58 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67

Timing Issues in Fracture Management

A Review of Current Concepts

Eric W. Fulkerson, M.D., and Kenneth A. Egol, M.D.

I
Abstract n a 2005 national survey, fractures represented a signifi-
The timing of operative fracture care is often confounded by cant proportion of severe injuries, with over one million
multisystem injuries, conflicting or absent literature, and lack hospital admissions related to musculoskeletal injury.
of communication between orthopaedic surgeons and other For 2004-2005, fractures were and continue to be the lead-
physicians providing care to the patient. Much has been pub- ing cause of injury-related hospital admissions, and account
lished regarding the proper sequence of events in providing for over half of all injury admissions.1 In people under age
care to patients with multisystem injuries. Only recently has 65, lower extremity fractures are the leading cause of trauma
the role of complex musculoskeletal injuries and the timing of admissions. Timing of operative fracture care is pertinent to
fixation in multiply-injured patients been explored in detail. both outcome and fiscal issues. By appropriately prioritiz-
Timing of care for pelvic injuries is frequently determined by ing care and optimizing fracture management, decreases in
the presence of injury to other organ systems, the presence morbidity, mortality, and hospital stays result in improved
of open wounds, and hemodynamic status. There is likely utilization of resources and reduced societal costs in asso-
an optimal time window for fixation. However, existing data ciation with a frequent injury of this population. From the
is often difficult to compare, given varying definitions and patient’s perspective, appropriate timing of fracture care can
protocols. Furthermore, reports are often conflicting, making improve long-term outcomes. This review focuses primarily
the determination of an optimal time-window difficult. Similar on controversies and critical issues regarding the timing of
concerns are present with lower extremity long bone fractures. operative fracture management. In addition, timing relative to
Injury to other organ systems must be considered with timing pelvis, acetabulum, and femoral shaft fracture care are often
of femur fixation, particularly in the presence of lung injury. affected by the presence of organ system injuries, and will
Tibia fractures are frequently complicated by the presence of be discussed in the setting of the multiply-injured patient.
a tenuous soft tissue envelope and other injury factors that General concerns related to the timing of fracture care
often alter the timing of fixation. These issues and, last, the include the presence of soft tissue injury and open fractures.
timing of care for calcaneus and talus injuries are reviewed, Condition of the soft tissues in closed injuries is often the
as risk of avascular necrosis and quality of articular reduction primary determinant of delays in management and the meth-
are related to the timing of fixation. ods chosen for fracture fixation. Open fractures conversely
increase the urgency of fracture care. The timing of debride-
Eric W. Fulkerson, M.D., was a Chief Resident in the Department ment, closure, and coverage are controversial, with variable
of Orthopaedic Surgery, NYU Hospital for Joint Diseases, and is data supporting previous protocols.2-6 Gunshot wounds
currently in private practice with Muir Orthopaedic Specialists, represent a unique subset of open fractures, the approach to
Walnut Creek, California. Kenneth A. Egol, M.D., is Associate
which is partially determined by the energy of the injury.
Professor, New York University School of Medicine, and Vice
Some fracture types warrant separate discussion. Femoral
Chairman for Education, Department of Orthopaedic Surgery,
NYU Hospital for Joint Diseases, NYU Langone Medical Center, neck fractures are treated differently, depending on patient
New York, New York. age and the energy of injury. Femoral shaft fracture treatment
Correspondence: Kenneth A. Egol, M.D., Department of Orthopae- timing is often affected by other injuries and the general
dic Surgery, Suite 1402, NYU Hospital for Joint Diseases, 301 East condition of the patient. Fractures of the tibia are particu-
17th Street, New York, New York 10003; kenneth.egol@nyumc.org. larly troublesome due the largely subcutaneous position of

Fulkerson EW, Egol KA. Timing issues in fracture management: a review of current concepts. Bull NYU Hosp Jt Dis. 2009;67(1):58-67.
 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67 59

Figure 1 A 19-year-old female presenting with hemodynamic instability. A sheet was placed prior to laparotomy, followed by external
fixation during the same procedure. Definitive fixation followed 1 week after admission. A, admission radiograph demonstrating an open
book pelvis. B, Temporary external fixation and reduction of the symphysis. C and D, Definitive fixation of the right anterior column
and pubic symphysis.

