Timing of Orthopaedic Surgery in the Multiply-injured Patient: Development of a Protocol for Early Appropriate Care

Early fixation of unstable fractures of the femur, pelvis, and acetabulum reduces some
complication rates. However, in patients with multiple injuries, the optimal treatment of
skeletal trauma may be affected by severe injury to the head, chest, or abdomen. The
relationship between associated injury severity and the timing of definitive management of
unstable fractures is not well-understood. The practice of "early total care," early
definitive fracture management, has been criticized by some, who have suggested that
additional hemorrhage with surgery may be associated with a deleterious systemic inflammatory
response. The alternative extreme of "damage control orthopedics (DCO)" has been recently
proposed as a means of providing provisional stability of major skeletal injury, generally
through external fixation. It is speculated that DCO will diminish the potential for systemic
compromise. However, the need for further (definitive) surgery on a delayed basis, and the
potential additional complications and costs associated with this strategy are controversial.
The investigators' goals are to define which injuries or parameters warrant delay of
definitive orthopaedic care, and to determine what time interval for fracture fixation
promotes optimal patient outcome. The investigators will assess the effects of fracture
fixation on head injury, chest injury, abdominal injury, mortality, complications, patient
outcomes, and costs.