Damage control orthopaedics and ATLS

1. Damage control
Orthopaedics
Dr. Pradeep Kumar Pathak
PGIMS Rohtak
dr.pathak09@gmail.com

2. ATLS-II
1. POYTRAUMA
2. SECOND HIT PHENOMENON
3. EARLY TOTAL CARE
4. DAMAGE CONTROL ORTHOPAEDICS
5. EARLY APPROPRIATE CARE

3. Polytrauma
• no consensus on definition
•ISS >18
•heamodynamic instability/ coagulopathy on
admission
•more than one system involvement:
• CNS, PULMONARY, ABDOMINAL, MUSCULOSKELETAL

4. • To describe the overall condition of the pt many trauma scoring
systems have been developed like-
• 1. Abbrevieted injury scale(AIS)
• 2. Injury severity scale(ISS)
• 3. Revised trauma score
• 4. Anatomic profile
• 5. Glasgow coma scale

5. ABBREVIATED INJURY SCALE(AIS):
• AIS is an anatomical scoring
system first introduced in 1969
• Injuries are ranked on a scale of
1 to 6,
• with 1 being minor, 5 severe,
and 6 a nonsurvivable injury.

6. Injury severity score
• based on AIS ( abbreviated injury scale)
• ISS is an anatomical scoring system that provides an overall score for
patients with multiple injuries.
• Each injury is assigned an AIS and is allocated to one of six body
regions (Head,Face, Chest, Abdomen, Extremities(including Pelvis),
soft tissue).
• Only the highest AIS score in each body region is used.
• The 3 most severely injured body regions have their score squared
and added together to produce the ISS score.

7. The ISS score takes values from 0 to 75. If an
injury is assigned an AIS of 6 (unsurvivable
injury), the ISS score is automatically assigned to
75

8. Before 1950s
• The multi trauma patient-too sick for an operation
• The surgical stabilization of the fractures of the long bones was not
routinely performed.
• Treatment preferred-cast and skeletal traction.

9. Late 1980-
• There is a beneficial effect of early stabilization of fractures on both
morbidity,mortality and hospital stay.
• early stabilization of femoral fractures dramatically reduces fat embolism
syndrome,pulmonary failure(ARDS) and postoperative complications.
• Pt were able to mobilize early and were discharged from hospital sooner
,avoiding the complications associated with prolonged bed rest.

10. • This new philosophy in the management of the pt with multiple
injuries-best operation for the patient is one ,early and definitive
procedure; was named:
EARLY TOTAL CARE(ETC)

11. EARLY TOTAL CARE(ETC)
• means appropriate definitive osteosynthesis as soon as possible.
• Early fracture stabilization within 24–48 h after trauma can decreases
mortality, the incidence of pneumonia, ARDS, thrombosis, enhance
pulmonary function, improve pain control and decrease pulmonary
embolism via early mobilization
• Late fixation was associated with alonger ICU and hospital stay and
average cost of hospitalization that was 50% higher than that of the
early fixation cohort.

12. When stabilization was delayed – the incidence of
pulmonary complications was higher, the hospital
and ICU stay days were increased

13. Early definitive stabilization of long bone fractures
reduced the incidence of the fat embolism syndrome
compared to traditional non surgical treatment.

14. Early 1990:
• Outcome after ETC- increased incidence of ARDS and MOF.
• Operative procedure used to fix the bone-could provoke rather than
protect from pulmonary complications.
• An unexpectedly high rate of pulmonary complications was reported
in young patients after reamed femoral intramedullary nailing.

15. • These complications developed mainly in pts with severe chest
injuries, severe hemodynamic shock and in cases operated with
reamed intramedullary nailing without thoracic trauma.
• This led to the conclusion that the method of stabilisation and the
timing of surgery may have played a major role in the development of
such complications.

16. • in addition some evidence suggested that although early fixation
might be beneficial, fixation in first 24 hours might actualy be
detrimental
• These findings indicated that ETC was not appropriate for all multiply-
injured patients and that there was a particular subgroup in whom
management by this approach was detrimental.

17. EMERGENCE OF THE 2-HIT MODEL
• 1-hit model : the initial trauma is believed to generate a major
inflammatory cascade with the potential for subsequent ARDS,
independent of the timing of fracture fixation. The development of
multiple organ failure is dependent on the extent of initial injury and
the timing and quality of resuscitation.
• 2-hit model: suggests that the initial trauma generates a less-severe
systemic inflammatory state. The immune system then becomes
primed for an exaggerated inflammatory response after a second
physiologic insult

18. • Once cells (neutrophils and
macrophages) are primed, a
noninjurious or mildly injurious
second stimulus causes an
excessive inflammatory reaction
that leads to cellmediated lung
injury

19. • C reactive protein
• neutrophil elastase
• platelet count
in a study it was observed that 80% of patients with post op MODS
despite low inflammatory markers had undergone extensive surgeries
conversely
71% of patients with benign outcome with elevated inflammatory
markers had undergone mild procedure.
if 2 parameters are abnormal
probability of postoperative MODS is
higher

