2013;74(5):1307–1314. [Abstract] [Google Scholar]
39. Glass NE, Burlew CC, Hahnhaussen J, Weckbach S, Pieracci FM, Moore EE, Stahel PF. Early definitive fracture fixation is safely performed in the presence of an open abdomen in multiply injured patients. J Orthop Trauma. 2017;31(12):624–630. [Abstract] [Google Scholar]
40. Roberts DJ Bobrovitz N Zygun DA Ball CG Kirkpatrick AW Faris PD, et al. . Indications for use of damage control surgery in civilian trauma patients: a content analysis and expert appropriateness rating study. Ann Surg. 2016;263(5):1018–1027. [Abstract] [Google Scholar]
41. Connor GS, McGwin G, Jr., MacLennan PA, Alonso JE, Rue LW, 3rd. Early versus delayed fixation of pelvic ring fractures. Am Surg. 2003;69(12):1019–1023 discussion 23-4. [Abstract] [Google Scholar]
42. Vallier HA, Cureton BA, Ekstein C, Oldenburg FP, Wilber JH. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. J Trauma. 2010;69(3):677–684. [Abstract] [Google Scholar]
43. Vallier HA Moore TA Como JJ Wilczewski PA Steinmetz MP Wagner KG, et al. . Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. J Orthop Surg Res. 2015;10:155. [Europe PMC free article] [Abstract] [Google Scholar]
44. Childs BR, Nahm NJ, Moore TA, Vallier HA. Multiple procedures in the initial surgical setting: when do the benefits outweigh the risks in patients with multiple system trauma? J Orthop Trauma. 2016;30(8):420–425. [Abstract] [Google Scholar]
45. Byrne JP, Nathens AB, Gomez D, Pincus D, Jenkinson RJ. Timing of femoral shaft fracture fixation following major trauma: a retrospective cohort study of United States trauma centers. PLoS Med. 2017;14(7):e1002336. [Europe PMC free article] [Abstract] [Google Scholar]
46. Taylor NA Smith AA Marr A Stuke L Greiffenstein P Schoen J, et al. . Does time to pelvic fixation influence outcomes in trauma patients? Am Surg. 2022;88(5):840–845. [Abstract] [Google Scholar]
47. Croce MA, Bee TK, Pritchard E, Miller PR, Fabian TC. Does optimal timing for spine fracture fixation exist? Ann Surg. 2001;233(6):851–858. [Abstract] [Google Scholar]
48. Chipman JG, Deuser WE, Beilman GJ. Early surgery for thoracolumbar spine injuries decreases complications. J Trauma. 2004;56(1):52–57. [Abstract] [Google Scholar]
49. Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Murphy T, Tepas JJ. The effect of early spine fixation on non-neurologic outcome. J Trauma. 2005;58(1):15–21. [Abstract] [Google Scholar]
50. McHenry TP Mirza SK Wang J Wade CE O'Keefe GE Dailey AT, et al. . Risk factors for respiratory failure following operative stabilization of thoracic and lumbar spine fractures. J Bone Joint Surg Am. 2006;88(5):997–1005. [Abstract] [Google Scholar]
51. Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Arce CA, Nguyen TQ, Tepas JJ, 3rd. The effect of early surgical treatment of traumatic spine injuries on patient mortality. J Trauma. 2007;63(6):1308–1313. [Abstract] [Google Scholar]
52. Frangen TM, Ruppert S, Muhr G, Schinkel C. The beneficial effects of early stabilization of thoracic spine fractures depend on trauma severity. J Trauma. 2010;68(5):1208–1212. [Abstract] [Google Scholar]
53. Pakzad H, Roffey DM, Knight H, Dagenais S, Yelle JD, Wai EK. Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes. Can J Surg. 2011;54(4):270–276. [Europe PMC free article] [Abstract] [Google Scholar]
54. Bliemel C Lefering R Buecking B Frink M Struewer J Krueger A, et al. . Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the trauma registry of DGU: treatment of spine injuries in polytrauma patients. J Trauma Acute Care Surg. 2014;76(2):366–373. [Abstract] [Google Scholar]
55. Park KC, Park YS, Seo WS, Moon JK, Kim BH. Clinical results of early stabilization of spine fractures in polytrauma patients. J Crit Care. 2014;29(4):694.e7–694.e9. [Abstract] [Google Scholar]
56. Konieczny MR, Strüwer J, Jettkant B, Schinkel C, Kälicke T, Muhr G, Frangen TM. Early versus late surgery of thoracic spine fractures in multiple injured patients: is early stabilization always recommendable? Spine J. 2015;15(8):1713–1718. [Abstract] [Google Scholar]
57. Lubelski D, Tharin S, Como JJ, Steinmetz MP, Vallier H, Moore T. Surgical timing for cervical and upper thoracic injuries in patients with polytrauma. J Neurosurg Spine. 2017;27(6):633–637. [Abstract] [Google Scholar]
