The 24-72 hour period after the initial injury appears to be the most at-risk time Stabilize fractures and bleeding Decrease the chance prior to the 24-72 hour high-risk of a second hit period.
Till 1970s - 80s Multiply injured patients were too unstable to survive surgical intervention. Early definitive fracture stabilization was performed only as an exception Signs of MODS in the first posttraumatic week was diagnosed as the ‘‘fat embolism syndrome’’, characterised by hypoxia, cerebral depression (somnolence, coma), coagulopathy (petechial bleeding) or renal failure (anuria). Surgical fracture stabilization were only performed in patients, who were in a condition, i.e. without signs of fat embolism syndrome.
Stabilization within 24 h, Aggressive Resuscitation1980sFirst meaningful study published, showing that early, definitive stabilization of longbone fractures reduced the incidence of the fat embolism syndrome compared totraditional non-surgical treatment. Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O, Paavilainen T. Primary operative fixation of long bone fractures in patients with multiple injuries. J Trauma 1977;17:111—21. A significant increase in ARDS associated with a delay in fracture stabilization in patients with multiple injuries • Increasingly significant in ISS > 40 Johnson K.: J Trauma 25(5): 1980 Early femoral fracture fixation in the multiple trauma patient resulted in statistically significant improvement in the rates of survival Bone LB et al: JBJS 71A(3): 1989
1990 ‘Borderline patient’ At particular risk of late, poor outcome.Patients with a very high ISS did not appear to benefit from ETC
CLINICAL EXAMPLE 16 y male, RTA • Pulmonary Contusions • Stable TBI • Bilateral Femoral # • Hip Dislocation ETC – BL Femoral Nailing
CLINICAL EXAMPLE96 h post femoral nailing Florid ARDSOutcome at 01 wk Autopsy IS IT INEVITABLE? OR PREVENTABLE ?
Life as a trauma surgeon would be easyif all we had to deal with was the fracture. COMPLICATING FACTORS The fracture always has a patient attached to it. This forces us to consider more than just the bones.
Clinical Parameters Used in Hannover, Germany, to Define the “Borderline” Patient forWhom DCO Is Often Preferred Polytrauma + ISS >20 + Thoracic trauma Polytrauma + Abdominal/pelvic trauma + Hemorrhagic shock (initial BP <90 mm Hg) ISS ≥ 40 in the absence of additional thoracic injury X Ray: B/L lung contusion Initial mean pulmonary arterial pressure >24 mm Hg Increase of >6 mm Hg in pulmonary arterial pressure during IM Nailing
COAGULOPATHICHYPOTHERMIA (T < 32)ACIDOSISSHOCKPRESUMED OR TIME > 6 HARTERIAL INJURY AND HAEMODYNAMIC INSTABILITYEXAGGERATED INFLAMMATORY RESPONSE
RELEASE COMPARTMENTS CONTROL HAEMORRHAGEREDUCE DISLOCATIONS FLUID RESUSCITATIONDEBRIDE OPEN WOUNDS CXR – ICD IF NECESSARYSTABILIZE LONG BONES/ PELVIS LATERAL CERVICAL SPINE X RAY X RAY PELVIS AP FAST/ DPLINITIAL EARLY EXTERNAL FIXATION RE EVALUATE MONITOR BP, URINE OUTPUT ABG REPEAT FAST IL-6STAGED INTRAMEDULLARY FIXATIONMINIMAL INVASIVE PLATE OSTEOSYNTHESIS
SHORT TERM GOALS REDUCE BLOOD LOSS MINIMIZE MEDIATOR RELEASE INCREASE PULMONARY FUNCTION REDUCE SEPSIS AND PAIN IMPROVE TREATMENT OF HEAD INJURY
Days 2—4 do not offer optimal conditions for definitive surgery.Primary procedures of greater than 6 h duration and major surgical procedures atdays 2—4 should be avoided.Between 5 – 14 days post injury
Prolonged operation could cause intraophypotension, hypoxia, coagulopathy, increasedblood loss and fluid requirements during andafter the orthopedic operation. DCO – EXTERNAL FIXATIONThis will be detrimental to cerebral perfusion andwould be an additional insult to the alreadyinjured brain, thus outweighing the benefits ofearly fracture stabilization.Maintenance of CPP >70 mm Hg and ICP <20 mm Hg should be mandatory before, during, and after surgical procedures.
LEAP StudyAn increasing trend toward limb salvagerather than immediate amputation forcomplex open lower-extremity injuries.A DCO approach to saving the limb Spanning external fixation, Antibiotic bead pouches Vacuum-assisted wound closure
An isolated complex extremity injury (other than a mangled limb)Complex proximal tibial fracturesDistal tibial pilon fractures.
CURRENT ISSUESEarly skeletal fixation is appropriate…• But what are the limits ? • Hemodynamic instability • Pulmonary instability • Severe head injury • Coagulopathy • Hypothermia
DCO: Principles in Polytrauma Ortho team must beresuscitators and stabilizers: not “fixers” Save the Patient First