Which factors influence timing in polytrauma?

BACKGROUND: The concept of damage control surgery has gained popularity in the last two decades. According to literature, in polytrauma, definitive fixation should be performed between the 4th or 5th day and the 10-12th from trauma, this window showed the lowest rate of complications rate (e.g. systemic inflammatory response syndrome and acute respiratory distress syndrome). This study aims to describe the factors that influence timing in patients with multiple injuries.METHODS: In this retrospective study, all patients admitted in 18 months as polytrauma to emergency department of level one trauma center were recruited. Inclusion criteria was an initial temporary fracture fixation and a subsequent definitive fixation of at least one fracture between pelvis, femur or tibia. The following data has been collected: demographic data, type of pelvic, femur or tibia fractures, presence of other fractures, fixation timing, admission to intensive care unit (ICU), number of days spent in ICU, Injury Severity Score (ISS), skin lesions, internal organ lesions/diseases (cerebral, thoracic, abdominal or systemic diseases), presence of fever (temperature higher than 38 °C). Surgical orthopedic and non-orthopedic reports were reviewed. Correlations between delay in definitive fixation and the presence of internal organ lesions/diseases, fever before fixation, skin lesions, the necessity of other orthopedic and non-orthopedic surgeries were tested.RESULTS: The study analyzed a total of 82 patients (19 pelvic fracture, 29 femur fracture and 56 tibia fracture). Mean definitive fixation timing was 10.2 days for pelvis, 10 days for femur and 10.5 days for tibia. Upon univariate analysis, the presence of internal organ lesions/diseases (P=0.0036) or temperature before fixation (P=0.0055) significantly delayed the correct pelvic fixation timing; as for tibia fractures, the presence of skin lesions (P=0.0037), internal organ lesions/diseases (P=0.0451), non-orthopedic surgery (P=0.0007) or temperature before fixation (P=0.0296) also significantly delayed the correct bone fixation timing; with regards to femur fixation timing, there was no statistically significant association. Upon multivariate analysis, the presence of skin lesions (P=0.041) and non-orthopedic surgery (P=0.009) significantly delayed the correct tibia fixation timing.CONCLUSIONS: Our data show that the presence of skin lesions or internal organ lesions, the necessity of non-orthopedic surgeries and fever are the main causes of delay in definitive fixation in polytrauma. Therefore, in order to reduce complications and to improve the outcomes, treatment of those factors should be optimized.