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.
Abstract
The timing of operative fracture care is often confounded by
multisystem injuries, conflicting or absent literature, and lack
of communication between orthopaedic surgeons and other
physicians providing care to the patient. Much has been pub-
lished regarding the proper sequence of events in providing
care to patients with multisystem injuries. Only recently has
the role of complex musculoskeletal injuries and the timing of
fixation in multiply-injured patients been explored in detail.
Timing of care for pelvic injuries is frequently determined by
the presence of injury to other organ systems, the presence
of open wounds, and hemodynamic status. There is likely
an optimal time window for fixation. However, existing data
is often difficult to compare, given varying definitions and
protocols. Furthermore, reports are often conflicting, making
the determination of an optimal time-window difficult. Similar
concerns are present with lower extremity long bone fractures.
Injury to other organ systems must be considered with timing
of femur fixation, particularly in the presence of lung injury.
Tibia fractures are frequently complicated by the presence of
a tenuous soft tissue envelope and other injury factors that
often alter the timing of fixation. These issues and, last, the
timing of care for calcaneus and talus injuries are reviewed,
as risk of avascular necrosis and quality of articular reduction
are related to the timing of fixation.
Eric W. Fulkerson, M.D., was a Chief Resident in the Department
of Orthopaedic Surgery, NYU Hospital for Joint Diseases, and is
currently in private practice with Muir Orthopaedic Specialists,
Walnut Creek, California. Kenneth A. Egol, M.D., is Associate
Professor, New York University School of Medicine, and Vice
Chairman for Education, Department of Orthopaedic Surgery,
NYU Hospital for Joint Diseases, NYU Langone Medical Center,
New York, New York.
Correspondence: Kenneth A. Egol, M.D., Department of Orthopae-
dic Surgery, Suite 1402, NYU Hospital for Joint Diseases, 301 East
17th Street, New York, New York 10003; kenneth.egol@nyumc.org.
Fulkerson EW, Egol KA. Timing issues in fracture management: a review of current concepts. Bull NYU Hosp Jt Dis. 2009;67(1):58-67.
I
n a 2005 national survey, fractures represented a signifi-
cant proportion of severe injuries, with over one million
hospital admissions related to musculoskeletal injury.
For 2004-2005, fractures were and continue to be the lead-
ing cause of injury-related hospital admissions, and account
for over half of all injury admissions.1 In people under age
65, lower extremity fractures are the leading cause of trauma
admissions. Timing of operative fracture care is pertinent to
both outcome and fiscal issues. By appropriately prioritiz-
ing care and optimizing fracture management, decreases in
morbidity, mortality, and hospital stays result in improved
utilization of resources and reduced societal costs in asso-
ciation with a frequent injury of this population. From the
patient’s perspective, appropriate timing of fracture care can
improve long-term outcomes. This review focuses primarily
on controversies and critical issues regarding the timing of
operative fracture management. In addition, timing relative to
pelvis, acetabulum, and femoral shaft fracture care are often
affected by the presence of organ system injuries, and will
be discussed in the setting of the multiply-injured patient.
General concerns related to the timing of fracture care
include the presence of soft tissue injury and open fractures.
Condition of the soft tissues in closed injuries is often the
primary determinant of delays in management and the meth-
ods chosen for fracture fixation. Open fractures conversely
increase the urgency of fracture care. The timing of debride-
ment, closure, and coverage are controversial, with variable
data supporting previous protocols.2-6 Gunshot wounds
represent a unique subset of open fractures, the approach to
which is partially determined by the energy of the injury.
Some fracture types warrant separate discussion. Femoral
neck fractures are treated differently, depending on patient
age and the energy of injury. Femoral shaft fracture treatment
timing is often affected by other injuries and the general
condition of the patient. Fractures of the tibia are particu-
larly troublesome due the largely subcutaneous position of
 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
fixation timing concerns as well.
