Introduction
Trauma includes a wide range of injuries, including blunt trauma from accidents, falls, and assaults and penetrating injuries from gunshot wounds and stabbings. Traumatic injuries often involve multiple systems of the body, with orthopedic injuries being among the most common. Damage control orthopedics originally aimed to temporarily immobilize long bone fractures, like the femur, in severely injured patients to minimize the negative effects of non-life-saving surgeries, known as the "second hit" effect. Recently, DCO has expanded to include other injuries like pelvic, spine, and upper limb fractures.
What Is Damage Control Orthopedics?
Damage control orthopedics is an important approach in treating severely injured patients and it emerged as a response to the realization that fixing all fractures in polytrauma patients right away was not always the best approach. DCO is a strategy that focuses on identifying which patients can undergo lengthy surgeries safely and which cannot.
In DCO, the priority is stabilizing life-threatening injuries. DCO involves using modular, minimally invasive external frames for long bone fractures for temporary stabilization. Only after a few days, when the patient has recovered metabolically and respiratorily, is definitive fracture management undertaken. DCO is now widely accepted as a crucial strategy for treating unstable, severely injured patients.
What Are the Principles of Damage Control Orthopedics?
Damage control orthopedics is a strategic approach to managing severe orthopedic injuries in multi-system trauma. The primary goals of DCO are to prevent further harm and to stabilize the patient for subsequent definitive orthopedic interventions.
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Prioritizing Life Over Limb - In a trauma setting, the ABCDE approach (Airway, Breathing, Circulation, Disability, and Exposure) takes precedence over orthopedic concerns. Hemorrhage control and resuscitation are paramount to address life-threatening issues.
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Temporary Stabilization - DCO focuses on temporary fracture stabilization to prevent further soft tissue damage and contamination. External fixators, traction, and splints are commonly used to maintain alignment and reduce pain.
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Minimizing Surgical Insult - Prolonged surgical procedures are avoided during the initial phase of DCO to reduce the risk of complications. Surgical timing is postponed until the patient's overall condition is stable.
What Are the Key Parameters That Indicate the Need for DCO?
In deciding who should be treated with damage control orthopedics (DCO), several key parameters are considered to identify patients who may benefit from this approach:
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High injury severity score.
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Glasgow Coma Scale (GCS) of 8 or less, indicating severe neurological impairment.
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Multiple injuries with severe trauma in the pelvic and abdominal region.
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Hemorrhagic shock.
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Presence of fractures in both femurs.
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Radiographic evidence of pulmonary contusion indicates significant chest trauma.
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Hypothermia with a body temperature below 35 degrees Celsius.
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Head injury with an Abbreviated Injury Scale (AIS) score of three or greater, signifying a severe head injury.
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Elevated IL-6 levels above 500 pg/dL indicate a systemic inflammatory response.
These parameters help clinicians identify patients at higher risk due to the severity of their injuries. They may benefit from the DCO strategy, which focuses on stabilizing life-threatening conditions before definitive orthopedic treatment.
What Are the Procedures Done in Damage Control Orthopedics?
1. Resuscitation and Bleeding Control:
The top priority in resuscitation is to stop bleeding and prevent hypovolemic shock. Quick surgical intervention is crucial to control bleeding, especially when the systolic blood pressure remains low after vasoactive drug treatment. Surgical treatment is the foundation of resuscitation, with a focus on addressing potential sources of severe bleeding, such as skin injuries, chest, abdomen, pelvis, and limb fractures.
2. Temporary Fracture Stabilization:
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Pelvic fractures can lead to life-threatening bleeding. Immediate stabilization is essential. Pelvic binders effectively close the pelvic ring, reducing mortality rates. External fixation (ExFix) is an alternative but more time-consuming option.
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Patients with spinal fractures need prompt diagnosis and management. Early fixation is preferred, as it reduces complications, including neurological damage. Less invasive stabilizing systems (LISS) are recommended, but open decompression may be required in cases of neurological damage.
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Complex upper limb trauma requires careful attention. Debridement and radical cleaning of soft tissues are essential. Osteosynthesis methods like ExFix or plates can be used, focusing on preserving vascular, nerve, and tendon function.
3. Soft Tissue Management:
Soft tissue management in DCO involves thorough wound assessment, debridement of devitalized tissue, and wound closure or temporary coverage. In the acute phase of DCO, the focus is on achieving hemostasis and preventing contamination. Depending on the extent of soft tissue injury, primary closure, delayed closure, or open wound management with negative pressure wound therapy may be chosen.
4. Pharmacological Management:
Tranexamic acid (TXA) is used to control severe hemorrhage. It should be administered promptly, ideally in the prehospital phase. The timing and dosing of TXA remain debated. Agents like recombinant active factor VII and prothrombin complex concentrate are being explored. TXA within 3 hours of trauma is recommended.
5. Thromboembolic Prophylaxis:
Severely traumatized patients are at risk of deep vein thrombosis and pulmonary thromboembolism. Low molecular weight heparin (LMWH) is the preferred prophylactic drug. Mechanical compression methods are also used.
6. Antibiotic Prophylaxis:
Preventing infection in polytrauma patients is vital. Antibiotics should be administered early in open fractures, ideally within 3 hours of trauma. Strict aseptic measures should be followed to prevent infections in wounds. Autologous blood product regimens should not be altered, but antibiotic doses should be adjusted based on renal function.
When Should Non-lifesaving Interventions Be Performed for Multisystem Trauma Patients?
Non-life-saving interventions in a multisystem trauma patient should generally be delayed until the patient's immediate life-threatening issues have been addressed. Once the critical concerns are managed, non-life-saving interventions can be considered. These interventions include further diagnostic studies, definitive fracture management, wound closure, or other procedures to address injuries that, while significant, do not pose an immediate threat to the patient's life.
Once the patient's condition has been stabilized, definitive orthopedic surgery can be planned to address the specific injuries.
Delayed Definitive Surgery
The timing of definitive surgery varies but typically occurs after the patient's systemic issues have been resolved. Delayed surgery allows for better wound healing and a lower risk of infection. Orthopedic surgeons assess patients' readiness for definitive surgery based on laboratory values, vital signs, and clinical examination.
What Are the Complications and Considerations Associated With Damage Control Orthopedics?
While damage control orthopedics is crucial for trauma care, it is not without potential complications and considerations.
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Prolonged external fixation and delayed surgery can increase the risk of infection. Close monitoring and prophylactic antibiotics may be necessary.
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DCO may result in less optimal alignment and functional outcomes than immediate definitive surgery.
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DCO can be resource-intensive, requiring frequent monitoring and adjustments. Hospitals and healthcare systems must weigh the benefits against the costs.
Conclusion
DCO's main goal is to do only what is necessary to save the patient's life and avoid further harm. DCO is used worldwide, but it needs more validation through well-designed studies, and there is debate about whether it is overused and costly. As research continues to refine DCO strategies, it remains an invaluable tool in the multidisciplinary approach to trauma care.
