In-hospital mortality from femoral shaft fracture depends on the initial delay to fracture fixation and Injury Severity Score: a retrospective cohort study from the NTDB 2002-2006.
BACKGROUND
Optimal surgical timing for definitive treatment of femur fractures in severely injured patients remains controversial. This study was performed to examine in-hospital mortality for patients with femur fractures with regard to surgical timing, Injury Severity Score (ISS), and age.


METHODS
The National Trauma Data Bank version 7.0 was used to evaluate in-hospital mortality for patients presenting with unilateral femur fractures. Patients were stratified into four groups by surgical timing (ST) and four groups by ISS. χ tests were used to evaluate baseline interrelationships. Binary regression was used to examine the association between time to surgery, ISS score, age, and mortality after adjusting for patient medical comorbidities, and personal demographics.


RESULTS
A total of 7,540 patients met inclusion criteria, with a 1.4% overall in-hospital mortality rate. For patients with an isolated femur fracture, surgical delay beyond 48 hours was associated with nearly five times greater mortality risk compared with surgery within 12 hours (adjusted relative risk, 4.8; 95% confidence interval, 1.6-14.1). Only severely injured patients (ISS, 26+) had higher associated mortality with no delay in surgical fixation (ST1 < 12 hours) relative to ST2 of 13 hours to 24 hours with an adjusted relative risk of 4.2 (95% confidence interval, 1.0-16.7). The association between higher mortality rates and surgical delay beyond 48 hours was even stronger in the elderly patients.


CONCLUSIONS
This study supports the work of previous authors who reported that early definitive fixation of femur fractures is not only beneficial, particularly in the elderly, but also consistent with more recent studies recommending at least 12-hour to 24-hour delay in fixation in severely injured patients to promote better resuscitation.


METHODS
Therapeutic study, level III.
From the Dartmouth-Hitchcock Medical Center; Department of Orthopaedics (R.V.C., S.C.G., K.F.S.), Dartmouth Medical School (R.V.C., K.F.S.); and Clinical Trial Unit (K.F.S.), The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
Robert Victor
RV
Cantu
Sara Catherine
SC
Graves
Kevin F
KF
Spratt
D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D005264:Femoral Fractures / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery; D005500:Follow-Up Studies; D005592:Fracture Fixation; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult