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To determine the neurologic risks associated with early fracture fixation (FF) in multitrauma patients with head injuries. We reviewed 33 blunt trauma patients with significant closed head injuries (Abbreviated Injury Scale (AIS) score > or = to 2) requiring operative FF. Nineteen patients underwent early FF defined as < or = to 24 hours after injury, and 14 patients underwent late FF defined as >24 hours after injury. The two groups were well matched in regards to age, 40.3 years (range, 8-88 years) versus 36.4 years (range, 8-75 years), admission Glasgow Coma Scale score (12 +/- 4 vs. 11 +/- 5), and Injury Severity Score (25 +/- 10 vs. 27 +/- 12). Additionally, the groups had similar neurologic and orthopedic injury scores (AIS-CNS score = 3.3 +/- 0.9 vs. 3.1 +/- 0.9, AIS-Ortho score = 3.0 +/- 0.9 vs. 2.9 +/- 0.7). Data were collected concerning the volume of fluid resuscitation, neurologic complications, and clinical outcomes. The early FF group received significantly more fluids in the first 48 hours (14.0 +/- 10.2 vs. 8.7 +/- 3.5 liters, p < 0.05). The early group trended towards a higher rate of intraoperative hypotension (systolic blood pressure < 90 mm Hg, 16% vs. 7%) and intraoperative hypoxia (02 -Saturation < or = to 90, 11% vs. 7%). The neurologic complication rate was similar in the two groups (early FF = 16% vs. late FF = 21%), but the average discharge Glasgow Coma Scale score was lower in the early group (13.5 +/- 3.7) when compared with the late FF patient group (15.0 +/- 0.0). Early FF leads to greater fluid administration in patients with head injuries. Hypoxemia and hypotension, risk factors for secondary brain injury, may contribute to a poor neurologic outcome after early fixation. Prospective studies evaluating the impact of the timing of FF on head injury are indicated.