Damage Control
Orthopaedics(DC
Presented
O )
By
Hany A.Y. Al-Dakar
Specialist of orthopedic&
traumatology
Al-Mahmoudia General Hospital
HISTORICAL
PERSPECTIVES
The philosophy prevailed that the
polytrauma patient was ‘too sick to
operate on’
The development of fat embolism
syndrome and pulmonary dysfunction
was feared (Bradford DS ET AL., 1970)
Definitive surgical stabilization was
often delayed to 10-14 days
Cast and skeletal tractions preferred
Pioneering studies showed
that early stabilization of
femoral fractures reduces
dramatically the incidence of
Fat Emb.Syndrome, pulmonary
failure (ARDS) and
postoperative complications
“ There is a beneficial effect of early
Stabilization of fractures on both
mortality and morbidity and length
of hospital stay.”
This new philosophy was named
Early Total Care ( ETC ). “The patient is
too sick not to be treated surgically”
Surgeries were done within 24 hrs of admission
A variety of unexpected
complications related to the early
stabilization of fractures of long
bones was described.
These complications mainly
developed in patients with
severe chest injuries,
severe hemodynamic shock
post reamed intramedullary
nailing without thoracic trauma.
This led to the conclusion that the method
of stabilization and the timing of surgery
may have played a major role in the
development of such complications.
An approach to achieve rapid skeletal
stabilization of major orthopedic injuries
to stop the cycle of ongoing musculo -
skeletal injury and to control hemorrhage
Its purpose is to avoid worsening of the
patient's condition by the "second hit" of
a major orthopedic procedures
WHAT IS
DAMAGE CONTROL ?
Damage control is a Navy term defined as “the capacity of a ship to
absorb damage and maintain mission integrity
DAMAGE CONTROL IS A NAVAL TERM:-
SAVE THE SHIPE
LIMIT THE DAMAGE
EMERGENCY REPAIR
FINISH THE MISSION
DAMAGE CONTROL ORTHOPAEDICS (DCO)
Relatively recent concept in Orthopaedic practice
Early rapid Containment
& Stabilization of Orthopedic injuries
without worsening the patient general
condition
Indications
• Critically ill polytrauma patient
• Unfavorable surgical environment
• Battlefield limb injuries & mass
casualties
Damage Control 0rthopedics
Definition
An approach that
1- Contains & Stabilizes Orthopaedic
Injuries so that the Patient’s Overall
Physiology can improve
2- Avoid worsening of the patient’s
condition by a major Orthopaedic
Procedure
3- Delay Definitive Fracture Repair in
borderline or unstable patient till
condition is optimized
Damage Control Orthopedics:
Its priorities are:
Control of hemorrhage
Provisional stabilization of major skeletal
fractures
Management of soft-tissue injuries
Minimizing the degree of surgical insult to the
patient.
1. Recognize who needs
damage control.
2. Salvage operations.
3. Keep the patient alive.
4. Accept morbidity of
the salvage procedures.
5. Definitive repair later
PATHOPHYSIOLOGY
THE BLOODY VICIOUS CIRCLE
BLOOD
BLEEDING
TRANSFUSION
HYPOTHERMIA
COAGULOPATHY
TRAUMA TRIAD OF DEATH
TRAUMA MORTALITY
Early death
– Blood loss
– Brain injury
Late death
– Secondary brain injury
– Host defense failure -sepsis
TWO-HITS THEORY
First Hit (Truma)
–Hypoxia
– Hypotension
– organ & soft tissue injury
– fractures
Second Hit (operation)
– ischemia/reperfusion injury
– compartment syndrome
– operative intervention
– infection
Physiological response to injury
Inflammatory immune response
Innate immune response
Adaptive immune response
Systemic Inflammatory Response Syndrome
(SIRS)
Compensatory Anti-inflammatory Response
Syndrome (CARS)
Multi Organ Dysfunction Syndrome (MODS)
Inflammatory immune response
EARLY innate immune response
DELAYED adaptive immune response
Innate = Hyperinflammation = SIRS
Adaptive = Immunosuppression = CARS
Early innate immune response
Activation of PMN, monocytes, macrophages, and
endothelial cells
Release of pro-inflammatory mediators (cytokines
and molecular mediators)
Considered the hyperinflammatory period
SIRS DEFINITION
Heart rate: > 90 bpm
WBC: <4000/mm3 or >12000/mm3 or >10%
immature PMNs
Respiratory rate: >20/min with PaCO2<32mmHg
Core temperature: <360C or >380C
2 of 4 parameters = SIRS
Delayed adaptive immune response
Non-apoptotic necrotic/dead cells produce
alarmins plus Endogenous triggers (DAMPs =
damage-associated molecular patterns) →
autoimmune tissue destruction
Considered the immunosuppression period
or CARS
Interplay of SIRS and CARS
Mild-Moderate Injury
Anti-inflammatory Pro-inflammatory
SIRS
Systemic Response
Insult
Innate Immune
Response
D7 D14
Adaptive Immune Homeostasis
Response
CARS
Balanced SIRS-CARS maintains homeostasis
Pathological immune response
IMBALANCE BETWEEN SIRS AND CARS
Severe injury 1st Hit Intense CARS
Early MODS/death
Moderate Injury 1st Hit Incomplete Resolution
2nd Hit
2nd Operation within D3-5
Sepsis
Amplification of SIRS
Delayed-onset MODS/death
Pathological immune response
Severe Injury
Anti-inflammatory Pro-inflammatory
SIRS
Systemic Response
Insult
Innate Immune
Response
Adaptive Immune
Response
CARS
Imbalanced CARS>SIRS leads to hypo-inflammation or early MODS
Pathological immune response
Moderate to severe injury
Anti-inflammatory Pro-inflammatory
SIRS
2nd Hit
Systemic Response
Insult
Innate Immune
Response
Adaptive Immune
Response
CARS
Imbalanced SIRS>CARS leads to hyper-inflammation or delayed MODS
MODS
Cerebral - Cerebral edema
CVS - Hypotension and shock
Respiratory - Acute lung injury, ARDS
Liver - hepatocytes dysfunction
GI -Increased mucosal permeability
Bacterial translocation
Renal - Renal tubular necrosis, acute renal failure
Hematologic - DIVC
SO..WHAT WE ARE
What Are We Doing?