Fracture Care in the Multiply-Injured Patient
Multiply-injured patients can be divided into two general and
distinct categories: those that are hemodynamically stable and
those that are unstable. Strict adherence to Advanced Trauma
Life Support® (ATLS®) principles is mandatory, as overlooked
injuries or inadequate treatment of injuries will be detrimental
or life threatening. The role of the orthopaedic surgeon in
this setting is to determine the nature of the bony injury and
the subsequent urgency of care in the setting of concomitant
injuries. Of particular importance in the early phase of trauma
care is the presence of pelvic or long bone fractures and the
extent of associated soft tissue injury. The presence of vascular
injury, neurologic deficits, and compartment syndrome are
also within the province of the orthopaedic evaluation.
Hemodynamic Stability
Most of the classic literature on hemodynamic stability is
based on evaluation of penetrating trauma (Fig. 1).7 The
“triad of death” is a term coined to describe patient decom-
pensation in the presence of acute blood loss, resulting in
hypothermia, coagulopathy, and acidosis.8-10 Prevention or
reversal of these factors avoids death by exsanguination.11
More recent studies account for the influence of orthopaedic
injuries on this triad.12 In some cases, delaying or limiting
early orthopaedic intervention can be beneficial. Applying
these principles has been termed as “bail out” or “damage
control” orthopaedic surgery, and represents a crucial part
of appropriate management of the multiply-injured patient.13
Prior to the extensive studies in the multiply-injured pa-
tient, the previous gold standard was fixation of long bones
within 24 hours of injury.14,15 This was thought to minimize
ongoing hemorrhage and possibly fat embolization. Due to
the high incidence of complications associated with early
fixation, this approach in multiply-injured patients has been
called into question.16 With early fixation of long-bone frac-
tures, blunt trauma patients faired worse than those patients
who had surgical delays. Blunt trauma patients have a high
incidence of thoracic and soft tissue injury, and represent
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
ing from 5% to 42%.39-45 The wide range in mortality can be
ascribed to numerous factors, including age, injury severity
score, bony instability, open fractures, and bowel injury.46-51
As high energy pelvis injuries are rarely isolated, patient
status ranges from stable to in extremis, depending on the
extent and type of involved multiple organ system injuries.
Avoiding iatrogenic harm to the patient via inappropriate
surgical timing and sequence requires an organized, multi-
disciplinary approach. Orthopaedic surgeons play a crucial
role by engaging early in decision-making regarding timing
of fracture fixation. Prior to the work of Letournel and Judet
in the 1970s, pelvic fractures were managed nonoperatively
with predictably dismal outcomes.52-54 Over the last 30 years,
much has been written about the management of pelvic in-
juries. However, interpretation of this literature is confused
by an inconsistent use of terms. “Early” surgery ranges from
8 hours in some studies55 to a week in others36,56 or as late
as 21 days in another study.57 “Late” might encompass the
period of 2 weeks58 to 3 months.59 Terms such as clinical
and functional outcome are sometimes used interchange-
ably, further complicating the interpretation of existing data.
Moreover, these are rarely isolated injuries, adding to the
complexity of decision making.
Several factors play into the initial approach to bony
stabilization, including hemodynamic status and response
to resuscitation, fracture pattern, associated injury, and
inflammatory status. Hemodynamic status is of particular
concern, as the pelvis may be the primary source of bleeding
or be contributing very little to bleeding. In the presence of
ongoing thoracic or abdominal hemorrhage, orthopaedic
management beyond placement of a pelvic binder is delayed.
