The optimal timing of surgical fracture stabilization in trauma patients

Surgical interventions in trauma patients can amplify the initial systemic inflammatory response to injury. Aggressive early definitive surgical care could be detrimental in patients with physiological compromise or specific injury patterns. It has been shown, however, that early fracture fixation has a trend towards better outcome in patients with less severe injuries. Delaying all orthopedic surgery in critically injured patients can be a safe alternative but has several disadvantages. In the year 2000 the term Damage Control Orthopedics (DCO) was first described. It was derived from the general surgical concept of staged care in complex abdominal trauma. The concept involved initial temporary external fixation of all long bone fractures in critically ill patients. Following initial external fixation, IM nailing was performed in the next 10 days when the patient’s physiology had improved. The identified indication for DCO included traumatic brain injury, hemodynamic instability, severe thoraco-abdominal injuries and multiple long bone fractures. DCO is an attractive approach as it achieves early fracture stabilization without the risks of IMN or the need of traction devices, there are however, some potential downsides. There is no consensus in the literature in regards to optimal timing of fracture fixation for some patient groups. The main hypothesis explored in this body of work is that early definitive surgery in selected patients has superior results. To investigate this hypothesis a review article and five clinical studies were conducted. The research findings support the importance of physiological assessment of a trauma patient in decision making for initial and secondary surgeries. The decision between Damage Control Orthopaedics and Early Total Care is a dynamic process and needs an early multidisciplinary approach. Which modality is chosen is dependent on multiple modifiable and non-modifiable parameters.