DOING?
We’re limiting the 2nd hit.
WE ARE LIMITING THE 2ND HIT
PATIENT SELECTION
Polytrauma Patient
Polytrauma is a Syndrome of Multiple
Injuries exceeding a defined Injury Severity
Score
ISS > = 17
Sequential Post traumatic Systemic
Inflammatory Reactions
(SIRS)
Dysfunction or failure of Remote Systems
or Organs which are not injured
(MODS – MOF)
PATIENT CLINICALLY ASSESSED ABOUT THEIR PHYSICAL
STATUS AND CLASSIFIED AS:-
I. STABLE: GRADE 1
II. BORDERLINE: GRADE2
III. UNSTABLE: GRADE 3
IV. EXTREMIS: GRADE 4
Patient categorization
Parameter Stable Borderline Unstable In Extremis
Shock SBP (mmHg) 100 or more 80-100 60-80 50-60
Blood unit/2h 0-2 2-8 5-15 >15
Lactate < 2.0 2.5 >2.5 Severe
Base deficit Normal No data No data >6-18
UO ml/h >150 50-150 <100 <50
Class I II-III III-IV IV
Coagulation Platelets >110,000 90-110,000 70-90,000 <70,000
Factors II/V 90-100% 70-80% 50-70% <50%
Fibrinogen >1 g/dL 1 g/dL <1 g/dL DIC
d-Dimer Normal Abnormal Abnormal DIC
Temperature >340C 33-350C 30-320C <300C
Soft Tissue Chest AIS 2 or 2 2 or more 2 or more 3 or more
Injuries TTS 0 I-II II-III IV
Abd (Moore) <II <III III III or >III
Pelvic AO A B or C C C
Limb AIS I-II II-III III-IV Crush
COAGULOPATHIC
HYPOTHERMIA (T <32)
ACIDOSIS
SHOCK
PERSUMED OPRATIVE TIME > 6H
ARTERIAL INJURY AND HAEMODYNAMIC INSTABILITY
EXAGGERATED INFLAMMATORY RESPONSE
MANAGMENT
Femoral fractures in a multiply
injured
Pelvic ring injuries with shock
Polytrauma in a geriatric patient
Long bone fractures with chest or
head injuries
Mangled extremities
APPLICATION OF DCO
STRATEGY
Multiply injured patient
Physiologically unstable
Severe chest injury
Severe hemorrhge
Mass casualty situation
STATGED TREATMENT
Stage 1: early temporary External Fixation
OT Stabilization of unstable fractures and the control of
hemorrhage and, if indicated, decompression of
intracranial lesion.
ICU Stage 2: resuscitation of the patient in ICU and
optimization of his condition.
Stage 3: delayed definitive management of the
OT fracture
What to do ? - Clinical status
Stable Borderline Unstable or
In extremis
Resuscitate
Reevaluate
Stabilized Uncertain
ETC ? DCO
OP - ICU
Steps of Damage Control Orthopaedics
Control Bleeding
Manage Soft tissues
Spanning Ex. Fixator
Antibiotic Pouch
Vacuum Dressings
Control Bleeding
Manage Soft tissues
Spanning External Fixator
Antibiotic Pouch
Vacuum Dressings
SECONDARY PROCEDURE
WHEN?
Timing of surgery
Timing Physiological Status Surgical Intervention
Normal response to resuscitation
Day 1 Early Total Care
Day 1
Partial response to resuscitation
Damage Control Surgery
Day 1
No response to resuscitation
Life-saving surgery
Day 2-5 Hyperinflammation ‘Second-look’ only
Day 6-10 Window of opportunity Definitive surgery
Day 12-21 Immunosuppression No surgery
Week 3+ Recovery 20 reconstructive surgery
AO Philosophy
CONCLUSION
DAMAGE CONTROL ORTHOPAEDICS (DCO)
Is a Way of thinking
The aim is to Save lives not just fixing a fracture in a
limb
Orthopedic team become a resuscitators & stabilizers not
just a fixers
Early Skeletal fixation (DCO) is appropriate by external
fixator
As Early Total Care may be very risky in
Hemodynamic instability
Pulmonary instability
Sever head injury
Lethal triad (Coagulopathy, Hypothermia & Acidosis)
Do not kill your
Borderline patient by
(ETC)
Help him to live by
(DCO)
Give him the chance to
fight another day
Ortho team must be resuscitators and
stabilizers: not “fixers”