Associated long bone fractures should be immediately
splinted with coverage of open wounds. Frequently, radio-
graphs are delayed. Data presented recently suggest that
temporary placement of a pelvic binder is safe, regardless
of fracture pattern, and may reduce mortality in conjunction
with early angiography.60
Not uncommonly, debate will arise in the early manage-
ment of the multiply-injured patient with an unstable fracture
pattern regarding the proper sequence of events. A study
looking at this scenario found that unstable fractures are likely
to be the primary source of bleeding. A 60% mortality rate
was encountered if laparotomy preceded pelvic angiography,
compared with a 25% mortality rate if the sequence was
reversed. Although this study was limited by a small number
of patients, angiography prior to exploratory laparotomy was
recommended in the presence of unstable fracture patterns.61
Another frequent controversy is the timing of angiogra-
phy versus external fixation. Miller reviewed 1,171 pelvic
ring injuries and found that if contrast blush was present on
initial CT, patients that were nonresponders to resuscitation
had a 73% rate of positive angiography. They concluded
that in patients with a contrast blush on CT associated with
any degree of hemodynamic instability, angiography should
precede pelvic external fixation.62 In contradictory studies ar-
terial bleeding amenable to embolization is a rare occurrence
61
in pelvic fractures, and, therefore, recommend emergent
external fixation for hemodynamically unstable patients.63,64
If the response to external fixation is inadequate, angiogra-
phy should follow. This continues to remain a controversial
issue, and is likely to vary between trauma centers.63,64 It is
important that institutions have a protocol agreed upon by
the various services, so care of these complex patients can
be delivered efficiently.
For most abdominal procedures, a pelvic binder will
not interfere with the operation In the presence of unstable
fracture patterns, placement of an external fixator should be
allowed during the same round of anesthesia. For patients
in extremis, external fixators may be placed bedside in the
intensive care unit (ICU) if clearance for the operating room
(OR) is unlikely.53 Open pelvis fractures are associated with
high mortality rates due to hemorrhage in the early phase,
and overwhelming sepsis in the days and weeks to follow.
Emergent irrigation and debridement with definitive fixa-
tion, even in the presence of clean wounds, is warranted.
Fecal diversion and repair of vaginal lacerations may also
be needed.65
Management of pelvic fractures frequently occur in the
setting of the multiply-injured patient and add to the com-
plexity of managing this injury. With hemodynamic instabil-
ity or associated injuries preventing extended procedures,
external fixation as a temporizing measure should be done
early. The timing of angiography remains controversial but
should be performed early, whether before or after external
fixation. With open fractures, definitive stabilization can
be performed in the early phase provided there is adequate
resuscitation and clean wounds. In cases where definitive
fixation is delayed, there is controversy as to the ideal time
window for surgery. Recent data suggests allowing the acute
inflammatory phase to pass. Five studies exist comparing
early versus late fixation, none of which represent Level
I evidence.55,56,66-68 Furthermore, data is confused by an
inconsistent definition of “early” in these studies. Of these
studies, only one presented outcome at 2-year follow-up.63
The overall conclusion of these studies is that fixation within
2 to 3 weeks offers the best chance for improved radiographic
and functional outcomes for pelvis and acetabulum fractures.
After 3 weeks, callus and scar formation severely limit the
ability to obtain an anatomic reduction, require more exten-
sile approaches, and result in worsened functional outcomes.
For high energy pelvis and acetabulum fractures, a delay
in definitive fixation is the rule rather than the exception.
Based on available literature, the ideal window for secondary
procedures is 6 days to 3 weeks post-injury.
Open Fracture Debridement
The standard of care over the last century for open fractures
has been emergent irrigation and debridement within 6 to 8
hours.69 However, no human studies supporting this protocol
exist. These timing recommendations are likely derived from
the pre-asepsis war era, data on bacterial doubling times,
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
associates reviewed 554 open fractures in children and found
only an association of time of antibiotic administration with
decreases in infection rates.2 Debridement was performed
as late as 24 hours post-injury. This study was limited by
involving only pediatric fractures, and no attempt was made
to examine other variables. Noumi and coworkers reviewed
88 patients and examined factors contributing to deep infec-
tion after IM nailing of open long bone fractures. Only the
fracture grade was consistent with increased infection risk.
AO classification was predictive of nonunion. However, no
association was found between timing of debridement and
the risk for infection or nonunion.3 Harley and colleagues
reviewed 241 long bone fractures and recorded transport
time from the field to hospital admission, which was fre-
quently in excess of 8 hours. A weak association between
debridement time after 13 hours and infection was found.
