Damag control orthopedic

1. DAMAGE CONTROL ORTHOPEDIC
Dr.
Mohamed Iraqi Gadallah
Consultant orthopedic
Master degree
EG. Board
Arab Board

2. • Specialty evolved after WW I
• Trauma is the Heritage
of Orthopaedic surgery
• Trauma is the common
thread of all
Orthopaedi
c Subspecialties
Evolution of Orthopaedic Surgery

3. USS YORKTOWN
04 June 1942 – Battle of
Midway
LIVE TO FIGHT
ANOTHER DAY

4. USS YORKTOWN
04 June 1942 – Battle of
Midway

5. UNITED STATES NAVY:
The capacity of the ship to absorb
damage and maintain mission
integrity

6. Interleukins 6 and
8.
IL
falling
over
5 days

7. “Second
Hit”

8. The 24-72 hour period after the initial injury appears to be the most
at-risk time
Stabilize fractures and
bleeding prior to the 24-72
hour high-risk period.
Decrease the
chance
of a second hit

9. An approach that
1- Contains & Stabilizes Orthopaedic
Injuries so that the Patient’s Overall
Physiology can improve
2- Avoid worsening of the patient’s
condition by a major Orthopaedic
Procedure
3- Delay Definitive Fracture Repair in
borderline or unstable patient till
condition is optimized

10. Polytrauma Patient
Polytrauma is a Syndrome of Multiple
Injuries exceeding a defined Injury
Severity Score
ISS > = 17
Sequential Post traumatic Systemic
Inflammatory Reactions
(SIRS)
Dysfunction or failure of Remote
Systems or Organs which are not
injured
(MODS – MOF)

11. Definitive open reduction & internal
fixation is delayed until the
inflammatory response and tissue
edema have decreased and the patient
is in a stable clinical condition
Applied in polytrauma patients with
pelvic and long bones fractures to avoid
the “second hit” of an extensive
definitive procedure and minimize initial
morbidity – mortality
Early rapid fracture stabilization by external fixation
Avoiding prolonged operative times
Preventing the onset of the
lethal triad ( Coagulopathy, Acidosis & Hypothermia )
Damage control orthopedics (DCO)

12. 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.

13. Early total care of major bone fractures in polytrauma pts
was questioned
Are we doing good or more harm to the patient ?
Evolved in 1990’s
Research at a cellular level
Pathophysiology of multiply injured pt
Systemic inflammatory response to
trauma. (SIRS)
“Second hit” phenomenon

14. Stabilization within 24 h, Aggressive
Resuscitation1980s
First meaningful study published, showing that early, definitive stabilization
of long bone fractures reduced the incidence of the fat embolism
syndrome compared to traditional 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

15. Remember that
Orthopedics is a
Reconstructive
Surgery

16. DAMAGE CONTROL ORTHOPAEDICS (DCO)

17. Patients with a very high ISS did not appear to benefit
from ETC
‘Borderline patient’
At particular risk
of late, poor
outcome.
199
0

18. Cytokine storm (pro inflammatory mediators)
imbalance between the two immune responses (SIRS vs
CARS)
MODS (Multi organ Dysfunction Syndrome)
MOF (Multi organ Failure Syndrome)

19. Inflammatory mediators (SIRS ) Systemic inflammatory response syndrome
Anti-inflammatory mediators (CARS) Compensatory anti-inflammatory response syndrome
Imbalance between the two immune responses (SIRS vs CARS) => (MODS -MOF)
Multi organ (Dysfunction -Failure ) Syndrome
(Parenchymal cell Necrosis (Apoptosis & Necrosis)
Trauma
Tissue inj.
Toxins
Oxidants
Infection
Inflammatory Mediators Release
Organ
Injury
Common Pathophysiological Pathways
SIRS
CARS
Anti-inflammatory mediators (Immune System)
Cytokine
S
T
O
R
m

