Femoral shaft fractures constitute one of the most common injuries requiring orthopedic surgical intervention in high-energy trauma, particularly among young adults. These injuries frequently result from motor vehicle collisions, falls from height, and other blunt trauma mechanisms [1]. When such fractures are associated with abdominal trauma—defined by an Abbreviated Injury Scale (AIS) score ≥3 for the abdominal region—the complexity of clinical management significantly increases. The dual burden of orthopedic and visceral injury challenges both diagnostic priorities and surgical timing.

In isolated femoral fractures, early definitive fixation—most commonly with intramedullary nailing—has been shown to reduce the risk of pulmonary complications, shorten hospital stay, and facilitate earlier mobilization [2]. However, in patients with concomitant abdominal trauma, early fixation has historically been approached with caution due to the theoretical risk of precipitating systemic inflammatory responses or “second hit” phenomena during the acute phase of injury [3].

The concept of "damage control orthopedics" emerged in the late 1990s and gained traction through the 2000s, recommending a staged approach in polytrauma patients. Initial external stabilization was advocated to minimize physiologic stress until the patient reached a more stable condition for definitive internal fixation [4]. Nevertheless, this paradigm has evolved as trauma resuscitation and critical care have advanced. By the mid-2000s, evidence began to challenge the presumption that delayed fixation was always superior in multisystem trauma. Several observational studies suggested that when physiologic criteria such as normalized pH, base excess, and lactate levels were met, early fixation was not only feasible but beneficial [5,6].

Despite growing interest, consensus on the optimal timing of femoral fracture fixation in the context of abdominal trauma remains elusive. The presence of visceral injury adds potential for hemodynamic instability, transfusion requirement, and systemic inflammatory response syndrome (SIRS), which may complicate intraoperative and postoperative recovery [7]. Furthermore, the abdominal pathology itself—especially hollow viscus perforation or hepatic laceration—may dictate surgical urgency, delaying orthopedic prioritization.

Given the complexity of this clinical overlap and the paucity of focused outcome studies in this subgroup, the present study was conducted to evaluate surgical outcomes in patients with femoral shaft fractures and associated abdominal trauma. Specifically, we aimed to compare early versus delayed definitive fixation with respect to complication rates, intensive care needs, and overall hospital outcomes.

A retrospective observational study was conducted at the Department of Orthopedics, D.D. Medical College and Hospital, Chennai. The study period spanned one year, from January 2010 to December 2010. Prior approval for the study protocol was obtained from the Institutional Ethics Committee of D.D. Medical College and Hospital, Chennai.

The study included adult patients (≥18 years) who presented with a radiologically confirmed unilateral femoral shaft fracture (classified as AO/OTA 32) in conjunction with abdominal trauma of at least moderate severity (Abbreviated Injury Scale [AIS] score ≥3 for the abdominal region).

Inclusion criteria were:

• Admission within 12 hours of injury
• Underwent definitive surgical fixation of the femur
• Had adequate abdominal trauma documentation via FAST, CT, or intraoperative findings
• Complete records including operative notes, ICU stay, and follow-up data for a minimum of 30 days

Exclusion criteria included:

• Polytrauma with head injury (AIS head ≥3)
• Pathological fractures

Pregnancy

Patients with pre-existing coagulopathy or sepsis on admission

Death within 24 hours of arrival (to avoid confounding early mortality)

Missing or incomplete records

Patients were stratified into two groups based on timing of femoral fixation:

Early fixation group: patients who underwent definitive intramedullary nailing within 24 hours of admission

Delayed fixation group: patients who underwent fixation 24 hours or later after initial admission

The decision regarding timing of surgery was guided by physiological stabilization parameters including systolic blood pressure >90 mmHg, base excess >–5.5 mmol/L, arterial pH ≥7.25, and serum lactate <4 mmol/L. Patients not meeting these benchmarks were initially managed with supportive care and underwent delayed fixation once stabilized.

All patients underwent reamed antegrade intramedullary nailing performed under general or spinal anesthesia by experienced orthopedic surgeons following standardized protocols.

Data were extracted from medical records, operative logs, and trauma registries. Parameters collected included:

• Demographics (age, gender)
• Mechanism of injury
• Injury Severity Score (ISS)
• Time to fixation
• ICU and hospital length of stay
• Ventilator duration
• Intraoperative blood loss
• Postoperative complications: pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), sepsis, surgical site infection
• 30-day all-cause mortality

Statistical analysis was performed using SPSS version 16.0. Continuous variables were expressed as mean ± standard deviation (SD) and compared using independent samples t-tests. Categorical variables were analyzed using chi-square or Fisher’s exact test where appropriate. A multivariate logistic regression model was applied to evaluate the independent effect of early fixation on pulmonary embolism, adjusting for confounders including age, ISS, and comorbidities. A p-value <0.05 was considered statistically significant.

Table 1: Demographic and Injury Characteristics

Table 2: Outcome Measures

Table 3: Complication Profile by Fixation Timing

Table 4: Logistic Regression – Predictors of Pulmonary Embolism

Fig 1: ICU free days

Fig 2: Complications

Among the 180 patients studied, the early and delayed fixation groups were demographically and clinically similar at baseline. The average age was 33.6 ± 12.1 years in the early fixation group and 34.4 ± 12.3 years in the delayed group. A majority of patients were male (72.4% and 74.4%, respectively), and road traffic accidents were the most common mechanism of injury across both groups. Injury Severity Scores were comparable (27.3 ± 9.1 vs 28.1 ± 8.4), indicating equivalent initial trauma burden. Intraoperative blood loss also showed no significant difference (650 ± 230 mL vs 670 ± 260 mL).

