• Dieter Rixen, Guido Grass, Stefan Sauerland, Rolf Lefering, Marcus R Raum, Nedim Yücel, Bertil Bouillon, Edmund A M Neugebauer, and Polytrauma Study Group of the German Trauma Society.
• Department of Trauma/Orthopedic Surgery, University of Witten/Herdecke at the Hospital Merheim, Cologne, Germany. D.Rixen@uni-koeln.de
• J Trauma. 2005 Dec 1; 59 (6): 1375-94; discussion 1394-5.

BackgroundFemur-shaft fracture treatment (FSFT) follows controversial management concepts after multiple trauma: primary-definitive osteosynthesis, secondary-definitive osteosynthesis after temporary external fixation (EF) in all patients, or individualized primary- or secondary-definitive osteosynthesis ("risk-adapted damage control orthopedics"). This study compares the concepts by analyzing literature evidence and a prospective multicenter database.MethodsA systematic literature analysis was performed. The German Trauma Society trauma registry was used to assess variables predictive of treatment concept.ResultsContradictory results in 63 controlled trials failed to support a "generalized management strategy." In all, 1,465 FSFTs in 8,057 trauma registry patients (age 39 +/- 19.5 years; Injury Severity Score [ISS] 23.5 +/- 14.9; 17.3% mortality) were treated initially (<24 hour) by EF, nail, or plate in 47.0%, 41.1%, and 11.9%, respectively. Despite large interhospital variability, EF was more likely with increasing severity of ISS, Glasgow Coma Score, thorax trauma, base excess, coagulation abnormalities, and initial probability of death.ConclusionsClinical "reality" reflects the controversies of "scientific evidence" for FSFT after multiple trauma in Germany. Although decision making is currently based on unvalidated criteria, anatomic and physiologic injury severity appears to influence the choice of management concept.

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