What is The Effectiveness of Early Versus Delayed Surgical Fixation of Orthopaedic Injuries on Mortality and Functional Outcomes in Multiply Injured Patients? : A Systematic Review
Keywords:
Polytrauma, fracture fixation, surgical timing, damage control orthopedics, mortality, functional outcomesAbstract
Introduction: The optimal timing for surgical fixation of orthopedic injuries in multiply injured patients remains controversial, with conflicting evidence regarding early versus delayed intervention. This review synthesizes current evidence on the effectiveness of early compared to delayed surgical fixation on mortality and functional outcomes in polytrauma patients.
Methods: A comprehensive review of 80 studies examining timing of surgical fixation in multiply injured patients was conducted. Studies included randomized controlled trials, cohort studies, systematic reviews, and meta-analyses. Early fixation was variably defined as within 24-72 hours, delayed beyond these cutoffs. Outcomes assessed included mortality, complications (ARDS, pneumonia, multiple organ failure), healthcare utilization, and functional outcomes.
Results: Early definitive fixation was not associated with increased mortality in adequately resuscitated patients (1.4% vs 1.6%, p=0.78) (1). However, early surgery in specific high-risk populations—particularly thoracic spine fractures with hemoglobin <10 mg/dL—showed significantly increased mortality (p<0.01) (14). Early fixation consistently reduced ARDS (1.7% vs 5.3%, p=0.048) (1), pneumonia (8.6% vs 15.2%, p=0.07), hospital length of stay (10.5 vs 14.3 days, p=0.001), and ICU days (5.1 vs 8.4 days, p=0.006). Damage control orthopedics offered no survival advantage over early total care (OR 0.92) and increased complications (39). Functional outcome data were limited, though early spinal decompression improved neurological recovery (log OR 0.82, p<0.001) (18).
Discussion: Benefits of early fixation depend on adequate resuscitation, with subclinical hypoperfusion (lactate ≥2.5 mmol/L) predicting poor outcomes (13). Injury pattern significantly influences optimal timing, with thoracic spine injuries requiring caution while lumbar and extremity fractures benefit from early intervention.
Conclusion: Early fixation within 24-48 hours is safe and beneficial in adequately resuscitated polytrauma patients but should be avoided in those with subclinical hypoperfusion or specific high-risk injury combinations. A physiology-driven, injury pattern-specific approach optimizes outcomes.
References
H. Vallier, D. Super, T. Moore, J. Wilber (2013) Do Patients With Multiple System Injury Benefit From Early Fixation of Unstable Axial Fractures? The Effects of Timing of Surgery on Initial Hospital Course. Journal of Orthopaedics and Trauma. https://doi.org/10.1097/BOT.0b013e3182820eba
Krishna Oochit, M. A. Imran, A. Marsh (2025) Early vs. late definitive fixation of pelvic ring fractures in resuscitated polytraumatized patients: a systematic review and meta-analysis. Archives of Orthopaedic and Trauma Surgery. https://doi.org/10.1007/s00402-025-06152-9
J. Harvin, William H Harvin, E. Camp, et al (2012) Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: A decade of experience with 1,376 diaphyseal femur fractures. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0b013e3182782696
H. Vallier, B. Cureton, Charles Ekstein, et al (2010) Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. Journal of Trauma. https://doi.org/10.1097/TA.0b013e3181e50914
C. Schinkel, T. Frangen, A. Kmetič, et al (2005) Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome. Journal of Trauma. https://doi.org/10.1097/01.TA.0000222669.09582.EC
P. Stahel, Todd F Vanderheiden, M. Flierl, et al (2013) The impact of a standardized “spine damage-control” protocol for unstable thoracic and lumbar spine fractures in severely injured patients: A prospective cohort study. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0b013e31827d6054
Mohamed E. El-Abtah, M. J. Roach, Michael L. Kelly (2025) Meta-analysis of early versus late fixation of traumatic unstable thoracolumbar spine fractures in patients with or without spinal cord injury. Journal of clinical neuroscience. https://doi.org/10.1016/j.jocn.2025.111238
