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I. STATEMENT OF THE PROBLEM The optimal timing for long-bone stabilization in polytrauma patients has been debated for the last two decades. Much of the relevant literature focused on long-bone fracture as a femoral fracture; however, a substantial portion of published studies include various fractures (tibia, humerus, spine, and/or pelvis). Reported benefits of early long-bone stabilization in polytrauma patients include increased patient mobilization by eliminating the need for traction and decreased pulmonary morbidity (fat emboli syndrome, pneumonia, adult respiratory distress syndrome [ARDS]), late septic sequelae, hospital care costs, mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and ventilator days. Some authors suggest that early long-bone stabilization in polytrauma patients increases blood loss, fluid administration, and surgical stress, pulmonary morbidity, and mortality. However, others intimate that pulmonary morbidity (pulmonary shunt) is similar in those undergoing early or late stabilization (i.e., no worse, no better). There have been additional concerns regarding the timing of long-bone stabilization in patients with brain or chest injury. Problems with early fixation of long bones in patients with brain injury include secondary brain injury as a result of hypoxemia, hypotension, and/or complexity of controlling intracranial hypertension, increased mortality, and increased fluid administration, which might exacerbate cerebral edema. Other investigators suggest that early long-bone stabilization is not advised in patients with pulmonary contusion, multiple rib fractures, or hemopneumothorax, since there is increased pulmonary morbidity (ARDS, fat embolism syndrome), especially when intramedullary nailing and reaming are used. However, others indicate that chest injury patients with early intramedullary nailing have similar outcomes compared with later intramedullary nailing or other stabilization techniques (i.e., no worse or better). Other studies suggest that pulmonary contusion patients have similar pulmonary morbidity (PaO2/FIO2 and duration of mechanical ventilation) with early or late stabilization (i.e., no worse or better).

the journal of trauma/the journal of trauma

Practice Management Guidelines for the Optimal Timing of Long-Bone Fracture Stabilization in Polytrauma Patients: The EAST Practice Management Guidelines Work Group