the tibia. Finally, injuries to the hindfoot often present with “triad of death” is a term coined to describe patient decom-
fixation timing concerns as well. pensation in the presence of acute blood loss, resulting in
hypothermia, coagulopathy, and acidosis.8-10 Prevention or
Fracture Care in the Multiply-Injured Patient reversal of these factors avoids death by exsanguination.11
Multiply-injured patients can be divided into two general and More recent studies account for the influence of orthopaedic
distinct categories: those that are hemodynamically stable and injuries on this triad.12 In some cases, delaying or limiting
those that are unstable. Strict adherence to Advanced Trauma early orthopaedic intervention can be beneficial. Applying
Life Support® (ATLS®) principles is mandatory, as overlooked these principles has been termed as “bail out” or “damage
injuries or inadequate treatment of injuries will be detrimental control” orthopaedic surgery, and represents a crucial part
or life threatening. The role of the orthopaedic surgeon in of appropriate management of the multiply-injured patient.13
this setting is to determine the nature of the bony injury and Prior to the extensive studies in the multiply-injured pa-
the subsequent urgency of care in the setting of concomitant tient, the previous gold standard was fixation of long bones
injuries. Of particular importance in the early phase of trauma within 24 hours of injury.14,15 This was thought to minimize
care is the presence of pelvic or long bone fractures and the ongoing hemorrhage and possibly fat embolization. Due to
extent of associated soft tissue injury. The presence of vascular the high incidence of complications associated with early
injury, neurologic deficits, and compartment syndrome are fixation, this approach in multiply-injured patients has been
also within the province of the orthopaedic evaluation. called into question.16 With early fixation of long-bone frac-
tures, blunt trauma patients faired worse than those patients
Hemodynamic Stability who had surgical delays. Blunt trauma patients have a high
Most of the classic literature on hemodynamic stability is incidence of thoracic and soft tissue injury, and represent
based on evaluation of penetrating trauma (Fig. 1).7 The the “first hit.” Early definitive fixation of long bones, par-
60 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67

ticularly intramedullary (IM) nailing, resulted in higher

rates of multiple organ failure and acute respiratory distress
syndrome (ARDS).17 It was postulated that the second hit
to the lungs and other end organs were related to surgical
procedures for fixation of long bones.18 Pape and colleagues
performed a meta-analysis of 114 papers in the trauma lit-
erature concerning the validity of early fracture fixation in
the setting of the multiply-injured patient.8 Indicators that
are useful in dictating the timing of fracture fixation were
determined from the collective data of these studies.
Damage control orthopaedics (DCO) was a primary focus
of this meta-analysis review. Its development was in response
to poorer outcomes observed with early definitive fracture fix-
ation and the associated “second hit.”19,20 Temporizing external
fixation allowed for the avoidance of lengthy procedures that
may have worsened the triad of death. Particularly damaging
were procedures lasting more than 6 hours, as these were as-
sociated with increased rates of ARDS and multisystem organ
failure (MOF).21,22 The investigators concluded that factors
of direct concern to orthopaedic surgeons were associated
with adverse outcomes; these were, namely, the presence of
multiple long bone fractures, pelvic trauma in the presence of
hemorrhagic shock, presumed operative time of greater than Figure 2 A 44-year-old female sustained bilateral floating knee
