title: Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course.
abstract: OBJECTIVE
  We hypothesized that early definitive management (within 24 hours of injury) of mechanically unstable fractures of the pelvis, acetabulum, femur and spine would reduce complications and shorten length of stay.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  Level 1 trauma center.
  
  
  METHODS
  1005 skeletally mature patients with Injury Severity Score (ISS) ≥18 with pelvis (n = 259), acetabulum (n = 266), proximal or diaphyseal femur (n = 569), and/or thoracolumbar spine (n = 98) fractures. Chest (n = 447), abdomen (n = 328), and head (n = 155) injuries were present.
  
  
  METHODS
  Definitive surgery was within 24 hours in 572 patients and after 24 hours in 433.
  
  
  METHODS
  Complications related to the initial trauma episode included infections, sepsis, pneumonia, deep venous thrombosis, pulmonary embolism, acute respiratory distress syndrome (ARDS), organ failure, and death.
  
  
  RESULTS
  Days in intensive care unit (ICU) and total hospital stay were lower with early fixation (5.1 ± 8.8 vs. 8.4 ± 11.1 ICU days (P = 0.006); 10.5 ± 9.8 versus 14.3 ± 11.4 total days (P = 0.001), after adjusting for ISS and age. Fewer complications (24.0% vs. 35.8%, P = 0.040), ARDS (1.7% vs. 5.3%, P = 0.048), pneumonia (8.6% vs. 15.2%, P = 0.070), and sepsis (1.7% vs. 5.3%, P = 0.054) occurred with early versus delayed fixation. Logistic regression was used to account for differences in age and ISS between the early and delayed groups. Adjustment for severity of chest injury was included when analyzing pulmonary complications including pneumonia and ARDS.
  
  
  CONCLUSIONS
  Definitive fracture management within 24 hours resulted in shorter ICU and hospital stays and fewer complications and ARDS, after adjusting for age and associated injury types and severity. Surgical timing must be determined with consideration of the physiology of the patient and complexity of surgery. Parameters should be established within which it is safe to proceed with fixation. These data will serve as a baseline for comparison with prospective evaluation of such parameters in the future.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH 44109, USA. heathervallier@yahoo.com
authors.forename: Heather A
authors.initials: HA
authors.lastname: Vallier
authors.forename: Dennis M
authors.initials: DM
authors.lastname: Super
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Moore
authors.forename: John H
authors.initials: JH
authors.lastname: Wilber
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D005593:Fracture Fixation, Internal / Q000706:statistics & numerical data*; D050723:Fractures, Bone / Q000453:epidemiology* / Q000601:surgery*; D006801:Humans; D007593:Joint Instability / Q000453:epidemiology* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000453:epidemiology* / Q000601:surgery*; D009820:Ohio / Q000453:epidemiology; D010343:Patient Admission / Q000706:statistics & numerical data; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014850:Waiting Lists; D055815:Young Adult