Introduction to the Concept of Damage Control Orthopaedics
The initial treatment of a femur fracture can significantly impact patient survival, as was dramatically demonstrated during World War I. In the first 2 years of that conflict, open femur fractures carried an 80% mortality rate. Remarkably, this was reduced to approximately 7% by 1918 after initiating the early, routine use of the Thomas splint, which resulted in length stable reductions and, presumably, a decrease in associated blood loss. Long bone fractures, particularly femoral shaft fractures, can result in significant hemorrhage and liberation of marrow contents into the systemic circulation. Although the exact mechanisms continue to be elucidated, these events have the potential to adversely impact patient physiology well beyond the musculoskeletal system, particularly in multiply injured patients (MIPs). A recent combined review of the trauma registries at two level I trauma centers, which included 2027 femoral shaft fractures, revealed that femur fractures remain an independent predictor of mortality and acute respiratory distress syndrome (ARDS). As a result, femur fractures have served as the model for studies examining techniques to reduce complications in MIPs.
Currently, it is nearly universally accepted that early total care (ETC), defined as the definitive fixation of fractures within approximately the first 24 hours after injury, is appropriate for the vast majority of patients. When contrasted and compared with treatment of femur fractures with prolonged traction and delayed fixation, ETC avoids the deleterious effects of prolonged recumbence and is associated with improved survival and decreased complication rates. Some studies, however, have suggested that ETC has the opposite effect in certain subsets of the MIP population, namely those with severe pulmonary and head injuries. For these individuals, damage control orthopaedics (DCOs)—namely, the initial treatment of fractures with provisional external fixation followed by delayed definitive fixation—has potential advantages and is commonly used ( Fig. 11-1 ). Similar to ETC, such an approach avoids the deleterious effects of prolonged recumbence but in contrast spares the patient from the additional physiologic burden of major surgery soon after injury, particularly the embolization of fat and marrow contents associated with intramedullary instrumentation that has been associated with secondary injury to the pulmonary capillary endothelium.
Although DCO protocols have been implemented at most trauma centers in the United States and Europe, the specific clinical indications remain unclear. Unfortunately, much of the DCO literature describes studies of limited scientific and statistical power because of the complex nature of this patient population. Difficulties in the study of these patients include their dynamic and often complicated clinical course, quantification of the impact of associated injuries, and an evolving understanding of the underlying pathophysiology of the inflammatory process. Confounding factors include multiple significant trauma care improvements in resuscitation, ventilation and intensive care unit (ICU) clinical advances that occurred concurrently with the implementation of DCO protocols, as well as potential underlying differences in the populations and geographic variation in resuscitative protocols.
In addition, the definition of DCO has gradually expanded in some studies to include non-MIP patients, further confusing the literature. At first, the term DCO described the use of femoral external fixation in a MIP as a temporizing measure—or bridge—to allow appropriate resuscitation before the definitive procedure. Over time, a change in this definition has resulted in the use of the term DCO to describe external fixation of relatively isolated extremity fractures to provide temporary stabilization, typically to allow for resolution of soft tissue swelling or local wound healing or to protect a vascular repair before definitive fracture fixation. Clearly, these patients differ dramatically from MIPs in need of systemic resuscitation to allow for safe definitive fracture treatment. It is therefore useful to adopt the term limb damage control (LDC), as used by Roberts and colleagues, to differentiate between these diverse patient populations and treatment strategies. The local advantages of LDC are well documented and discussed elsewhere in this text (i.e., periarticular tibial plateau or pilon fractures). The systemic advantages of DCO are less clear.
Today’s orthopedic traumatologists must be adept in evaluation of MIPs and prepared to individualize treatment strategies in a dynamic manner, often in collaboration with other trauma-related specialists. This chapter reviews the history of ETC and DCO, presents the pathophysiologic basis for DCO, and provides evidence-based practice recommendations for patients in whom ETC may be inappropriate in an effort to limit adverse systemic effects of fracture treatment.
History of Damage Control Orthopaedics Versus Early Total Care
Early termination of emergent laparotomies for penetrating trauma upon completion of lifesaving interventions was initiated by general surgeons in the 1980s. Appreciating the similarities that this approach shared with shipboard damage control efforts practiced by the U.S. Navy, Rotondo first used the term damage control to describe this laparotomy management tactic in 1993. Maritime damage control is a shipboard doctrine applied to limit damage from a fire or other hazard to a defined area of the ship and therefore maximize the overall survivability of a damaged vessel. This is achieved by anticipating and rapidly containing the cascade of aftereffects of a potentially catastrophic initial hazard, typically fire or flooding. Simply stated, it is an effort to “keep the ship afloat.” With similar goals in mind for trauma patients, surgical damage control consists of three phases, as described by Feliciano and colleagues: (1) initial operative intervention for control of life-threatening bleeding and decontamination; (2) intensive care transfer for correction of the deadly triad of hypothermia, acidosis, and coagulopathy followed by (3) a return to the operating room (OR) for definitive repair of the intraabdominal injuries. Better than expected survival rates have been realized with this strategy, which remains popular and effective today. Eventually, damage control strategies were developed for the initial treatment of extraabdominal trauma to include the musculoskeletal system.
