Damage Control Orthopaedics

Definition

 

Approach that contains and stabilises orthopaedic injuries

- so that the patient's overall physiology can improve

 

Aim to avoid second hit of a major orthopaedic procedure

- delay definitive fracture repair until a time when the overall condition of the patient is optimised

 

History

 

Damage control began in general surgery

 

Phase 1

- control bleeding with packs

Phase 2

- resuscitate patient

Phase 3

- definitive surgery

 

Pathogenesis

 

One hit

- initial massive injury and shock

- intense systemic inflammatory syndrome

- macrophages, leucocytes, NK cells, interleukin, complement

- can precipitate multiorgan damage and failure

- i.e. increase endothelial permeability in lungs and predispose to ARDS / MODS

 

Second hit

- restimulates / hyperstimulates inflammatory system

- i.e. prolonged surgical procedures

 

Injury severity markers

 

IL6

- correlates well with degree of injury

- now routine in large trauma centres

 

CRP, TNF, IL 1 and 8

- no correlation to injury severity

 

Genetic predisposition

- DLA-DRII

 

Indications for DCO

 

Unstable patients / patient in extremis

 

Bilateral lung contusions / thoracic trauma 

 

Abdominal / pelvic trauma and hemorrhagic shock

 

Bilateral femur fractures

 

Parameters

1.  Acidotic:  pH < 7.24, lactate > 2.5 mmol/l

2.  Hypothermia:  temperature < 35

3.  Transfusion: > 10 units of blood

4.  Coagulopathy:  platelets < 90 000

4.  Long operative times > 90 minutes

5.  > 65 / geriatric patient

 

Exaggerated inflammatory response

- IL 6 > 800 ug/ml

 

Injury Severity Score / ISS

- > 20 with chest trauma

- > 40

 

Injury Severity Score

 

Based on Injury Scale / AIS

- 9 body regions

- head / face / neck / chest / spine / abdomen / UL / LL / external

- rated in severity 1 - 6

- max of 75

- minor / moderate / serious / severe / critical / untreatable

- a score of 6 in any region indicates futility of medial care

 

ISS

- 6 body regions

- head and neck / face / thorax / abdomen / extremity / external

- top 3 scores in any region are squared

- major trauma > 15

 

Timing of secondary Orthopaedic Procedures

 

Inflammatory response not diminished until day 6

 

Probably once patient stable