title: Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma.
abstract: BACKGROUND
  Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (<24 hours) versus late (>24 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients.
  
  
  METHODS
  A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables.
  
  
  RESULTS
  No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50-1.08). The quality of evidence was rated as "low." No significant reduction in infection (RR, 0.4; 95% CI, 0.10-1.6) or VTE (RR, 0.63; 95% CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated "low."
  
  
  CONCLUSIONS
  In trauma patients with open or closed femur fractures, we suggest early (<24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.
authors.affiliation: From the Department of Surgery (R.R.G., T.L.O., S.S.), JPS Health Network, Fort Worth; and Department of Surgery (D.A.), East Texas Medical Center, Tyler, Texas; Departments of Surgery (E.R.H., B.L.), and Orthopaedic Surgery (E.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Orthopaedics (H.A.V.), MetroHealth, Cleveland, Ohio; Department of Surgery (T.R.), Borgess Health, Kalamazoo, Michigan; Department of Surgery (J.K.L.), Advocate Medical Group, Chicago, Illinois; Department of Surgery (J.W.), Oregon Health and Science University, Portland, Oregon; and Department of Trauma and Acute Care Surgery (F.B.R.), Lancaster General Health, Lancaster, Pennsylvania.
authors.forename: Rajesh R
authors.initials: RR
authors.lastname: Gandhi
authors.forename: Tiffany L
authors.initials: TL
authors.lastname: Overton
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.forename: Brandyn
authors.initials: B
authors.lastname: Lau
authors.forename: Heather A
authors.initials: HA
authors.lastname: Vallier
authors.forename: Thomas
authors.initials: T
authors.lastname: Rohs
authors.forename: Erik
authors.initials: E
authors.lastname: Hasenboehler
authors.forename: Jane Kayle
authors.initials: JK
authors.lastname: Lee
authors.forename: Darrell
authors.initials: D
authors.lastname: Alley
authors.forename: Jennifer
authors.initials: J
authors.lastname: Watters
authors.forename: Frederick B
authors.initials: FB
authors.lastname: Rogers
authors.forename: Shahid
authors.initials: S
authors.lastname: Shafi