Pape (2009) — Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery.

Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery.

Pape, Olson, et al.·J Am Acad Orthop Surg·2009·216 citations·Trauma

This 2009 narrative review by Pape et al. synthesizes four decades of evidence on fracture fixation timing in multitrauma patients. It presents a four-grade physiologic classification system (stable, borderline, unstable, in extremis) and operationalizes the decision between early total care and damage control orthopedics. The paper defines specific intraoperative thresholds that should trigger conversion to a staged approach in borderline patients.

Key Findings

Multitrauma patients are assigned to one of four physiologic grades based on meeting three of four criteria (shock, coagulation, temperature, soft-tissue injury):
- Grade I (Stable): BP ≥100 mm Hg, 0-2 blood units/2 hr, ATLS Class I — cleared for definitive surgery
- Grade II (Borderline): BP 80-100 mm Hg, 2-8 blood units/2 hr, ATLS Class II-III. Individualized decision
- Grade III (Unstable): BP <90 mm Hg, 5-15 blood units/2 hr, ATLS Class III-IV. Temporary fixation only
- Grade IV (In Extremis): BP ≤70 mm Hg, >15 blood units/2 hr. Hemorrhage control first, fractures are secondary
Delaying femoral shaft fixation beyond 12 hours reduces mortality by approximately 50% in multisystem trauma patients. This finding from Morshed et al. (N=3,069, National Trauma Data Bank) is the largest dataset supporting damage control orthopedics over early total care.
When proceeding with definitive fixation in a borderline patient, abort and temporize if any of these intraoperative thresholds are breached:
- PaO₂/FiO₂ drops below 250 mm Hg
- Temperature falls below 32°C
- Fluid requirement exceeds 3 L or 5 units of blood
Fakhry et al. found 4.6% mortality with day-1 surgery vs. 0% mortality when definitive fixation was delayed more than 1 day. The authors recommend delaying femoral repair 24-48 hours when severe chest injury is present.
Patients with GCS <9 who undergo fracture fixation within 2 hours of admission carry an eightfold increased risk of intraoperative hypotension. 36 of 43 patients with poor neurologic outcomes had cerebral perfusion pressures <70 mm Hg in the first 24 hours, though study results conflict.
The external fixator is the primary damage control orthopedics tool. It can be applied rapidly with minimal blood loss, allows wound access and compartment monitoring, improves mobility over traction, and facilitates pulmonary toilet. Damage control nailing (unlocked retrograde nail, limited reaming) is an alternative for femoral fractures.
Prolonged immobilization without fixation carries its own risks: pneumonia, decubitus ulcers, prolonged ICU stay, and disuse atrophy, which is why timely stabilization is important.

Board PearlMorshed et al. concluded that delaying femoral shaft fixation beyond 12 hours in multisystem trauma reduces mortality by about 50%. Match the approach to physiology: stable patients get fracture surgery as needed, unstable patients are resuscitated first, borderline patients are individualized, and patients in extremis get life-saving measures then damage control.

Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery.

Key Findings

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Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery.

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Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery.

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Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery.

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