In the mid-20th century, early manipulation of long bone fractures was considered unsafe. Because of concerns that fracture manipulation and fixation would increase the incidence of fat emboli, these patients were considered “too sick” for surgery. Traction, prolonged bed rest, and delayed operative interventions were therefore the typical and accepted practice for long bone fractures. In 1967, Kuntscher recommended: “Do not nail immediately, but wait a few days,” with special precautions for patients with multiple fractures or evidence of fat emboli. Others advocated delays of up to 14 days before intervention. Predictably, the consequences were severe. As noted by John Border, “traction produces an obtunded patient in the enforced supine position,” which led to deleterious pulmonary effects, poor functional results, and high mortality rates.
In the 1980s, delayed care of femur fractures began to be supplanted by early or immediate fixation. Theorizing that fat embolization was an ongoing process that continued until fracture fixation, Riska and Myllynen of Finland, from the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Foundation, first demonstrated improved outcomes with early fixation. In their retrospective series, 22% of patients in the non- or late-stabilization group developed fat emboli syndrome compared with only 4.5% in the early stabilization group. With the primary goal of improving functional recovery, the AO group also actively promoted early fixation for closed fractures, considering fracture patients “too sick not to be treated surgically.” Such an approach was subsequently supported by multiple outcome studies (10 retrospective, one prospective), which focused on the relationship between the timing of fixation of fractures and associated morbidity or mortality. Among the retrospective studies, LaDuca and colleagues extended the AO approach to open fractures using plate osteosynthesis and reported no episodes of fat emboli syndrome or cardiopulmonary failure. Describing the experience of the John Border group, Seibel noted increased ICU stays with delayed stabilization of femur or acetabular fractures. Early fixation reduced the risk of complications, with the caveat, “as long as they are done correctly and in the presence of good oxygen transport and blood clotting.” In contrast, traction significantly increased the cost of care and risk of multiple systems organ failure. Goris and colleagues reported their experience in the Netherlands, where reductions in mortality and ARDS were realized with early plate osteosynthesis. Johnson and colleagues similarly reported a fivefold increase in ARDS and mortality rate if fixation was delayed beyond 24 hours. This was most pronounced for the severely injured (Injury Severity Score [ISS] >40).
The first randomized, prospective study to support early fixation of long bone fractures was conducted by Bone and colleagues at Parkland Memorial Hospital, Dallas, Texas. Eighty-three patients with femoral shaft fractures and ISS of 18 or greater were divided into early fixation (<24 hours) and late fixation (>48 hours) groups. In the 46 patients in the early fixation group, a total of 16 pulmonary complications were observed (ARDS, pulmonary embolism [PE], fat emboli syndrome, or abnormal blood gases), including only one case of ARDS. In the 37 patients in the late fixation group, 50 pulmonary complications were observed with six cases of ARDS. These results were considered a confirmation of the findings of the previous retrospective studies, and resulted in “. . . the overwhelming recommendation . . . that early stabilization of long bone fractures should be performed in multiply injured patients.” ETC became the standard of care, and practice patterns changed. In Border’s group, the average duration for traction before fixation of femoral shaft fractures decreased from 9 to 2 days. Today, the Bone study is viewed with only slightly less enthusiasm. The only statistically significant difference presented was an increase in total hospital costs for the delayed fixation group. The more clinically relevant findings exhibited by the late group—increased pulmonary complications and longer hospital and ICU stays—were merely trends that failed to reach statistical significance. In addition, the randomization process was somewhat flawed, resulting in associated pulmonary injuries in 10 of 37 patients in the delayed fixation group compared with only one of 46 in the early group.
In the 1990s, concerns were raised that in a select group of MIPs—those with severe chest injuries and hemodynamic instability—ETC, particularly intramedullary nailing (IMN) of femur fractures, could actually increase rather than decrease the incidence of ARDS or multiple organ failure (MOF). ARDS and MOF are the dreaded end points of the systemic inflammatory response syndrome (SIRS), an exaggerated inflammatory response that ultimately damages organ systems that may have been uninvolved in the initial trauma. There are two inflammatory models for SIRS that are described: in the “one-hit” model, a massive initial injury and shock incite SIRS, resulting in early end-organ injury. In the “two-hit” model, an initial injury or “first hit” incites a more appropriately heightened state of SIRS that, if followed by a “second hit,” can be amplified and result in late MOF. Second hits may be from severe hemorrhage, incomplete resuscitation, infection, or major surgery. Of concern for this MIP subset was the potential for the timing of fixation and/or method of fixation to act as a second hit.