6 hours, and PA pressures over 6 mmHg during IM nailing, injuries after striking a bridge piling with her car. In addition to
which is indicative of significant lung injury.8 By examining orthopaedic injuries, she suffered a left hemoneumothorax, with
the indicators of adverse outcome, four physiologic factors multiple rib fractures and a grade 2 liver laceration. Bilateral ex-
resulting in decompensation in multiply-injured patients were ternal fixators provided temporary stabilization during the same
anesthetic as the exploratory laparotomy. Definitive fixation was
identified. In addition to the previously described triad of delayed until hospital day 5.
death, soft tissue injury was a fourth and equally important fac-
tor affecting blunt trauma patients. This factor is intentionally sociated with IM nailing while providing bony stability. In
nebulous, as fractures, compromise of extremity soft tissue, general, the management of lung injury takes precedence over
and chest injury all significantly affect the early phase course. definitive bony stabilization.35 This may necessitate temporary
Thus, fracture care is an important component in successfully management with external fixation or traction. Post-injury
managing multiply-injured patients. inflammatory status is also a predictor of MOF in multiple
Timing of fracture care is dependent on adequate resusci- trauma patients and has been given the term systemic inflam-
tation. Patient data readily available as markers of adequate matory response syndrome (SIRS). IL-6 as a study marker
response to resuscitation are a serum lactate of under 2.5 of inflammation remains elevated during post-injury days 2
mmol/L and base deficit of less than 8 mEq/L.23-26 Urine out- through 4, indicating ongoing fluid imbalance and a sustained
put, pulse rate, and blood pressure should ideally all normal- inflammatory response. Surgical procedures performed dur-
ize prior to fracture stabilization.27 Of particular importance ing this period are associated with a higher complication rate.
to outcome are reversal of coagulopathy and correction of In the event that procedures are carried out during the acute
core body temperature. One study noted a 100% mortality inflammation phase, adverse events are more likely.36 This
rate if core body temperature was not restored during the has been termed the second hit. The first traumatic event is
early phase.28 Assessment of these factors and the initial the injury, followed by a second traumatic event, surgery. In a
response to resuscitation allows placing patients into one review of 4,134 patients undergoing surgery on days 2 through
of four categories during the early phase of resuscitation: 4, MOF was avoided if secondary procedures were delayed
stable, borderline, unstable and in extremis.8 until post-injury day 6.37 A second study found normalization
Some associated injuries are particularly problematic. of cytokine levels by day 6.38 The findings of these studies are
Only one study investigated the influence of thoracic trauma consistent with the second-hit theory and suggest that second-
as an independent marker of increased morbidity, and noted ary procedures, such as nailing long bones or definitive pelvic
increased rates of MOF in the presence of thoracic trauma.29 stabilization, be delayed until at least day 6 in patients with
Multiple studies demonstrate worsened lung function with abnormal laboratory values or incomplete resuscitation.
thoracic trauma and its association with higher mortality
rates.30-33 Therefore, employment of DCO is warranted in the Pelvic Fractures
presence of significant thoracic trauma (Fig. 2).34 External Pelvic fractures represent the third most common cause of
fixation is a viable option, as it avoids further lung insult as- death in motor vehicle collisions, with mortality rates rang-
 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67 61

