Damage Control Orthopaedics

Definition

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

• purpose :

- avoid worsening of the patient's condition by the “second hit” of a major orthopaedic procedure

- delay definitive fracture repair until a time when the overall condition of the patient is optimized

Physiology

SIRS = systemic inflammatory response syndromeCARS = counter-regulatory anti-inflammatory response syndrome

The First and Second-Hit Phenomena

MODS = multiple organ dysfunction syndromeARDS = adult respiratory distress syndrome

Markers of Immune ReactivityGroup Examples

Interleukins (IL)IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-11, IL-12, IL-13, IL-18

Tumor necrosis factors (TNF) TNF, lymphotoxin (LT)

Interferons (IFN) IFN-alpha, IFN-beta, IFN-gamma

Colony stimulating factors (CSF) G-CSF, M-CSF, GM-CSF

• C-reactive protein, procalcitonin, TNF-α, IL-1, and IL-8 are not reliable markers

• IL-6 reliable index of the magnitude of systemic inflammation and correlates with the outcome

• IL-10 correlate with the initial degree of injury and persistently high levels of IL-10 correlate with sepsis.

• HLA-DR class-II molecules markers of immune reactivity and a predictor of outcome following trauma

• ratio of IL-6 to IL-10 correlate with injury severity after major trauma and is used to predict the degree of injury following trauma

• level of plasma DNA suggested as a potentially valuable prognostic marker for patients at risk

• at present, IL-6 and HLA-DR class-II molecules, accurately predict the clinical course and outcome after trauma.

Patient Selection for Damage Control Orthopaedics

• Patients who have sustained orthopaedic trauma are divided into :

a)Stable - local preferred method

b)Borderline - damage control orthopaedics often preferred

c) Unstable - damage control orthopaedics

d)In extremis - damage control orthopaedics

Clinical grading criteria ( Pape et al)

Injury complexes suitable for damage control orthopaedics

Femoral Fracture

• Femoral fractures in a multiply injured patient are not automatically treated with intramedullary nailing because :

- ‘second hit’- fat emboli• Patients with a chest injury are most prone to deterioration

after an intramedullary nailing procedure• Bilateral femoral fracture is associated with a higher

mortality rate and incidence of adult respiratory distress syndrome than is a unilateral femoral fracture

• Increase in mortality may be more closely related to associated injuries and physiologic parameters than to the bilateral femoral fracture itself

Pelvic Ring Injuries

• Exsanguinating haemorrhage associated with pelvic fracture

• Conditions where haemorrhage can be expected, when there is pelvic injury :

-Posterior pelvic ring injuries

-Anterior-posterior compression type III injuries, lateral compression injuries

-Pelvic fracture in patients over 55 years old

What is done?• Minimally invasive pelvic stabilisation- Pelvic binder- External fixator- Pelvic c-clamp- Pelvic stabilizer

• Angiography and embolisationIndications :1.Initial treatment of pelvic fractures associated with

hypotension that have not responded to the placement of a pelvic binder, external fixator, pelvic c-clamp, or pelvic stabilizer and transfusion of four units or more of blood

2. expanding retroperitoneal hematoma,3. a vascular blush seen on CT 4. a massive retroperitoneal hematoma observed on CT- Timing is important- Embolisation later than 3 hours after injury increased

risk of mortality-Average procedure time is 90 minutes

• Pelvic PackingIndication :1. Patient with severe hypotension and a pelvic fracture

that is unresponsive to other initial treatment measures, associated with imminent risk of death

Chest Injuries

Treatment of multiply injured patients with long bone fractures and a chest injury:

• early fracture stabilisation (within 48 hours)is safe and may be beneficial

• early fracture stabilisation is safe and maybe beneficial

Chest radiograph showing a ruptured left hemidiaphragm and femoral fracture in a multiply injured patient

Initial external fixation was performed at the time of the diaphragmatic repair

Staged intramedullary nailing was performed on post-injury day 2

Head Injuries• Early stabilisation doesn’t enhance or worsen the

outcome in patients with head injury.

Management :• Based on the individual clinical assessment and

treatment requirements• Damage control orthopaedics can provide temporary

osseous stability to an injured extremity, functioning as a temporary bridge to staged definitive osteosynthesis, without worsening the patient's head injury or overall condition.

• Aggressive management of intracranial pressure• Maintenance of cerebral perfusion pressure at >70 mm

Hg and intracranial pressure at <20 mm Hg

Mangled Extremities

• DCO approach to save the limb :

a) Spanning external fixator

b) Antibiotic bead pouches

c) Vacuum assisted wound closure

Antibiotic bead pouch for treatment of an open proximal tibial fracture

Isolated Complex Lower-Extremity Trauma

• “limb damage control orthopaedics”• Proximal tibial articular and metaphyseal

fractures, metaphyseal fractures, distal tibial pilon fractures

• Useful for preventing soft-tissue complications by spanning the articular segment with an external fixator and avoiding areas of future incisions.

• Then minimally invasive plate osteosynthesis can be performed at a stage when the condition of the soft tissue envelope is optimized.

When can secondary orthopaedic procedures be performed?

• Days 2, 3 and 4 are not safe ( marked immune reactions and increased generalised oedema)

• Days 6 to 8 less risk

The current treatment algorithm from Hannover, Germany, for the use of damage control orthopaedics. ER = emergency room, ABG = arterial blood gases, FAST = focused assessment sonography for trauma, I/O ratio = intake/output ratio, ABP = arterial blood pressure, IL-6 = interleukin-6