Damage control orthopaedics (DCO) is an approach that temporarily stabilizes orthopaedic injuries to avoid worsening a polytrauma patient's condition through a "second hit" of major surgery. It focuses on early hemorrhage control, resuscitation to correct coagulopathy/acidosis/hypothermia, and external or rapid internal fixation, delaying definitive repair until the patient is stabilized. Injuries suitable for DCO include pelvic ring fractures with hemorrhage, femoral fractures in patients with chest injuries, and mangled or complex lower extremities. The timing of later definitive surgery depends on the patient's physiological status. DCO principles aim to make orthopaic teams "resuscit

1. DAMAGE CONTROL
ORTHOPAEDICS
Presenter - Dr Akhil John
Moderator - Dr N Ravinder Kumar

2. Contents
• Definition
• Polytrauma
• Physiological Response
• Triage protocol
• Damage control orthopaedics
• Management

3. 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

4. • Basic principles include arresting hemorrhage;
• restoring blood volume;
• and correcting Coagulopathy, Acidosis and Hypothermia.

5. • Early rapid fracture stabilization by external fixation
• Avoiding prolonged operative times
• Preventing the onset of thelethal triad ( Coagulopathy, Acidosis &
Hypothermia )

6. WHAT IS POLYTRAUMA
• Polytrauma and multiple trauma are medical terms
describing the condition of a person who has been subjected
to multiple traumatic injuries, The term is defined via an
Injury Severity Score (ISS)>/=17
• Sequential Post traumatic Systemic Inflammatory
Reactions (SIRS)
• Dysfunction or failure of Remote Systems or Organs which
are not injured(MODS – MOF)

7. ⚫Todescribe 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

8. 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.

9. Injury severity score(ISS)-
⚫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), External).
⚫ Only the highest AIS score in each body region is used.

10. ⚫The 3 most severely injured body regions have their score
• squared and added together to produce the ISS score.
• 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

11. Physiological response to injury
 Inflammatory immune response
• Innate immune response
• Adaptive immune response
 Systemic Inflammatory Response Syndrome (SIRS)
 Compensatory Anti-inflammatory Response Syndrome (CARS)
 Multi Organ Dysfunction Syndrome (MODS)

12. Inflammatory immune response
 EARLY innate immune response
 DELAYED adaptive immune response
• Innate = Hyperinflammation = SIRS
• Adaptive = Immunosuppression = CARS

13. Early innate immune response
 Neutrophils (major cellular ‘player’) are drawn to the site of injury by
IL-8 and C5a (chemokines)
 Priming neutrophils for defence and debridement of injured
tissue, and mediating inflammation
 Activation of PMN, monocytes, macrophages, NKC and endothelial
cells
 Release of pro-inflammatory mediators (cytokines and
molecular mediators)
 Considered the hyperinflammatory period

14. SIRS DEFINITION
 Heart rate: > 90 bpm
 WBC: <4000/mm3 or >12000/mm3 or >10% immature PMNs
 Respiratory rate: >20/min with PaCO2<32mmHg
 Core temperature: <360C or >380C
• 2 of 4 parameters = SIRS

15. Delayed adaptive immune response
 Non-apoptotic necrotic/dead cells produce alarmins plus
Endogenous triggers (DAMPs = damage-associated molecular
patterns)
 CD5+ B-cells to produce natural antibody without prior exposure and
subsets of T- cells to inflict self-reactivity → autoimmune tissue
destruction
 Considered the immunosuppression period or CARS

16. Interplay of SIRS and CARS
2- 4 Days
24
–
48
H.
6-8 Days

17. Pathological immune response
• IMBALANCE BETWEEN SIRS AND CARS
• Severe injury 1st Hit Intense CARS
Early MODS/death
• Moderate Injury 1st Hit Incomplete Resolution
• 2nd Operation within D3-5 Sepsis
Amplification of SIRS
Delayed-onset MODS/death
•

18. MODS
 Cerebral - Cerebral edema
 CVS - Hypotension and shock
 Respiratory- Acute lung injury, ARDS
 Liver - High APR and cytokines, hepatocytes dysfunction
 GI - Increased mucosal permeability , Bacterial translocation
 Renal - Renal tubular necrosis, acute renal failure
 Hematologic - DIC

19. Polytrauma (2 hit phenomenon)
‘First Hit’ Impacts by Trauma
The Patient The Limb/Organ System

20. ‘Second Hit’ Impacts by Surgery and Resuscitation
The Patient The Limb

21. First Hit Impacts - How do you decide your
fluid replacement?
• Classification of Hypovolaemic Shock and Physiologic Changes
Class I Class II Class III Class IV
Blood loss (liter) Up to 0.75 0.75-1.5 1.5-2.0 > 2
% TBV 15% 30% 40% >40%
Pulse rate < 100 > 100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal or inc Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output > 30 ml/hr 20-30 5-15 Negligible
Mental status Slightly anxious Mildly anxious Anxious/confused Confused/lethargic
Fluid Replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood

22. What is your fluid replacement regimen?
• Fluid resuscitation
• Shock due to primary haemmorrhage
Ongoing bleeeding 2o resuscitation regimen
Lethal triad Coagulopathy , acidosis ,
hypothermia

