- The patient is a 21-year-old male who was in a motor vehicle accident where the car hit a tree. He suffered a closed fracture of the left superior and inferior ramus pubis and a closed comminuted fracture of the proximal left femur. He also had a bladder rupture causing gross hematuria. - Due to his injuries and decreased level of consciousness, he was diagnosed with polytrauma with an ISS score of 18. His management involved damage control orthopedics with skin traction applied to the left lower limb and a pelvic bandage. - The document discusses the concepts of damage control orthopedics versus early total care, describing DCO as a temporary stabilization approach to avoid further

1. POLYTRAUMA
&
ETC vs DCO
Iswahyudi
Spine Subdivision
Spv. : dr. A. Dewi Kurniati, M.Kes, Sp.OT
Tuesday, May19th 2020

2. IDENTITY
Name : SH
Age : 21 years old / Male
Admission : March 23rd , 2020 at 17:30

3. AUTOANAMNESIS
(at 17:35)
• Suffered since 15 hours before admitted to Wahidin Sudirohusodo General Hospital
• Patient was a passenger of a car, and then the car hit a tree
• Patient cannot remember the mechanism of injury
• There is a history of loss of consciousness
• There are history of vomitting
• History of hypertension (-)
• History of diabetes mellitus (-)
• Patient was reffered from Barru General Hospital
Chief Complain : Pain at left thigh

4. PRIMARY SURVEY
(at 17.40)
A : Clear
B : RR = 22 x/min, symmetric, spontaneous, thoracoabdominal type.
C : TD : 100/70 mmHg.
HR: 90 x/min, regular, strong
D : GCS 10 (E3M5V2), light reflex +/+ , pupil isochors, Ø : 2.5
mm/2.5mm,
E : T = 36.50 C (axillary)

5. CLINICAL FINDINGS
(at 17.50)

6. SECONDARY SURVEY
(at 17.55)
Pelvis Region
Look : Deformity (-), Swelling (-), Hematoma (+), Wound (-)
Feel : Tenderness can not be evaluated due to decreased level of conciousness
Move : Active and passive movement of bilateral hip joint can not be evaluated due
to decreased level of conciousness
NVD : Sensibility can not be evaluated due to decreased level of conciousness,
dorsalis pedis and posterior tibialis arteries pulsation are palpable.
Capillary refill time < 2 seconds.

7. CLINICAL FINDINGS
(at 17.50)

8. SECONDARY SURVEY
(at 17.55)
Left Thigh Region
Look : Deformity (+), Swelling (+), Wound (-), Hematoma (+)
Feel : Tenderness can not be evaluated due to decreased level of conciousness
Move : Active and passive movement of hip joint can not be evaluated due to
decreased level of conciousness
Active and passive movement of knee joint can not be evaluated due to
decreased level of conciousness
NVD : Sensibility can not be evaluated due to decreased level of conciousness.
Dorsalis pedis and posterior tibialis arteries pulsation are palpable.
Capillary refill time < 2 seconds.

9. RADIOLOGY FINDING
at (18.00)

10. RADIOLOGY FINDING
at (18.00)

13. LABORATORY FINDINGS
(at 18.20)
• WBC : 22,6 x 103/mm3
• RBC : 3,39 x 106/mm3
• HGB : 8,6 g/dl
• HCT : 30 %
• PLT : 246 x 103/mm3
• CT : 8’00’’
• BT : 3’00’’
• RBS: 138 mg/dl
 Ureum : 66 mg/dl
 Creatinin : 2,84 mg/dl
 SGOT : 211 U/L
 SGPT : 176 U/L
 HbsAg : Non-reactive
 Sodium : 136 mmol/l
 Potassium: 7,3 mmol/l
 Chloride : 111 mmol/l
 LED I/II : 6 / 17

14. Injury Severity Score
AIS
Abdominal and pelvic content
3 9
Lower extremity
3 9
ISS
18

15. DIAGNOSIS
• Closed Fracture left superior et inferior ramus pubis
• Closed comminutive Fracture 1/3 Proximal Left Femur
• Gross Hematuria due to Urinary Bladder Rupture

16. MANAGEMENT
• IVFD NaCl 0,9%
• Analgesic
• Report to Orthopaedic senior, advice:
– Apply skin traction at left lower limb load 3kg
– Hb series per hour
– Blood transfusion PRC 2 bag
– Consult cito to urology department
– Apply pelvic bandage
– USG Whole Abdomen
– Report to Orthopaedic consultant :

17. Apply Pelvic Bandage

18. Applied skin traction at right lower limb

19. DEFINITION
Polytrauma is a syndrome of
multiple injuries with ISS>17
exceeding a defined severity with
sequential systemic reactions
that may lead to dysfunction or
failure of remote and vital
systems, which have not
themselves been directly injured
Keel M. Trentz., Patophysiology of Polytrauma. Int. J. Care. Injured ; 2005; p.691-709
Chou D., Barry M., Brohi K., Principles of Resuscitation and Polytrauma Management. Orthopaedic Trauma 2015; p.1.

