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Damage Control OrthopaedicsJ Bone Joint Surg Am. 2005;87:434-449
Evolved in 1990’s
Early total care of major bone fractures in polytrauma pts was questioned.
Are we doing good or more harm to the patient.
Definition
an approach that contains and
stabilizes orthopaedic injuries so that
the patient’s overall physiology can
improve.
delay definitive fracture repair until patient condition is optimized
principle
avoid worsening of the patient’s
condition by a major orthopaedic
procedure.
Focus-1. control of hemorrhage.2. management of soft-tissue injury.3. achievement of provisional fracture
stability.
Evolution of fracture management
< 1950’s- status of exfix
1950-1. AAOS2. ILLIZAROV
NOV 6TH 1958
Maurice Müller, Hans Willenegger, Martin Allgöwer and …..
Formed the AO-ASIF group in view of
the poor functional results after non-
operative Rx of #
AO PRINCIPLE
early restoration of function, whether
a patient was being treated for an
isolated fracture or for multiple
injuries.
AGGRESSIVE TRAUMATOLOGY
THIS PATIENT IS TOO SICK NOT TO BE TREATED SURGICALLY
(1960-1990)
Bone et al . J Bone Joint Surg Am. 1989;71:336-40.
reported that the incidence of
pulmonary complications was higher
when femoral fixation was delayed.
1990’s
Research at a cellular level flourished
Pathophysiology of multiply injured pt
Concept of systemic inflammatory response
to trauma. “second hit” phenomenon.
Physiology of DamagE Control Orthopaedics
EFFECTS OF TRAUMA & SURGERY
Stimulating SIRS
immunosuppression
Dec of immunoglobulins , interferon
Anergy
Delayed hypersensitivity skin-testing.
Increased risk of posttraumatic sepsis
Biochemical markers
Currently only two markers
IL-6 HLA-DR class-II
Can accurately predict clinical outcome after trauma.
Clinical patient Selection
Trauma scores-
1. The abbreviated injury scale
2. Injury severity score
3. Revised trauma score
4. Anatomic profile
5. Glasgow coma scale
stableboderlin
e
Unstable In
extremis
STABLE PTS
Stable patients should be treated
with the
local preferred method.
Unstable patients
patients in extremis
should be treated with damage
control
orthopaedics.
orthopaedic injury complexes
femoral fractures in a multiply
injured
pelvic ring injuries with shock
polytrauma in a geriatric patient.
Chest injury
Two schools of thought
Early fixation is safe and beneficial
1. Bone et al : Early vs delayed stabilization of
femoral fractures. J B JS. 1989;71:336-40.
Thoracic trauma and early intramedullary nailing of femur fractures: are we doing harm? J Trauma. 1997;43:24-8.
No increase inmorbidity or mortality in association with early intramedullary
nailing (within twenty-four hours) of femoral
fractures in patients who had sustained blunt thoracic trauma.
Delayed Internal Fixation of Femoral
Shaft
Fracture Reduces Mortality Among
Patients with Multisystem Trauma
JBJS 2009
FOUR TIME ZONES
By delaying fixation beyond 12 hrs-
1. Allowed time for resuscitation
2. reduces mortality by approximately 50%.
3. Abdominal trauma pts had max benefit
4. Only exception time zone 24-48 hrs
HEAD INJURY
Early stabilization does not enhance or worsen the outcome in pts with head injury.
Individualize Rx
Cerebral perfusion pressure at >70
mm Hg
Intracranial pressure at <20 mm Hg
MANGLED EXTREMITIES
LEAP STUDY
Hypothesis- amputation would prove to have a better functional outcome than reconstruction.
1. SIP scores
2. % return to work
3. Reconstruction group-
Higher complication rate
More surgeries
More hospital admissions
6.4% risk of amputation
Secondary OrthopaedicProcedure
Days 2, 3, and 4 are not safe for performing definitive surgery.
Day 6 to 8 less risk as the SIRS is low
STEPS OF DCO
1. Control bleeding
2. Manage soft tissues
3. Spanning exfix
4. Antibiotic pouch
5. VAC dressings