title: Is There an Impact of Concomitant Injuries and Timing of Fixation of Major Fractures on Fracture Healing? A Focused Review of Clinical and Experimental Evidence.
abstract: OBJECTIVE
  This review aims to summarize current knowledge regarding the underlying patho-mechanisms of delayed fracture healing in polytraumatized patients.
  
  
  METHODS
  The following search terms were used: "fracture", "hemorrhage," "chest trauma," "inflammation," "inflammatory response," "fracture healing," "delayed healing," "nonunion," "fracture stabilisation," "intramedullary nailing," "external fixation," "early total care," and "damage control." Medline, Embase, and Cochrane Library were searched for studies published between January 1, 1990 through March 30, 2014. Of 1322 publications, 68 were included in the current summary.
  
  
  CONCLUSIONS
  Concomitant injuries and the strategy for fracture stabilization seem to affect bone metabolism and fracture healing. Among the relevant patho-mechanisms, interactions between the local and systemic inflammatory response seem to play a role. However, the consequences of fracture fixation strategies in case of severe concomitant injuries on local inflammation and bone healing remain unknown.
  
  
  METHODS
  Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Department of Orthopaedic Trauma at Aachen University, University Hospital Aachen, Aachen, Germany; †Experimental Trauma Surgery, Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany; ‡Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany; §Surgical Research, Department of Trauma Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany; and ‖Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Frankfurt, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Hildebrand
authors.forename: Martijn
authors.initials: M
authors.lastname: van Griensven
authors.forename: Markus
authors.initials: M
authors.lastname: Huber-Lang
authors.forename: Stefanie B
authors.initials: SB
authors.lastname: Flohe
authors.forename: Hagen
authors.initials: H
authors.lastname: Andruszkow
authors.forename: Ingo
authors.initials: I
authors.lastname: Marzi
authors.forename: Hans-Christoph
authors.initials: HC
authors.lastname: Pape
mesh_terms: D000818:Animals; D019317:Evidence-Based Medicine; D005593:Fracture Fixation, Internal / Q000706:statistics & numerical data*; D017102:Fracture Healing; D050723:Fractures, Bone / Q000453:epidemiology* / Q000601:surgery*; D006801:Humans; D009104:Multiple Trauma / Q000453:epidemiology* / Q000628:therapy; D015995:Prevalence; D018570:Risk Assessment; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D016896:Treatment Outcome