Damage Control OrthopaedicsJ Bone Joint Surg Am. 2005;87:434-449

Evolved in 1990’s

Early total care of major bone fractures in polytrauma pts was questioned.

Are we doing good or more harm to the patient.

Definition

an approach that contains and

stabilizes orthopaedic injuries so that

the patient’s overall physiology can

improve.

delay definitive fracture repair until patient condition is optimized

principle

avoid worsening of the patient’s

condition by a major orthopaedic

procedure.

Focus-1. control of hemorrhage.2. management of soft-tissue injury.3. achievement of provisional fracture

stability.

Evolution of fracture management

< 1950’s- status of exfix

1950-1. AAOS2. ILLIZAROV

NOV 6TH 1958

Maurice Müller, Hans Willenegger, Martin Allgöwer and …..

Formed the AO-ASIF group in view of

the poor functional results after non-

operative Rx of #

AO PRINCIPLE

early restoration of function, whether

a patient was being treated for an

isolated fracture or for multiple

injuries.

AGGRESSIVE TRAUMATOLOGY

THIS PATIENT IS TOO SICK NOT TO BE TREATED SURGICALLY

(1960-1990)

Bone et al . J Bone Joint Surg Am. 1989;71:336-40.

reported that the incidence of

pulmonary complications was higher

when femoral fixation was delayed.

1990’s

Research at a cellular level flourished

Pathophysiology of multiply injured pt

Concept of systemic inflammatory response

to trauma. “second hit” phenomenon.

Physiology of DamagE Control Orthopaedics

EFFECTS OF TRAUMA & SURGERY

Stimulating SIRS

immunosuppression

Dec of immunoglobulins , interferon

Anergy

Delayed hypersensitivity skin-testing.

Increased risk of posttraumatic sepsis

Biochemical markers

Currently only two markers

IL-6 HLA-DR class-II

Can accurately predict clinical outcome after trauma.

Clinical patient Selection

Trauma scores-

1. The abbreviated injury scale

2. Injury severity score

3. Revised trauma score

4. Anatomic profile

5. Glasgow coma scale

stableboderlin

e

Unstable In

extremis

STABLE PTS

Stable patients should be treated

with the

local preferred method.

Unstable patients

patients in extremis

should be treated with damage

control

orthopaedics.

orthopaedic injury complexes

femoral fractures in a multiply

injured

pelvic ring injuries with shock

polytrauma in a geriatric patient.

Chest injury

Two schools of thought

Early fixation is safe and beneficial

1. Bone et al : Early vs delayed stabilization of

femoral fractures. J B JS. 1989;71:336-40.

Thoracic trauma and early intramedullary nailing of femur fractures: are we doing harm? J Trauma. 1997;43:24-8.

No increase inmorbidity or mortality in association with early intramedullary

nailing (within twenty-four hours) of femoral

fractures in patients who had sustained blunt thoracic trauma.

Delayed Internal Fixation of Femoral

Shaft

Fracture Reduces Mortality Among

Patients with Multisystem Trauma

JBJS 2009

FOUR TIME ZONES

By delaying fixation beyond 12 hrs-

1. Allowed time for resuscitation

2. reduces mortality by approximately 50%.

3. Abdominal trauma pts had max benefit

4. Only exception time zone 24-48 hrs

HEAD INJURY

Early stabilization does not enhance or worsen the outcome in pts with head injury.

Individualize Rx

Cerebral perfusion pressure at >70

mm Hg

Intracranial pressure at <20 mm Hg

MANGLED EXTREMITIES

LEAP STUDY

Hypothesis- amputation would prove to have a better functional outcome than reconstruction.

1. SIP scores

2. % return to work

3. Reconstruction group-

Higher complication rate

More surgeries

More hospital admissions

6.4% risk of amputation

Secondary OrthopaedicProcedure

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

Day 6 to 8 less risk as the SIRS is low

STEPS OF DCO

1. Control bleeding

2. Manage soft tissues

3. Spanning exfix

4. Antibiotic pouch

5. VAC dressings