Overview
Definition:
Damage control orthopedics (DCO) is a phased surgical approach to the management of severe extremity trauma in the critically injured patient
It prioritizes early stabilization of fractures and immediate life-saving interventions, deferring definitive fracture fixation until the patient is physiologically resuscitated and stable
This strategy aims to prevent the secondary insult of a massive inflammatory response triggered by prolonged operative time and significant blood loss in an unstable patient.
Epidemiology:
Polytrauma patients, defined as individuals with multiple severe injuries, frequently sustain associated extremity fractures
The incidence varies with trauma mechanisms, but approximately 30-40% of severe trauma patients have at least one long bone fracture
The optimal timing and sequence of orthopedic interventions in these complex cases remain a critical area of focus for trauma surgeons and orthopedic specialists.
Clinical Significance:
Effective DCO coordination is paramount in reducing morbidity and mortality in polytrauma
It aims to prevent the "deadly dozen" cycle of acidosis, coagulopathy, and hypothermia, which can be exacerbated by aggressive early surgical intervention
Proper sequencing of orthopedic procedures alongside other life-saving measures significantly improves patient outcomes, reduces infection rates, and minimizes complications like ARDS and MOF.
Clinical Presentation
Symptoms:
Patients present with severe pain, inability to bear weight, obvious deformity of limbs
They are often obtunded or sedated due to head injuries or shock, making subjective symptom reporting unreliable
Look for signs of significant soft tissue injury, open fractures, and neurovascular compromise.
Signs:
Gross limb deformity
Crepitus on palpation
Open wounds with exposed bone or soft tissue
Palpable pulses distal to the injury
Presence of paresthesia or paralysis indicates neurovascular compromise
Signs of hemorrhagic shock: tachycardia, hypotension, altered mental status, pallor, clammy skin
Associated injuries: thoracic, abdominal, pelvic, head injuries.
Diagnostic Criteria:
The diagnosis of polytrauma necessitating DCO is usually clear from the initial trauma evaluation and resuscitation
Key indicators include Injury Severity Score (ISS) > 15, New Injury Severity Score (NISS) > 15, presence of at least two severe injuries in different body regions (e.g., pelvic fracture with intracranial hemorrhage), or hemodynamic instability requiring massive transfusion.
Diagnostic Approach
History Taking:
Focus on the mechanism of injury (high-speed MVC, fall from height, crush injury)
Assess pre-injury comorbidities that may affect resuscitation and surgical tolerance
Rapid assessment of airway, breathing, circulation, disability, and exposure (ABCDE) is critical.
Physical Examination:
Perform a rapid, systematic head-to-toe examination, guided by ATLS principles
Assess all four limbs for deformities, open wounds, swelling, neurovascular status
Thoroughly examine the trunk, pelvis, and spine for associated injuries
Document all findings meticulously.
Investigations:
Initial investigations include: Complete Blood Count (CBC) with differential, coagulation profile (PT, INR, aPTT), electrolytes, arterial blood gases (ABG) with lactate for acid-base status and oxygenation
Imaging: Pelvic X-ray, Chest X-ray, FAST scan for intra-abdominal injuries
CT scan of the head, cervical spine, chest, abdomen, and pelvis is crucial for identifying all injuries
Long bone X-rays are performed after initial resuscitation
Definitive fracture imaging follows resuscitation and initial stabilization.
Differential Diagnosis:
The primary focus is not on differential diagnosis of individual fractures in the polytrauma setting but on identifying and prioritizing all life-threatening injuries
The differential diagnoses for shock include hypovolemic (hemorrhage), cardiogenic, obstructive, and distributive causes, with hemorrhage from pelvic fractures, long bones, and intra-abdominal/thoracic injuries being most common in orthopedics.
Management
Initial Management:
Resuscitation is the cornerstone of DCO
This involves aggressive fluid resuscitation, blood product transfusion (balanced ratio of RBCs, FFP, platelets), correction of acidosis and coagulopathy, and airway management
Definitive fracture management is delayed until the patient is hemodynamically stable, acid-base balance is corrected, and hypothermia is resolved
Initial orthopedic intervention typically involves temporary external fixation to control hemorrhage, reduce pain, and prevent further soft tissue damage.