The damage control concept used for truncal injuries was applied to long bone fractures under the moniker of “damage control orthopaedics” (DCO), as coined by Scalea and colleagues. DCO is generally conducted by immobilizing a long bone or pelvic fracture with a temporizing external fixator to achieve the advantages associated with ETC (fracture stability, decreased pain, ease of nursing care, improved patient positioning in the ICU, decreased fat emboli ) while minimizing the potential adverse effects of major surgery (blood loss, hypothermia, and inflammatory system stimulation associated with medullary canal manipulation), which could serve as a second hit. After adequate resolution of physiologic stability and after the patient is no longer hypersusceptible to the second hit of intramedullary instrumentation, definitive fixation is conducted. Avoiding the consequences of an exaggerated second hit and the development of the lethal triad is the goal of DCO, which far outweighs the major disadvantage of external fixation, which is a need for a second surgical procedure, potentially increased cost, and an increased infection risk with prolonged application.
Identification of the subset of patients who would benefit from DCO is a continuing process, generating much controversy because indiscriminant application of DCO strategies could actually be harmful and associated with significant unnecessary expense. The generation of all-inclusive algorithms and strictly defined indications and treatment recommendations for the orthopaedic management of MIPs has proven elusive. In 2005, Rixen and colleagues reviewed 63 controlled DCO trials and failed to find a “generalized management strategy.” Even proponents admit that considerable clinical judgment and experience remain prerequisites to the appropriate application of DCO. Despite considerable experience, published DCO implementation rates varied dramatically among highly regarded institutions—12% at the University of Maryland’s R. Adams Cowley Shock Trauma Center (2002–2005) versus 57% at Denver Health Medical Center (1993–2006) for similarly described patient populations. Improved understanding of the inflammatory process and the importance of resuscitation are critical in better defining the appropriate DCO population.
Diagnosis and Classification of the Basic Pathophysiology and Inflammatory Process in Critically Injured Patients
The Basic Characteristics of Shock
A complex neuroinflammatory response follows injury. The precipitating causes of this are generally the combination of inadequate cellular perfusion, severe soft tissue injury, or both. Regardless, any combination of shock, defined as inadequate oxygen delivery or injured or nonviable tissue, precipitates this reaction. This reaction was first called the ebb and flow phenomena . More recently, it has been characterized as inflammatory first and then counterinflammatory later. If there is no inflammatory response, the patient succumbs to overwhelming shock. If the inflammatory response is hyperexaggerated, organ failure typically occurs. Thus, a balance of inflammation and counterinflammation is necessary for good patient outcomes. Unfortunately, clinicians have essentially no ability to actually manipulate the inflammatory response. Many compounds have been investigated as the “silver bullet” that will modulate the inflammatory response; none has been shown to be effective. This is likely because of the complex nature of the inflammatory response. A single compound or treatment is simply not sufficient. Even if one pathway is blocked, the body finds a way around that particular pathway.
Clinically, this complex system is manifested in one of three ways. In the first scenario, injuries and hemorrhage are recognized early, and the patient is resuscitated quickly. Although there may be complications of direct organ injury, in general, these patients do well. In the second scenario, patients present in profound shock or with multiple injuries. If resuscitation attempts are unsuccessful, these patients generally die of acute fulminant organ failure early on, generally within 24 hours. In the third scenario, resuscitation is delayed in which case organ failure usually complicates injury. The goal of early treatment is to achieve resuscitation early to avoid adverse outcomes.
Multiple organ dysfunction syndrome or MOF almost always occurs in the same order. The lungs fail first, usually within 48 to 72 hours. This is followed in sequence by renal failure and hepatic failure. Although our ability to support patients in ICUs has become greatly amplified in the past few years, in fact, the mortality rate from sequential organ failure remains quite high and largely unchanged over the years. Patients with a combination of respiratory failure, oliguric renal failure, and hepatic failure still have mortality rates that approach 80%.
The Basic Principles of Resuscitation
Optimal resuscitation involves early recognition of injury and shock and then rapid restoration of circulating volume to support cardiac output and peripheral oxygen delivery. Various philosophies exist to optimally resuscitate patients. Although an in-depth discussion of these is beyond the scope of this chapter, it is probably important to articulate certain principles.
Achieving Hemostasis
Traditionally, 2 L of isotonic crystalloid was used as the initial bolus of fluid to treat patients who presented in hemorrhage shock. This was both diagnostic and therapeutic and allowed classification into one of three categories, responder, transient responder, and nonresponder. However, we now realize that ongoing crystalloid resuscitation contributes to the overall proinflammatory state.
