This document discusses the principles of damage control orthopedics (DCO) for treatment of polytrauma patients. DCO involves a staged approach, with initial temporary stabilization of fractures using external fixation, followed by resuscitation and optimization of the patient. Definitive stabilization is then performed after 4 days once the acute inflammatory response has subsided to minimize additional surgical stress. Femur fractures stabilized with external fixation can be converted to intramedullary nailing within 2-3 weeks once the risk of infection is low. Pelvic and acetabular fractures may also be definitively treated 7-10 days after injury. The goal of DCO is to balance life-saving care of injuries with avoiding lethal complications through additional

1. Dr.GOPI
Damage Control Orthopedics
DR.PONNILAVAN
ORTHO RESIDENT
PONDICHERRY

2. Polytrauma
• Defined as
- Multisystem
- Multiorgan
- Post-traumatic insult
with profound pathophysiological & metabolic changes.

3. • Management of polytrauma patients has
changed considerably during the past century.
• Advances in fields of fracture fixation
techniques & intensive care have contributed to
better Rx of a polytraumatized patient.

4. • Prior to 1970, early surgical fracture stabilization of long bone fractures
after multiple trauma was not routinely advocated.
It was believed that multiple injured patient did not have the physiological
reserve to withstand the prolonged operations.

5. Early Total Care (ETC)
• Introduction of standardized, definitive surgical protocols led to the
concept of it in 1980s.
This concept was subsequently applied universally, in all patient
groups, regardless of injury severity and distribution.
In the following decade, it was recognized that early stabilization
of skeletal injuries produced poor results in certain critically ill patients.

6. Early Total Care is particularly not
applicable for patients with significant
thoracic, abdominal & head injuries and
those with high injury severity scores (ISS).
In response, the concept of damage control
orthopedics (DCO) was developed in the
1990s.

7. DCO methodology is characterized by primary,
rapid, temporary fracture stabilization.
Secondary definitive management once the
acute phase of systemic disturbance has passed.

8. CONCEPT OF DAMAGE CONTROL SURGERY
• The term ‘damage control’ was originally coined by the US Navy in
reference to the “capacity of a ship to absorb damage and maintain
mission integrity”.

9. The 24-72 hour period after the initial injury
appears to be the most risky time
• Early Total Care
• Stabilize fractures and bleeding
prior to the 24-72 hour high risk
period
• Damage Control care
• Initial temporary stabilization only
in 24–72 hour high risk period

10. Rolando et al
First applied the term ‘damage
control surgery’
For management of patients with penetrating
abdominal trauma

11. Based on the concept of damage
control surgery, the application of the
same principles to the management
of the multiply-injured patients with
associated fractures of the long bones
& pelvic fractures was termed
‘damage control orthopedics’.

12. TWO HIT PHENONMENON

13. TWO HIT PHENONMENON

15. DCO consists of three stages
Damage control principles algorithm
• Stage 1: Early temporary stabilization of fracture and hemorrhage
control and intracranial decompression, if necessary
• Stage 2: Resuscitation and patient optimization
• Stage 3: Definitive stabilization (after day 4) of fractures

16. For temporary stabilization of fractures
Favored technique
external fixator
This can be rapidly applied
for stabilizing of fractures
& avoids any additional
stress on the patient.

17. • There are several criteria on which the stable physiological state of the
patient is determined in the second stage.
• Patient is considered optimized
- Stable hemodynamics
- Stable oxygen saturation
- Serum lactate level < 2 mmol / liter
- No coagulation disturbances
- Patient is afebrile and
- There is adequate urinary output

18. - 3rd stage of definite # fixation, usually entails IM nailing & is carried
out when the patient condition is optimized.
• Two recent studies have supported the success of this approach in
multiple injured patients.

19. Scalea et al
Reviewed patients who had femoral # s treated with either primary IM
nailing or an external fixation
They found that pts treated with external fixators tended to be more severely injured.
Operative time & average blood loss was less with external fixation than with
nailing.

20. • In the 2nd study echoed advantageous effect of delayed definitive
fixation for managing fractures of shaft of femur in appropriately
selected cases.
• There is some concern regarding increased risk of infection & optimal
time for conversion of external fixation to IM nailing.
• Rates of infection after conversion of external fixation of femur to IM
nailing range between 1.7% and 3% & are comparable to those for
several series for primary IM nailing of femur.
Nowotorski et al

21. Bhandari et al
examining conversion of external fixation to IM
nailing in the lower limb
Rate of infection decreased significantly when the interval between the two procedures was < 14 days.

22. Pape et
al
Assessed proinflammatory cytokine (IL-6) levels to predict for development of multiple organ
dysfunction.
Pts who underwent definitive Sx at 2-4 days post-injury developed a significantly increased
inflammatory response compared with those who were operated on 5-8 days post-injury

23. Pape et al
• High association between combination of high initial IL-6 measurements
& secondary surgery on days 2 to 4 and development of multiple organ
failure.
• It was concluded that the definitive operation should be delayed until
after the 4th day from initial surgery.

24. • Conversion of external fixation can be performed safely within the
first two weeks and has a very low rate of infection.
external fixation
intramedullary nailing
< 2weeks –
low rate of
infection

25. Damage control orthopedics
• DCS - Stepwise approach in management of patients with multiple
injuries
- Designed to take account of the difficulties encountered in
dealing with patients who are hemodynamically unstable.
Thus, the concept of DCO entails performing initially the least
morbid procedures that preserve life and prevent death whilst avoiding
potentially lethal complications, such as ARDS & multiple organ failure.

26. DCO involves staging definitive care of patient to avoid stress adding to the overall
trauma the patient has undergone.
Trauma is associated with a surge in inflammatory mediators, which peak 2 to 5
days after trauma.
After the initial burst of cytokines & other mediators, leukocytes are “primed” and
can be activated easily with further trauma such as surgery. This may lead to
multisystem organ failure or ARDS. To minimize the additional trauma added with
surgery, traumatologists will often treat only potentially life-threatening injuries
during this acute inflammatory window.
SUMMARY

27. •In severely injured polytrauma pt or
one with significant chest trauma, only
emergent & urgent conditions should
be treated.
-Compartment syndrome,
fractures associated with
vascular injury, unreduced
dislocations, long bone
fractures, open fractures, or
unstable spine fractures should
be stabilized acutely.
Acute stabilization is achieved primarily
via external fixation
• Femur # may be converted
from an external fixator to an
IM nail within 3 weeks.

28. If longer periods of time are necessary, a staged removal of the
external fixator and subsequent nailing several days later is
recommended.
Definitive Rx of pelvic & acetabular fractures may be delayed for
7 to 10 days in polytrauma patients to allow consolidation of the
pelvic hematoma and resolution of the acute inflammatory
response.

30. THANK U
Source – Mercer
- Kulkarni