20. GIANT TEMPLATE
Medical Powerpoint Template
- Tissue damage release
proinflammatory cytokines
- Hypermetabolism conditions
- MODS/MOF
- Releasing anti-inflammatory
cytokines
- Overwhelming anti-inflammatory
response
- Immunosupression
Hyperinflammation-
SIRS
Hypoinflammation-
CARS
Keel M. Trentz., Patophysiology of Polytrauma. Int. J. Care. Injured ; 2005; p.691-709

21. PHYSIOLOGY

22. PATHOLOGY

23. Early definitive stabilization of long bone fractures reduced the
incidence of the fat embolism syndrome compared to traditional non
surgical treatment.

25. An unexpectedly high rate of pulmonary complications was reported in young patients after reamed
femoral intramedullary nailing who had not suffered thoracic trauma.

26. They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft of
the femur in selected multiply injured patients(ISS>25)

29. Chou D., Barry M., Brohi K., Principles of Resuscitation and Polytrauma Management. Orthopaedic Trauma 2015; p.7

30. Chou D., Barry M., Brohi K., Principles of Resuscitation and Polytrauma Management. Orthopaedic Trauma 2015; p.9

31. DAMAGE CONTROL ORTHOPAEDICS
The concept of damage control orthopaedics (DCO) originally
concerned the provisional immobilisation of long bone fractures in
the severely traumatised patient in order to minimise the traumatic
effects of non-life saving surgical procedures, termed the “second
hit” effect
Guerrado E., et al : Damage Control Orthopedics : State of the Art. World Journal of Orthopedics, 2019; p.1-13

32. DAMAGE CONTROL ORTHOPAEDICS
• An approach to contain and stabilize an orthopaedic injury
to improve patient’s physiology
• Designed to avoid worsening patients condition due to “second hit”
phenomenon
• Delay definitive surgery until patient condition is optimized
• Focuses on hemorrhagic control, management of soft-tissue injury
and provisional fracture stability

33. RESUSCITATION
• Stop the bleeding
• Avoid hypovolemic shock
– To achieve cerebral perfusion
– Permissive hypotension
• Massive transfusion protocol
– RBC : FFP : Platelets = 1 : 1 : 1
• Indicators of adequate resucitation
– Mean arterial pressure > 60 mmHg
– Heart rate < 100 times per minutes
– Serum lactate levels < 2.5 mmol/L
– Base deficite between -2 to +2
Guerrado E., et al : Damage Control Orthopedics : State of the Art. World Journal of Orthopedics, 2019; p.1-13
Chou D., Barry M., Brohi K., Principles of Resuscitation and Polytrauma Management. Orthopaedic Trauma 2015; p.4
Ball CG., Damage Control Rescucitation : Histrory, Theory and Technique: Can J Surg 2014 ; p.55-59
Orthobullet Trauma 2017

34. FRACTURE MANAGEMENT
• Femur fractures
– External fixation
– Intramedullary nail
• Spinal fractures
– Less-invasive surgery system
– Speedy open decompression
• Upperlimb fractures
– Preserve vascular, nerve and tendon function
Guerrado E., et al : Damage Control Orthopedics : State of the Art. World Journal of Orthopedics, 2019; p.1-13

35. PHARMACOLOGY
• Antifibrinolytic
• Thromboembolic prophylaxis
• Antibiotics prophylaxis
Guerrado E., et al : Damage Control Orthopedics : State of the Art. World Journal of Orthopedics, 2019; p.1-13

37. Summary
• Initial evaluation is important
• Changing trends in management of politraumatized patient
• Proper selection of patient for ETC and DCO
• Multidisciplinary approach

38. Question 1

40. Question 2

42. Question 3

44. Question 4

46. Question 5

48. THANK YOU