April 11, 2024

Damage control orthopedics (DCO) is an approach that contains and stabilizes orthopedic injuries so that the patient’s overall physiology can improve.

A principle of treatment designed to reduce the systemic burden of surgical procedures on the already traumatized patient

See also: Fat Embolism Syndrome

See also: Distraction Osteogenesis

See also: External Fixator Principles

See also: Spinal Injuries

Focuses on:

Control of hemorrhage

Management of soft-tissue injury

Achievement of provisional stability while avoiding additional insults to the patient

Damage Control Orthopaedics

Goal

Limit ongoing hemorrhage, hypotension, and release of inflammatory factors

Management of soft tissue injury

Limited debridement

Limit stress on injured brain

Provisional fracture stability

Delay definitive fixation

The Dangers of Unstabilized Long Bones

Pulmonary insult

Stimulated inflammatory mediators

Muscle damage

Pain

Increase narcotic use

Negative effect on vital signs

Immobilized supine in traction

Poor pulmonary effort

Decubitus breakdown

CT scans, ICU care, etc…

Systemic Effects of Trauma

Systemic Effects of Trauma

First Hit

Permeability of pulmonary capillaries increased -> ARDS

Systemic Effects of Trauma

Effect of IM Nailing

Increased IM Pressure

Embolic Showers On Echocardiograms

Caused by

Canal Opening

Reaming

Nail Insertion (both reamed & unreamed)

Principles of Damage control orthopedics

1.Early expeditious stabilization of unstable fractures and control of hemorrhage

External fixation: Fast and minimally invasive

Reduced operative time

Reduced inflammatory mediator release

Principles of DCO

2.  ICU resuscitation

Warming

Resuscitation

Optimizaiton

Principles of DCO

3.  Definitive Management

Once condition optimized

Convert femoral Ex-fix to  IM nail

Safe conversion without unacceptably high risk up to at least  two weeks

Ex-Fix

Advantage:

No reaming

Fast

More stable than traction

Can be done at the bedside in ICU without C-arm

Data to support Damage control orthopedics

Data is difficult to interpret because studies to date are retrospective with unmatched groups

No selection criteria

No protocol for application of DCO principles

Groups treated with DCO principles are usually more severely injured than those with immediate IM nailing

Small numbers of patients limit power of studies

Early Total Care

Definitive Early Fixation

Nail or Plate

Damage Control

Temporary Stability

External Fixator

Limit Further Blood Loss

Limit Anesthetic Time

Delay Definitive Fracture fixation

Scoring Systems

Abbreviated injury scale

Injury severity score

Revised trauma score

Glasgow coma score

Borderline Patients

Injury: 1st Hit

Surgery: 2nd Hit

May exceed the patient’s biologic reserve

May lead to adverse outcome

Borderline Patients

Borderline Patients

Borderline Patients

Femoral fractures in multiply injured

Pelvic ring injuries with exsanguinating hemorrhage

Polytrauma in geriatric patients

Femoral fractures

Femoral fractures

Femoral fractures

Pelvic Fractures

Exanguinating hemorrhage

Osseous

Venous

Arterial

Internal iliac artery (superior gluteal artery)

Common / External Iliac artery

Pelvic Fractures

Posterior pelvic ring injuries:

2-3 fold increase in blood replacement

Pelvic Fractures

Patients >55 years: more likely to produce hemorrhage and require angiography

Do angiography if:

Massive / Expanding retroperitoneal hematoma

Vascular blush on CT

Angiography done  >3 hours of injury : 5-fold increase in mortality

Resuscitation: Role of Orthopaedics

Goal: limit ongoing hemorrhage and hypotension

pelvic ring injury–

   external fixation reduced

   mortality from 43% to 7%

   (Reimer, J Trauma, ’93)

Geriatric Fractures

Chest Injuries

5 clinical parameters helpful in determining the appropriateness of long bone stabilization

  1. The severity of pulmonary dysfunction

2.Hemodynamic status

3. Estimated operative time

4. Estimated blood loss

5. Fracture status (open/closed)

Operative Fracture Care

Surgery is often the optimal form of fracture treatment in the head-injured polytrauma patient

Advantages

Alignment

Articular congruity

Early rehabilitation

Facilitated nursing care

Reduces persistent pain at the fracture site

The positive effect on the patient’s metabolism, muscle tone, cerebral function

Operative Fracture Care

Perform early surgery when appropriate

MUST minimize

hypotension

hypoxia 

elevated ICP

Consider temporary methods

    (external fixation)

Fixation must be adequate

Patient may be non compliant

“accelerated” healing cannot be relied upon

Advances in Care of Head Injured

ICP monitoring

Maintenance of cerebral perfusion pressure > 70 mmHg and ICP <20 mmHg is mandatory before, during and after surgical procedures

Allow for safer surgery in the head injured

Occult Injuries in head injuries

Cervical spine injuries

Missed injuries

Fractures, dislocations: ~11% of orthopedic injuries

Peripheral nerve injuries are particularly common  (as high as 34%)

Occult fractures in children with head injuries are also common (37-82%)

Mangled extremity

LEAP (lower extremity assessment project)

Absolute indication for amputation

Anatomic disruption of the tibial nerve

Crush injury >6 hours warm ischemia

Presence of 2/3 relative indication

serious polytrauma

severe injury of the ipsilateral foot

anticipation of protracted course to obtain soft-tissue coverage or tibial reconstruction

Mangled extremity

Hansen et al

MESS ≥ 7

100 % amputation rate

Mangled extremity

Gilson et al

Patients who underwent reconstruction 

took longer to achieve full weight bearing

More rehospitalization

Prolonged hospital stay

Webb et al

Wound coverage with flaps + ex-fix had worse results than amputation in Type III open tibial fractures

When can secondary Orthopedic procedure Safe?

Day 2-4 : NOT SAFE compared to 6-8

Marked immune response ongoing

Increase generalized oedema

Future directions

DCO ideal for

Unstable patients

Patient in Extremis

Some Borderline patients

B/L femur fractures

Pelvic ring injuries w/ profound hemorrhage

Multiple injuries in elderly

Special group (chest injuries, head injuries, mangled extremity)

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