Damage contol orthopaedics

Introduction

Many orthopaedic patients who have sustained multiple injuries benefit from the early total care of major bone fractures.

However this strategy is not the best option, and indeed might be harmful for some multiply injured patients.

Since going for early surgery is not the optimal approach for those patients, the concept of damage control orthopaedics has evolved

Damage control orthopaedics emphasizes the stabilization and control of the injury, often with use of spanning external fixation, rather than immediate fracture repair.

Definition

It is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology can improve.

Its purpose is to avoid worsening of the patient’s condition by the “second hit” of a major orthopaedic procedure and to delay definitive fracture repair until a

time when the overall condition of the patient is optimized.

Minimally invasive surgical techniques such as external fixation are used initially.

Damage control focuses on− control of hemorrhage − management of soft-tissue injury − achievement of provisional fracture stability

while avoiding additional insults to the patient

History

The concept of damage control surgery was developed first in the field of abdominal surgery

The era of damage control orthopaedics started around 1993.

During the 1990s more was learned about the parameters associated with adverse outcomes in multiply injured patients and about the systemic inflammatory response to trauma

It became clear that fracture surgery, especially intramedullary nailing, has systemic physiologic effects.

These effects became known as the “second hit” phenomenon

Physiology

Traumatic injury leads to systemic inflammation followed by a period of recovery mediated by a counter-regulatory anti imflammatory response

Within this inflammatory process, there is a fine balance between the beneficial effects of inflammation and the potential for the process to cause and aggravate tissue injury leading to ARDS and multiple organ dysfunction syndrome

The initial massive injury and shock can give rise to an intense systemic inflammatory syndrome with the potential to cause remote organ injury

When the stimulus is less intense and would normally resolve without consequence, the patient is vulnerable to secondary inflammatory insults that can reactivate the systemic inflammatory response syndrome and precipitate late multiple organ dysfunction syndrome

The second insult may be as a result of a variety of circumstances, such as sepsis and surgical procedures

Hyperstimulation of the inflammatory system, by either single or multiple hits, is considered by many to be the key element in the pathogenesis of adult respiratory distress syndrome and multiple organ dysfunction syndrome

Markers of Immune Reactivity

Inflammatory markers may hold the key to identifying patients at risk for the development of posttraumatic complications such as multiple organ dysfunction syndrome

It appears that, at present, only two markers, IL-6 and HLA-DR class-II molecules, accurately predict the clinical course and outcome after trauma

Genetic Predisposition andAdverse Outcomes

Biological variation and genetic predisposition are increasingly mentioned as explanations of why serious posttraumatic complications develop in some patients and not in others

i.e. Some individuals may be “preprogrammed” to have a hyperreaction to a given traumatic insult

Use of biochemical and geneticnmarkers to identify patients “at risk” after orthopaedic trauma may facilitate

clinical decision-making regarding when to switch from early total care to damage control orthopaedics

Patient Selection for Damage Control Orthopaedics

Because biomechanical and genetic testing is currently not practical, it remains a clinical decision when to shift from early total care to damage control orthopaedics

Should be decided on the basis of the patient's overall physiologic status and injury complexes

Many trauma scoring systems have been developed in an attempt to describe the overall conditon of the trauma patient.

However, Bosse et al. noted that “there is no score that assists in decision-making during the acute resuscitation phase.”

Therefore, it may be that one cannot rely exclusively on a scoring system

Patients who have sustained orthopaedic trauma have been divided into four groups:−stable−borderline−unstable−in extremis

Stable patients should be treated with the preferred method for managing their orthopaedic injuries.

Unstable patients and patients in extremis should be treated with damage control orthopaedics for their orthopaedic injuries

Borderline patients are more difficult to define Probably best treated with damage control

orthopaedics

Clinical Parameters Used to Define the “Borderline” Patient for Whom Damage Control Orthopaedics Is Often Preferred−Polytrauma + Injury severity score of >20

points or and additional thoracic trauma−Polytrauma + Injury severity score of ≥40

points in the absence of additional thoracic injury

−Polytrauma with abdominal/pelvic trauma and hemorrhagic shock (initial blood pressure <90 mm Hg)

The Injury Severity Score (ISS), an anatomical scoring system that provides an overall score for patients with multiple injuries.

