Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

BACKGROUND:The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. METHODS:In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an injury severity score (ISS) ≥ 16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury into three groups: Early Total Care (ETC <24 h), Safe Definitive Surgery (SDS < 48 h), and Damage Control (DC >48 h). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. RESULTS:Between Jan 1, 2016, and Dec 31, 2022, 1471 patients were included (mean age 55.6 ± 20.4 years, mean ISS 23.1 ± 11.4). The group distribution was ETC; n = 85 (5.8%), SDS; n = 665 (45.2%), and DC; n = 721 (49.0%), mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe non-lethal abdominal injuries (OR 2.2, 95%CI 1.4 to 3.5) and spinal injuries (OR1.6, 95%CI 1.2 to 2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR1.7, 9%%CI 1.4 to 2.2). Severe TBI was associated with DC (OR1.3, 95% CI 1.1 to 1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR0.3, 95%CI 0.2 to 0.4). CONCLUSION:Major spinal injuries and certain abdominal injuries, if identified as non-lethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by Safe Definitive Surgery (definitive care <48 h) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. LEVEL OF EVIDENCE:III Therapeutic / Care Management.