ing from 5% to 42%.39-45 The wide range in mortality can be in pelvic fractures, and, therefore, recommend emergent
ascribed to numerous factors, including age, injury severity external fixation for hemodynamically unstable patients.63,64
score, bony instability, open fractures, and bowel injury.46-51 If the response to external fixation is inadequate, angiogra-
As high energy pelvis injuries are rarely isolated, patient phy should follow. This continues to remain a controversial
status ranges from stable to in extremis, depending on the issue, and is likely to vary between trauma centers.63,64 It is
extent and type of involved multiple organ system injuries. important that institutions have a protocol agreed upon by
Avoiding iatrogenic harm to the patient via inappropriate the various services, so care of these complex patients can
surgical timing and sequence requires an organized, multi- be delivered efficiently.
disciplinary approach. Orthopaedic surgeons play a crucial For most abdominal procedures, a pelvic binder will
role by engaging early in decision-making regarding timing not interfere with the operation In the presence of unstable
of fracture fixation. Prior to the work of Letournel and Judet fracture patterns, placement of an external fixator should be
in the 1970s, pelvic fractures were managed nonoperatively allowed during the same round of anesthesia. For patients
with predictably dismal outcomes.52-54 Over the last 30 years, in extremis, external fixators may be placed bedside in the
much has been written about the management of pelvic in- intensive care unit (ICU) if clearance for the operating room
juries. However, interpretation of this literature is confused (OR) is unlikely.53 Open pelvis fractures are associated with
by an inconsistent use of terms. “Early” surgery ranges from high mortality rates due to hemorrhage in the early phase,
8 hours in some studies55 to a week in others36,56 or as late and overwhelming sepsis in the days and weeks to follow.
as 21 days in another study.57 “Late” might encompass the Emergent irrigation and debridement with definitive fixa-
period of 2 weeks58 to 3 months.59 Terms such as clinical tion, even in the presence of clean wounds, is warranted.
and functional outcome are sometimes used interchange- Fecal diversion and repair of vaginal lacerations may also
ably, further complicating the interpretation of existing data. be needed.65
Moreover, these are rarely isolated injuries, adding to the Management of pelvic fractures frequently occur in the
complexity of decision making. setting of the multiply-injured patient and add to the com-
Several factors play into the initial approach to bony plexity of managing this injury. With hemodynamic instabil-
stabilization, including hemodynamic status and response ity or associated injuries preventing extended procedures,
to resuscitation, fracture pattern, associated injury, and external fixation as a temporizing measure should be done
inflammatory status. Hemodynamic status is of particular early. The timing of angiography remains controversial but
concern, as the pelvis may be the primary source of bleeding should be performed early, whether before or after external
or be contributing very little to bleeding. In the presence of fixation. With open fractures, definitive stabilization can
ongoing thoracic or abdominal hemorrhage, orthopaedic be performed in the early phase provided there is adequate
management beyond placement of a pelvic binder is delayed. resuscitation and clean wounds. In cases where definitive
Associated long bone fractures should be immediately fixation is delayed, there is controversy as to the ideal time
splinted with coverage of open wounds. Frequently, radio- window for surgery. Recent data suggests allowing the acute
graphs are delayed. Data presented recently suggest that inflammatory phase to pass. Five studies exist comparing
temporary placement of a pelvic binder is safe, regardless early versus late fixation, none of which represent Level
of fracture pattern, and may reduce mortality in conjunction I evidence.55,56,66-68 Furthermore, data is confused by an
with early angiography.60 inconsistent definition of “early” in these studies. Of these
Not uncommonly, debate will arise in the early manage- studies, only one presented outcome at 2-year follow-up.63
ment of the multiply-injured patient with an unstable fracture The overall conclusion of these studies is that fixation within
pattern regarding the proper sequence of events. A study 2 to 3 weeks offers the best chance for improved radiographic
looking at this scenario found that unstable fractures are likely and functional outcomes for pelvis and acetabulum fractures.
to be the primary source of bleeding. A 60% mortality rate After 3 weeks, callus and scar formation severely limit the
was encountered if laparotomy preceded pelvic angiography, ability to obtain an anatomic reduction, require more exten-
compared with a 25% mortality rate if the sequence was sile approaches, and result in worsened functional outcomes.
reversed. Although this study was limited by a small number For high energy pelvis and acetabulum fractures, a delay
of patients, angiography prior to exploratory laparotomy was in definitive fixation is the rule rather than the exception.
recommended in the presence of unstable fracture patterns.61 Based on available literature, the ideal window for secondary
Another frequent controversy is the timing of angiogra- procedures is 6 days to 3 weeks post-injury.
phy versus external fixation. Miller reviewed 1,171 pelvic
ring injuries and found that if contrast blush was present on Open Fracture Debridement
initial CT, patients that were nonresponders to resuscitation The standard of care over the last century for open fractures
had a 73% rate of positive angiography. They concluded has been emergent irrigation and debridement within 6 to 8
that in patients with a contrast blush on CT associated with hours.69 However, no human studies supporting this protocol
any degree of hemodynamic instability, angiography should exist. These timing recommendations are likely derived from
precede pelvic external fixation.62 In contradictory studies ar- the pre-asepsis war era, data on bacterial doubling times,
terial bleeding amenable to embolization is a rare occurrence and limited animal studies.70 Several studies that call into
62 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67

