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Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process
Roman Pfeifer1, Felix Karl-Ludwig Klingebiel, Zsolt J Balogh
1From the Department of Trauma Surgery (R.Pf., F.K.-L.K., Y.K., H.-C.P.), Harald-Tscherne Laboratory for Orthopaedic and Trauma Research (R.Pf., F.K.-L.K., Y.K., H.-C.P.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Traumatology (Z.J.B.), John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia; Department of Orthopaedic and Trauma Surgery (F.J.P.B.), Lucerne Cantonal Hospital, Lucerne, Switzerland; Riverside University Health System Medical Center and Loma Linda University School of Medicine (R.C.), Loma Linda, California; Department of Orthopaedics and Traumatology (C.F.), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong; Academic Department of Trauma and Orthopaedics (P.V.G.), School of Medicine, University of Leeds; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom; Department of Trauma Surgery (F.Hie.), University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Orthopaedics (F.Hil.), Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany; Emergency Surgery Unit (H.K.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Trauma Surgery (T.L.), Aarau Cantonal Hospital, Aarau, Switzerland; Department of Trauma (I.M.), Hand, and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany; Department of Neurosurgery (M.F.O.), Clinical Neuroscience Center (M.F.O.), University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Surgery (R.Pe.), Trauma Surgery, Hamad Medical Corporation, Doha, Qatar; Department of Surgery (R.Pe.), Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic; Department of Orthopedics and Spine Surgery (S.R.), Ganga Hospital, Coimbatore, India; Department of Surgery, Division of Orthopaedic Surgery (E.H.S.), University of Western Ontario, London, Ontario, Canada; Department of Orthopaedic Surgery (H.A.V.), Case Western Reserve University, Cleveland, Ohio; and Department of Orthopaedics (B.A.Z.), UT Health San Antonio, San Antonio, Texas.
Insights
Early fracture fixation within 24 hours is recommended for polytrauma patients, even with associated injuries. Expert consensus guides optimal timing for major fracture care to improve patient outcomes.
Area of Science:
- Trauma Surgery
- Orthopedic Surgery
- Evidence-Based Medicine
Background:
- Timing of major fracture care significantly impacts polytrauma patient outcomes.
- Standardized treatment strategies for concomitant injuries are lacking.
- This study addresses the critical need for expert recommendations on fracture care timing in complex trauma.
Purpose of the Study:
- To provide expert recommendations on the timing of major fracture care in polytrauma patients.
- To address specific concomitant injuries including brain, thorax, abdomen, spine, vasculature, and multiple fractures.
- To establish evidence-based guidelines for optimal surgical intervention timing.
Main Methods:
- Systematic review of Medline and EMBASE databases.
- Delphi method involving 17 international multidisciplinary experts.
- Consensus development with a ≥75% agreement threshold and GRADE evidence rating.
Main Results:
- 73 publications were included from 12,476 identified.
- 47 publications recommended early surgery, with 45 defining this within 24 hours.
- 20 consensus statements were developed, with 15 achieving 100% expert agreement.
Conclusions:
- Major fracture care should be initiated and completed within 24 hours of admission.
- Exceptions are permitted only if clinical status or severe associated injuries preclude surgery.
- These statements provide crucial guidance for managing complex polytrauma patients.
Background:
The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures.
Methods:
This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach.
Results:
A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2).
Conclusion:
A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room.
Level Of Evidence:
Systematic Review/Meta-Analysis; Level IV.
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