Efficacy and safety of early surgical fixation of fractures in patients with traumatic brain injury: a scoping review

Introduction

Traumatic brain injury (TBI) is a significant public health concern globally, with an estimated 69 million individuals sustaining a TBI each year. North America has the highest annual incidence of all-cause TBI observed, with 1299 cases per 100,000 people, compared to other regions (1). In the United States (U.S.), TBI contributed to 2.8 million emergency visits, hospitalizations, and deaths in 2013, which constituted 1.9% of the total emergency department visits, hospitalizations, and deaths that year (2).

Traumatic brain injuries often occur alongside other trauma-related injuries, such as facial, chest, pelvis, and upper and lower extremity fractures, which complicate clinical management due to the interplay between neurological and physical damage. Among the 1.8 million TBI cases recorded in the National Trauma Databank from 2007 to 2014, 60.2% of them had an isolated facial fracture (3). The association between facial fractures and TBIs is well-documented (4,5), with evidence suggesting that the presence of facial fractures significantly increases the risk of sustaining a brain injury (6,7) and is correlated with worse clinical outcomes (8,9). Beyond facial fractures, around 33–50% of TBI cases are associated with severe extracranial injuries to the extremities, chest, and abdomen (10).

The management of patients with concomitant TBI and facial or orthopedic fractures requires a multidisciplinary approach to address both the immediate and long-term needs of the patient. In individuals with isolated facial injuries requiring oral maxillofacial surgery (OMFS), early surgical intervention is recommended to prevent neurological complications, decrease morbidity, and reduce mortality (11). Additionally, timely intervention may reduce the risk of complications such as infection and scar tissue formation between displaced bone fragments (12). However, when TBI is also present in OMFS patients, the timing of surgery is critical. While early treatment can mitigate the risks associated with untreated fractures, specific timeframes must be observed. For instance, a 7 to 10-day window is recommended for mandible fractures, whereas an extended period of up to 14 days is considered acceptable for fractures of the middle and upper third of the face (8). These intervals, shorter in pediatric patients and longer in geriatric populations, are generally deemed adequate to allow for the resolution of cerebral hematoma and the stabilization of neurological function (13). In orthopedic surgery patients with concomitant TBI, fixation within 24–48 hours may be beneficial but the optimal timing is still controversial due to risks such as secondary brain damage (14).

Early intervention can help reduce the risk of infection, prevent malunion or nonunion of fractures, and improve overall patient outcomes (15). However, this approach can also pose significant risks, particularly in unstable patients with severe neurological injuries who are highly susceptible to respiratory and hemodynamic changes during surgery and anesthesia (16-20). Delayed surgical intervention, on the other hand, can allow providers time to focus on competing priorities, such as stabilizing the patient’s medical condition, managing potential intracranial hypertension, and optimizing hemodynamic stability (21-23). This approach can reduce the risks associated with early surgery, such as massive blood loss and perioperative complications. However, delayed intervention can lead to increased tissue swelling, complicating the surgical procedure, and potentially resulting in suboptimal functional and aesthetic outcomes due to healing in malposition (24). Additionally, prolonged immobilization of fractures may lead to joint pain, stiffness, and reduced function due to muscle atrophy (25).

Given these conflicting considerations, the timing of surgical fixation of fractures in TBI patients with concomitant OMFS or orthopedic injuries remains an important question in trauma care. The decision to proceed with early or delayed intervention must be individualized, taking into account the patient’s overall medical condition, the severity of the facial, orthopedic, and neurological injuries, and the potential risks and benefits of each approach. While the timing of surgical intervention is individualized, understanding the efficacy and safety of early versus delayed surgical treatment of fractures allows clinicians to optimize patient risk stratification. This scoping review aims to synthesize findings from available studies to evaluate the differences in outcomes between early and delayed surgical fixation. Specifically, we examine the impact of timing on neuropsychological, functional, and overall recovery outcomes in TBI patients undergoing surgical treatment for facial fractures, orthopedic injuries, or rib fractures. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-21/rc).

Methods

A comprehensive search of PubMed, Embase, Web of Science, and Cochrane was performed on June 30, 2024, to locate articles related to OMFS or orthopedic injuries in patients with TBI. The search strategy (Table 1) involved the use of several pertinent keywords and their combinations, including “traumatic brain injury”, “oral and maxillofacial surgery”, “facial fractures”, “time factors”, and “orthopedic procedures”. The search covered literature published from 1994 to 2024 to capture the most relevant and up-to-date research.