58. Kobbe P Krug P Andruszkow H Pishnamaz M Hofman M Horst K, et al. . Early spinal injury stabilization in multiple-injured patients: do all patients benefit? J Clin Med. 2020;9(6):1760. [Europe PMC free article] [Abstract] [Google Scholar]
59. Sousa A, Rodrigues C, Barros L, Serrano P, Rodrigues-Pinto R. Early versus late spine surgery in severely injured patients—which is the appropriate timing for surgery? Global Spine J. 2022;12(8):1781–1785. [Europe PMC free article] [Abstract] [Google Scholar]
60. McKinley W, Meade MA, Kirshblum S, Barnard B. Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury. Arch Phys Med Rehabil. 2004;85(11):1818–1825. [Abstract] [Google Scholar]
61. Fehlings MG Vaccaro A Wilson JR Singh A W Cadotte D Harrop JS, et al. . Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(2):e32037. [Europe PMC free article] [Abstract] [Google Scholar]
62. Rahimi-Movaghar V, Niakan A, Haghnegahdar A, Shahlaee A, Saadat S, Barzideh E. Early versus late surgical decompression for traumatic thoracic/thoracolumbar (T1-L1) spinal cord injured patients. Primary results of a randomized controlled trial at one year follow-up. Neurosciences (Riyadh). 2014;19(3):183–191. [Europe PMC free article] [Abstract] [Google Scholar]
63. Battistuzzo CR Armstrong A Clark J Worley L Sharwood L Lin P, et al. . Early decompression following cervical spinal cord injury: examining the process of care from accident scene to surgery. J Neurotrauma. 2016;33(12):1161–1169. [Abstract] [Google Scholar]
64. Grassner L Wutte C Klein B Mach O Riesner S Panzer S, et al. . Early decompression (< 8 h) after traumatic cervical spinal cord injury improves functional outcome as assessed by spinal cord independence measure after one year. J Neurotrauma. 2016;33(18):1658–1666. [Abstract] [Google Scholar]
65. Nayak B Krishnamurthy BH Kumar A Patro SK Sahoo PK Biswal D, et al. . Results of early versus delayed decompression for traumatic cervical spinal cord injury: a single center prospective study. Indian J Neurotrauma. 2018;15(1):23–28. [Google Scholar]
66. Du JP, Fan Y, Zhang JN, Liu JJ, Meng YB, Hao DJ. Early versus delayed decompression for traumatic cervical spinal cord injury: application of the AOSpine subaxial cervical spinal injury classification system to guide surgical timing. Eur Spine J. 2019;28(8):1855–1863. [Abstract] [Google Scholar]
67. Tanaka C Tagami T Kaneko J Fukuda R Nakayama F Sato S, et al. . Early versus late surgery after cervical spinal cord injury: a Japanese nationwide trauma database study. J Orthop Surg Res. 2019;14(1):302. [Europe PMC free article] [Abstract] [Google Scholar]
68. Nasi D, Ruscelli P, Gladi M, Mancini F, Iacoangeli M, Dobran M. Ultra-early surgery in complete cervical spinal cord injury improves neurological recovery: a single-center retrospective study. Surg Neurol Int. 2019;10:207. [Europe PMC free article] [Abstract] [Google Scholar]
69. Burke JF Yue JK Ngwenya LB Winkler EA Talbott JF Pan JZ, et al. . Ultra-early (<12 hours) surgery correlates with higher rate of American Spinal Injury Association Impairment Scale conversion after cervical spinal cord injury. Neurosurgery. 2019;85(2):199–203. [Abstract] [Google Scholar]
70. Wutte C Becker J Klein B Mach O Panzer S Stuby FM, et al. . Early decompression (<8 hours) improves functional bladder outcome and mobility after traumatic thoracic spinal cord injury. World Neurosurg. 2020;134:e847–e854. [Abstract] [Google Scholar]
71. Badhiwala JH Wilson JR Witiw CD Harrop JS Vaccaro AR Aarabi B, et al. . The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol. 2021;20(2):117–126. [Abstract] [Google Scholar]
72. Balas M Guttman MP Badhiwala JH Lebovic G Nathens AB da Costa L, et al. . Earlier surgery reduces complications in acute traumatic thoracolumbar spinal cord injury: analysis of a multi-center cohort of 4108 patients. J Neurotrauma. 2022;39(3–4):277–284. [Abstract] [Google Scholar]
73. Badhiwala JH, Ahuja CS, Fehlings MG. Time is spine: a review of translational advances in spinal cord injury. J Neurosurg Spine. 2018;30(1):1–18. [Abstract] [Google Scholar]
74. Ramakonar H, Fehlings MG. 'Time is Spine': new evidence supports decompression within 24 h for acute spinal cord injury. Spinal Cord. 2021;59(8):933–934. [Europe PMC free article] [Abstract] [Google Scholar]
