This document discusses the evolution of approaches to treating patients with multiple traumatic injuries, including polytrauma. It describes how the concept of early total care (ETC), involving early definitive fixation of fractures, was later found to potentially cause harm in unstable patients. This led to the emergence of damage control orthopedics (DCO), which focuses on temporary stabilization and minimizing surgical insult in critically injured patients. DCO principles include provisional fixation, delayed definitive treatment until the patient is more stable, and categorizing patients as stable, unstable or borderline to guide surgical timing and approach. The document also discusses related concepts like early appropriate care (EAC) and damage control for spine injuries.
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
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Damage control &
Early Appropriate care in Orthopedics
ContentsEvolution of poly trauma management
Early total care
Damage control orthopedic care
Early appropriate care
Introduction
Trauma is the leading cause of death in young populatio
Immediate death – 50%- minutes
Lethal head injury
Hemorrhagic shock
Early death - 30%- hrs
Secondary brain injury
Hemorrhagic shock
Late death – 20% - days to weeks
ARDS
Pneumonia
MODS
Damage control surgery
Evolution of Polytrauma Management
Management concept - Delayed management
Splints, casts and traction
Definite surgery delayed for 10 -14 days
Prolonged bed rest and hospital stay
Damage control surgery
Decubitus ulcer
Disuse atrophy
Early definitely stabilization long bone fracture reduced incidence of fat embolism syndrome
Early Total Care
Damage control surgery
Usually within the first 24hrs
Early Total Care - Advantages
Early fixation favors skin and soft tissue healing
Prevent ongoing tissue damage
Pain relief
Improve joint function
Early mobilization
Respiratory distress
Pneumonia
Early stabilisation of hemodynamically unstable or/and had concomitant chest or head injury patients develop high mortality
mainly by ARDS and MODs
Reasons for the high mortality ?
Two hit phenomena
These findings indicated that
ETC is not appropriate for unstable poly trauma patients
Damage control surgery
Damage control is a new term first used by the US Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship.
Goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed.
Basic strategies of DCO -
Control of haemorrhage
Damage control surgery
Minimize the second hit
Immediate and rapid stabilization of long bone fractures - EF
Release of tight soft tissue compartments
Reductions of dislocations
Surgical debridement of open wounds
Amputation, in cases of unsalvageable extremities
Definitive fixation is later
Immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected polytrauma patients.
Which patient need DCO approach ?
Patients who have sustained orthopedic trauma have been divided into four groups:
Damage control surgery
Patient categorization
Limitations of DCO
Axial skeleton and femoral fractures
No external fixation
Even ex fix , patient mobilization is poor - bed ridden condition
Anatomical reduction favours pain relief, soft tissue healing and muscle function
Limitations of DCO
Classification of patient condition is not static, dynamic and changed with resuscitation
DCO recommended for those patients who are unstable or in extremis however the optimal time and type of treatment, who are in border line remain controversial
Can read freely here
https://sethiortho.blogspot.com/
Damage control &
Early Appropriate care in Orthopedics
ContentsEvolution of poly trauma management
Early total care
Damage control orthopedic care
Early appropriate care
Introduction
Trauma is the leading cause of death in young populatio
Immediate death – 50%- minutes
Lethal head injury
Hemorrhagic shock
Early death - 30%- hrs
Secondary brain injury
Hemorrhagic shock
Late death – 20% - days to weeks
ARDS
Pneumonia
MODS
Damage control surgery
Evolution of Polytrauma Management
Management concept - Delayed management
Splints, casts and traction
Definite surgery delayed for 10 -14 days
Prolonged bed rest and hospital stay
Damage control surgery
Decubitus ulcer
Disuse atrophy
Early definitely stabilization long bone fracture reduced incidence of fat embolism syndrome
Early Total Care
Damage control surgery
Usually within the first 24hrs
Early Total Care - Advantages
Early fixation favors skin and soft tissue healing
Prevent ongoing tissue damage
Pain relief
Improve joint function
Early mobilization
Respiratory distress
Pneumonia
Early stabilisation of hemodynamically unstable or/and had concomitant chest or head injury patients develop high mortality
mainly by ARDS and MODs
Reasons for the high mortality ?
Two hit phenomena
These findings indicated that
ETC is not appropriate for unstable poly trauma patients
Damage control surgery
Damage control is a new term first used by the US Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship.
Goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed.
Basic strategies of DCO -
Control of haemorrhage
Damage control surgery
Minimize the second hit
Immediate and rapid stabilization of long bone fractures - EF
Release of tight soft tissue compartments
Reductions of dislocations
Surgical debridement of open wounds
Amputation, in cases of unsalvageable extremities
Definitive fixation is later
Immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected polytrauma patients.
Which patient need DCO approach ?
Patients who have sustained orthopedic trauma have been divided into four groups:
Damage control surgery
Patient categorization
Limitations of DCO
Axial skeleton and femoral fractures
No external fixation
Even ex fix , patient mobilization is poor - bed ridden condition
Anatomical reduction favours pain relief, soft tissue healing and muscle function
Limitations of DCO
Classification of patient condition is not static, dynamic and changed with resuscitation
DCO recommended for those patients who are unstable or in extremis however the optimal time and type of treatment, who are in border line remain controversial
The poly traumatized patient the role of orthopedic surgeonMohamed Abulsoud
The management of polytraumatized patient is multidisplinary team .
Orthopaedic surgeon in the striker of the team
Resuscitation and survey is a key for excellent outcome
Timing of surgery is very crucial
ETC Vs. DCO should be considered carefully
Appraoch to patient with polytrauma and Damage control orthopedicsKaushal Kafle
A brief approach to patient with polytrauma, physiological response of body with trauma, the trimodal mortality, golden hour, lethal triad of trauma, two hit hypothesis, inflammatory mediators, prehospital care, primary survey, secondary survey, ABCDE approach, Adjucts are included. Besides thc concept of Damage control orthopedics, trend in fracture management , evolution , principle, indication , surgical stratergies, advantage, limitation, definitive fixation and EAC and ETC are included in breif.
Damage control orthopaedics emphasizes the stabilization and control of the injury, often with use of spanning external fixation, rather than immediate fracture repair. The concept of damage control orthopaedics is not new; it has evolved out of the rich history of fracture care and abdominal surgery.
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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
26.
27.
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
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