question the urgency of open fracture care exist. Skaggs and complication rates increased. This introduced the principle of
associates reviewed 554 open fractures in children and found the second look, with closure between day 4 and 7 or closure
only an association of time of antibiotic administration with by secondary intention if the wound bed was not clean.74
decreases in infection rates.2 Debridement was performed This is currently a widely practiced approach. Advances
as late as 24 hours post-injury. This study was limited by in wound care have improved soft tissue management with
involving only pediatric fractures, and no attempt was made open fractures. At present, the best predictor of outcome is
to examine other variables. Noumi and coworkers reviewed the adequacy of irrigation and debridement.75
88 patients and examined factors contributing to deep infec- Confusion in the interpretation of the literature exists
tion after IM nailing of open long bone fractures. Only the due to poor observer reliability in grading open fractures
fracture grade was consistent with increased infection risk. and the existence of few well-conducted studies regarding
AO classification was predictive of nonunion. However, no the timing of closure. Of the six studies regarding timing
association was found between timing of debridement and of open fracture closure in the English literature, five were
the risk for infection or nonunion.3 Harley and colleagues retrospective case series or a mixed series.76,77 The only
reviewed 241 long bone fractures and recorded transport prospective study failed to grade wounds,5 and one study
time from the field to hospital admission, which was fre- had only 62 patients.6 However, some conclusions of these
quently in excess of 8 hours. A weak association between studies are noteworthy. Benson and associates found that
debridement time after 13 hours and infection was found. infection was independent of closure method.5 Cullen found
The role of extended transport time and delay in antibiotics no increased infection rate with primary wound closure of
was not explored.4 Data from the LEAP (Lower Extremity clean wounds in children after irrigation and debridement.78
Assessment Project) group, a multicenter limb salvage study, DeLong reviewed six management methods, and found no
yielded 315 open fractures. After multivariate analysis, only correlation with infection rates.79
time of injury to admission was discovered to correlate with Some studies examined the factors that affect the timing
infection risk. Time to debridement was not predictive of of wound closure. Gustilo and Anderson noted that wounds
infection. The investigators cited resuscitation and early left open greater than 2 weeks were likely to develop nosoco-
administration of broad spectrum antibiotics, or either, as mial infections.77 Patzakis followed culture results obtained
possible reasons for the importance of admission time.71 at initial irrigation and debridement, and found only an
Only one study correlates risk of infection with time to de- 18% correlation of isolates obtained initially with species
bridement. For open tibia fractures, Kindsfater and Jonassen identified in late deep infections.80 These studies suggest the
found increased infection rates if debridement was delayed wound may be most sterile after the initial irrigation and de-
more than 5 hours post-injury. However, there were multiple bridement. Although no Level I studies exist, primary closure
dissimilarities between treatment time groups that were not is warranted on the basis of available data in clean wounds
accounted for and likely represent confounding variables.72 when atraumatic closure is possible. Delayed closure after
Of the limited data that exist, most studies conclude that a second look should be employed if the quality of tissue is
time to debridement is not an independent predictor of in question after the initial irrigation and debridement.
deep infection for open fractures. More important is time
to admission and the early administration of antibiotics. Flap Coverage of Open Wounds
Timing of debridement should be determined by ad- When flap coverage is required, it may be performed either
equacy of resuscitation, presence of appropriate and alert during fracture stabilization or as a secondary procedure.
staff, and OR availability. Open fractures should be consid- One study investigated free flap coverage at three time
ered an urgency rather than an emergency in the absence of intervals in 532 patients: immediately, within 72 hours
limb-threatening injury. Although no Level I data exists, it of fracture stabilization, and after 72 hours. Earlier bone
is unlikely that the quality of data will improve, as there are healing and reduced infection rates were seen if coverage
numerous uncontrollable factors preventing such a study.70 was completed within 72 hours of fracture stabilization.
A secondary benefit was a 10-fold decrease in length of
Timing of Open Fracture Wound Closure stay.81 Another study involving 84 patients with type IIIb
Timing of delayed versus primary closure of open fractures or IIIc tibia fractures found an increase in infection rate if
is largely derived from wartime experience in the pre- flap coverage was delayed (30%, more than 72 hours vs
asepsis era as well. Trueta advocated closed treatment of 6%, fewer than 72 hours).82 Available data suggests flap
open fractures.73 This introduced the principle of thorough coverage should occur within 72 hours in the presence of a
debridement of devitalized tissue, after which the wound was clean wound bed and a stabilized fracture. Immediate skin
encased in a cast not to be removed until healing occurred. grafting obviates a separate procedure.
According to Truetta, the cast was left in place, “unless it
became wet and soft, or there was an intolerable stench, or Fractures Associated with Gunshot Wounds
the patient’s condition showed that some complication had Gunshot wounds always involve some degree of soft tis-
developed.” With the introduction of penicillin, in 1943, sue injury (Fig. 3). The extent of injury is best described
debridement was no longer emphasized, and local wound in terms of energy and velocity; high mass projectiles will
 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67 63