Julia Dormann, K. Horst, Karolina Dahms, et al (2025) The optimal timing for definitive operative stabilization of pelvic fractures in polytrauma patients: effects on clinical outcomes – a systematic review. European Journal of Trauma and Emergency Surgery. https://doi.org/10.1007/s00068-025-02774-1
A. Enocson, Natalie Lundin (2023) Early versus late surgical treatment of pelvic and acetabular fractures a five-year follow-up of 419 patients. BMC Musculoskeletal Disorders. https://doi.org/10.1186/s12891-023-06977-8
Suzanne C. Arnold, Emanuele Lagazzi, R. K. Wagner, et al (2024) Two big bones, one big decision: When to fix bilateral femur fractures. Injury. https://doi.org/10.1016/j.injury.2024.111610
R. Gandhi, Tiffany L. Overton, E. Haut, et al (2014) Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000000434
Mitchel R Obey, D. Clever, D. Bechtold, et al (2021) In-Hospital Morbidity and Mortality With Delays in Femoral Shaft Fracture Fixation. Journal of Orthopaedics and Trauma. https://doi.org/10.1097/BOT.0000000000002271
B. Grey, R. Rodseth, D. Muckart (2013) Early fracture stabilisation in the presence of subclinical hypoperfusion. Injury. https://doi.org/10.1016/j.injury.2012.08.062
M. Konieczny, J. Strüwer, B. Jettkant, et al (2015) Early versus late surgery of thoracic spine fractures in multiple injured patients: is early stabilization always recommendable? The spine journal. https://doi.org/10.1016/j.spinee.2013.07.469
H. Pape, D. Rixen, J. Morley, et al (2007) Impact of the Method of Initial Stabilization for Femoral Shaft Fractures in Patients With Multiple Injuries at Risk for Complications (Borderline Patients). Annals of Surgery. https://doi.org/10.1097/SLA.0b013e3181485750
M. Sewell, K. Vachhani, Asif Alrawi, Richard Williams (2018) Results of Early and Late Surgical Decompression and Stabilization for Acute Traumatic Cervical Spinal Cord Injury in Patients with Concomitant Chest Injuries. World Neurosurgery. https://doi.org/10.1016/j.wneu.2018.06.146
Marjorie C. Wang, N. Temkin, R. Deyo, et al (2007) Timing of surgery after multisystem injury with traumatic brain injury: effect on neuropsychological and functional outcome. Journal of Trauma. https://doi.org/10.1097/01.TA.0000215581.50234.56
Karen HQ Toh, Tim Cheok, R. Martin, Henrik Baecker (2025) CLINICAL OUTCOMES FOLLOWING EARLY VERSUS DELAYED DECOMPRESSION IN PATIENTS WITH THORACOLUMBAR SPINE INJURIES: A SYSTEMATIC REVIEW AND META-ANALYSIS. Orthopaedic Proceedings. https://doi.org/10.1302/1358-992x.2025.16.037
Y. Kalbas, Yannik Stutz, F. Klingebiel, et al (2025) Criteria to clear polytrauma patients with traumatic brain injury for safe definitive surgery (<24 h). Injury. https://doi.org/10.1016/j.injury.2025.112149
H. Vallier, Xiaofeng Wang, T. Moore, et al (2013) Timing of Orthopaedic Surgery in Multiple Trauma Patients: Development of a Protocol for Early Appropriate Care. Journal of Orthopaedics and Trauma. https://doi.org/10.1097/BOT.0b013e31829efda1
P. Kobbe, Patrick Krug, H. Andruszkow, et al (2020) Early Spinal Injury Stabilization in Multiple-Injured Patients: Do All Patients Benefit? Journal of Clinical Medicine. https://doi.org/10.3390/jcm9061760
Sebastian Ndlovu, Stanley Masunda, Emmanuel Oladeji, et al (2025) Early versus late surgical stabilisation of unstable thoracolumbar spine fractures in adult polytrauma patients: a systematic review and meta-analysis. Health Sciences Review. https://doi.org/10.1016/j.hsr.2025.100217
C. Bliemel, R. Lefering, B. Buecking, et al (2014) Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: Treatment of spine injuries in polytrauma patients. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0b013e3182aafd7a
Nickolas J. Nahm, H. Vallier (2012) Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: A systematic review of randomized and nonrandomized trials. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0b013e3182701ded