There are now two randomized prospective trials that demonstrate that raising blood pressure to normal before surgical hemostasis is obtained is of no benefit. Raising blood pressure to normal in response to hypotension merely displaces the hemostatic clot that is formed on the injured blood vessels. Hypotension recurs, and the patient again requires resuscitation, which is often accomplished using additional crystalloid. This creates a dangerous cycle of repeated bleeding, hypotension, and dilution of coagulation factors. Hypothermia soon follows, and the mortality rate increases.
Damage control resuscitation is a treatment scheme that is used in the most severely injured patients as part of a total strategy to limit ongoing injury caused by shock. This involves limited crystalloid resuscitation and permissive hypotension until surgical hemostasis has been obtained. Crystalloid fluid is minimized, and volume replacement is achieved with a combination of packed red blood cells (PRBCs), fresh-frozen plasma, and platelets. Although the optimal ratio of red blood cells and component therapy has yet to be defined, many have espoused that this should be 1 : 1 : 1. Others disagree, believing that less plasma is necessary. Virtually all would agree that red blood cells, plasma, and platelets should be used as opposed to crystalloid fluid, particularly in the most severely injured patients.
Volume Replacement
After initial hemostasis has been obtained, volume replacement can be liberalized. Good data suggest that the ability to normalize lactate is the single most important prognostic feature in patients after injury. However, the best method to normalize lactate is variable. Certainly, supporting cardiac output and oxygen delivery to optimally perfuse peripheral tissues seems reasonable. However, estimating the amount of intravascular volume necessary to do that can be difficult. In previous years, invasive monitoring was used to more precisely define filling pressures and cardiac output. More recently, the use of bedside echocardiography has been demonstrated to be a useful way to guide resuscitation.
Optimizing Pulmonary Function
Respiratory failure after injury is relatively common. This may be due to direct concussive force injury to the lungs, as well as the inflammatory response to injury outside of the thoracic cavity and inadequacy of resuscitation. Early ARDS or respiratory insufficiency is relatively common in MIPs. The discussion around the role of bony injury complicating early respiratory failure has evolved over the years. Earlier data suggested that early total fracture care was deleterious to pulmonary function . More recent data suggest that this is often not the case. It is important to optimize pulmonary function and achieve normalization of lactate before proceeding with fracture stabilization, particularly intramedullary instrumentation. However, this can almost always be accomplished within a relatively short period of time, allowing fracture care to proceed safely.
Intraoperative management of hemodynamics is also an important part of the philosophy of early total fracture care. Ideally, anesthesiologists very familiar with the care of MIPs will be available. They should understand the blood loss associated with both fractures and fracture fixation. Intraoperative fluid needs may be quite impressive. Intraoperative hypotension may negatively impact the long-term outcome, particularly in patients with traumatic brain injury (TBI). Thus, careful monitoring of cardiovascular performance in the OR is essential to allow early total fracture care to be a useful strategy. If an experienced anesthesiologist is not available at the time of patient presentation, initial damage control followed by definitive fracture fixation later may be wise as opposed to early total fracture care.
Early Fracture Care versus Damage Control Orthopaedics
In the case of a MIP with bony injury, decisions must be made as to when early total fracture care is appropriate as opposed to DCO. This generally involves discussions among the orthopaedic surgeons, ICU staff, and trauma surgeons. Risks and benefits of each therapeutic scheme must be weighed for every individual patient. In general, if patients are optimally resuscitated as evidenced by ability to clear lactate to normal, early total fracture care is often the wisest idea. If not, a damage control approach would be wiser.
Some specific injuries may influence the decision to proceed with ETC versus damage control. For instance, care for TBI usually involves serial physical examinations, repeat imaging, or both. Operative early total fracture care does not allow that to happen. Thus, DCO may be preferable to allow for careful monitoring of the brain injury.
The same may be true in patients with traumatic aortic injury and in patients with complex solid viscus injuries. The catecholamine swing that may be associated with IMN may increase blood pressure, negatively impacting the aortic injury. Certainly, serial physical examinations and serial hematocrits are a part of the nonoperative management of patients with blunt liver and spleen injuries.
However, in a well-functioning trauma system, many of these issues can be resolved and still allow for early total fracture care, perhaps not 12 hours after admission but within 24 hours. Repeat head computed tomography (CT) at 6 hours can be very helpful in predicting the trajectory of brain injury. Early stent grafting of traumatic aortic injuries stabilizes the aorta. A period of observation of liver and splenic injuries may often give the general surgeon sufficient comfort that definitive fracture care can proceed safely.
The decision as to whether to use early total fracture care versus DCO can be complicated. Optimal communication between all services involved is necessary to develop a cohesive plan. General surgeons must understand the important role that bony injury plays in patient outcome and the physiologic burden that comes with multiple fractures. Orthopaedic surgeons must understand the physiologic principles around resuscitation and optimization of cardiovascular performance. However, when this conversation occurs, early total fracture care is possible in the vast majority of patients, even those with significant injuries other than those to the bones.