Hospital outcomes revealed clear advantages for early fixation. Patients managed within 24 hours had a significantly shorter hospital stay (12.4 ± 5.3 vs 15.8 ± 6.0 days, p < 0.001) and ICU stay (4.1 ± 2.2 vs 5.6 ± 2.9 days, p = 0.005). Pulmonary embolism was notably less frequent in the early group (1.0%) compared to those fixed later (6.1%), with statistical significance (p = 0.02). Although ventilator use trended lower in early fixation (2.2 ± 1.8 vs 2.8 ± 2.1 days), the difference did not reach statistical significance (p = 0.06). Other complications such as ARDS (3.1% vs 4.9%), sepsis (7.1% vs 7.3%), wound infection (2.0% vs 3.7%), and mortality (3.1% vs 4.9%) did not differ significantly between groups.

Analysis of secondary complications showed a consistent pattern of higher rates in delayed cases: deep vein thrombosis (4.9% vs 2.0%), pneumonia (8.5% vs 5.1%), acute kidney injury (6.1% vs 3.1%), and wound dehiscence (2.4% vs 1.0%), though none were statistically significant.

Multivariate logistic regression identified early fixation as a significant protective factor against pulmonary embolism (adjusted OR 0.18; 95% CI: 0.04–0.82; p = 0.03). Other significant predictors included ICU stay beyond five days (OR 2.95; p = 0.007) and ISS ≥30 (OR 2.12; p = 0.045). Visual comparison of complication rates and ICU-free days also favored early surgery.

Femoral shaft fractures associated with intra-abdominal trauma represent a particularly vulnerable subset of polytrauma patients. Managing such cases requires a delicate balance between timely orthopedic stabilization and minimizing physiological insult in the context of ongoing visceral injury.

The present study aimed to evaluate whether definitive fixation within 24 hours, in patients with controlled physiology, results in better outcomes compared to delayed fixation. The rationale stemmed from the hypothesis that early stabilization, when guided by resuscitation parameters, can reduce systemic complications, ICU burden, and hospital stay.

Our findings reinforce this hypothesis. Patients in the early fixation group demonstrated significantly shorter hospital (12.4 ± 5.3 vs 15.8 ± 6.0 days) and ICU stay durations (4.1 ± 2.2 vs 5.6 ± 2.9 days), alongside a markedly lower incidence of pulmonary embolism (1.0% vs 6.1%, p = 0.02). These results mirror the multicenter study by Bosse et al., which confirmed the safety and efficacy of early fixation in multi-injured patients provided physiological benchmarks were met [8]. Likewise, Cross et al. emphasized reduced ventilator dependency and thromboembolic events with early intramedullary nailing in trauma populations [9].

The reduced rate of embolic complications is supported by Giannoudis et al., who documented fewer fat embolism syndromes and improved pulmonary metrics with early stabilization of long bone fractures [10]. Similarly, Brundage et al. noted that timely fixation shortened ICU exposure and reduced systemic inflammation in abdominal trauma cohorts [11].

Although no significant differences were observed in mortality, ARDS, or sepsis, trends favored early fixation. This parallels the work of Taitsman et al., who reported non-inferior safety profiles for early surgery even in multiply injured patients [12].

Clinically, these findings support an evidence-based shift toward early definitive fixation following adequate resuscitation. This approach aligns with trauma principles that prioritize early mobility and minimized ICU burden to reduce complications.

This study demonstrates that early definitive fixation of femoral shaft fractures in patients with associated abdominal trauma, when performed within 24 hours of admission and after adequate resuscitation, results in significantly shorter ICU and hospital stays and a lower incidence of pulmonary embolism. Mortality and other major complications were not significantly increased in the early group, underscoring the safety of timely surgical intervention. These findings support the integration of early fixation strategies into trauma management protocols, particularly when physiologic parameters such as pH, lactate, and base excess indicate stability.

Acknowledgements: The authros would like to express their gratitude towards the departmental staff for their support while conducting this study

Conflicts of interest: None declared

1. Brumback RJ, Virkus WW. Diaphyseal femoral fractures. In: Rockwood and Green’s Fractures in Adults. 6th ed. Lippincott Williams & Wilkins; 2006:1845–1925.
2. Pape HC, Giannoudis PV, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg. 2002;183(6):622–629.
3. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71(3):336–340.
4. Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma. 2000;48(4):613–621.
5. Harwood PJ, Giannoudis PV, Probst C, Pape HC. The timing of initial stabilization of femoral shaft fractures in polytrauma patients: a systematic review of the literature. J Trauma. 2005;58(1):104–110.
6. Taeger G, Ruchholtz S, Waydhas C, Nast-Kolb D. Damage control orthopedics in patients with multiple injuries is effective, safe, and minimizes complications. J Trauma. 2005;59(2):409–416.
7. Grotz MRW, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open femoral fractures: development of a standard operating protocol. Injury. 2005;36(1):102–109.
8. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924–1931.
9. Cross WW, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop. 2008;42(4):377–386.
10. Giannoudis PV, Tzioupis C, Pape HC. Fat embolism: the reamer-irrigator-aspirator system and beyond. Injury. 2006;37(Suppl 4):S30–S38.
11. Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV. Timing of femur fracture fixation: effect on outcome in patients with abdominal injuries. J Trauma. 2002;52(2):299–307.
12. Taitsman LA, Lynch JR, Agel J, Barei DP, Nork SE. Risk factors for femoral nonunion after femoral shaft fracture. J Trauma. 2009;67(6):1389–1392.