20. “DAMAGE CONTROL ERA”
• Damage control is a new term first used by the United States Navy
during World War II to describe emergency measures for control of
flooding that threatens to sink a ship.
• Central goal is to ensure survival of the ship until it reaches a port
where definitive repairs can be safely performed

21. • 43 femoral fractures with mean ISS of 27
• early temporary external fixation for a median of 4 days before staged nailing.
• compared with 281 patients who underwent primary femoral nailing with a median ISS of
17
• The median operative time for external fixation was 35 minutes, compared with 135
minutes for primary intramedullary nailing.
• Despite a significantly higher incidence of laparotomy, AIS-head score of 3 or greater,
shock on presentation, and days in the ICU, the damage control cohort had only 4 deaths
• femoral fractures should be fixed as early as possible
• nailing vs traction vs ex. fixator
• some patients were not physiologically replete enough to withstand early nailing.
Paradoxically, this subset of patients would be poor candidates for prolonged traction,
and thus external fixation was a bridge to definitive treatment, affording the advantages
of fixation with minimal operative time and physiologic insult

22. Damage control orthopaedics(DCO)
• Damage control orthopaedics(DCO)is a strategy that focuses on
managing and stabilising major orthopaedic injuries in selected
polytrauma patients who are in an unstable or extremis physiological
state.
• Its priorities are –
• control of haemorrhage,
• provisional stabilisation of major skeletal fractures, -
management of soft-tissue injuries
• minimising the degree of surgical insult to the patient.

23. DCO
• Rapid emergency surgery to save life or limb – NOT involving complex
reconstructive surgery
• Control bleeding
• Decompress cranium, pericardium, thorax, abdomen and limbs
• Decontaminate wounds and ruptured viscera
• Splint fractures
• Cast, traction, pelvic binder, ex-fix
• Definitive surgery performed several days later

24. Staged Treatment
Stage 1 :early
temporary external
fixation
stabilization
Stage2:
resuscitation of the
patient in ICU and
optimization of his
condition.
Stage 3 :delayed
definitive
management of the
fracture

25. DCO :guidelines
• Patients who have sustained orthopaedic trauma have been divided
into four groups:
• -stable
• - unstable, and
• - Borderline
• extremis

28. borderline category
• Blood pressure 80–100 mmHg
• Received 2–8 blood units within 2 h
• Lactate 2.5 mmol/dL
• Platelets 90–110,000/ml
• Fibrinogen 1 g/dl
• Body temperature 33–35 °C
• Thoracic trauma AIS >2
• Horovitz index 300
• Abdominal trauma Moore < III
• Pelvic type B/C injury (AO classifi cation)
• Extremity trauma AIS 2–3

29. DCO: guidelines
• severe traumatic brain injury
• ISS >40 (without thoracic
trauma)
• ISS >20 with thoracic trauma
• abdominal trauma
• pelvic disrution
• bilateral femur fracture
• bilateral femoral fractures
• pulmonary contusion noted on
radiographs
• hypothermia <35 degrees C
• head injury with AIS of 3 or
greater
• IL-6 values above 500pg/dL
• acidosis (lactate >2.5 mmol/L)
• GCS of 8 or below

30. Optimal time of surgery
patient are at increased risk of ARDS and multisystem failure during acute
inflammatory window (period from 2 to 5 days characterized by a surge in
inflammatory markers) therefore only potentially life-threatening injuries
should be treated in this period including
• compartment syndrome
• fractures with vascular injuries
• unreduced dislocations
• long bone fractures
• unstable spine fractures
• open fractures

31. definitive treatment delayed for
• 7-10 days for pelvic fractures
• within 3 weeks for femur fractures (conversion from exfix to IMN)
• 7-10 days for tibia fractures (conversion from external fixation to
IMN)

32. Spine Damage Control (SDC)
• ETC in spine injuries means operation within 24 h compared to
delayed defi nitive stabilization.
• SDC Defined as a staged procedure of immediate posterior fracture
reduction and instrumentation within 24 h (day-1 surgery).
• After stabilization and restored physiology a scheduled 360° spinal
fusion based on biomechanical aspects if necessary is performed.
More than 2/3 of these patients needed exclusively posterior
stabilization.

33. DCO : Drawbacks
• possibility of infection after external fixation
• need for additional surgery.
• increased cost of treatment
• longer stay at hospital

34. early appropriate care (EAC)
• early appropriate care (EAC) to describe the preferential fixation of
femoral fractures in the first 24 hours in contrast to other extremity
fractures that could be splinted and fixed at a later date.
• stable
• unstable
• borderline

35. summary

38. reconsideration
• Eventually, it became apparent that the 2-hit model was not an all-or-
none phenomenon, and that some patients could undergo early
extensive fracture fixation without developing postoperative organ
failure
• not all patient need Early total care
• not all patient are benefitted by DCO
• this lead to evolution of Early