Management of the Multiply Injured Patient
The Decision for Damage Control Orthopaedic Surgery
The ultimate goals of fracture treatment are to allow patient mobilization, early joint range of motion, and reconditioning therapy to achieve fracture healing and functional recovery consistent with the preinjury state. Fracture stabilization allows for a reduction in painful neurostimulation; optimizes muscle and soft tissue relationships, thereby preventing ongoing soft-tissue damage; and facilitates easier nursing care, rehabilitation, and hospital discharge. Isolated orthopaedic injuries in a patient without polytrauma are treated according to the requirements of the injury, the skill and clinical bias of the surgeon, and the characteristics of the patient. However, orthopaedic injuries in MIPs require surgeons to use a tactful reserve based on a “triage mentality.” In these patients, fracture care must reflect the level of physiologic stability or instability, and orthopaedic surgeons must appropriately time and titrate interventions to enhance the patient’s physiologic recovery rather than risk exacerbation of the inflammatory response by overaggressive pursuit of ETC. The management philosophy of DCO involves the use of rapid temporizing techniques and the maturation of a professional discipline necessary to avoid temptation to be overly invasive in the initial phase.
Damage control orthopaedic surgery is not for every patient with multiple fractures or every patient with multiple injuries and several fractures. Rather, it is for injured patients whose inflammatory responses will potentially be overwhelmed by further stimuli (i.e., reaming and intramedullary nail fixation of long bones, excessive surgical blood loss, and intraoperative fluid shifts). These are patients with a major constellation of injuries that have been recognized as having significant impact on the inflammatory and physiologic response. These injuries are usually associated with deranged physiology that has been difficult to correct or is undercorrected, such as hypovolemic shock, coagulopathy, or acidosis. Delayed manifestations of certain conditions such as lung or intracranial injury are also clues to deciding which patients may be better served by a damage control mode of care.
Assessment
One aim of the assessment during the initial resuscitation is to determine whether the injured patient with orthopaedic injuries can withstand ETC without overwhelming the inflammatory process. Pape and colleagues have proposed classifying patients into one of four categories (grades) of relative physiologic stability based on a series of parameters including level of shock, core body temperature, degree of associated coagulopathy, and characteristics of associated injuries to other body systems.
Patients who are stable according to the criteria offered by Pape and colleagues are generally able to safely undergo ETC, presuming there is ongoing monitoring of the critical parameters of physiologic stability throughout the case with reconsideration at any point if those parameters change resulting in relative instability. However, appropriate management of patients in other categories is more controversial. Most North American trauma centers use ETC much more aggressively than the criteria proposed by Pape and colleagues would indicate is appropriate. For example, using Abbreviated Injury Scale (AIS) chest of 3 or less as a marker for patients who are unstable or in extremis is wholly inconsistent with practice at most North American trauma centers. Furthermore, measurement of individual clotting factor levels, fibrinogen levels, or D-dimer levels is uncommon. Coagulopathy is initially defined as “present” or “absent” based on simpler, less effective gauges, including platelet counts and international normalized ratio. However, regardless of the specific criteria, the development of center-specific protocols for determining which patients are sufficiently stable to tolerate ETC versus those who are either borderline or unstable and therefore better suited for DCO is necessary. This determination must be based on readily available measures of injury severity, coagulopathy, shock, and body temperature. DCO is generally appropriate for patients who are not stable and will not become stable within 24 hours of the original injury.
Care for the Stable Patient (Grade I)
These patients have never been in shock and have only minor associated injuries that are not expected to further compromise physiologic stability. These patients are treated with the preferred method of care for their musculoskeletal injuries. Long bone fractures can be definitively fixed with reamed intramedullary nails or plates. The timing of the index surgery is usually in the first 24 to 36 hours, depending on OR and surgeon availability.
Care for the Borderline Patient (Grade II)
These patients are the most difficult to define and are the subjects of considerable debate within the literature on DCO. In general, these patients have lower extremity fractures, especially of the femur or a pelvic ring injury. They have also sustained other severe trauma, such as pulmonary contusions or brain injuries, which have the potential to worsen. These patients often demonstrate episodes of cardiovascular instability and hypoxia. The initial response to injury and treatment may compromise the patient’s ability to withstand the second surgical hit necessary for the definitive management of the orthopaedic injuries. Therefore, the borderline patient has the propensity to deteriorate and develop major complications and die. These patients require additional resuscitation, and more important, time for the severity of injuries to declare themselves before definitive surgical intervention is recommended for the musculoskeletal injury.