The role of extended transport time and delay in antibiotics
was not explored.4 Data from the LEAP (Lower Extremity
Assessment Project) group, a multicenter limb salvage study,
yielded 315 open fractures. After multivariate analysis, only
time of injury to admission was discovered to correlate with
infection risk. Time to debridement was not predictive of
infection. The investigators cited resuscitation and early
administration of broad spectrum antibiotics, or either, as
possible reasons for the importance of admission time.71
Only one study correlates risk of infection with time to de-
bridement. For open tibia fractures, Kindsfater and Jonassen
found increased infection rates if debridement was delayed
more than 5 hours post-injury. However, there were multiple
dissimilarities between treatment time groups that were not
accounted for and likely represent confounding variables.72
Of the limited data that exist, most studies conclude that
time to debridement is not an independent predictor of
deep infection for open fractures. More important is time
to admission and the early administration of antibiotics.
Timing of debridement should be determined by ad-
equacy of resuscitation, presence of appropriate and alert
staff, and OR availability. Open fractures should be consid-
ered an urgency rather than an emergency in the absence of
limb-threatening injury. Although no Level I data exists, it
is unlikely that the quality of data will improve, as there are
numerous uncontrollable factors preventing such a study.70
Timing of Open Fracture Wound Closure
Timing of delayed versus primary closure of open fractures
is largely derived from wartime experience in the pre-
asepsis era as well. Trueta advocated closed treatment of
open fractures.73 This introduced the principle of thorough
debridement of devitalized tissue, after which the wound was
encased in a cast not to be removed until healing occurred.
According to Truetta, the cast was left in place, “unless it
became wet and soft, or there was an intolerable stench, or
the patient’s condition showed that some complication had
developed.” With the introduction of penicillin, in 1943,
debridement was no longer emphasized, and local wound
complication rates increased. This introduced the principle of
the second look, with closure between day 4 and 7 or closure
by secondary intention if the wound bed was not clean.74
This is currently a widely practiced approach. Advances
in wound care have improved soft tissue management with
open fractures. At present, the best predictor of outcome is
the adequacy of irrigation and debridement.75
Confusion in the interpretation of the literature exists
due to poor observer reliability in grading open fractures
and the existence of few well-conducted studies regarding
the timing of closure. Of the six studies regarding timing
of open fracture closure in the English literature, five were
retrospective case series or a mixed series.76,77 The only
prospective study failed to grade wounds,5 and one study
had only 62 patients.6 However, some conclusions of these
studies are noteworthy. Benson and associates found that
infection was independent of closure method.5 Cullen found
no increased infection rate with primary wound closure of
clean wounds in children after irrigation and debridement.78
DeLong reviewed six management methods, and found no
correlation with infection rates.79
Some studies examined the factors that affect the timing
of wound closure. Gustilo and Anderson noted that wounds
left open greater than 2 weeks were likely to develop nosoco-
mial infections.77 Patzakis followed culture results obtained
at initial irrigation and debridement, and found only an
18% correlation of isolates obtained initially with species
identified in late deep infections.80 These studies suggest the
wound may be most sterile after the initial irrigation and de-
bridement. Although no Level I studies exist, primary closure
is warranted on the basis of available data in clean wounds
when atraumatic closure is possible. Delayed closure after
a second look should be employed if the quality of tissue is
in question after the initial irrigation and debridement.
Flap Coverage of Open Wounds
When flap coverage is required, it may be performed either
during fracture stabilization or as a secondary procedure.
One study investigated free flap coverage at three time
intervals in 532 patients: immediately, within 72 hours
of fracture stabilization, and after 72 hours. Earlier bone
healing and reduced infection rates were seen if coverage
was completed within 72 hours of fracture stabilization.
A secondary benefit was a 10-fold decrease in length of
stay.81 Another study involving 84 patients with type IIIb
or IIIc tibia fractures found an increase in infection rate if
flap coverage was delayed (30%, more than 72 hours vs
6%, fewer than 72 hours).82 Available data suggests flap
coverage should occur within 72 hours in the presence of a
clean wound bed and a stabilized fracture. Immediate skin
grafting obviates a separate procedure.
