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Abstract
Background:
The best time to definitively fix a fracture in long-bones of polytrauma patients is still controversial. While early total care in the past has been recommended to minimize pulmonary complications, concerns about the "second hit" phenomenon have been used to recommend delayed or staged strategies in physiologically unstable patients. The effect of the timing of fixation on the acute respiratory distress syndrome (ARDS) and the length of stay of the intensive care unit (ICU) is still not fully established.
Objectives:
To test the hypothesis that early rather than delayed definitive fixation of long-bone fractures in adult polytrauma patients is associated with lower incidence of ARDS and ICU length of stay.
Methods:
A systematic review was performed of comparative studies of early versus delayed definitive fixation in adult polytrauma patients with long-bone fractures. Randomized and comparative observational studies on ARDS and/or ICU length of stay were included. Data was abstracted on ARDS as a dichotomous outcome and ICU length of stay as a continuous outcome. A random-effects model by DerSimonian and Laird was used to obtain pooled risk ratios (RR) for ARDS. For the studies in which there were zero events in one of the arms, a continuity correction was applied. ICU length of stay was narratively combined because dispersion data are lacking in sufficient number of studies.
Results:
Three comparative studies involving 321 patients were used in the ARDS meta-analysis. Early definitive fixation was associated with a reduced risk of ARDS in comparison to late strategies (RR 0.37, 95% CI 0.09–1.49). However, this reduction was not statistically significant. A moderate heterogeneity was observed (I² = 44%). ICU length of stay was inconsistently reported across studies, and only one study reported mean ± standard deviation values that were suitable for use in quantitative analysis, so it was not possible to conduct a pooled meta-analysis for ICU length of stay. Available evidence suggested a trend towards a shorter ICU duration with early fixation.
Conclusion:
Early definitive fixation of long-bone fractures in adult polytrauma patients showed a non-significant trend of decreased ARDS compared with delayed stabilization strategies. Due to limited and heterogeneous reporting, definitive conclusions about the length of stay in the ICU cannot be made. Prospective studies that are larger, employ standardized outcome reporting, are necessary to elucidate the effect of timing of fixation on the outcomes in pulmonary and critical care.