The inclusion criteria for this review were studies written in English that addressed the timing of surgical intervention in patients with TBI and concomitant facial, orthopedic, or rib fractures. High-quality studies, such as randomized controlled trials (RCTs), prospective cohort studies, and meta-analyses, were prioritized, along with key review articles that provided comprehensive overviews of the topic. Studies that were not relevant to the research question, as well as non-English publications, were excluded. Two independent reviewers (R.P. and M.B.B.) screened the titles and abstracts of identified articles for relevance. Following the initial screening, the full texts of potentially relevant articles were appraised to determine their eligibility for inclusion. Discrepancies in the selection process were resolved through consultation with a third reviewer (D.D.B.).

Key information from each selected source was documented, including author, publication year, study design, sample size, patient demographics, type and timing of surgical intervention, and the main outcomes measured. The selected articles were then subjected to a thematic analysis to identify recurring patterns and concepts. Specifically, the studies were categorized into three main themes: OMFS injuries, orthopedic injuries, and rib fractures. This thematic analysis involved a systematic approach where the extracted data were reviewed iteratively to group findings under these themes based on the nature of the injuries and their relevance to the timing of surgery in TBI patients. This process enabled us to synthesize findings comprehensively within each theme, highlighting similarities, differences, and gaps in the literature. The thematic framework provided a focused lens through which the data could be organized and interpreted, ensuring a robust and structured synthesis of the evidence.

Due to the heterogeneity of study populations, differences in how time to surgical intervention was measured, and the insufficient number of compatible outcome measures, a meta-analysis was deemed inappropriate. A narrative synthesis approach was adopted to collate and interpret the findings from the included studies. This method involved summarizing the key points from each study, identifying common themes, and contrasting different study results. The synthesis aimed to provide a balanced and comprehensive review of the timing of surgical intervention in TBI patients with OMFS injuries, drawing parallels with findings from orthopedic and rib fracture studies where relevant.

Results

The initial search strategy captured a total of 228 studies (Figure 1), of which 10 studies were included in this review (Table 2) (14,26-34). Studies were published between 1998 and 2024. Data from these studies ranged from 1990 to 2020 and evaluated the outcomes of early versus delayed surgical repair of OMFS or orthopedic injuries in TBI patients. Specifically, four studies examined the incidence of complications or differences in outcome with early or delayed repair of OMFS injuries (29,30,32,33), four studies evaluated patients with orthopedic injuries (14,28,31,34), and two larger studies assessed outcomes in patients with rib fractures (26,27). These studies varied in design and consisted of eight retrospective cohort studies (26-33), one prospective cohort study (34), and one meta-analysis (14).

Figure 1 Flowchart for a scoping review of the early versus delayed surgical fixation in oral maxillofacial surgery for patients with concomitant traumatic brain injury.

Of the 10 included studies, seven studies distinguished between early (or concurrent) and delayed surgery, with “early surgery” ranging from immediate to within 72 hours post-injury, and “delayed surgery” occurring from within a day of admission to at least 72 hours post-injury (26,28,29,31-34). The primary and secondary outcomes varied widely, with the most common being the Glasgow Outcome Scale (GOS) score, length of stay, and mortality, which was measured at different time points and sometimes for only a subset of patients. Patient demographics across these studies varied, with average age ranging from 6.3 to 58.0, male patients comprising 22.1% up to 83.3% of the studied populations, and motor vehicle accidents as the mechanism of injury in 8.3% to 75.5% of cases.

Facial fracture fixation timing and TBI

Wang et al. [2007] reported that in patients with TBI and multisystem trauma, early orthopedic and facial fracture fixation did not worsen neuropsychological or functional outcomes, while delayed surgery increased pneumonia rates and hospital stays without affecting mortality (32). You et al. [2018] supported these findings, noting that the timing of cranial and facial surgical interventions in patients with TBI did not significantly affect GOS outcomes at 3, 6, and 12 months (33). Additionally, Shibuya et al. [2007] described that complication rates were increased up to 15% in TBI patients with delays in facial fracture repairs (30). In contrast, Rothweiler et al. [2018] found that delaying surgery for facial fractures did not increase complications and resulted in fewer additional hospital stays and plate removals (29).

Insights from orthopedic surgery in TBI patients

The timing of orthopedic procedures provides additional insight. Mendelson et al. [2001] suggested that delaying femur fracture fixation in pediatric TBI patients did not significantly impact orthopedic or neurological outcomes, but it did result in a longer hospital stay (28). Zheng et al. [2024] reported that TBI patients who underwent early internal extremity fixation were not linked to unfavorable functional outcomes, increased mortality, complications, or extended length of stay at 6 months (34). Starr et al. [1998] emphasized that delay in femur fracture stabilization in TBI patients may increase pulmonary complications, while early stabilization does not raise the risk of neurological complications (31). Lu et al. [2020] conducted a meta-analysis that showed delayed fracture fixation (over 14 days post-injury) in TBI patients with extremity fractures was linked to nonunion or malunion, while fixation within 24 hours did not impact mortality, pneumonia, or neurological outcomes (14).