Fractures Associated with Gunshot Wounds
Gunshot wounds always involve some degree of soft tis-
sue injury (Fig. 3). The extent of injury is best described
in terms of energy and velocity; high mass projectiles will
 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67
Figure 3 A 24-year-old male after a gunshot wound to the right
shoulder from an assault rifle. Extensive soft tissue injury and
severe comminution prevented preservation of the humeral head.
The patient eventually underwent shoulder hemiarthroplasty.
impart a high quantity of energy and shotgun blasts result
in massive soft tissue injury despite being low-velocity
weapons.83-85 Fortunately, most gunshot wounds are low
energy in the civilian setting.86 This results in the fracture
rather than soft tissue dictating management strategy.
Roughly half of all bony injuries involve the femur, 23%
involve the forearm, 17% result in humerus fractures, and
11% include the tibia.87 With stable fracture patterns in
low energy injuries, exploration may lead to increased risk
of nonunion and infections. As a result, these injuries are
often treated nonoperatively.
Unstable fracture patterns necessitate operative fixation.
Irrigation and debridement should be undertaken in the set-
ting of massive soft tissue injury that occurs with high energy
and shotgun injuries. External fixation versus immediate
definitive fixation is determined by the extent of soft tissue
coverage, soft tissue viability, and wound contamination.
Several studies found no increased risk of infection when
definitive fixation was delayed. However, early surgery can
significantly reduce length of stay and associated costs,
and allow for early limb mobilization.88-90 Early antibiotic
administration is essential, and includes a first generation
cephalosporin. Studies support continued administration
for 24 to 72 hours with low-energy injuries. Single dose
aminoglycosides should be added if contamination is sus-
pected or present up to 24 hours before surgery. High-energy
wounds are always treated as open fractures. Addition of an
aminoglycoside should be routine.85 These injuries require
aggressive debridement, as the zone of injury always extends
well beyond the missile tract. A vacuum effect seen with
high velocity wounds will often drag foreign material into
the wound, furthering the need for aggressive debridement.
Any question of compartment syndrome should result in
early fasciotomy.91,92
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
with outcomes.93 Fixation was performed either within 24
hours of admission or after more than 24 hours following ad-
mission. One-third had early surgery, with no improvement
in mortality rates, no improvement in ambulation potential,
and no difference in postoperative pain or length of stay after
surgery. However, due to performing the procedure early,
a decrease in duration of severe pain and overall length of
stay was observed. The investigators concluded that early
surgery is warranted in medically stable patients to reduce
costs and control pain, although no functional improvement
was seen at 6 months.
Young Patients and Femoral Neck Fractures
The risk of avascular necrosis (AVN) in young patients sus-
taining femoral neck fractures is 30% to 35%. It was thought
that early anatomic reduction and decompression of the
intracapsular hematoma were essential in reducing this risk.
Indeed, anatomic fixation has been shown to reduce the risk
of AVN, and femoral head blood flow is improved with early
fixation. However, little is known regarding the long-term
functional implications of this data. A recent study94 using
a retrospective cohort of 38 patients examined the effect of
early versus delayed fixation of femoral neck fractures in
patients 60 years of age or younger. This particular age was
chosen as it was the most common cutoff for performing a
primary total hip or hemiarthroplasty. Patients were followed
for at least 2 years and consisted of an early and late cohort;
29 patients had displaced fractures at an average age of 46
years. Functional outcomes and AVN rates were compared.
Although no difference in functional outcome scores was
present, there was a statistically significant increase in AVN
in the late fixation group. The investigators conclusions were
tempered by limitations in the study that included a small
cohort and a shorter average duration of follow-up in the
late fixation group. It is also possible that the end results
of increased AVN rates may not manifest for many years,
warranting further study.
