# Timing of definitive fracture fixation in patients with concomitant traumatic brain injuries – A systematic review of the literature by the IMPACT group

## TL;DR

This study reviews evidence on when to fix fractures in patients with brain injuries, finding early treatment may help those with mild injuries but more research is needed.

## Contribution

A systematic review of timing for fracture fixation in polytrauma patients with traumatic brain injuries, highlighting gaps in current evidence.

## Key findings

- Early fracture fixation within 24 hours may benefit patients with mild traumatic brain injuries.
- Decision-making is more complex for moderate and severe traumatic brain injuries, often requiring individualized approaches.
- Current studies show significant heterogeneity in inclusion criteria and outcomes, indicating a need for more consistent research.

## Abstract

The timing of definitive fracture care in polytrauma patients remains a complex topic, especially in the presence of concomitant intracranial injuries, which often dictate surgical priorities. The International MultidisciPlinAry Consensus panel on polyTrauma (IMPACT) recently proposed recommendations on the timing of surgical interventions in polytrauma patients with competing priorities and identified some gaps in evidence. The aim of this study is to provide a systematic review of the scientific evidence on the timing of fracture fixation in patients with traumatic brain injuries (TBI).

A systematic review on MEDLINE and EMBASE was performed, including original articles published between 2000 and 2024, comparing the outcomes of early (≤ 24 h) versus late (> 24 h) definitive fracture fixation in polytrauma patients with TBI. Demographic data, overall injury severity, and TBI severity of the respective cohorts were taken into consideration for qualitative analysis. Additionally, complication rates and outcomes were assessed.

A total of 9782 studies were identified. After applying the inclusion and exclusion criteria, 7 studies were finally included. Overall, significant heterogeneity was observed in the selection criteria, with some studies focusing on more severe and others on milder TBI, using different criteria. Overall, most studies provide evidence that early fracture fixation in patients with mild TBI might be beneficial for patients’ outcomes.

Early definitive fracture fixation within 24 h should be attempted in polytrauma patients with concomitant mild TBI under specific conditions, which were previously defined by the IMPACT group. Furthermore, current evidence suggests that this approach is both safe and beneficial in a carefully selected patient population. In cases of moderate and severe TBI, decision-making is usually more difficult and complex, often requiring it to be individualized. However, we identified several gaps in the existing literature, particularly with regard to the heterogeneity of the available studies in terms of inclusion criteria, injury morphologies and investigated outcome parameters. Prospective or detailed registry studies are required to obtain further insight into this relevant topic.

The online version contains supplementary material available at 10.1007/s00068-025-02981-w.