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Damage Control

Orthopaedics(D
CO)
Moderator:Dr Vijay Kumar
Co-Moderator:Dr Venketish
Presenter:Dr Navin Singh
All India Institute of Medical Sciences
New Delhi
Objectives-
Polytrauma
Historical perspetive
Introduction of DCO
Pathophysiology of DCO
Literature on DCO
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
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
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.

.
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.
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
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.
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.
Treatment preferred-cast and skeletal traction.
1970-
Studies shows that early stabilization of
femoral fractures dramatically reduces fat
embolism syndrome,pulmonary failure(ARDS)
and postoperative complications.
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.
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)
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
.

When stabilization was delayed the incidence of


pulmonary complications was higher, the hospital
and ICU stay days were increased
Early definitive stabilization of long bone
fractures reduced the incidence of the fat
embolism syndrome compared to
traditional non surgical treatment.
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.
An unexpectedly high rate of pulmonary complications was
reported in young patients after reamed femoral
intramedullary nailing who had not suffered thoracic trauma.
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.
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.
Pulmonary complications
were related to the severity
of injury rather than to
timing of fracture fixation
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)
(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.
DAMAGE CONTROL
ERA
Clinical Course-Three factors:
1.Trauma load(First hit)
2.Biological response
3.Treatment(Surgical Load,Second hit)
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, S47S52
Staged Treatment
Physiology-
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
First and second hit phenomenon:
Damage control philosophy in polytruma;
Surg Cdr us Dadhwar, Maj N Pathak
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.
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
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
Treatment goals
Stop the ongoing injury
Stop the ongoing injury
Remote organ injury occurs as a consequence of musculoskeletal injur
Remote organ injury
Clinical causes:
- 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
Stop
Reducethe ongoing injury
dislocations
Stabilize long bones
Splints & traction
Splints
Essentially& traction
stable fractures
External Fixator is a device uses for
stabilization and immobilization of
long bone open fractures.
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.


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.

47
Biomechanics

Thus Stiffness is inversely proportional to the


distance of the assembly from the bone

(closer the frame to bone -more stable


assembly)

48
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

49
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damage/repair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early
Reduceskeletal
blood loss stabilization
Issues while applying
DCO-
1. Safety????

2. Timing of definitive fixation????

3. Is DCO associated with high rate of


infection????
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 .


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.
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.
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%)
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

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