This is based on the Abbreviated Injury Scale (AIS), a standardized system of classification for the severity of injuries graded on a scale of 1 (minor) to 5 (critical and life threatening)

Each injury is assigned an AIS score and is allocated to one of six body regions: head, face, chest, abdomen, extremities (including pelvis), and external structures.

The total ISS score is calculated from the sum of the squares of the three worst regional values.

The ISS ranges from 1 to 75

−Radiographic findings of bilateral lung contusion

−Initial mean pulmonary arterial pressure of >24 mm Hg

−Increase of >6 mm Hg in pulmonary arterial pressure during intramedullary nailing

Among other factors, thoracic trauma appears to play a crucial role in predisposition to deterioration

However, whether femoral fractures in patients with chest trauma should be treated with definitive stabilization or should be stabilized with a temporary external fixator remains a subject of debate

Clinical Parameters Associated with Adverse Outcomes in Multiply Injured Patients−Unstable condition or resuscitation difficult −Coagulopathy (platelet count <90,000)−Hypothermia (<32°C)−Shock and >25 units of blood needed−Bilateral lung contusion on first plain

radiograph

−Multiple long-bone injuries and truncal injury; abbreviated injury score of ≥2 points

−Presumed operation time >6 hr−Arterial injury and hemodynamic instability

(blood pressure <90 mm Hg)−Exaggerated inflammatory response (e.g., IL-6

>800 pg/mL)

The clinical situation, including the presence or absence of a criterion indicating borderline status and factors associated with a high risk of adverse outcomes should determine how the patient is treated

Certain specific orthopaedic injury complexes appear to be more amenable to damage control orthopaedics; these include-−femoral fractures in a multiply injured patient, −pelvic ring injuries with exsanguinating

hemorrhage−polytrauma in a geriatric patient.

Femoral Fractures- Femoral fractures in a multiply injured patient are

not automatically treated with intramedullary nailing because of concerns about the second hit of such a procedure.

In addition to the second hit, embolic fat from use of instrumentation in the medullary canal will worsen the pulmonary status.

Patients with a chest injury are most prone to deterioration after an intramedullary nailing procedure

Bilateral femoral fracture is a unique scenario in polytrauma that is associated with a higher mortality rate and incidence of adult respiratory distress syndrome than is a unilateral femoral fracture

Ideal for damage control orthopaedics

Pelvic Ring Injuries Exsanguinating hemorrhage associated with

pelvic fracture is another injury complex suitable for DCO

The specific radiographic pattern of the pelvic ring injury and the mechanism of the injury can help one to anticipate the amount of bleeding, but there is no precise injury pattern that predicts hemorrhage consistently

There are some consistent findings associated with a higher likelihood of hemorrhage−Posterior pelvic ring injuries are associated with a

two to threefold increase in blood replacement requirements compared with anterior injuries

−Anterior-posterior compression type-III injuries and lateral compression injuries are associated with a high prevalence of vascular injury (22% and 23%, respectively)

−Pelvic fractures in patients over fifty-five years old are more likely to produce hemorrhage and require angiography

Damage control orthopaedics for a pelvic ring injury with exsanguinating hemorrhage involves −rapid clinical decision-making −multiple teams for resuscitation−minimally invasive pelvic stabilization (e.g.,

with a pelvicbinder, external fixator, pelvic c-clamp, or pelvic stabilizer).

Patients who do not respond to these measures should

be considered for angiography and embolization if they are likely to survive the trip to the angiography

otherwise, they should be considered for pelvic packing once any underlying coagulopathy has been corrected

Geriatric Trauma Elderly trauma patients require special evaluation

and treatment because of their higher mortality rate following trauma

This increased mortality wasdue to–−lower Glasgow coma score −greater transfusion requirements−greater fluid infusion requirements

As compare to younger population These differences highlight the importance of

considering damage control orthopaedics for elderly patients.