Nickolas J. Nahm, John J Como, J. Wilber, H. Vallier (2011) Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. Journal of Trauma. https://doi.org/10.1097/TA.0b013e3181fc93a2
D. Rojas, J. Coleman, E. Moore, et al (2020) The Association of Surgical Timing and Injury Severity With Systemic Complications in Severely Injured Patients With Pelvic Ring Injuries. Journal of Orthopaedics and Trauma. https://doi.org/10.1097/BOT.0000000000001946
Natalie Enninghorst, László Tóth, K. King, et al (2010) Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option. Journal of Trauma. https://doi.org/10.1097/TA.0b013e3181d27b48
Eva Steinfeld, K. Horst, Kelly Ansems, et al (2025) Optimal timing of stabilization and operative technique for extremity fractures in polytrauma patients: a systematic review and meta-analysis. European Journal of Trauma and Emergency Surgery. https://doi.org/10.1007/s00068-024-02762-x
K. Oochit, A. Imran, A. Marsh (2024) 9 Early vs Late Definitive Fixation of Pelvic Ring Fractures in Polytraumatized Patients. a Systematic Review and Meta-Analysis. British Journal of Surgery. https://doi.org/10.1093/bjs/znae163.185
Sacha Halvachizadeh, R. Pfeifer, James Duncan, et al (2024) Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures? Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000004252
T. Sangkomkamhang, W. Thinkhamrop, B. Thinkhamrop, W. Laohasiriwong (2018) Incidence and risk factors for complications after definitive skeletal fixation of lower extremity in multiple injury patients: a retrospective chart review. F1000Research. https://doi.org/10.12688/f1000research.14825.1
Meng Jiang, Chang‐Li Li, Cheng-la Yi, Shao-tao Tang (2016) Early intramedullary nailing of femoral shaft fracture on outcomes in patients with severe chest injury: A meta-analysis. Scientific Reports. https://doi.org/10.1038/srep30566
Joseph Gutbrod, Dustin L. Stwalley, Anna N. Miller (2024) Effect of surgical fixation timing on in-hospital mortality and morbidity of distal femur fractures. Injury. https://doi.org/10.1016/j.injury.2024.111927
Nina E. Glass, C. Burlew, J. Hahnhaussen, et al (2017) Early Definitive Fracture Fixation is Safely Performed in the Presence of an Open Abdomen in Multiply Injured Patients. Journal of Orthopaedics and Trauma. https://doi.org/10.1097/BOT.0000000000000959
J. Richards, Andrew J. Medvecz, N. O’Hara, et al (2020) Musculoskeletal Trauma in Critically Injured Patients: Factors Leading to Delayed Operative Fixation and Multiple Organ Failure. Anesthesia and Analgesia. https://doi.org/10.1213/ANE.0000000000005252
H. Pape, F. Hildebrand, S. Pertschy, et al (2004) Changes in the Management of Femoral Shaft Fractures in Polytrauma Patients: From Early Total Care to Damage Control Orthopedic Surgery. Journal of Trauma. https://doi.org/10.1097/01.TA.0000025660.37314.OF
D. Lubelski, S. Tharin, John J Como, et al (2017) Surgical timing for cervical and upper thoracic injuries in patients with polytrauma. Journal of Neurosurgery : Spine. https://doi.org/10.3171/2017.4.SPINE16933
J. Tan, Tianyi Wu, J. Tan, et al (2020) Definitive Surgery Is Safe in Borderline Patients Who Respond to Resuscitation. Journal of Orthopaedics and Trauma. https://doi.org/10.1097/BOT.0000000000001999
B. Coimbra, Junsik Kwon, Bishoy L Zakhary, et al (2025) Damage control does not offer a survival advantage and increases the risk of serious complications compared with early total care in severely injured patients with femoral shaft fractures. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000004594
S. Halva, R. Pfeifer, F. Klingebiel, et al (2024) Assessment of Safe Early Fixation Strategies in a Cohort Polytraumatized Patients – How is the Surgical Treatment Influenced by the Injury Pattern? British Journal of Surgery. https://doi.org/10.1093/bjs/znae118.065
Emanuele Lagazzi, D. Argandykov, Amory de Roulet, et al (2023) Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000004100
David G. Rojas, Julia R. Coleman, Ernest E. Moore, et al (2019) Complications Associated With Early Versus Delayed Fixation of Pelvic Ring Injuries. https://doi.org/10.26226/morressier.5cffabaef6074e97f94aae68