Multiple debridements are often required in these cases,

and are generally repeated every 48 hours on days 2 through
10 or until the wound edges are viable. Closure within 10
days has been associated with decreased length of stay, ear-
lier mobilization, and lower risk of nosocomial infection.88

Femoral Neck Fractures

Femoral neck fractures represent a wide spectrum of inju-
ries, the consideration of which can be grossly divided into
those that occur in the younger population versus those
occurring in the elderly and the issue of high versus low
energy. These categorizations may influence the urgency of
fracture care. Hip fractures in the elderly are associated with
a high mortality rate and are associated with poor functional
outcomes. A recent investigation representing four centers
and 1,206 patients is the first prospective trial associating
timing of femoral neck and intertrochanteric hip fractures
Figure 3 A 24-year-old male after a gunshot wound to the right
with outcomes.93 Fixation was performed either within 24
shoulder from an assault rifle. Extensive soft tissue injury and hours of admission or after more than 24 hours following ad-
severe comminution prevented preservation of the humeral head. mission. One-third had early surgery, with no improvement
The patient eventually underwent shoulder hemiarthroplasty. in mortality rates, no improvement in ambulation potential,
and no difference in postoperative pain or length of stay after
impart a high quantity of energy and shotgun blasts result surgery. However, due to performing the procedure early,
in massive soft tissue injury despite being low-velocity a decrease in duration of severe pain and overall length of
weapons.83-85 Fortunately, most gunshot wounds are low stay was observed. The investigators concluded that early
energy in the civilian setting.86 This results in the fracture surgery is warranted in medically stable patients to reduce
rather than soft tissue dictating management strategy. costs and control pain, although no functional improvement
Roughly half of all bony injuries involve the femur, 23% was seen at 6 months.
involve the forearm, 17% result in humerus fractures, and
11% include the tibia.87 With stable fracture patterns in Young Patients and Femoral Neck Fractures
low energy injuries, exploration may lead to increased risk The risk of avascular necrosis (AVN) in young patients sus-
of nonunion and infections. As a result, these injuries are taining femoral neck fractures is 30% to 35%. It was thought
often treated nonoperatively. that early anatomic reduction and decompression of the
Unstable fracture patterns necessitate operative fixation. intracapsular hematoma were essential in reducing this risk.
Irrigation and debridement should be undertaken in the set- Indeed, anatomic fixation has been shown to reduce the risk
ting of massive soft tissue injury that occurs with high energy of AVN, and femoral head blood flow is improved with early
and shotgun injuries. External fixation versus immediate fixation. However, little is known regarding the long-term
definitive fixation is determined by the extent of soft tissue functional implications of this data. A recent study94 using
coverage, soft tissue viability, and wound contamination. a retrospective cohort of 38 patients examined the effect of
Several studies found no increased risk of infection when early versus delayed fixation of femoral neck fractures in
definitive fixation was delayed. However, early surgery can patients 60 years of age or younger. This particular age was
significantly reduce length of stay and associated costs, chosen as it was the most common cutoff for performing a
and allow for early limb mobilization.88-90 Early antibiotic primary total hip or hemiarthroplasty. Patients were followed
administration is essential, and includes a first generation for at least 2 years and consisted of an early and late cohort;
cephalosporin. Studies support continued administration 29 patients had displaced fractures at an average age of 46
for 24 to 72 hours with low-energy injuries. Single dose years. Functional outcomes and AVN rates were compared.
aminoglycosides should be added if contamination is sus- Although no difference in functional outcome scores was
pected or present up to 24 hours before surgery. High-energy present, there was a statistically significant increase in AVN
wounds are always treated as open fractures. Addition of an in the late fixation group. The investigators conclusions were
aminoglycoside should be routine.85 These injuries require tempered by limitations in the study that included a small
aggressive debridement, as the zone of injury always extends cohort and a shorter average duration of follow-up in the
well beyond the missile tract. A vacuum effect seen with late fixation group. It is also possible that the end results
high velocity wounds will often drag foreign material into of increased AVN rates may not manifest for many years,
the wound, furthering the need for aggressive debridement. warranting further study.
Any question of compartment syndrome should result in Concern over the effects of increased intracapsular pres-
early fasciotomy.91,92 sure secondary to hematoma has also raised questions about
64 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67

