Damage control orthopaedics is an approach that temporarily stabilizes orthopaedic injuries to avoid worsening a patient's condition through definitive surgery. It aims to delay repair until the patient's physiology improves. Key indications include unstable pelvic fractures, femoral fractures in patients with chest injuries, and mangled or isolated lower extremity trauma. Temporary external fixation is often used followed by staged definitive surgery once the patient stabilizes in 2-8 days. Monitoring inflammatory markers like IL-6 helps determine when secondary procedures can be safely performed.

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