Timing of rib fracture fixation

Lagazzi et al. [2023] and Liao et al. [2023] demonstrated that timely surgical fixation of rib fractures in TBI patients conferred significant benefits (26,27). Lagazzi et al. highlighted reduced length of stays in the hospital and intensive care units (ICU) with early rib fixation, while Liao et al. observed better mortality in patients with concomitant flail chest and mild to moderate TBI.

Repair of extracranial injuries in TBI patients—OMFS, orthopedic, or rib fractures

The key findings across the included studies revealed that early surgical intervention does not lead to worse outcomes or increased rates of complications for TBI patients with facial fractures. Specifically, 3 out of the 4 OMFS-TBI studies showed no outcome differences between early and delayed surgery (29,32,33). In the other OMFS-TBI study, complication rates were increased in TBI patients with delays in facial fracture repairs (30). All four of the studies involving orthopedic injuries and TBI found no differences in neurological outcomes between early or delayed surgery (14,28,31,34) while 2 out of the 4 reported no differences in mortality between the two groups (14,34). The findings from the two studies of rib fractures were not different (26,27). One reported no differences in mortality (27), whereas the other found a shorter hospital length of stay in patients who underwent early surgical repair (26).

Despite the observed heterogeneity in the population, group distribution, and outcomes, the consistent finding across all categories is that early surgical intervention yields outcomes that are at least as favorable as those of delayed intervention. Additionally, early surgical intervention may be associated with fewer complications and a shorter hospital length of stay. These findings highlight the potential for early intervention to enhance overall recovery times without compromising neurological outcomes.

Discussion

Based on the limited data from the studies involving patients with concurrent TBI and OMFS injuries and drawing parallels from similar findings in TBI patients with orthopedic injuries or rib fractures, our review confirms that early surgical repair of these fractures is both feasible and safe in the absence of emergent neurological or cardiovascular complications. Early surgical intervention does not pose an increased risk for neurological outcomes or mortality. However, it is important to individualize care for each patient. Clinicians should consider possible complications and implement measures to prevent perioperative hemodynamic and respiratory instability, massive blood loss, and intracranial hypertension to optimize patient safety and outcomes.

Surgical and systemic benefits and risks of early versus delayed surgical repair

The potential benefits of early surgical repair in patients with concurrent TBI and OMFS or orthopedic fractures include enhanced alignment and stabilization of bone fragments, minimized scar tissue formation between displaced fragments, and a lower risk of malunion and nonunion, leading to superior aesthetic and functional outcomes (13,14,26,27,29,32,33). Early intervention has also been associated with shorter hospital and ICU stays (26,28,32), as well as a decreased risk of pulmonary and infectious complications (30-32). However, the risks associated with early surgery must be carefully considered, particularly in patients with severe TBI who are vulnerable to perioperative hemodynamic and respiratory instability (9,26,35). Early surgical intervention can lead to perioperative complications, especially in patients with significant blood loss or underlying cardiovascular disease, who can experience compromised organ perfusion and neurological deterioration (36,37). In patients with concurrent TBI and multiple major orthopedic fractures, early stabilization is recommended provided that rapid hemorrhage control, vital signs stabilization, and tissue perfusion are prioritized (23). Additionally, airway management in patients with facial fractures may be complicated, increasing the risk of respiratory difficulties and desaturation during the procedure (20).

Delayed surgical repair may allow for the medical stabilization of TBI patients with OMFS or orthopedic injuries, reducing the risk of perioperative complications in unstable individuals. This delayed approach facilitates the management of neurological, cardiovascular, and respiratory conditions, and provides time for initial swelling and inflammation to subside, which may enhance surgical planning (38-40). Furthermore, delayed repair has been shown to lower the incidence of plate removal, offering an enhanced recovery process without compromising overall outcomes (29,41). Several studies in our review suggest that delayed fixation does not compromise neurological outcomes (14,28,29,31-34). However, the drawbacks of delayed intervention include prolonged immobilization, which can lead to further tissue swelling, complicating the surgical procedure, and potentially resulting in suboptimal functional outcomes (39,42,43). Additionally, prolonged ICU stays can worsen the emotional and financial burden on caregivers of patients with TBI (44).

Neurological outcomes after early versus delayed surgical repair

A significant limitation of the existing literature is the variability in neurological outcome measures used to compare early versus delayed surgical interventions in TBI patients with extracranial injuries. While some studies primarily focused on the rate of neurological complications (14,29,31), others offered valuable insights into the neurological outcomes associated with each approach (28,32-34). Notably, these four studies reported comparable GOS scores, yet one found that early intervention was associated with improved neuropsychological composite scores, highlighting the potential cognitive benefits of early surgery (32).