Jakob Hax, M. Teuben, Sacha Halvachizadeh, et al (2023) Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries. Global Spine Journal. https://doi.org/10.1177/21925682231216082
Sven Hager, H. Eberbach, R. Lefering, et al (2020) Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. https://doi.org/10.1186/s13049-020-00737-6
O. Burianov, S. Dubrov, T. Omelchenko, et al (2020) DOES THE TERM OF DEFINITIVE OSTEOSYNTHESIS OF MULTIPLE LONG BONE FRACTURES OF LOWER EXTREMITIES IMPACT ON TREATMENT OUTCOMES IN POLYTRAUMA PATIENTS. EUREKA: Health Sciences. https://doi.org/10.21303/2504-5679.2020.001332
F. Lavini, E. Carità, C. Dall'oca, et al (2007) Internal femoral osteosynthesis after external fixation in multiple-trauma patients. Strategies in Trauma and Limb Reconstruction. https://doi.org/10.1007/s11751-007-0012-x
Natalie Enninghorst, László Tóth, K. King, et al (2009) TS11 *ACUTE INTERNAL FIXATION OF PELVIC RING FRACTURES: SAFE AND EFFICIENT. https://doi.org/10.1111/J.1445-2197.2009.04934_11.X
Rafik Abu-Ramadan, Z. A. Qureshi, S. Majdi (2015) Orthopaedic Approach in Patients with Multiple Injuries
H. Pape, D. Rixen, J. Morley, et al (2012) IMPACT OF THE METHOD OF INITIAL STABILISATION FOR FEMORAL FRACTURES IN POLYTRAUMA PATIENTS AT RISK FOR COMPLICATIONS (BORDERLINE PATIENTS): A PROSPECTIVE RANDOMISED ANALYSIS BY THE EPOFF STUDY GROUP
G. Volpin, H. Shtarker, Neda Trajkovska, J. Saveski (2011) DAMAGE CONTROL ORTHOPAEDICS IN POLYTRAUMATIZED PATIENTS
C. Probst, Tarané Probst, A. Gaensslen, et al (2007) Timing and duration of the initial pelvic stabilization after multiple trauma in patients from the German trauma registry: is there an influence on outcome? Journal of Trauma. https://doi.org/10.1097/TA.0B013E31802EFAEE
Giles L. Devaney, J. Bulman, K. King, Z. Balogh (2020) Time to definitive fixation of pelvic and acetabular fractures. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000002860
J. Godzik, Jonathan F. Dalton, Courtney Hemphill, et al (2019) Early surgical intervention among patients with acute central cord syndrome is not associated with higher mortality and morbidity. Journal of Spine Surgery. https://doi.org/10.21037/JSS.2019.09.26
Teng-fei Zhu, Wengiu Zhao, Han-Lin Zheng, Jia-Xiang Wu (2018) [Application of damage control orthopedics for the treatment of severe multiple fractures]. Zhongguo gu shang = China journal of orthopaedics and traumatology. https://doi.org/10.3969/j.issn.1003-0034.2018.02.010
G. Feldman, R. Mosheiff, Khalil Nasrallah, et al (2021) Evolution of treatment of femoral shaft fracture in polytrauma: Did damage control orthopaedics improve the outcome? A retrospective study. Injury. https://doi.org/10.1016/j.injury.2021.04.031
Y. Zhang, Kai Sun, Yuling Wang, et al (2017) Early vs late fracture fixation in severe head and orthopedic injuries. American Journal of Emergency Medicine. https://doi.org/10.1016/j.ajem.2017.12.067
M. Tuttle, Wade R. Smith, Allison E. Williams, et al (2009) Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient. Journal of Trauma. https://doi.org/10.1097/TA.0b013e3181aa21c0
G. Taeger, S. Ruchholtz, C. Waydhas, et al (2005) Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. Journal of Trauma. https://doi.org/10.1097/01.TA.0000175088.29170.3E
J. Dimar, L. Carreon, J. Riina, et al (2010) Early Versus Late Stabilization of the Spine in the Polytrauma Patient. Spine. https://doi.org/10.1097/BRS.0b013e3181f32bcd
S. Cimbanassi, Robert V. OʼToole, M. Maegele, et al (2019) Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000002407
T. Scalea, S. Boswell, J. Scott, et al (2004) External Fixation as a Bridge to Intramedullary Nailing for Patients with Multiple Injuries and with Femur Fractures : Damage Control Orthopedics. https://doi.org/10.1097/00005131-200409001-00002
H. Vallier, T. Moore, John J Como, et al (2015) Teamwork in Trauma: System Adjustment to a Protocol for the Management of Multiply Injured Patients. Journal of Orthopaedics and Trauma. https://doi.org/10.1097/BOT.0000000000000383
R. Pfeifer, F. Klingebiel, Z. Balogh, et al (2024) Early major fracture care in polytrauma—priorities in the context of concomitant injuries: A Delphi consensus process and systematic review. Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000004428