the risk of AVN. Of the 29 femoral neck fractures in this maintaining a low threshold for suspicion of compartment
study, decompression was performed in only one case, and syndrome. Each of these factors has a bearing on the timing
no increase in AVN was observed. Previous studies docu- of operative management. Immediate surgery is indicated in
ment increased pressure with femoral neck fractures, but the presence of vascular injury and compartment syndrome.
do not correlate this with increased AVN rates. One study Open fracture care timing is controversial as discussed previ-
exists that found increased rates of AVN, but discovered a ously. Early knee spanning external fixation is appropriate
correlation with the severity of the fracture pattern rather for nearly all high energy injuries and may be indicated by
than the presence of hematoma.95 The investigators conclude significant pre-tibial swelling and articular incongruity, or
the utility of the functional scores would be best with ap- either alone.
proximately 1,200 patients, necessitating a large multicenter Soft tissue conditions ultimately dictate the timing and
trial. Furthermore, a follow-up of 10 years would be needed method of tibial plateau fracture fixation, as the condition
to determine the long-term effects of AVN. At present, the of the soft tissue envelope is the best predictor of postopera-
best conclusion that can be drawn is that early fixation for tive wound complications. Some have advocated immediate
patients under 60 when feasible may reduce the rate of AVN, fixation prior to the development of swelling. However,
although this may not have any effect on outcome. surgery is rarely able to be completed within 8 hours of
injury, by which time significant swelling has occurred and
Femoral Diaphysis Fractures will likely complicate wound closure. Furthermore, swelling
As previously discussed with multiply-injured patients, will progress after surgery, potentially worsening the risk of
early external fixation with all but stable patients is standard. wound complications.
Bhandari and coworkers96 conducted a meta-analysis of ex-
isting literature concerning conversion to definitive fixation. Soft Tissue Injury and Tibial Fractures
Of the 185 patient cohort, all studies were Level IV evidence Tscherne devised a classification scheme for soft tissue inju-
and included open fractures, which limits applicability to ries in closed tibial shaft fractures.98 However, as with many
closed injuries. Low infection rates across all studies were classifications, its use is limited by poor observer reliability.
observed if conversion occurred within 28 days. Although These injuries are also a continuum, defying discreet cat-
not significant, there was a trend to increased infection after egorization. Nevertheless, it is still used to provide a general
28 days. Nowatarski and colleagues97 reviewed 59 femoral idea of injury severity. Injuries are graded C0 to CIII based
shaft fractures, of which 40 were closed injuries. Most were on severity and presence of associated conditions. In addi-
converted within 7 days, and 4 underwent staged conversion tion to wound grade, clinical signs are also of importance.
secondary to pin drainage. They likewise encountered low Loss of skin wrinkles indicates extensive swelling, as does
infection rates, and high healing rates. The study concluded delay in capillary refill or blanching of skin edges during
that conversion within a week is safe, and staged conversion closure. Fracture blisters are problematic, as bloody blisters
in the presence of draining pin sites yields good results. indicate an incompetent epidermis and are associated with a
Limited data regarding the ideal time to conversion from high incidence of wound complications. Three options for
external fixation exists. However, the general window of 2 surgical management of tibial fractures exist: immediate
to 4 weeks yields high rates of union and low infection. After definitive fixation, delayed stabilization after provisional
4 weeks of external fixation, consideration to completion in splinting, and staged external fixation. Fixation within 24
external fixation should be given. Bhandari reviewed nine hours is acceptable for C0 or CI injuries, and is not precluded
studies concerning IM nail conversion of tibial fractures; all by the presence of superficial abrasions and mild contusions.
studies included open fractures. However, the overall trend This situation commonly presents with simple diaphysis and
was decreased infection rates for conversion to IM nailing low-energy ankle fractures that present early.
within 28 days. Delayed fixation is indicated for CII or CIII injuries.
Surgery within the first week carries a high risk of complica-
Tibial Fractures tions. Early fixation of plateau fractures in this category is
Tibial plateau fractures can be categorized by age of the pa- associated with a 42% rate of wound complications and a
tient and the energy of the injury. Higher energy injuries are 33% rate of osteomyelitis. Multiple studies have identified
often associated with ligamentous, vascular, and degloving high complication rates with early fixation of tibial plafond
injuries. Additionally, high energy fractures are character- fractures. The study with a delay of 24 days exhibited the
ized by comminution and typical fracture patterns. Shatzker lowest complication rate. One study is an obvious outlier and
types IV through VI are associated with extensive soft tis- may represent a different severity of injury from the other
sue injury and poor outcome. The treatment goals of these investigations. Two studies employed a similar protocol
injuries are restoration of the mechanical axis, restoration of early external fixation, with fibula fixation followed by
of joint congruity, and minimization of iatrogenic soft tis- delayed definitive fixation. It seems that the ideal time for
sue injury. Early management of high energy tibial plateau definitive fixation of tibial plafond fractures is between 12
fractures includes a thorough neurovascular examination, and 24 days. The data concerning management of tibia frac-
assessment of swelling, fracture blisters, skin avulsion, and tures suggest there is little downside to delaying definitive
 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67 65

fixation pending recovery of the soft tissue envelope. Early and Synthes, and participates in stock ownership of Johnson
stabilization with splinting or external fixation allows for & Johnson.
maintenance of alignment and length, shortening the time
to recovery of the soft tissue, and simplifying the definitive References
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