Care for Unstable Patients (Grade III)
These patients have persistent cardiovascular instability and require ongoing resuscitation to correct the abnormal physiologic state. Major non-lifesaving procedures that would cause blood loss or major fluid shift must be avoided. These patients should undergo continued resuscitation in a controlled intensive care environment. The initial stabilization of long bone fractures can be accomplished with skeletal traction. As the patient’s clinical course is better defined and more normal physiology is achieved though resuscitation, early intramedullary nailing (IMN) may be performed. If, however, the patient remains unstable, damage control using external fixation of the fractures should be considered. When necessary, these procedures can be performed at the bedside in the trauma ICU to prevent further instability from transport to and from the OR. Definitive fracture fixation should wait until there has been adequate resuscitation and physiologic stability, which may involve multiple days from the injury.
Care for Patients in Extremis (Grade IV)
These patients are the most critical and unstable after sustaining acute life-threatening injuries. Adequate resuscitation is difficult to achieve during the initial 24 hours after injury. These patients are not candidates for any major non-lifesaving surgical procedures in the first few days of hospitalization. External fixation of the long bone fractures should be considered as a bridge to definitive internal fixation. Temporary skeletal traction can be used in the acute resuscitation period but should be revised to formal external fixation if definitive fixation is expected to be significantly delayed. If the patient is in the OR for lifesaving surgery, expedited external fixation of the long bone fractures should be performed in concert with other lifesaving surgery.
Damage Control Orthopaedic Treatment Principles
Management Goals
The primary goal in the care of musculoskeletal injuries in MIPs is to limit the ongoing local and systemic injury associated with the musculoskeletal injury itself without causing a second physiologic hit in a patient who is in a hyperinflammatory state as a result of total injury load. Care is directed at resuscitation, correction of acidosis and coagulopathy, and limiting ongoing soft tissue injury associated with unstable long bone or pelvic fractures. For musculoskeletal injuries, the hierarchy of interventions follows this algorithm: (1) control extremity and pelvic hemorrhage, (2) correct ischemia (including reduction of dislocations and gross limb deformity, (3) débride contaminated traumatic wounds, (4) stabilize long bone fractures or unstable pelvic ring injuries, (5) reconstruct articular injuries, and (6) care for lesser fractures.
The revascularization of ischemic tissue occurs through fracture reduction, joint relocation, acute compartment syndrome fasciotomies, or vascular repair. Timely intervention helps to preserve functional tissue and can restore perfusion to critical tissues at risk for necrosis. Adequate surgical débridement of devitalized tissues and decontamination of open wounds minimizes the negative sequelae of the inflammatory response and decreases the risk of sepsis. Reduction and stabilization of major long bone fractures and unstable pelvic injuries reduces blood loss and transfusion requirements and minimizes ongoing soft tissue injury. The relocation of joints and the reduction and splinting of closed articular fractures helps to reduce pain and protect soft tissues until definitive fixation is physiologically appropriate.
Surgical Timing and Titration of Care
A multidisciplinary team approach is recommended for effectively coordinating resuscitation and surgical goals in MIPs. The general trauma surgeon is the “captain of the ship” and should clearly communicate the overall treatment plan, including the timing and appropriateness for surgical interventions. The decision to proceed to the OR versus the trauma ICU is dictated by the patient’s physiologic recovery from trauma and response to resuscitative measures. If the patient is in the OR for lifesaving surgical procedures, communication of the immediate orthopaedic goals with the trauma team is critical. Fractures can be quickly stabilized with external fixation and contaminated wounds quickly debrided along with fasciotomies to address compartment syndrome or impending compartment syndrome as needed. When possible, simultaneous surgeries (i.e., laparotomy and extremity) should be orchestrated with prioritization of the critical procedures and reasonable end points established to limit surgical insult. Lifesaving thoracic, abdominal, pelvic, and neurosurgical procedures take precedence over extremity fracture stabilization. In critically unstable patients, DCO offers a safe and effective means to stabilize musculoskeletal injuries. It is impractical and often impossible to proceed with definitive care of long bone or complex periarticular fractures in these patients.
Teams should avoid heroic measures and know “when to quit” if a patient’s condition deteriorates intraoperatively. Constant reevaluation of the patient’s resuscitation and condition is critical along with communication among the trauma team, anesthesiologist, and subspecialty surgeons. Index surgeries in MIPs should be limited to 2 hours. Falling core temperatures, worsening coagulopathy, unresolved or worsening base deficit, hypoxia, mixed venous desaturation, increasing peak airway pressures, and increased intracranial pressure (ICP) are all signs of imminent danger and signals that procedures should cease unless they are immediately lifesaving. At this point, the patient requires further stabilization and resuscitation in the trauma ICU. Bedside DCO, including fracture-spanning external fixation, fasciotomies, and basic wound débridement, may be necessary for patients too labile for the OR. These measures serve to bridge the gap before definitive orthopaedic surgery occurs in the OR.
External Fixation
External fixation is the workhorse of DCO and postulated to reduce the systemic inflammatory response and subsequent organ dysfunction and mortality. It does require a second operation to convert to definitive fixation and possibly an increase in the rate of infection if the timeframe to conversion becomes markedly prolonged.
