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
- 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)