Concern over the effects of increased intracapsular pres-
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
study, decompression was performed in only one case, and
no increase in AVN was observed. Previous studies docu-
ment increased pressure with femoral neck fractures, but
do not correlate this with increased AVN rates. One study
exists that found increased rates of AVN, but discovered a
correlation with the severity of the fracture pattern rather
than the presence of hematoma.95 The investigators conclude
the utility of the functional scores would be best with ap-
proximately 1,200 patients, necessitating a large multicenter
trial. Furthermore, a follow-up of 10 years would be needed
to determine the long-term effects of AVN. At present, the
best conclusion that can be drawn is that early fixation for
patients under 60 when feasible may reduce the rate of AVN,
although this may not have any effect on outcome.
Femoral Diaphysis Fractures
As previously discussed with multiply-injured patients,
early external fixation with all but stable patients is standard.
Bhandari and coworkers96 conducted a meta-analysis of ex-
isting literature concerning conversion to definitive fixation.
Of the 185 patient cohort, all studies were Level IV evidence
and included open fractures, which limits applicability to
closed injuries. Low infection rates across all studies were
observed if conversion occurred within 28 days. Although
not significant, there was a trend to increased infection after
28 days. Nowatarski and colleagues97 reviewed 59 femoral
shaft fractures, of which 40 were closed injuries. Most were
converted within 7 days, and 4 underwent staged conversion
secondary to pin drainage. They likewise encountered low
infection rates, and high healing rates. The study concluded
that conversion within a week is safe, and staged conversion
in the presence of draining pin sites yields good results.
Limited data regarding the ideal time to conversion from
external fixation exists. However, the general window of 2
to 4 weeks yields high rates of union and low infection. After
4 weeks of external fixation, consideration to completion in
external fixation should be given. Bhandari reviewed nine
studies concerning IM nail conversion of tibial fractures; all
studies included open fractures. However, the overall trend
was decreased infection rates for conversion to IM nailing
within 28 days.
Tibial Fractures
Tibial plateau fractures can be categorized by age of the pa-
tient and the energy of the injury. Higher energy injuries are
often associated with ligamentous, vascular, and degloving
injuries. Additionally, high energy fractures are character-
ized by comminution and typical fracture patterns. Shatzker
types IV through VI are associated with extensive soft tis-
sue injury and poor outcome. The treatment goals of these
injuries are restoration of the mechanical axis, restoration
of joint congruity, and minimization of iatrogenic soft tis-
sue injury. Early management of high energy tibial plateau
fractures includes a thorough neurovascular examination,
assessment of swelling, fracture blisters, skin avulsion, and
maintaining a low threshold for suspicion of compartment
syndrome. Each of these factors has a bearing on the timing
of operative management. Immediate surgery is indicated in
the presence of vascular injury and compartment syndrome.
Open fracture care timing is controversial as discussed previ-
ously. Early knee spanning external fixation is appropriate
for nearly all high energy injuries and may be indicated by
significant pre-tibial swelling and articular incongruity, or
either alone.
Soft tissue conditions ultimately dictate the timing and
method of tibial plateau fracture fixation, as the condition
of the soft tissue envelope is the best predictor of postopera-
tive wound complications. Some have advocated immediate
fixation prior to the development of swelling. However,
surgery is rarely able to be completed within 8 hours of
injury, by which time significant swelling has occurred and
will likely complicate wound closure. Furthermore, swelling
will progress after surgery, potentially worsening the risk of
wound complications.
Soft Tissue Injury and Tibial Fractures
Tscherne devised a classification scheme for soft tissue inju-
ries in closed tibial shaft fractures.98 However, as with many
classifications, its use is limited by poor observer reliability.
These injuries are also a continuum, defying discreet cat-
egorization. Nevertheless, it is still used to provide a general
idea of injury severity. Injuries are graded C0 to CIII based
on severity and presence of associated conditions. In addi-
tion to wound grade, clinical signs are also of importance.