In addition, treatment should be directed toward measures that enhance immediate mobilization and the avoidance of prolonged bed rest in this patient population.

important to consider damage control orthopaedics for elderly patients.

In addition, treatment should be directed toward measures that enhance immediate mobilization and the avoidance of prolonged bed rest in this patient population.

Special Situations in Damage Control Orthopaedics

Chest Injuries Traditionally, there have been two divergent

schools of thought related to the treatment of multiply injured patients with long-bone fractures and a chest injury−some believing that early fracture stabilization

is safe and maybe even beneficial−others believing that early fracture stabilization

is not safe and may be harmful

A selective approach should be used for patients with long-bone fractures and a chest injury

Clinical parameters may be helpful in determining the appropriateness of early long-bone stabilization: −severity of pulmonary dysfunction−Hemodynamic status−estimated operative time −Estimated blood loss−fracture status (open or closed)

Head Injuries The initial management of a patient with a head

injury should be similar to that of other trauma patients, with a focus on the rapid control of hemorrhage and restoration of vital signs and tissue perfusion.

A brain injury can be made worse if resuscitation is inadequate or if operative intervention such as long-bone fixation decreases mean arterial pressure or increases intracranial pressure.

The treatment protocol for unstable patients should be based on the individual clinical assessment and treatment requirements rather than on mandatory policies with respect to the timing of fixation of long-bone fractures.

damage control orthopaedics can provide temporary osseous stability to an injured extremity without worsening the patient's head injury or overall condition.

Aggressive management of intracranial pressure appears to be related to an improved outcome

Intracranial pressure monitoring should be utilized in the intensive care unit as well as during surgical procedures in the operating room.

Maintenance of cerebral perfusion pressure at >70 mm Hg and intracranial pressure at <20 mm Hg should be mandatory before, during, and after surgical procedures

Orthopaedic injuries should be managed aggressively with the assumption that full neurological recovery will occur

Mangled Extremities A damage control orthopaedics approach to

saving the limb may make it possible to improve surgeon-controlled

variables that appear to be related to better outcome

E.g. The use of spanning external fixation, antibiotic bead pouches and the vacuum-assisted wound closure technique may provide a bridge to staged osseous reconstruction and soft tissue coverage procedures

Isolated Complex Lower-Extremity Trauma Indication for a limited form of damage control

orthopaedics Specific injuries that are amenable to this

approach include−complex proximal tibial articular and

metaphyseal fractures−distal tibial pilon fractures.

These clinical situations usually combine a complex fracture pattern, either open or closed, with a substantial soft-tissue injury.

Limb damage control orthopaedics is useful for preventing soft-tissue complications by spanning the articular segment with an external fixator and avoiding areas of future incisions.

Then definative fixation can be performed at a stage when the condition of the soft tissue envelope is optimized.

Timing of Secondary Orthopaedic Procedures

One of the most important issues in damage control orthopaedics

Days 2, 3, and 4 are not safe for performing definitive surgery.

marked immune reactions are ongoing and increased generalized edema is observed.

Summary

Damage control orthopaedics is ideal for an unstable patient or a patient in extremis, and it has some utility for the borderline patient as well

Specific injury complexes for which damage control orthopaedics should be considered are femoral fractures (especially bilateral fractures), pelvic ring injuries with profound hemorrhage, and multiple injuries in elderly patients

Specific subgroups of multiply injured orthopaedic patients who may benefit from damage control orthopaedics are those with a head injury, chest trauma, or a mangled limb

A limited form of damage control orthopaedics (limb damage control orthopaedics) is a rational alternative for the treatment of isolated, complex limb injuries

Clinical data and emerging discoveries in molecular medicine may continue to provide answers to the question of when orthopaedic surgeons should use a damage control orthopaedics approach

Prospective, multicenter studies may ultimately be necessary to better understand the role of damage control orthopaedics in the treatment of patients who have sustained orthopaedic trauma, especially those with concomitant injuries to the chest and head.

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