Although this approach may increase the final cost of care, the surgeon must decide, based on the relative risks of ETC versus staged procedures, whether or not the patient will benefit from the DCO approach. Short, simple, and relatively bloodless fracture stabilization can be achieved with external fixators. Simple frame half-pin external fixation using two pins above and below each fracture segment provides excellent provisional stability for diaphyseal fractures. Joint-spanning frames achieve indirect reduction through ligamentotaxis to stabilize periarticular fractures. Complex and elaborate frames are unnecessary for DCO and prolong operative time. Self-drilling and self-tapping half-pins are time efficient and adequate for temporizing frames that bridge the gap between resuscitative fracture stabilization and later definitive fixation. These frames can be revised to increase stability or converted to definitive plate or nail fixation after adequate physiologic stabilization.
It is typically desirable for external fixators intended to achieve DCO to be applied rapidly. To accomplish rapid application, DCO frame systems typically recommend use of self-drilling pins as opposed to separately predrilling and then placing pins by hand. Separate predrilling with hand placement of pins may have the advantage of decreasing thermonecrosis at the pin site and therefore potentially prolonging purchase at the pin–bone interface. Predrilling does not improve the pullout strength of pins acutely. Because the pins in a DCO frame will generally be removed within 2 to 3 weeks to allow for definitive operative stabilization of the injury with internal fixation, there is minimal opportunity for them to fail secondary to generation of excessive heat on insertion. Therefore, the benefit of predrilling in terms of decreased bone necrosis is offset by the advantage of predrilling in terms of speed of application in the typical DCO circumstance.
Pelvic Stabilization and Hemodynamic Control
Pelvic ring injuries with widening or rotational or vertical displacement often require emergent, provisional stabilization to prevent hemorrhage and control hypovolemic shock. Repeat examinations to test pelvic stability should be avoided during the acute setting because the goal of pelvic stabilization is to encourage hemostasis and stabilize intrapelvic clot formation. Simple but effective temporizing means of pelvic volume control include internal rotation with taping of the lower extremities and circumferential pelvic antishock sheets or binders centered over the greater trochanters. These devices limit surgical access to the abdomen and perineum, however. Emergent laparotomy may require removal of these binders with resultant destabilization of the pelvic reduction and disruption of intrapelvic clots.
Percutaneous stabilization of the pelvis can be achieved with the pelvic C-clamp or resuscitative iliac crest pelvic external fixation. These methods can be performed rapidly at the bedside or in the OR. Pelvic external fixation techniques such as supraacetabular pin placement that are necessarily more time consuming and require significant fluoroscopic assistance should be avoided in hemodynamically unstable MIPs whenever possible. Persistent exsanguination in MIPs with unstable pelvic injuries may require a combination of external fixation, retroperitoneal packing, and angiography with embolization. In some severe injuries, emergent percutaneous screw stabilization of the sacroiliac joint may be beneficial, although this technique should be reserved for surgeons who are highly experienced with the procedure. Distortions to normal anatomy associated with wide displacement of the sacroiliac joint and the pressures of performing the procedure in the context of gross hemodynamic instability combine to markedly increase the degree of difficulty relative to more elective situations. Definitive internal fixation of the pelvis should be delayed until the patient’s condition will tolerate prolonged surgery and blood loss.
Managing Other Musculoskeletal Injuries
High-energy open fractures, traumatic amputations, and acute compartment syndrome are common in MIPs. Awake examinations by the orthopaedist are not often possible because these patients are usually intubated early on in the trauma resuscitation. A low threshold for fasciotomy is recommended for patients with tense compartments in the face of high-energy fracture patterns and vascular or crush injuries. Emergent fasciotomy may be done at the bedside or in the OR. Fasciotomies in this situation should be considered as part of the damage control process. The goal is to limit the ongoing injury to the muscles within affected compartments secondary to actual or impending ischemia.
Wound contamination and necrosis associated with mangled extremities and traumatic amputations present a significant metabolic load to the MIP. A delay in treatment can intensify the systemic inflammatory response. Débridement, irrigation, and revision amputation to a stable level can be lifesaving. The decision concerning limb salvage versus amputation is especially important in critical patients. The physiologic stress and suspected systemic impact of multiple surgeries necessary to achieve limb salvage must be weighed before deciding whether or not to amputate acutely in the context of a physiologically unstable patient.
Other closed, non–long bone fractures and dislocations can be managed with provisional reduction and splinting until the patient is sufficiently stable to tolerate extended procedures. This reduction and splinting can often be done at the bedside with adequate sedation and little additional stress to the MIP. These injuries are often uncovered during secondary and tertiary examinations.
It is often tempting to proceed with acute operative stabilization of distal musculoskeletal injuries using tourniquet control to limit hemorrhage and arguing that by limiting intraoperative blood loss, there is minimal risk of worsening the acute systemic inflammatory response. There is evidence, however, that tourniquet-mediated ischemia-reperfusion is associated with pulmonary dysfunction in animal models and may increase vent days in MIPs undergoing IMN of associated femoral shaft fracture at the same operative sitting.