Mazin Osman, Khald Alhamoud Almatar, Fahad Almatar, et al (2025) Outcomes of Early Versus Delayed Definitive Surgical Intervention in Multisystem Trauma Patients: A Systematic Review of Timing Strategies in General Surgery Emergencies. Cureus. https://doi.org/10.7759/cureus.90136
F. Klingebiel, Markus F. Oertel, Y. Kalbas, et al (2025) Timing of definitive fracture fixation in patients with concomitant traumatic brain injuries – A systematic review of the literature by the IMPACT group. European Journal of Trauma and Emergency Surgery. https://doi.org/10.1007/s00068-025-02981-w
H. Pakzad, D. Roffey, H. Knight, et al (2011) Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes. Canadian journal of surgery Journal canadien de chirurgie. https://doi.org/10.1503/cjs.008810
L. Scaramuzzo, F. Tamburrelli, E. Piervincenzi, et al (2013) Percutaneous pedicle screw fixation in polytrauma patients. European spine journal. https://doi.org/10.1007/s00586-013-3011-2
L. Bone, P. Giannoudis (2011) Femoral shaft fracture fixation and chest injury after polytrauma. Journal of Bone and Joint Surgery American volume. https://doi.org/10.2106/JBJS.J.00334
Saam Morshed, Christopher M. Mikhail, Theodore Miclau III (2015) Timing of Femoral Shaft Fracture Fixation Affects Length of Hospital Stay in Patients with Multiple Injuries. The Open Orthopaedics Journal. https://doi.org/10.2174/1874325001509010324
T. Frangen, S. Ruppert, G. Muhr, C. Schinkel (2007) [Respiratory failure in thoracic spine injuries. Does the timing of dorsal stabilization have any effect on the clinical course in multiply injured patients?]. Der Orthopade. https://doi.org/10.1007/S00132-007-1049-8
H. Pape, K. Grimme, M. Griensven, et al (2003) Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. Journal of Trauma. https://doi.org/10.1097/01.TA.0000075787.69695.4E
P. Weninger, M. Figl, R. Spitaler, et al (2007) Early unreamed intramedullary nailing of femoral fractures is safe in patients with severe thoracic trauma. Journal of Trauma. https://doi.org/10.1097/01.TA.0000243203.38466.E0
H. J. Iqbal, J. Alsousou, Sohan Shah, et al (2018) Early Surgical Stabilization of Complex Chest Wall Injuries Improves Short-Term Patient Outcomes. Journal of Bone and Joint Surgery American volume. https://doi.org/10.2106/JBJS.17.01215
Ki-Chul Park, Ye-Soo Park, W. Seo, et al (2014) Clinical results of early stabilization of spine fractures in polytrauma patients. Journal of critical care. https://doi.org/10.1016/j.jcrc.2014.03.003
R. Yamamoto, K. Udagawa, Yusho Nishida, et al (2021) Clinical parameters and optimal candidates for early definitive fixation of extremity injury: A nationwide study. Journal of Orthopaedic Science. https://doi.org/10.1016/j.jos.2021.10.002
J. Byrne, A. Nathens, David Gomez, et al (2017) Timing of femoral shaft fracture fixation following major trauma: A retrospective cohort study of United States trauma centers. PLoS Medicine. https://doi.org/10.1371/journal.pmed.1002336
Gustavo Sardinha Lisboa Leite, Diego Olandoski de Oliveira, Mariana Demétrio de Sousa Pontes, C. F. P. S. Herrero (2025) Early vs. late surgery in thoracic spine fractures: impact on clinical outcomes in polytrauma patients. European Journal of Trauma and Emergency Surgery. https://doi.org/10.1007/s00068-025-03003-5
Victor S. Ritter, F. Lin, Anna Miller, R. Ostrum (2022) Fixation of humerus shaft fractures in polytrauma patients does not improve short-term outcomes. Injury. https://doi.org/10.1016/j.injury.2022.11.060
Ahmad S. Alobaidi, Ammar Al-Hassani, A. El-Menyar, et al (2016) Early and late intramedullary nailing of femur fracture: A single center experience. International Journal of Critical Illness and Injury Science. https://doi.org/10.4103/2229-5151.190649
S. Bhamre, Salil Ibrahim (2024) A PROSPECTIVE COMPARATIVE STUDY OF EARLY TOTAL CARE VS DAMAGE CONTROL ORTHOPEDICS IN POLY-TRAUMATIZED PATIENTS. Indian Journal Of Applied Research. https://doi.org/10.36106/ijar/2802957
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