Systematic Review: Early versus Delayed Surgical Fixation of Long Bone Fractures in Polytrauma Patients – Impact on Morbidity, Mortality, and Functional Outcomes
Mohammed Alssir MohammedAhmed *1, Dr. Salem Alanbari 2, Dr. Mohamed Yousif Mohamed Yousif3, Dr. Aiman Shaif Saleh Hussein4, Dr. Aref Abdelrahman Ba Nafae5, Dr. Ahmed Ibrahim Suleiman Eldasiss6, Dr. Hozifa Mohammed Ali Abdelmaged7
1. Orthopedic spine surgeon, Head of orthopedic department – Shabwa General Hospital Authority, Ataq, Yemen.
2. Consultant trauma and orthopaedic surgery, associated professor Shabwa University – faculty of Medicine.
3. Registrar trainee trauma and orthopaedic surgery – Sudan Medical Specialization Board.
4. Specialist Trauma and Orthopaedic Surgery, Shabwa General Hospital Authority (SGHA), Ataq – Yemen.
5. Consultant trauma and orthopaedic surgery, Shabwa General Hospital Authority (SGHA), Ataq – Yemen.
6. Orthopedic surgery resident at Temple’s street children’s health, Ireland.
7. Orthopaedic oncology surgeon, Assistant Professor Alzaeim Alazhari University – Khartoum North – Sudan.
*Correspondence to: Mohammed Alssir MohammedAhmed, Orthopedic spine surgeon, Head of orthopedic department – Shabwa General Hospital Authority, Ataq, Yemen.
Copyright
© 2025 Mohammed Alssir MohammedAhmed is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 10 Oct 2025
Published: 16 Oct 2025
DOI: https://doi.org/10.5281/zenodo.17403963
Abstract
Background: The question of optimal surgical timing for long bone fractures in polytrauma patients continues to generate considerable debate within the trauma surgery community. Three principal management strategies have emerged Early Total Care (ETC), advocating for immediate definitive surgical stabilization; Damage Control Orthopedics (DCO), which emphasizes initial temporary stabilization followed by staged definitive reconstruction; and Early Appropriate Care (EAC), a tailored approach that combines the benefits of both strategies based on physiological response to resuscitation. This systematic review synthesizes contemporary evidence comparing these approaches, with particular attention to their effects on patient morbidity, mortality, and functional recovery.
Methods: We performed an extensive literature search encompassing PubMed and Cochrane CENTRAL databases, identifying systematic reviews, meta-analyses, randomized controlled trials, and cohort studies published through October 2025. Our search targeted investigations comparing early surgical intervention (typically within 24-36 hours of injury) against delayed approaches (beyond 36 hours) for long bone fractures in adult polytrauma populations. We prioritized studies reporting mortality rates, major complications including Acute Respiratory Distress Syndrome (ARDS) and Multiple Organ Failure (MOF), and long-term functional outcomes.
Results: Our literature analysis identified substantial evidence from recent systematic reviews and meta-analyses. The evidence demonstrates that physiologically stable polytrauma patients benefit from early definitive fixation (ETC), particularly intramedullary stabilization of femoral fractures, which correlates with reduced intensive care unit stays and shorter mechanical ventilation periods. Unstable or physiologically compromised patients require DCO strategies to prevent the "second hit" phenomenon and minimize systemic inflammatory complications. The emerging EAC protocol offers a middle ground for borderline patients who demonstrate adequate response to resuscitation, allowing definitive fixation within 36 hours when specific physiological criteria are met (lactate <4.0 mmol/L, pH ≥7.25, base excess ≥-5.5 mmol/L). Notably, patients with concurrent severe traumatic brain injury do not demonstrate worsened outcomes with early fixation. Significant heterogeneity exists across studies regarding temporal definitions and patient stratification criteria.
Conclusion: Determining appropriate timing for long bone fracture fixation in polytrauma patients necessitates individualized physiological assessment rather than adherence to rigid temporal protocols. Stable patients derive clear benefits from ETC approaches, unstable patients require DCO management to prevent potentially catastrophic complications, and borderline patients who respond to resuscitation may benefit from the EAC protocol. This review documents the field's evolution from dichotomous ETC versus DCO protocols toward a three-tiered, physiology-driven decision-making model. Future investigations should focus on standardizing patient selection criteria and refining treatment algorithms through high-quality prospective research.
Keywords: Polytrauma, long bone fractures, early total care, damage control orthopedics, early appropriate care, mortality, morbidity, ARDS, functional outcomes, surgical timing.
