Prospective RCT of 178 adults with acute femoral fractures randomized to early stabilization (within 24 hours) or delayed stabilization (beyond 48 hours). Patients were stratified by ISS into isolated femoral fracture (ISS <18) and multiple-injury (ISS ≥18) groups. Outcomes measured: pulmonary complications, intubation duration, ICU days, hospital stay, and total cost.
Every prior study supporting early long-bone fixation in polytrauma was retrospective. This 1989 RCT by Bone et al. Was the first prospective randomized evidence — and it confirmed the principle decisively, rendering traction-first management obsolete for multiply injured patients.
When your polytrauma patient (ISS ≥18) has a femoral fracture, the clock starts at injury. Fixation within 24 hours is the target. Waiting beyond 48 hours. Even briefly. Drives up ARDS, fat embolism, intubation time, ICU days, and cost.
For isolated femoral fractures without polytrauma, timing did not change pulmonary outcomes at all. This distinction matters: the urgency for early fixation is injury-burden dependent, not fracture-type dependent.
The authors could not identify the specific fixation method used. A methodological gap later addressed by Pape et al. (1993), who raised the question of whether intramedullary nailing itself contributes to pulmonary complications in patients with lung contusion, setting the stage for damage control orthopedics.
Prospective RCT of 178 adults with acute femoral fractures randomized to early stabilization (within 24 hours) or delayed stabilization (beyond 48 hours). Patients were stratified by ISS into isolated femoral fracture (ISS <18) and multiple-injury (ISS ≥18) groups. Outcomes measured: pulmonary complications, intubation duration, ICU days, hospital stay, and total cost.
Every prior study supporting early long-bone fixation in polytrauma was retrospective. This 1989 RCT by Bone et al. Was the first prospective randomized evidence — and it confirmed the principle decisively, rendering traction-first management obsolete for multiply injured patients.
When your polytrauma patient (ISS ≥18) has a femoral fracture, the clock starts at injury. Fixation within 24 hours is the target. Waiting beyond 48 hours. Even briefly. Drives up ARDS, fat embolism, intubation time, ICU days, and cost.
For isolated femoral fractures without polytrauma, timing did not change pulmonary outcomes at all. This distinction matters: the urgency for early fixation is injury-burden dependent, not fracture-type dependent.
The authors could not identify the specific fixation method used. A methodological gap later addressed by Pape et al. (1993), who raised the question of whether intramedullary nailing itself contributes to pulmonary complications in patients with lung contusion, setting the stage for damage control orthopedics.