21. 16 y male, RTA
• Pulmonary
Contusions
• Stable TBI
• Bilateral Femoral #
• Hip Dislocation
ETC – BL Femoral
Nailing
CLINICAL
EXAMPLE

22. IS IT
INEVITABLE?
OR
PREVENTABLE
CLINICAL
EXAMPLE
96 h post femoral
nailing
Florid ARDS
Outcome at 01 wk
Autopsy

23. Life as a trauma surgeon would be
easy if all we had to deal with the
fracture alone.
The fracture always has a
patient attached to it.
This forces us to consider more
than just the bones.
COMPLICATING
FACTORS

24. Clinical Parameters Used in Hannover, Germany, to Define the
“Borderline” Patient for Whom 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

25. COAGULOPATHIC
HYPOTHERMIA (T < 32)
ACIDOS
IS
SHOCK
PRESUMED OR TIME > 6 H
ARTERIAL INJURY AND HAEMODYNAMIC
INSTABILITY EXAGGERATED
INFLAMMATORY RESPONSE

27. RELEASE
COMPARTMENTS
REDUCE DISLOCATIONS
DEBRIDE OPEN WOUNDS
STABILIZE LONG BONES/
PELVIS
INITIAL EARLY EXTERNAL
FIXATION
STAGED INTRAMEDULLARY
FIXATION MINIMAL INVASIVE PLATE
OSTEOSYNTHESIS
CONTROL
HAEMORRHAGE
FLUID
RESUSCITATION
CXR – ICD IF NECESSARY
LATERAL CERVICAL
SPINE X RAY X RAY
PELVIS AP
FAST/ DPL
RE EVALUATE
MONITOR
BP, URINE
OUTPUT ABG
REPEAT
FAST IL-6

28. SHORT TERM
GOALS
REDUCE BLOOD LOSS
MINIMIZE MEDIATOR
RELEASE INCREASE
PULMONARY FUNCTION
REDUCE SEPSIS AND PAIN
IMPROVE TREATMENT OF HEAD
INJURY

30. Initial focus on Stabilization
External fixation
▪ Limited debridement
▪ Limited or no internal
fixation or definitive care
 Delayed definitive fixation (5-
7 days)

31. Days 2—4 do not offer optimal conditions for definitive surgery.
Primary procedures of greater than 6 h duration and major surgical
procedures at
days 2—4 should be avoided.
Between 5 – 14 days post
injury

35. Prolonged operation could cause intraop
hypotension, hypoxia, coagulopathy,
increased blood loss and fluid
requirements during and after the
orthopedic operation.
This will be detrimental to cerebral perfusion
and would be an additional insult to the
already injured brain, thus outweighing the
benefits of early fracture stabilization.
Maintenance of CPP >70 mm Hg and ICP <20 mm Hg should be
mandatory before, during, and after surgical
procedures.
DCO – EXTERNAL
FIXATION

36. LEAP
Study
An increasing trend toward limb
salvage rather than immediate
amputation for complex open lower-
extremity injuries.
A DCO approach to saving the limb
Spanning external fixation,
Antibiotic bead pouches
Vacuum-assisted wound
closure

37. An isolated complex extremity injury (other than a
mangled limb)
Complex proximal tibial
fractures Distal tibial pilon
fractures.

38. Control Bleeding
Manage Soft tissues
Spanning Ex. Fixator
Antibiotic Pouch
Vacuum Dressings

39. Severe Head injury (GCS <9) or
unstable pt
Damage control surgery
Convert to definitive at 5+ days
Mild head injury (GCS 13 -15); stable
pt
Early total care
Intermediate head injury
Patient stability vs. Complexity of
surgery

41. CURRENT
ISSUES
Early skeletal fixation is
appropriate…
• But what are the
limits ?
• Hemodynamic instability
• Pulmonary instability
• Severe head injury
• Coagulopathy
• Hypothermia

42. Do not kill your
Borderline patient by
(ETC)
Help him to live by
(DCO)
Give him the chance to
fight another day