Damage control orthopedics (DCO) is an upcoming concept in orthopedics.

1. Damage Control Orthopaedics

2. Definition
• is an approach that contains and stabilizes
orthopaedic injuries so that the patient’s overall
physiology can improve.
• purpose :
- avoid worsening of the patient's condition by the
“second hit” of a major orthopaedic procedure
- delay definitive fracture repair until a time when
the overall condition of the patient is optimized

3. Physiology
SIRS = systemic inflammatory response syndrome
CARS = counter-regulatory anti-inflammatory response syndrome

4. The First and Second-Hit Phenomena
MODS = multiple organ dysfunction syndrome
ARDS = adult respiratory distress syndrome

5. Markers of Immune Reactivity
Group Examples
Interleukins (IL)
IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-
10, IL-11, IL-12, IL-13, IL-18
Tumor necrosis factors (TNF) TNF, lymphotoxin (LT)
Interferons (IFN) IFN-alpha, IFN-beta, IFN-gamma
Colony stimulating factors (CSF) G-CSF, M-CSF, GM-CSF

6. • C-reactive protein, procalcitonin, TNF-α, IL-1, and IL-8 are not
reliable markers
• IL-6 reliable index of the magnitude of systemic inflammation
and correlates with the outcome
• IL-10 correlate with the initial degree of injury and
persistently high levels of IL-10 correlate with sepsis.
• HLA-DR class-II molecules markers of immune reactivity and a
predictor of outcome following trauma
• ratio of IL-6 to IL-10 correlate with injury severity after major
trauma and is used to predict the degree of injury following
trauma
• level of plasma DNA suggested as a potentially valuable
prognostic marker for patients at risk
• at present, IL-6 and HLA-DR class-II molecules, accurately
predict the clinical course and outcome after trauma.

7. Patient Selection for Damage Control
Orthopaedics
• Patients who have sustained orthopaedic
trauma are divided into :
a)Stable - local preferred method
b)Borderline - damage control orthopaedics
often preferred
c)Unstable - damage control orthopaedics
d)In extremis - damage control orthopaedics

8. Clinical grading criteria ( Pape et al)

9. Injury complexes
suitable for damage
control orthopaedics

10. Femoral Fracture
• Femoral fractures in a multiply injured patient are not
automatically treated with intramedullary nailing because :
- ‘second hit’
- fat emboli
• Patients with a chest injury are most prone to deterioration
after an intramedullary nailing procedure
• Bilateral femoral fracture is associated with a higher
mortality rate and incidence of adult respiratory distress
syndrome than is a unilateral femoral fracture
• Increase in mortality may be more closely related to
associated injuries and physiologic parameters than to the
bilateral femoral fracture itself

12. Pelvic Ring Injuries
• Exsanguinating haemorrhage associated with
pelvic fracture
• Conditions where haemorrhage can be
expected, when there is pelvic injury :
-Posterior pelvic ring injuries
-Anterior-posterior compression type III injuries,
lateral compression injuries
-Pelvic fracture in patients over 55 years old

14. What is done?
• Minimally invasive pelvic stabilisation
- Pelvic binder
- External fixator
- Pelvic c-clamp
- Pelvic stabilizer
• Angiography and embolisation
Indications :
1.Initial treatment of pelvic fractures associated with
hypotension that have not responded to the
placement of a pelvic binder, external fixator, pelvic c-
clamp, or pelvic stabilizer and transfusion of four units
or more of blood

15. 2. expanding retroperitoneal hematoma,
3. a vascular blush seen on CT
4. a massive retroperitoneal hematoma observed on CT
- Timing is important
- Embolisation later than 3 hours after injury increased
risk of mortality
-Average procedure time is 90 minutes
• Pelvic Packing
Indication :
1. Patient with severe hypotension and a pelvic fracture
that is unresponsive to other initial treatment
measures, associated with imminent risk of death

16. Chest Injuries
Treatment of multiply injured patients with long
bone fractures and a chest injury:
• early fracture stabilisation (within 48 hours)is
safe and may be beneficial
• early fracture stabilisation is safe and maybe
beneficial

17. Chest radiograph showing a ruptured left hemidiaphragm and femoral fracture in a
multiply injured patient

18. Initial external fixation was performed at the time of the diaphragmatic repair

19. Staged intramedullary nailing was performed on post-injury day 2

20. Head Injuries
• Early stabilisation doesn’t enhance or worsen the
outcome in patients with head injury.
Management :
• Based on the individual clinical assessment and
treatment requirements
• Damage control orthopaedics can provide temporary
osseous stability to an injured extremity, functioning
as a temporary bridge to staged definitive
osteosynthesis, without worsening the patient's head
injury or overall condition.
• Aggressive management of intracranial pressure
• Maintenance of cerebral perfusion pressure at >70 mm
Hg and intracranial pressure at <20 mm Hg

21. Mangled Extremities
• DCO approach to save the limb :
a) Spanning external fixator
b) Antibiotic bead pouches
c) Vacuum assisted wound closure
Antibiotic bead pouch for
treatment of an open proximal
tibial fracture

22. Isolated Complex Lower-Extremity
Trauma
• “limb damage control orthopaedics”
• Proximal tibial articular and metaphyseal
fractures, metaphyseal fractures, distal tibial
pilon fractures
• Useful for preventing soft-tissue complications by
spanning the articular segment with an external
fixator and avoiding areas of future incisions.
• Then minimally invasive plate osteosynthesis can
be performed at a stage when the condition of
the soft tissue envelope is optimized.

23. When can secondary orthopaedic
procedures be performed?
• Days 2, 3 and 4 are not safe ( marked immune
reactions and increased generalised oedema)
• Days 6 to 8 less risk

24. The current treatment algorithm from Hannover, Germany, for the use of damage
control orthopaedics. ER = emergency room, ABG = arterial blood gases, FAST =
focused assessment sonography for trauma, I/O ratio = intake/output ratio, ABP =
arterial blood pressure, IL-6 = interleukin-6