Kalbas Yannik, Stutz Yannik, Klingebiel Felix Karl-Ludwig, Halvachizadeh Sascha, Teuben Michel Paul Johan, Ricklin John, Sivriev Ivan, Hax Jakob, Urgiles Carlos Ordonez, Jensen Kai Oliver, Oertel Markus Florian, Pape Hans-Christoph, Pfeifer Roman
Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland; Harald-Tscherne Laboratory for Orthopaedic and Trauma Research, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
Harald-Tscherne Laboratory for Orthopaedic and Trauma Research, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
Injury. 2025 May;56(5):112149. doi: 10.1016/j.injury.2025.112149. Epub 2025 Jan 11.
Optimizing treatment strategies in polytrauma patients is a key focus in trauma research and timing of major fracture care remains one of the most actively discussed topics. Besides physiologic factors, associated injuries, and injury patterns also require consideration. For instance, the exact impact and relevance of traumatic brain injury on the timing of fracture care have not yet been fully investigated.
In this retrospectively cohort study at a level one trauma center, patients requiring trauma team activations from 2015 to 2020 were screened. Patients with an injury severity score >16 and at least one body region requiring operative fixation were included. Patients who underwent their first definitive surgery <24 h were stratified as group SDS (Safe Definitive Surgery) and >24 h as group DFC (Delayed Fracture Care). Outcomes were early mortality (<72 h), SIRS and sepsis, timing to first definitive surgery and completed reconstruction, total number of surgeries, and factors influencing the surgical strategy (e.g., unstable physiology). Odds ratios for treatment strategies and influencing factors were calculated using the Fisher`s exact test with conditional maximum likelihood estimate.
From a total of 901 patients screened, 239 were included in the analyzes (Group DFC: 151, Groups SDS: 88). Groups did not significantly differ regarding early mortality, SIRS and sepsis. Group SDS had a significantly lower mean number of operations (4.3 vs. 5.3; p = 0.037) and a significantly shorter mean time until completion of reconstructive operations (10 days vs. 15 days; p = 0.013). Unstable physiology and intracranial trauma sequelae with the necessity for neurosurgical interventions (NSI) were identified as most significant factors for delaying definitive fracture care (OR: 2.85; 95 % CIs: 1.56 to 5.33 and OR: 5.59; 95 % CIs: 1.63 to 29.85), while the presence of intracranial bleeding (IB) without NSI did not have a significant influence (OR: 1.21; 95 % CIs: 0.63 to 2.34).
The necessity of NSI and unstable physiology are highly relevant factors for delaying definitive fracture care in polytrauma patients, while the presence of IB without NSI had less impact. In this cohort, early definitive fracture care in physiologically stable patients without NSI, was not associated with increased patient morbidity.
优化多发伤患者的治疗策略是创伤研究的关键重点，主要骨折治疗的时机仍然是讨论最为活跃的话题之一。除生理因素外，合并伤和损伤模式也需要考虑。例如，创伤性脑损伤对骨折治疗时机的确切影响和相关性尚未得到充分研究。
在这家一级创伤中心进行的这项回顾性队列研究中，对2015年至2020年需要创伤团队启动的患者进行了筛查。纳入损伤严重程度评分>16且至少有一个身体部位需要手术固定的患者。首次确定性手术在<24小时内进行的患者被分层为SDS组（安全确定性手术），>24小时的患者为DFC组（延迟骨折治疗）。结局指标包括早期死亡率（<72小时）、全身炎症反应综合征和脓毒症、首次确定性手术和完成重建的时间、手术总数以及影响手术策略的因素（如生理不稳定）。使用带有条件最大似然估计的Fisher精确检验计算治疗策略和影响因素的比值比。
在总共筛查的901例患者中，239例纳入分析（DFC组：151例，SDS组：88例）。两组在早期死亡率、全身炎症反应综合征和脓毒症方面无显著差异。SDS组的平均手术次数显著更低（4.3次对5.3次；p = 0.037），完成重建手术的平均时间显著更短（10天对15天；p = 0.013）。生理不稳定和需要神经外科干预（NSI）的颅内创伤后遗症被确定为延迟确定性骨折治疗的最显著因素（比值比：2.85；95%置信区间：1.56至5.33和比值比：5.59；95%置信区间：1.63至29.85），而无NSI的颅内出血（IB）的存在没有显著影响（比值比：1.21；95%置信区间：0.63至2.34）。
NSI的必要性和生理不稳定是多发伤患者延迟确定性骨折治疗的高度相关因素，而无NSI的IB的存在影响较小。在该队列中，生理稳定且无NSI的患者早期进行确定性骨折治疗与患者发病率增加无关。
