Damage control orthopaedics

1. Moderator:Dr Vijay Kumar
Co-Moderator:Dr Venketish
Presenter:Dr Navin Singh
All India Institute of Medical Sciences
New Delhi

2. Objectives-
 Polytrauma
 Historical perspetive
 Introduction of DCO
 Pathophysiology of DCO
 Literature on DCO

3.  Polytrauma: As patients with an Abbreviated Injury
Scale (AIS) score greater than 2 in at least two Injury
Severity Score (ISS) body regions (2 × AIS score > 2).
 The Journal of Trauma and Acute Care Surgery [2014,
77(4):620-623

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(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.
 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.  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.

9. 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.

10.  Treatment preferred-cast and skeletal traction.

11. 1970-
 Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism
syndrome,pulmonary failure(ARDS) and postoperative
complications.

12. Late 1980-
 There is a beneficial effect of early stabilization of
fractures on both morbidity,mortality and hospital
stay.
 Pt were able to mobilize early and were discharged
from hospital sooner ,avoiding the complications
associated with prolonged bed rest.

13.  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)

14.  ETC-Patients were able to mobilise early and were
discharged from hospital sooner, avoiding the
complications associated with prolonged bed rest.
 J Trauma 1985;25:375-84
 J Trauma 1990;30:792-8

15. When stabilization was delayed – the incidence of
pulmonary complications was higher, the hospital and ICU
stay days were increased

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

17. 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.

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

19.  These complications developed mainly in pts with severe
chest injuries,severe hemodynamic shock and in cases post
reamed intramedullary nailing without thoracic trauma.
J Trauma 1993;34:540-8
J Bone Joint Surg [Br] 1999;81-B:356-61.20.
 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.

20.  The 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.

21. Pulmonary complications were related
to the severity of injury rather than to
timing of fracture fixation

22. 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)

23.  (ISS)>25 :Higher infammatory burden, acute lung
injury, and increased mortality rate.
 Some patients who are so severely injured that they
cannot tolerate long operations, blood loss, and
especially medullary canal manipulation, without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis.

24. “DAMAGE CONTROL ERA”
Clinical Course-Three factors:
1.Trauma load(First hit)
2.Biological response
3.Treatment(Surgical Load,Second hit)

25. Damage Control Orthopaedics:
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state.(1)
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.
1. Injury, Int. J. Care Injured (2009) 40S4, S47–S52

26. 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

27. Physiology-

29. The cytokine response evidenced by fever, leukocytosis,
hyperventilation, tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
J.bone jt surg.1999;81(Br):256-61
J Trauma 2003;55:7-13

31. First and second hit phenomenon:

33. Damage control philosophy in polytruma;
Surg Cdr us Dadhwar, Maj N Pathak

34.  Patients who have sustained orthopaedic trauma have been
divided into four groups:
-stable
- Borderline
- unstable, and
- in extremis.
Pape HC, Hildebrand F, Pertschy S, Zelle B, Ga-rapati R, Grimme K, Krettek C, Reed RL 2nd.
Changes in the management of femoral shaft fractures in polytrauma patients: from early
total care to damage control orthopedic surgery.
J Trauma. 2002;53:452-62.

35.  Stable patients-ETC
 Unstable and in extremis-DCO
 Borderline-

38. Basic strategies of DCO-
 Immediate and rapid stabilization of long bone
fractures, typically with external fxation
 Release of tight soft tissue compartments
(compartment syndrome)
 Reductions of dislocations
 Surgical debridement of open wounds
 Amputation, in cases of unsalvageable extremities

39. Treatment goals
Stop the
ongoing injury
Facilitate
patient care
Restore
function

40. Stop the ongoing injury
Remote organ injury
occurs as a consequence
of musculoskeletal
injury
Mediators :
• activated neutrophils
• chemical mediators
• fat emboli
• marrow contents

41. Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemia/reperfusion
 Primay target : lungs
 Secondary targets : gut, kidney, brain, etc
 Resultant injury is progressive : ARDS/MODS

42. Stop the ongoing injury
Release
compartments
Reduce
dislocations
Debride open
wounds
Stabilize
long
bones

43. Stabilize long bones
Splints &
traction
Ex-fix

44. Splints & traction
Best
reserved for:
Essentially
stable
fractures
Isolated
extremity
fractures

45.  “External Fixator is a device uses for
stabilization and immobilization of long bone
open fractures.”

46.  Minimally invasive operations
 External fixation of femur – 35 minutes ,90 ml blood
loss
 Intramedully nailing of femur -130 minutes ,400 ml
blood loss
 Scales et al., “ external fixation as a bridge to
intramedullary for patients with multiple injuries and
with femur fractures : damage control orthopaedics”
J.Trauma 2000;48 :613-23.

47. 47
Biomechanics of External Fixator
 Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis.

48. 48
 Thus Stiffness is inversely proportional to the distance
of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics

49. 49
Mechanics of Bone Pin Interface
To increase stability of bone –pin interface
1. Adequate no. of pins in each fragments
( 2 for most bone & 3 for femur)
2. Increase pin pitch .
3. Increase size of pin

50. Indications for Rapid Ex Fix
 Patient in extremis
 Massive open injury (degloving injury)
 Vascular damage/repair
 Mass casualities

51. Patient in Extremis
 Multiple other severe injuries
 Extreme hypotension
 Coagulopathy
 Massive head injury
 Aortic transection

52. Early skeletal stabilization
Reduce
blood loss
Minimize
mediator
release
Improve
pulmonary
function
Decrease
sepsis and
pain
Improved
treatment
of head
injured

53. Issues while applying DCO-
1. Safety????
2. Timing of definitive fixation????
3. Is DCO associated with high rate of infection????

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

55. In patients with multiple injuries-EF is viable alternative to attain
temporary stabilization-rapid and causes minimal blood loss;can be
followed by IMN when pt is stabilized.

56. An aggressive and early damage control approach to treat
femuur fractures in severe polytrauma patients led to low
mortality rate comparing to the predicted mortality bu TRISS.

57. When is the right time to perform secondary
definitive surgery????
 In a study by Pape et al-compared two group having
same ISS and GCS:
group 1- early definitive surgery between 2- 4
days(46% MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (15.7%)

58. Infection rate after DCO is comparable to those after
primary IMN.Pin site contamination was more common
where the fixator was in place for >14 days