Loss of skin wrinkles indicates extensive swelling, as does
delay in capillary refill or blanching of skin edges during
closure. Fracture blisters are problematic, as bloody blisters
indicate an incompetent epidermis and are associated with a
high incidence of wound complications. Three options for
surgical management of tibial fractures exist: immediate
definitive fixation, delayed stabilization after provisional
splinting, and staged external fixation. Fixation within 24
hours is acceptable for C0 or CI injuries, and is not precluded
by the presence of superficial abrasions and mild contusions.
This situation commonly presents with simple diaphysis and
low-energy ankle fractures that present early.
Delayed fixation is indicated for CII or CIII injuries.
Surgery within the first week carries a high risk of complica-
tions. Early fixation of plateau fractures in this category is
associated with a 42% rate of wound complications and a
33% rate of osteomyelitis. Multiple studies have identified
high complication rates with early fixation of tibial plafond
fractures. The study with a delay of 24 days exhibited the
lowest complication rate. One study is an obvious outlier and
may represent a different severity of injury from the other
investigations. Two studies employed a similar protocol
of early external fixation, with fibula fixation followed by
delayed definitive fixation. It seems that the ideal time for
definitive fixation of tibial plafond fractures is between 12
and 24 days. The data concerning management of tibia frac-
tures suggest there is little downside to delaying definitive
 Bulletin of the NYU Hospital for Joint Diseases 2009;67(1):58-67
fixation pending recovery of the soft tissue envelope. Early
stabilization with splinting or external fixation allows for
maintenance of alignment and length, shortening the time
to recovery of the soft tissue, and simplifying the definitive
procedure. How late is too late for conversion from external
fixation is uncertain, but conversion within 4 weeks appears
to correlate with reduced infection risk.
Hindfoot Fractures
Calcaneus injuries are also complicated by a tenuous soft tis-
sue envelope. Available studies suggest a narrow window for
fixation exists; 7 to 14 days are often required for diminution
of swelling, and after 3 weeks, wound closure and fracture
callus can be problematic. Early fixation of these fractures
has been associated with skin flap necrosis, infection and
the need for multiple surgical interventions.
The talus has a tenuous blood supply, resulting in a high
incidence of AVN with displaced neck fractures. Closed
reduction may be attempted, and thereby delay the need
for urgent surgery. However, such reduction is difficult to
obtain and maintain. Although concern over the risk of AVN
was the reasoning behind emergent reduction, no decrease
in AVN has been observed with early reduction. However,
skin tenting often mandates emergent operative intervention.
Open talus fractures are common with Hawkins 3 and 4
fractures. If extruded and planned for reinsertion, emergent
irrigation and debridement are required.99 Two out of 19
treated patients had postoperative infections, and functional
outcomes were difficult to assess. Overall, the conclusion
was that immediate irrigation and debridement followed by
reimplantation is a safe procedure, and preserves normal
anatomy. However, high failure rates are observed regardless
of treatment strategy, necessitating salvage procedures such
as hindfoot fusion. In cases where immediate reimplantation
is not possible, delayed reconstruction and fusion with bulk
allograft is an option. However, clinical experience is limited
to small series and case reports.100
Conclusion
The timing of operative fracture care is often complicated by
multiple issues, particularly in the presence of other injuries.
Due to confusing and often conflicting data regarding the
timing of fracture care, early involvement in patient care by
the orthopaedic service is essential. Discussion with other
involved specialties can facilitate appropriate care, and
minimize fracture complications. Orthopaedic surgeons thus
play a crucial role in ensuring the optimal patient care, and
should be active participants in the decision-making process.
Disclosure Statement
Eric Fulkerson, M.D., has no financial or proprietary interest
in the subject matter or materials discussed, including, but
not limited to, employment, consultancies, stock ownership,
honoraria, and paid expert testimony. Kenneth A. Egol,
M.D., is an unpaid consultant to Exactech, Inc., has received
institutional support from Biomet, Smith & Nephew, Stryker,
65
and Synthes, and participates in stock ownership of Johnson
& Johnson.
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