Damage control orthopaedics (DCO) is an approach that temporarily stabilizes orthopaedic injuries in severely injured trauma patients to avoid worsening their condition. It focuses on controlling hemorrhage, managing soft tissue injury, and achieving provisional fracture stability through temporary stabilization methods like external fixation. This allows time for the patient's physiology to stabilize before definitive repair and reduces the risks of complications from a major orthopaedic procedure when the patient is still unstable. DCO has evolved from traditional approaches as an understanding has grown of the body's inflammatory response to trauma and risks of multiple hits.

1. Damage Control Orthopaedics
Mohamed Abulsoud (M.D)
Lecturer of orthopedic surgery
Faculty of medicine – Al-Azhar university
Cairo- Egypt

2. Damage control orthopaedics is an approach that
contains and stabilizes orthopaedic injuries so that
the patient’s overall physiology can improve.
Its purpose is to avoid worsening of the patient’s
condition by the “second hit” of a major
orthopaedic procedure and to delay definitive
fracture repair until a time when the overall
condition of the patient is optimized.
Introduction

3. Damage control focuses
• control of hemorrhage,
• management of soft-tissue injury,
• achievement of provisional fracture stability,
while avoiding additional insults to the
patient.
Introduction

4. • The term damage control
was borrowed from a
traditional Navy term and
philosophy.
• Temporary measures are
used to limit further damage
and stabilize the ship to
allow for a thorough
assessment of the damage
and development of a
comprehensive strategy for
definitive repair
Historical overview

5. Evolution
• The advent of damage control orthopedics
(DCO) in the late 1990s and early 2000s
represented a major shift if philosophy for the
treatment of orthopedic injuries in severely
injured trauma patients.

6. • In the 1960s delayed fixation of long bone
fractures was recommended. Immediate
stabilization was associated with mortality rates
up to 50% due to perioperative pulmonary and
cardiovascular complication.
• Patients with long bone fractures were treated
with traction or splinting for 10–14 days, until the
effects of fat embolism syndrome resolved and
pulmonary, cardiovascular, neurovascular and
coagulation systems had stabilized.
Evolution

7. • In the 1980s, a major shift occurred in the
treatment of long bone fractures in multiply
injured trauma patients.
• There is a beneficial effect of early
stabilization of fractures on both mortality and
morbidity and length of hospital stay.
• This new philosophy in the management of
the patient with multiple injuries was named
Early Total Care ( ETC ).
Evolution

8. • In early 1990s, Outcome after ETC – increased
incidence of adult respiratory distress
syndrome ARDS and multiple organ failure
(M.O.F)
• These complications mainly developed in
patients with severe chest injuries, severe
hemodynamic shock and in cases post reamed
intramedullary nailing without thoracic
trauma.
Evolution

9. • Polytrauma
• Polytrauma is a syndrome of multiple injuries
exceeding a defined severity (ISS ≥ 17) with
sequential systemic reactions that may lead to
dysfunction or failure of remote organs and
vital systems, which have not themselves been
directly injured
Definitions

11. Definitions

12. Definitions
• Stable patients have no immediately life-threatening
injuries and respond to initial therapy.
• Borderline patients have stabilized in response to
initial resuscitative attempts but sustained injuries that
put them at risk of rapid deterioration .
• Unstable patients remain hemodynamically unstable
despite initial intervention and are at high risk for clinical
complications.
• Patients in extremis have ongoing uncontrolled blood
loss despite resuscitation and may die if blood loss is
not immediately stopped.

13. Definitions

14. Borderline patients
• Polytrauma + ISS > 20 + thoracic trauma (AIS > 2)
• Polytrauma + abdominal/pelvic trauma + hemorrhagic shock
(initial SBP < 90 mmHg)
• ISS > 40, without additional thoracic trauma
• Initial mean pulmonary arterial pressure > 24 mmHg
• Increase of pulmonary arterial pressure during
Intramedullary nailing of > 6 mmHg
• Bilateral femoral fractures
• Radiographic evidence of pulmonary contusion
• Hypothermia ( < 35C)
• Additional moderate or severe head injuries(AIS ≥ 3)

15. • Early total care (ETC): a concept implying the primary
definitive management of all major injuries within 24
hours after trauma
• Damage control orthopedics (DCO): minimally invasive
surgical techniques are used for the primary stabilization
of all major fractures. Based upon the patient’s
physiological status, temporary stabilization with external
fixation for certain fractures is used.
Definitions

16. Pathophysiology
• Traumatic injury leads to
systemic inflammation
(systemic inflammatory
response syndrome) followed
by a period of recovery
mediated by a counter-
regulatory anti-inflammatory
response.
• Within this inflammatory
process, there is a fine balance
between the inflammation
and the potential for the
process to cause and
aggravate tissue injury leading
to ARDS and MODS

