Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes.

BACKGROUND: Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS: Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS: One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION: Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE: Prognostic study, Level IV.