Avoiding Missed Opportunities: Value of the Team Approach for Care of Multiply Injured Patients
Multiply injured patients can present with any combination of injuries to different bodily systems (e.g., intracranial, thoracoabdominal, musculoskeletal). Agreement about the basic concepts of care by each subspecialist involved in the case needs to be developed early on in the treatment plan. Clear communication among the major players (i.e., trauma, neurosurgery, and orthopaedic surgery) needs to occur throughout the course of care for a patient. Too often, DCO opportunities are missed as the trauma team brings the patient to the OR rapidly for a lifesaving procedure and then, as an afterthought, notifies the orthopaedic team of multiple suspected fractures as the patient is in transit to the trauma ICU. Débridement and external fixation equipment need to be readily available to the trauma room. Use of a radiolucent table for the emergent care of the trauma patient facilitates a smooth transition of care from the trauma team to the orthopaedic team. Arguments that patients cannot remain in the OR for an additional 20 to 30 minutes to allow for the application of an external fixator and débridement of contaminated wounds are often flawed and warrant careful consideration. The OR and the trauma ICU should be equally capable of continuing resuscitation, and resuscitation may be facilitated by wound débridement with associated extremity hemorrhage control and external fixation of long bones with associated limitation of ongoing soft tissue injury. Conversely, a blunt trauma victim who is rushed to the OR before obtaining a head CT to rule out epidural or subdural hematoma may be better served by going to CT without the delay that management of the extremity injuries might entail.
These decisions require the attention of trauma surgeons, orthopaedic surgeons, and neurosurgeons working closely together and communicating effectively with one another in an open and collegial fashion. Often the stress of the acute resuscitation makes this type of interaction more difficult and unnatural. Developing functional interpersonal relationships with other members of the trauma team in advance will likely lead to better patient care.
Conversion to Definitive Fixation
Damage control orthopaedic external fixation results in restoration of relative fracture stability. If applied appropriately, it should not burn any bridges relative to options for late conversion to definitive fixation. As the patient’s general condition improves, opportunities for return trips to the OR for non-lifesaving secondary procedures will emerge. Again, clear communication of orthopaedic treatment goals with the critical care and other trauma teams is critical to avoid missing opportunities at serial débridements and conversion of temporizing fixation to appropriate internal fixation constructs.
Definitive treatment of long bone fractures with external fixation is associated with high rates of complications, including malunion, shortening, nonunion, local and regional pin-related infection, and loss of motion at joints in proximity. The conversion of external fixation to IM nail appears to be relatively safe in the femur. The timing of this event should be considered so as not to incur substantial risk of compromising the patient’s recovery by secondary injury to the pulmonary capillary endothelium through reaming. The best time is when the inflammatory response has settled and the risk that a second hit will stimulate deterioration is not likely. Because monitoring the inflammatory process through assay of the mediators has not been demonstrated to be clinically functional, most surgeons wait until the inflammatory process has abated, usually 5 to 8 days after the injury. The patient must have no evidence of SIRS. A recent prospective study showed that MIPs operated on for secondary definitive surgery between days 2 and 4 have a significantly ( P <0.0001) increased inflammatory response compared with those operated on between days 6 and 8.
Nowotarski and colleagues reported on 59 patients with acute femoral shaft fractures treated with initial external fixation followed by staged conversion to an IM nail. The time in the external fixator averaged 7 days. All but four of the femurs were converted in a single-stage procedure. The four patients treated by a staged conversion had evidence of pin tract infections. For those cases, the external fixator was removed with curettage of the pin sites, and the patients were placed in traction to allow resolution of the pin tract infection with antibiotics. Ninety-seven percent of the fractures healed in 6 months. There was one deep infection that occurred in a patient with a type III open fracture. Bhandari and colleagues conducted a meta-analysis of studies looking at the infection rates and time to union for femoral and tibial fractures treated with IMN after initial external fixation. Of the six studies of femoral fractures, the average infection rate associated with single-stage conversion of external fixation to IMN was 3.6% (95% confidence interval: 1.8%–7.4%). The duration of external fixation ranged from 7 to 15 days. Union rates averaged 98%. In the single study evaluating two-stage femoral nailing after markedly extended periods of external fixation (50 days), the incidence of infection was 40% even after a 17-day interval between procedures. Results for the nine studies evaluating the results of tibial nailing after external fixation showed a higher risk of secondary infection with rates averaging 8.6% and an 83% reduction in the risk of infection if the length of external fixation was less than 8 days. Overall, the authors concluded that more prospective studies with better controls are needed but that it appears that extended time in frames before conversion to intramedullary fixation increases the risk of infection, particularly for tibial fractures.
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