17. • The First and Second-Hit Phenomena
• First hit phenomenon :- The body response by
stimulation of a variety of inflammatory
mediators in the immediate aftermath of
trauma
• IL-6 and HLA-DR class-II molecules(ICAM-1 e-
selectin and CD11b), accurately predict the
clinical course and outcome after trauma.
Pathophysiology

18. • the ratio of IL-6 to IL-10 was found to correlate
with injury severity after major trauma, and
this ratio was recommended as a useful
marker to predict the degree of injury
following trauma
Pathophysiology

19. • Second hit :-
• Another trauma during the acute phase
• major surgery
• adverse event during ICU treatment
• septic stimulus
Pathophysiology

20. Pathophysiology

21. The Lethal triad
Coagulopathy

22. – heart rate > 90 beats/min
– WBC count <4000cells/mm³ OR >12,000 cells/mm³
– respiratory rate > 20/min or PaCO2 > 32mm
– temperature < 36 ° or > 38°
Calculation
– each component is given 1 point if it meets the above
criteria
• Interpretation
– score of 2 or more meets criteria for SIRS
SIRS Score

23. Management

24. Management
1-Resuscitation

25. Goals to be achieved by damage control surgery
Management

26. Damage control orthopaedics (DCO)

27. Damage control orthopaedics (DCO)

28. The general aims and scopes for fracture
management are:
• control of hemorrhage;
• control of sources of contamination, removal
of dead tissue,
• prevention of ischemia-reperfusion injury;
• pain relief;
• facilitation of intensive care.
Damage control orthopaedics (DCO)

29. • Damage Control and Pelvic Ring Injuries
• exsanguinating hemorrhage is the major cause
of death in multiply injured patients with
pelvic ring disruptions.
• Concomitant bowel injury places these
fractures at high risk for infection and the
need for access to the abdomen for visceral or
genitourinary system injuries may limit the
treatment options .
Damage control orthopaedics (DCO)

30. • Damage control treatment in
pelvic ring injury
• sheet or pelvic binder, placed at the level
of the greater trochanters
• External Fixator
• C-Clamp
• Iliosacral screw
• Sacral bar (in stable and borderline pts)
• Angiography and embolization
Damage control orthopaedics (DCO)

31. Damage control orthopaedics (DCO)

32. • Damage control treatment for long
bones fractures
• Long bones fractures in a multiply
injured patient are not automatically
treated with intramedullary nailing
because of concerns about the
second hit of such a procedure
• patients with pulmonary injury
should undergo unreamed nailing to
avoid increased risk of ARDS.
Damage control orthopaedics (DCO)

33. • Bilateral femoral fracture is a
unique scenario in polytrauma
that is associated with a higher
mortality rate and incidence of
ARDS than is a unilateral femoral
fracture.
• the use of external fixation as a
temporizing measure allows for
the advantages of rigid fixation
without the risk of hypotension
and hypoxia associated with IMN
in seriously injured patients.
Damage control orthopaedics (DCO)

34. • 776 patients with unilateral and 118 patients
with bilateral femoral shaft fractures.
• Patients with bilateral femoral shaft fractures had
• Higher Injury Severity Score (ISS) (29.5 vs. 25.7
points),
• Higher incidence of ARDS (34.7% vs. 20.6%)
multiple organ failure (25.0% vs. 14.6%)
• Higher mortality rate (16.9% vs. 9.4%).

35. • Early fixation of long-bone fractures—
especially of the femoral shaft—in
polytrauma:
• facilitation of nursing care;
• early mobilization with improved pulmonary
function;
• shorter time on the ventilator;
• reduced morbidity and mortality
Damage control orthopaedics (DCO)

36. • External fixation of femur-
• 35 minutes
• 90 ml blood loss
• Intramedullary nailing of
femur-
• 130 minutes
• 400 ml blood loss
• Scales et al., 2000
Damage control orthopaedics (DCO)

37. Damage control orthopaedics (DCO)

38. Damage control orthopaedics (DCO)

41. • Damage control in spine trauma
• Spinal trauma range from 13% to 30% of
spinal injuries in polytraumatized patients.
• Injuries of the spine originate from motor
vehicle accidents and incidental as well as fall
from height in most cases
Damage control orthopaedics (DCO)

42. Damage control orthopaedics (DCO)

43. EAP
• Early Appropriate Care
– Acceptance different patients respond differently
to first and second hits
– Consider severity of initial injury
– Consider response to resuscitation
– What further surgery required
– Continued re assessment and ability to change
from ETO TO DCO

44. • Damage control orthopaedics is an approach
that contains and stabilizes orthopaedic
injuries so that the patient’s overall
physiology can improve.
• In damage control for trauma patients, the
main target is to perform temporary
operative procedures to provide time for
physiologic stabilization before definitive
surgical care.
Take home message

45. • Acidosis,hypothermia and coagulopathy are
called The lethal triad
• Measures to prevent and revert those triad
are of priority
• The use of external fixators , pelvic
stabilization and percutaneus pedicle screw
fixation should be considered in
polytraumatized patients in the first 24 hours
Take home message