75. Dimar JR, Carreon LY, Riina J, Schwartz DG, Harris MB. Early versus late stabilization of the spine in the polytrauma patient. Spine (Phila Pa 1976). 2010;35(21 Suppl):S187–S192. [Abstract] [Google Scholar]
76. Carreon LY, Dimar JR. Early versus late stabilization of spine injuries: a systematic review. Spine (Phila Pa 1976). 2011;36(11):E727–E733. [Abstract] [Google Scholar]
77. Liu J-M, Long X-H, Zhou Y, Peng H-W, Liu Z-L, Huang S-H. Is urgent decompression superior to delayed surgery for traumatic spinal cord injury? A meta-analysis. World Neurosurg. 2016;87:124–131. [Abstract] [Google Scholar]
78. McHenry TP, Holcomb JB, Aoki N, Lindsey RW. Fractures with major vascular injuries from gunshot wounds: implications of surgical sequence. J Trauma. 2002;53(4):717–721. [Abstract] [Google Scholar]
79. Teissier V Tresson P Gaudric J Davaine JM Scemama C Raux M, et al. . Importance of early diagnosis and care in knee dislocations associated with vascular injuries. Ann Vasc Surg. 2019;61:238–245. [Abstract] [Google Scholar]
80. Lewis RH, Jr., Perkins M, Fischer PE, Beebe MJ, Magnotti LJ. Timing is everything: impact of combined long bone fracture and major arterial injury on outcomes. J Trauma Acute Care Surg. 2022;92(1):21–27. [Abstract] [Google Scholar]
81. Glass GE, Pearse MF, Nanchahal J. Improving lower limb salvage following fractures with vascular injury: a systematic review and new management algorithm. J Plast Reconstr Aesthet Surg. 2009;62(5):571–579. [Abstract] [Google Scholar]
82. Fowler J, Macintyre N, Rehman S, Gaughan JP, Leslie S. The importance of surgical sequence in the treatment of lower extremity injuries with concomitant vascular injury: a meta-analysis. Injury. 2009;40(1):72–76. [Abstract] [Google Scholar]
83. TraumaRegister der Deutschen Gesellschaft für Unfallchirurgie. Annu Rep 2022. [Google Scholar]
84. Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma. 2005;19(8):551–562. [Abstract] [Google Scholar]
85. Halvachizadeh S Pfeifer R Duncan J Klingebiel FKL Kalbas Y Berk T, et al. . Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures? J Trauma Acute Care Surg. 2024;96:931–937. [Abstract] [Google Scholar]
86. Störmann P, Krämer S, Raab S, Kalverkamp S, Graeff P. Pathophysiology, diagnostics and therapy of pulmonary contusion—recommendations of the interdisciplinary Group on Thoracic Trauma of the Section NIS of the German Society for Trauma Surgery (DGU) and the German Society for Thoracic Surgery (DGT). Zentralbl Chir. 2023;148(1):50–56. [Abstract] [Google Scholar]
87. Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients—an update on principles, parameters and strategies for 2020. Injury. 2019;50(10):1656–1670. [Abstract] [Google Scholar]
88. Pape HC, Zelle BA, Hildebrand F, Giannoudis PV, Krettek C, van Griensven M. Reamed femoral nailing in sheep: does irrigation and aspiration of intramedullary contents alter the systemic response? J Bone Joint Surg Am. 2005;87(11):2515–2522. [Abstract] [Google Scholar]
89. Hildebrand F Giannoudis P van Griensven M Chawda M Probst C Harms O, et al. . Secondary effects of femoral instrumentation on pulmonary physiology in a standardised sheep model: what is the effect of lung contusion and reaming? Injury. 2005;36(4):544–555. [Abstract] [Google Scholar]
90. Pape HC, Remmers D, Rice J, Ebisch M, Krettek C, Tscherne H. Appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making. J Trauma. 2000;49(3):496–504. [Abstract] [Google Scholar]
91. Davis DD, Foris LA, Kane SM, Waseem M. Pelvic Fracture. In: StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC; 2023. [Google Scholar]
92. Klingebiel FK-L Hasegawa M Strähle O Kalbas Y Teuben M Halvachizadeh S, et al. . Surgical load in major fractures—results of a survey on the optimal quantification and timing of surgery in polytraumatized patients. Int Orthop. 2023;47(7):1677–1687. [Europe PMC free article] [Abstract] [Google Scholar]
93. Eggers C, Stahlenbrecher A. Injuries of the thoracic and lumbar spine. Unfallchirurg. 1998;101(10):779–790. [Abstract] [Google Scholar]
94. Mugesh Kanna R, Prasad Shetty A, Rajasekaran S. Timing of intervention for spinal injury in patients with polytrauma. J Clin Orthop Trauma. 2021;12(1):96–100. [Europe PMC free article] [Abstract] [Google Scholar]

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