1. Introduction
Managing polytraumatized patients—individuals sustaining injuries across multiple anatomical regions or physiological systems—represents one of the most challenging scenarios in contemporary trauma care. Polytrauma typically involves injury severity scores exceeding 16 points, frequently encompassing life-threatening injuries requiring coordinated multidisciplinary intervention [34]. Long bone fractures constitute a common component of these complex injury patterns, and their management significantly influences overall patient outcomes [13]. The debate surrounding optimal surgical timing for these fractures has persisted for decades, generating three distinct management philosophies: Early Total Care (ETC), Damage Control Orthopedics (DCO), and the more recently developed Early Appropriate Care (EAC) [9, 10, 30].
The ETC concept emerged during the 1980s, proposing immediate definitive fracture stabilization within the initial 24 hours following injury [51]. Advocates of this strategy contend that early surgical fixation attenuates the systemic inflammatory cascade, diminishes pulmonary complications such as fat embolism syndrome, enables earlier patient mobilization, and reduces both hospital and intensive care unit (ICU) duration [9]. The theoretical underpinning of ETC posits that prompt skeletal stabilization eliminates the ongoing inflammatory stimulus from unstable fracture sites while facilitating improved pulmonary management through patient mobilization. Historical investigations from the late 1980s and early 1990s documented substantial reductions in pulmonary complications and mortality when femoral fractures received early stabilization compared with conservative or delayed management [50].
However, research conducted during the 1990s revealed that certain high-risk, physiologically compromised patients experienced detrimental outcomes when subjected to major primary surgical interventions. These procedures appeared to function as a harmful "second hit," amplifying the post-injury inflammatory response and precipitating increased rates of ARDS and MOF [16, 52]. This observation proved particularly striking among patients with severe thoracic trauma, where early intramedullary femoral nailing demonstrated higher ARDS incidence compared with delayed or staged approaches [16].
These findings catalyzed development of the DCO philosophy. DCO represents a staged management approach prioritizing physiological stabilization over immediate definitive orthopedic reconstruction. The strategy involves rapid temporary fracture stabilization through external fixation, splinting, or skeletal traction, followed by planned definitive surgical repair once adequate resuscitation achieves physiological stability, typically within a 5-10 day post-injury window [9, 22]. This approach aims to minimize initial surgical burden and mitigate "second hit" phenomenon risks [7]. The DCO strategy recognizes that the period spanning days 2-4 post-injury represents a critical phase of ongoing immunological changes and fluid redistribution, during which major surgery should be avoided in high-risk populations [9].
The recognition that many polytrauma patients fall into a "borderline" category—neither completely stable nor in extremis—led to the development of Early Appropriate Care (EAC), also known as Safe Definitive Surgery (SDS). This third management protocol, championed by Vallier and colleagues, represents a tailored approach that offers the benefits of ETC with the safety considerations of DCO [30, 31]. The EAC protocol is based on the observation that the majority of polytrauma patients demonstrate dramatic response to damage control resuscitation, creating an opportunity for early definitive surgical fixation (within 24-36 hours) in patients who meet specific physiological criteria indicating adequate resuscitation [30].
The EAC protocol recommends definitive fracture fixation within 36 hours of injury provided that patients achieve demonstrable response to resuscitative efforts, specifically: serum lactate <4.0 mmol/L, pH ≥7.25, or base excess ≥-5.5 mmol/L [30]. This approach recognizes that borderline patients who respond appropriately to resuscitation can safely undergo early definitive fixation, potentially avoiding the complications associated with prolonged temporary fixation while maintaining the safety principles of DCO. The decision remains case-specific, and intraoperative deterioration may necessitate abandoning definitive procedures in favor of safer temporizing options.
Recent advances in trauma resuscitation, critical care medicine, and understanding of post-injury inflammatory responses have fostered this more refined, three-tiered approach to polytrauma management [5, 8, 31]. Critical parameters including lactate concentrations, base deficit, coagulation status (incorporating rotational thromboelastometry or ROTEM values), vasopressor requirements, and presence of severe associated injuries (such as traumatic brain injury or significant chest trauma) now form integral components of risk stratification protocols [5, 13, 30].
Despite this conceptual evolution, substantial heterogeneity persists across clinical practice and literature regarding patient selection criteria, definitions of "early" versus "delayed" fixation, and outcome measurement. This systematic review provides a comprehensive synthesis of contemporary evidence comparing the three management strategies for long bone fractures in polytrauma patients. We analyze the impact of surgical timing on critical outcomes, including mortality, major morbidities such as ARDS and MOF, and long-term functional recovery and quality of life, providing an evidence-based summary to inform clinical decision-making for this complex patient population.
2. Methods
We conducted this systematic review through comprehensive literature searching to identify studies examining surgical timing for long bone fracture fixation in polytrauma patients. Our search strategy was designed to be inclusive and broad, capturing evidence ranging from high-level systematic reviews to influential cohort investigations.
2.1 Search Strategy
We performed multi-database searches, primarily targeting PubMed (MEDLINE) and Cochrane CENTRAL, for articles published through October 2025. Our search strategy employed combin