Nailing of Femoral Shaft Fractures: What Is the Optimal Timing?

Older studies appear to conflict with more recent data, but current findings bridge the gap

Peter Pollack

In the 1980s, several articles supported early fixation of femur fractures, and the concept of early total care evolved during that time,” explained Robert V. Cantu, MD, lead author of “Optimal Timing for Intramedullary Nailing of Femoral Shaft Fractures Depends on Injury Severity,” during yesterday’s scientific presentation. “However, later research showed improved survival in severely injured patients—especially those with abdominal trauma—if surgery on the femur was delayed for at least 12 hours.”

“This question comes up very often in practice,” said Sara C. Graves, MD, coauthor and paper presenter. “When patients come in with multiple injuries, we’re often coordinating with other services and trying to determine the best time to take them to the operating room. We have to balance the patient’s need for more workup and optimization against the risk of complications involved in waiting longer.”

The research team reviewed data from the National Trauma Data Bank (version 7.0) on 7,540 patients with unilateral femur fractures. They stratified the patients by surgical timing (0–12 hours, n = 4,003; 13–24 hours, n = 1,751; 25–48 hours, n = 1,027; and 3–30 days, n = 759) and by injury severity score (ISS = 9, n = 2,796; ISS = 10–19, n = 3,155; and ISS = 21–75, n = 1,589).

Overall, 12 percent of patients were older than 65 years of age, 69 percent were female, 64 percent were white, 16 percent had an open fracture, and 9.6 percent had comorbidities. The overall in-hospital mortality rate was 1.4 percent.

Greater injury equals greater risk
“Among high-ISS patients, definitive fixation within 12 hours did display a slightly higher mortality rate compared to patients who received definitive fixation 12 to 24 hours after injury, or even 24 to 48 hours after injury,” said Dr. Cantu. “However, high-ISS patients made up the only group in which we noted that. Among patients with lower ISS, the trend was fairly flat for about the first 48 hours, with clearly increased mortality after 48 hours.”

“The impact of age was also very important,” said Dr. Graves. “Delayed fixation leading to higher mortality was even more pronounced in people older than 65 years of age. Unfortunately, that’s the subgroup that most likely requires additional workup or optimization. For older patients, any workup should be done as expeditiously as possible.”

According to Dr. Cantu, the study findings bridge a seeming dichotomy between earlier and later research.

“I view our paper as reaffirming studies from the 1980s that recommended early fixation of femur fractures as well as supporting more recent articles that show that for severely injured patients, a period of aggressive resuscitation prior to definitive fixation is beneficial. It also seems that waiting more than 48 hours even for severely injured patients is generally not advantageous.

Authors of “Optimal Timing for Intramedullary Nailing of Femoral Shaft Fractures Depends on Injury Severity,” include Dr. Cantu (no conflicts), Dr. Graves (no conflicts) and Kevin F. Spratt, PhD (no conflicts).