23. Voluminous crystalloid
• Dilutes coagulation factors
• Causes hypochloremic and lactate acidosis
• Supplies inadequate O2 to under perfused tissue

24. HAEMODYNAMIC ‘TRIAGE’ PROTOCOL
PATIENT CLINICALLY ASSESSED ABOUT THEIR PHYSICAL STATUS
AND CLASSIFIED AS:-
1. STABLE: GRADE 1
2. BORDERLINE: GRADE2
3. UNSTABLE: GRADE 3
4. EXTREMIS: GRADE 4

25. Parameter Stable Borderline Unstable In Extremis
Shock SBP (mmHg)
Blood unit/2h
Lactate
Base deficit
UO ml/h
Class
100 or more
0-2
< 2.0
Normal
>150
I
80-100
2-8
2.5
No data
50-150
II-III
60-80
5-15
>2.5
No data
<100
III-IV
50-60
>15
Severe
>6-18
<50
IV
Coagulation Platelets Factors
II/V Fibrinogen
d-Dimer
>110,000
90-100%
>1 g/dL
Normal
90-110,000
70-80%
1 g/dL
Abnormal
70-90,000
50-70%
<1 g/dL
Abnormal
<70,000
<50% DIC
DIC
Temperature >340C 33-350C 30-320C <300C
Soft Tissue
Injuries
Chest AIS
TTS
Abd (Moore)
Pelvic AO
Limb AIS
2 or 2
0
<II A
I-II
2 or more I-II
<III
B or C II-
III
2 or more II-
III
III C
III-IV
3 or more IV
III or >III C
Crush

26. Non-surgical DCR
1. Fluid Replacement in Balanced Resuscitation
● Initial fluid replacement with up to 2L crystalloid
Permissive hypotension to achieve SBP to 80- 90mmHg
• (radial pulse) until definitive control of bleeding is obtained
● Role of fluid challenge (250-500ml) tests to stratify responder, transient
responder, non-responder
2. Haemostatic Resuscitation
● Early blood versus HBOC transfusion decreases MODS
● Packed RBC, FFP and Platelets in 1:1:1 ratio
● Cryoprecipitate, Tranexamic acid, Recombinant factor-

27. 3. Correction of Metabolic Derangement
● Role of THAM (Tris-hydroxmethyl-amino-methane)
● Use of NaHCO3 to correct acidosis causes
hypercapnia?
4.Hypothermia Prevention and Treatment Strategies
● Limit casualties’ exposure
● Warm IV fluids and blood products before transfusion
● Use forced air warming devices before and after surgery
● Use carbon polymer heating mattress

28. Application of DCO
Stage 1
10 rapid temporary # stabilization (in trauma room/ICU/OR)
• 1.Control hemmorhage e.g. ext-fix pelvis
• 2.Debridement of open wound
• 3.Spanning ext-fix or unreamed nailing or reamed nailing using RIA
Stage 2
Resuscitation and ICU management
• 1.Close monitoring
• 2.Repletion of blood product
• 3.Further hemodynamic stabilization

29. Stage 3
• Definitive # fixation once the patient is optimized (avoid day 2-5)

30. Injury complexes
suitable for damage
control orthopaedics

31. Femur 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

32. • 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

33. 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

34. Mangement
• 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

35. 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

36. 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

37. 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

38. 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

39. 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.

40. Timing of surgery
Timing Physiological Status Surgical Intervention
Day 1 Normal response to resuscitation Early Total Care
Day 1
Partial response to resuscitation
Damage Control Surgery
Day 1
No response to resuscitation
Life-saving surgery
Day 2-5 Hyperinflammation ‘Second-look’ only
Day 6-10 Window of opportunity Definitive surgery
Day 12-21 Immunosuppression No surgery
Week 3+ Recovery 20 reconstructive surgery

41. DCO surgery
 External fixation
 Nailing if ISS<25
• 🞑 Unreamed/retrograde
• 🞑 Usage of new One-step Reamer-Irrigator- Aspirator

42. Mangled extremities -
Amputations vs Reconstruction
• Amputation group have a better
functional outcome rather than
the reconstruction and rapid
return to work
• Reconstruction group have
higher complication rate ,needs
more surgeries , more hospital
admissions
• 6.4% risk of amputation

43. Minimally invasive operations
External fixation of femur-
35 minutes 90 ml blood loss
Intramedullary nailing of
femur-130 minutes 400 ml blood
loss

44. Reamed IMN vs Ex Fix
• Reamed Intramedullary nailing Has been associated with
development of “second hit” phenomena
 Primary external fixation
• has not stimulated any inflammatory reaction“second hit”

45. Skeletal traction vs External fixation
External fixation of femur fractures in severely injured patients offers
no significant advantages compared with skeletal traction. The use of
ST as a temporization method remains a practical option.

46. CONCLUSION
• Incidence of Polytrauma is rising
• Initial evaluation and stabilisation is of paramount importance
• Changing trends in fluid therapy
• Proper selection of patient for ETC and DCO
• Multidisciplinary approach
DCO principles in polytrauma
Ortho team must be resuscitatorsand
stabilizers: not “fixers”

47. •THANK YOU