Despite the relatively small sample size of 96 patients, the Wang et al. [2007] study is of particular importance due to the inclusion of a neuropsychological composite score to assess neurological outcomes (32). The GOS used in most other studies is sometimes limited in its sensitivity to specific cognitive functions and lacks the detailed assessment provided by neuropsychological composite scores, which offer a more nuanced evaluation of cognitive domains and better track long-term cognitive recovery (45). The GOS is, nevertheless, a widely used, simple, and reliable tool for assessing the broad functional outcomes of neurological interventions. This scoring system provides a quick overview of a patient’s neurological recovery by categorizing them into clear, easily interpretable levels of function, making it especially useful in clinical settings and large-scale studies (46). Consistent with the findings in TBI patients with orthopedic injuries or rib fractures, GOS scores were comparable in both early and delayed surgical interventions of facial fractures, confirming that it is reasonably safe to repair extracranial injuries in TBI patients (32,33). Recent research in mild TBI highlights the utility of advanced neuroimaging techniques, such as functional and structural connectivity analyses, to uncover subtle network disruptions associated with cognitive impairments (47,48). These methods provide additional insights into cognitive recovery, complementing traditional outcome measures like the GOS by identifying potential biomarkers for targeted interventions.

While the current literature does not provide sufficient evidence to draw definitive conclusions about the optimal timing for surgical fixation of OMFS injuries in patients with concomitant TBI, we can still offer several recommendations based on our results and current TBI guidelines (Figure 2). Candidates for early OMFS intervention may be identified based on their emergent/non-emergent surgical indications and Glasgow Coma Scale classification. Patients with severe TBI and hemodynamic instability should be carefully evaluated due to their elevated risks associated with early surgery. Intracranial pressure monitoring may help guide the management of patients with these characteristics or who meet other high-risk criteria, such as structural brain damage, motor posturing, or multi-system injuries (49,50). While these recommendations provide a general overview, the treatment plan should be tailored to each patient to ensure optimal outcomes.

Figure 2 Treatment algorithm providing recommendations for surgical timing in TBI patients with concomitant OMFS injuries (49,50). Individualized treatment planning is essential to optimize patient outcomes and safety. CT, computed tomography; GCS, Glasgow Coma Score; ICP, intracranial pressure; OMFS, oral maxillofacial surgery; TBI, traumatic brain injury.

Limitations and future studies

The main limitations identified in this review include the low number of OMFS-TBI studies, small sample sizes, and variable outcome measures. Moreover, a majority of the studies are retrospective and originate from a single center. The retrospective nature of studies can introduce biases, incomplete information, and reduced control over variables, making it challenging to establish causality and potentially impacting the accuracy and reliability of the findings. These factors highlight the need for further high-quality research to strengthen the evidence base and guide clinical decision-making.

The limited number of OMFS studies on TBI patients restricts the generalizability of our findings. We therefore complemented our study with evidence from the orthopedic and trauma literature, which may not fully capture the unique challenges and outcomes of OMFS injury repair in TBI patients. Small sample sizes in the available studies limit the statistical power and robustness of conclusions. Small cohorts increase the risk of type II errors, where true differences between early and delayed intervention groups may go undetected (51). Additionally, variability in outcome measures reported across studies poses a challenge for synthesizing and comparing results. Different studies may use varying definitions and metrics for outcomes such as neurological recovery, functional status, and complication rates. Larger, multicenter studies are needed to provide more definitive evidence and enhance the reliability of findings. Standardizing outcome measures in future research would facilitate more accurate comparisons and meta-analyses, contributing to a clearer understanding of the optimal timing for surgical interventions in TBI patients with concomitant OMFS injuries.

Conclusions

The synthesis of available studies on the timing of surgical repair in TBI patients with facial and orthopedic injuries suggests that early surgical fixation of facial injuries is as feasible and safe as delayed surgical intervention, provided that perioperative risks are carefully managed. This conclusion aligns with findings from orthopedic and trauma research, underscoring the general principle that timely surgical management in polytrauma patients, including those with TBI, can be advantageous depending on the individual patient and their treatment plan.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-21/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-21/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-21/coif). A.N. serves as an unpaid editorial board member of the Journal of Oral and Maxillofacial Anesthesia from April 2023 to March 2025. A.N. also received grants from U-19 Grant – Framingham Heart Study (NIH) and served as a consultant for Third Poe Therapeutics and Takeda Pharmaceutical Company. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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