Medical Management:
Management focuses on physiological stabilization
This includes: Analgesia (opioids cautiously), sedation for intubation and mechanical ventilation, antibiotics for open fractures (e.g., first-generation cephalosporins for low-grade open fractures, broader spectrum for higher grades), tetanus prophylaxis, and DVT prophylaxis (mechanical and pharmacological once bleeding is controlled).
Surgical Management:
The DCO strategy involves two or three phases: Phase 1 (Damage Control): Within 6-24 hours of injury, perform abbreviated ORIF or external fixation for hemorrhage control, pain relief, and temporary alignment
Phase 2 (Resuscitation and Stabilization): Patient is transferred to the ICU for resuscitation, correction of coagulopathy, and management of other life-threatening injuries
Definitive surgical fixation is performed when the patient is physiologically ready
Phase 3 (Reconstruction): Delayed definitive reconstruction, bone grafting, or hardware removal after full recovery
Early external fixation of long bone fractures, pelvic fractures, and spinal fractures is common.
Supportive Care:
Intensive care unit (ICU) monitoring is essential for hemodynamic stability, respiratory support, and metabolic balance
Nutritional support, fluid management, and strict infection control are critical
Psychological support for the patient and family is also important.
Coordination Critical
Interdisciplinary Team:
Effective DCO requires seamless coordination between trauma surgeons, orthopedic surgeons, anesthesiologists, intensivists, radiologists, nurses, and physiotherapists
Regular multidisciplinary trauma meetings are crucial for consensus decision-making regarding timing of interventions.
Communication Protocols:
Clear communication channels are vital
Pre-operative briefings, intra-operative updates, and post-operative handover reports must be precise and comprehensive
Use of standardized communication tools like SBAR (Situation, Background, Assessment, Recommendation) can enhance clarity.
Patient Tracking:
A centralized system to track patient progress, physiological parameters, and planned interventions is essential
This ensures all team members are aware of the patient's status and the overall treatment plan.
Resource Allocation:
Efficient allocation of operating room time, ICU beds, and specialized equipment is critical
Prioritizing life-saving interventions over definitive fracture fixation in the initial phase ensures optimal resource utilization.
Complications
Early Complications:
Hemorrhage, compartment syndrome, fat embolism syndrome, acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), infection (sepsis, osteomyelitis, wound infections), deep vein thrombosis (DVT), pulmonary embolism (PE).
Late Complications:
Malunion, nonunion, post-traumatic arthritis, chronic pain, stiffness, nerve injury, psychological sequelae (PTSD).
Prevention Strategies:
Aggressive resuscitation and correction of coagulopathy, judicious use of tourniquets and external fixators, prompt recognition and management of compartment syndrome, early mobilization once stable, adherence to infection control protocols, DVT prophylaxis, and comprehensive rehabilitation.
Prognosis
Factors Affecting Prognosis:
Severity of initial injuries, age and comorbidities of the patient, promptness and effectiveness of resuscitation, adherence to the DCO protocol, development of complications (e.g., sepsis, MOF), and the quality of definitive surgical reconstruction.
Outcomes:
When managed effectively, DCO can significantly improve survival rates, reduce the incidence of MOF and ARDS, and lead to better functional outcomes compared to aggressive early definitive fixation in physiologically compromised patients.
Follow Up:
Long-term follow-up is crucial to monitor for complications, assess functional recovery, manage pain, and address psychological impacts
This includes regular clinical assessments, imaging studies, and physiotherapy.
Key Points
Exam Focus:
Understand the phased approach of DCO: initial damage control (hemorrhage control, temporary fixation), resuscitation phase, and definitive reconstruction
Recognize the physiological goals of resuscitation: correction of acidosis, coagulopathy, and hypothermia
Know indications for external fixation in polytrauma.
Clinical Pearls:
Think "whole patient first, fracture second" in polytrauma
The goal is to prevent the inflammatory cascade
External fixation is a bridge to definitive care, not an endpoint
Communicate effectively and frequently with the multidisciplinary team
Don't hesitate to delay definitive fixation if the patient is unstable.
Common Mistakes:
Attempting definitive fixation in unstable patients
Underestimating the inflammatory response to trauma and surgery
Poor communication between surgical teams
Inadequate resuscitation and correction of coagulopathy
Delayed recognition of compartment syndrome or other surgical emergencies.