Damage Control Principles Applied in Orthopaedic Surgery

1. Department of Orthopaedics
MH Kirkee
CME
DAMAGE CONTROL
ORTHOPAEDICS
Maj Rohit Vikas
Resident

2. May 1942 - Battle of Coral Sea

3. May 1942 - Battle of Coral Sea
USS Lexington

4. May 1942 - Battle of Coral Sea
USS Yorktown
USS YORKTOWN 1942
At Pearl Harbour

5. USS YORKTOWN
04 June 1942 – Battle of Midway
LIVE TO FIGHT ANOTHER DAY

6. USS YORKTOWN
04 June 1942 – Battle of Midway

7. UNITED STATES NAVY:
The capacity of the ship to absorb damage
and maintain mission integrity

8. An approach that contains and stabilizes orthopaedic injuries so
that the patient’s overall physiology can improve.
DCO should be regarded as a part of the resuscitation process

9. “Second Hit”

10. Interleukins 6 and 8.
IL falling
over
5 days

11. The 24-72 hour period after the initial injury appears to be the most at-risk time
Stabilize fractures and bleeding
Decrease the chance
prior to the 24-72 hour high-risk
of a second hit
period.

12. Till 1970s - 80s
Multiply injured patients were too unstable to survive surgical intervention.
Early definitive fracture stabilization was
performed only as an exception
Signs of MODS in the first posttraumatic week was
diagnosed as the ‘‘fat embolism syndrome’’,
characterised by hypoxia, cerebral depression
(somnolence, coma), coagulopathy (petechial
bleeding) or renal failure (anuria).
Surgical fracture stabilization were only performed in
patients, who were in a condition, i.e. without signs
of fat embolism syndrome.

13. Stabilization within 24 h, Aggressive Resuscitation
1980s
First meaningful study published, showing that early, definitive stabilization of long
bone fractures reduced the incidence of the fat embolism syndrome compared to
traditional non-surgical treatment.
Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O, Paavilainen T.
Primary operative fixation of long bone fractures in patients with multiple injuries.
J Trauma 1977;17:111—21.
A significant increase in ARDS associated with a delay in fracture stabilization in
patients with multiple injuries
• Increasingly significant in ISS > 40
Johnson K.: J Trauma 25(5): 1980
Early femoral fracture fixation in the multiple trauma patient resulted in
statistically significant improvement in the rates of survival
Bone LB et al: JBJS 71A(3): 1989

14. 1990
‘Borderline patient’
At particular risk
of late, poor outcome.
Patients with a very high ISS did not appear to benefit from ETC

15. CLINICAL EXAMPLE
16 y male, RTA
• Pulmonary Contusions
• Stable TBI
• Bilateral Femoral #
• Hip Dislocation
ETC – BL Femoral Nailing

16. CLINICAL EXAMPLE
96 h post femoral nailing
Florid ARDS
Outcome at 01 wk
Autopsy
IS IT INEVITABLE?
OR PREVENTABLE ?

17. Life as a trauma surgeon would be easy
if all we had to deal with was the fracture. COMPLICATING FACTORS
The fracture always has a patient
attached to it.
This forces us to consider more than just
the bones.

18. Clinical Parameters Used in Hannover, Germany, to Define the “Borderline” Patient for
Whom DCO Is Often Preferred
Polytrauma + ISS >20 + Thoracic trauma
Polytrauma + Abdominal/pelvic trauma + Hemorrhagic shock (initial BP <90 mm Hg)
ISS ≥ 40 in the absence of additional thoracic injury
X Ray: B/L lung contusion
Initial mean pulmonary arterial pressure >24 mm Hg
Increase of >6 mm Hg in pulmonary arterial pressure during IM Nailing

19. COAGULOPATHIC
HYPOTHERMIA (T < 32)
ACIDOSIS
SHOCK
PRESUMED OR TIME > 6 H
ARTERIAL INJURY AND HAEMODYNAMIC INSTABILITY
EXAGGERATED INFLAMMATORY RESPONSE

21. RELEASE COMPARTMENTS CONTROL HAEMORRHAGE
REDUCE DISLOCATIONS FLUID RESUSCITATION
DEBRIDE OPEN WOUNDS CXR – ICD IF NECESSARY
STABILIZE LONG BONES/ PELVIS LATERAL CERVICAL SPINE X RAY
X RAY PELVIS AP
FAST/ DPL
INITIAL EARLY EXTERNAL FIXATION
RE EVALUATE
MONITOR
BP, URINE OUTPUT
ABG
REPEAT FAST
IL-6
STAGED INTRAMEDULLARY FIXATION
MINIMAL INVASIVE PLATE OSTEOSYNTHESIS

22. SHORT TERM GOALS
REDUCE BLOOD LOSS
MINIMIZE MEDIATOR RELEASE
INCREASE PULMONARY FUNCTION
REDUCE SEPSIS AND PAIN
IMPROVE TREATMENT OF HEAD INJURY

28. Days 2—4 do not offer optimal conditions for definitive surgery.
Primary procedures of greater than 6 h duration and major surgical procedures at
days 2—4 should be avoided.
Between 5 – 14 days post injury

29. Multiply injured patient
Physiologically unstable
Severe chest injury (pulmonary insufficiency)
Severe TBI (hemorrhage or elevated ICP)
Mass casualty situation

33. Prolonged operation could cause intraop
hypotension, hypoxia, coagulopathy, increased
blood loss and fluid requirements during and
after the orthopedic operation.
DCO – EXTERNAL FIXATION
This will be detrimental to cerebral perfusion and
would be an additional insult to the already
injured brain, thus outweighing the benefits of
early fracture stabilization.
Maintenance of CPP >70 mm Hg and ICP <20 mm Hg should be mandatory before,
during, and after surgical procedures.

34. LEAP Study
An increasing trend toward limb salvage
rather than immediate amputation for
complex open lower-extremity injuries.
A DCO approach to saving the limb
Spanning external fixation,
Antibiotic bead pouches
Vacuum-assisted wound closure

35. An isolated complex extremity injury (other than a mangled limb)
Complex proximal tibial fractures
Distal tibial pilon fractures.

37. CURRENT ISSUES
Early skeletal fixation is appropriate…
• But what are the limits ?
• Hemodynamic instability
• Pulmonary instability
• Severe head injury
• Coagulopathy
• Hypothermia

38. DCO: Principles in Polytrauma
Ortho team must be
resuscitators and stabilizers:
not “fixers”
Save the Patient First