Abstract

The optimal timing of definitive fracture fixation in polytrauma remains unsettled, particularly when physiological derangement persists after initial resuscitation. Contemporary fracture-fixation strategies have therefore moved beyond a rigid choice between early total care (ETC) and damage control orthopedics (DCO) toward individualized decision-making based on physiological status, response to resuscitation, and anticipated surgical burden. This review aimed to evaluate physiological criteria and response-to-resuscitation parameters that have been proposed to guide the timing and strategy of major fracture fixation in adult patients with polytrauma. This structured narrative review searched PubMed/MEDLINE for publications from 2007 to 2026 that addressed fracture-fixation strategies, physiological status, response to resuscitation, trauma severity, or parameters relevant to surgical timing in adult polytrauma. Particular attention was given to distinguishing prognostic markers of adverse outcomes from physiological criteria specifically proposed to determine readiness for definitive fixation. Serum lactate, pH, and base excess were the parameters most consistently incorporated into physiology-guided fixation protocols. The early appropriate care (EAC) protocol proposed definitive fixation within 36 hours after adequate resuscitation, defined by at least one of the following criteria: lactate <4.0 mmol/L, pH ≥7.25, or base excess ≥−5.5 mmol/L. Other risk-adapted strategies incorporated hemodynamic, respiratory, metabolic, and coagulation parameters. Anatomical severity scores and inflammatory or metabolic biomarkers may support risk assessment, but they have not been validated as standalone thresholds for selecting ETC, DCO, or another fixation strategy. Current evidence does not demonstrate universal superiority of either ETC or DCO and instead supports repeated physiological reassessment. The timing of definitive fracture fixation in polytrauma should be individualized according to physiological status and response to resuscitation. Current evidence favors a dynamic, physiology-guided approach in which definitive fixation is performed as early as physiologically safe, whereas staged treatment is reserved for patients with persistent instability or inadequate recovery. Further prospective studies are needed to validate broadly applicable thresholds for surgical timing.

• Keywords: Multiple trauma; Damage control orthopedics; Early total care; Early appropriate care; Fracture fixation; Physiological resuscitation