Extract
Many orthopaedic patients who have sustained multiple injuries benefit from
the early total care of major bone fractures. However, the strategy is not the
best option, and indeed might be harmful, for some multiply injured patients.
Since foregoing all early surgery is not the optimal approach for those
patients, the concept of damage control orthopaedics has evolved. Damage
control orthopaedics emphasizes the stabilization and control of the injury,
often with use of spanning external fixation, rather than immediate fracture
repair. The concept of damage control orthopaedics is not new; it has evolved
out of the rich history of fracture care and abdominal surgery. This article
traces the roots of damage control orthopaedics, reviews the physiologic basis
for it, describes the subgroups of patients and injury complexes that are best
treated with damage control orthopaedics, reports the early clinical results,
and provides a rationale for modern fracture care for the multiply injured
patient.
Many orthopaedic patients who have sustained multiple injuries benefit from
the early total care of major bone fractures. However, the strategy is not the
best option, and indeed might be harmful, for some multiply injured patients.
Since foregoing all early surgery is not the optimal approach for those
patients, the concept of damage control orthopaedics has evolved. Damage
control orthopaedics emphasizes the stabilization and control of the injury,
often with use of spanning external fixation, rather than immediate fracture
repair. The concept of damage control orthopaedics is not new; it has evolved
out of the rich history of fracture care and abdominal surgery. This article
traces the roots of damage control orthopaedics, reviews the physiologic basis
for it, describes the subgroups of patients and injury complexes that are best
treated with damage control orthopaedics, reports the early clinical results,
and provides a rationale for modern fracture care for the multiply injured
patient.
Damage control orthopaedics is an approach that contains and stabilizes
orthopaedic injuries so that the patient's overall physiology can improve. Its
purpose is to avoid worsening of the patient's condition by the "second
hit" of a major orthopaedic procedure and to delay definitive fracture
repair until a time when the overall condition of the patient is optimized.
Minimally invasive surgical techniques such as external fixation are used
initially. Damage control focuses on control of hemorrhage, management of
soft-tissue injury, and achievement of provisional fracture stability, while
avoiding additional insults to the patient.
We previously stated that: "Information illustrating the benefits of
fracture stabilization after multiple trauma has been gathering for almost a
century."1 We
also noted that during this time "fears of the `fat embolism syndrome'
also dominated the philosophy in managing polytrauma patients." Early
manipulation of long-bone fractures was considered
unsafe2.
External fixation, an essential component of damage control orthopaedics,
developed slowly and was outpaced by the development of internal fixation. In
Switzerland in 1938, Räoul Hoffmann produced an external fixator frame
that allowed the fracture to be mechanically manipulated and
reduced3. In 1942,
Roger Anderson advocated castless ambulatory treatment of fractures with use
of a versatile linkage system, but the device was banned in World War II for
being too
elaborate3. In 1950,
a survey by the Committee on Fractures and Traumatic Surgery of the American
Academy of Orthopaedic Surgeons (AAOS) concluded that the complications of
external fixation frequently exceed any advantages of the
procedure3. Also in
1950, Gavril Abramovich Ilizarov developed the ring system for fractures and
deformities, but his device did not reach the West until the late 1970s. On
March 15, 1958, Maurice Müller, Hans Willenegger, and Martin
Allgöwer convened a group of interested Swiss general and orthopaedic
surgeons, including Robert Schneider and Walter Bandi at the Kantonsspital,
Chur, Switzerland, to discuss the status of fracture treatment, which usually
included traction and prolonged bed rest and led to poor functional results in
a high percentage of
patients4. On
November 6, 1958, these pioneering surgeons established the
Arbeitsgemeinschaft für Osteosynthesefragen (the Association for the
Study of Internal Fixation, or ASIF), or AO, in Biel,
Switzerland4. The
key objective of the AO was the early restoration of function, whether a
patient was being treated for an isolated fracture or for multiple
injuries4. Matter
noted that this strategy led to "aggressive traumatology involving early
total care of the trauma victim, culminating in the statement: This patient is
too sick not to be treated
surgically."4
By the 1980s, the accepted care of a major fracture was early or immediate
fixation5.
Substantiating this approach were eleven studies (ten retrospective and one
prospective), with the one by Bone et
al.6 being most
frequently cited. Bone et al. reported that the incidence of pulmonary
complications (adult respiratory distress syndrome, pneumonia, and fat
embolism) was higher and the stays in the hospital and the intensive care unit
were increased when femoral fixation was delayed.
In 1990, Border reported on a comprehensive study of patients with blunt
trauma that challenged the accepted practice of immediate definitive
fixation7. This
changed practice in the early 1990s, and a more selective approach to fracture
fixation was used; however, early fixation was still performed in most cases.
During the 1990s, more was learned about the parameters associated with
adverse outcomes in multiply injured patients and about the systemic
inflammatory response to
trauma8. It became
clear that fracture surgery, especially intramedullary nailing, has systemic
physiologic effects. These effects became known as the "second
hit" phenomenon.
The era of damage control orthopaedics started around 1993. Two reports
from one
institution9,10
described temporary external fixation of femoral shaft fractures in severely
injured patients. From 1989 to 1990, the frequency of using temporary external
fixation increased from <5% to >10%. The mean duration of external
fixation until intramedullary nailing was less than one week. Compared with
patients treated with immediate definitive fixation, those treated initially
with external fixation had more severe injuries, with higher injury severity
scores and transfusion requirements in the initial twenty-four hours. The term
"damage control" began to be used in the orthopaedic literature
over the last six to seven
years1,9-12.
The concept of damage control surgery was developed first in the field of
abdominal surgery. The benefits of controlling hemorrhage and contamination
and leaving the abdomen open, in lieu of definite repair of injuries and
closure of the abdomen, improved the survival of patients with the lethal
triad of hypothermia, acidosis, and coagulopathy. Abdominal damage control
surgery was described as the sum total of all maneuvers required to ensure
survival of a multiply injured patient who was exsanguinating; its purpose was
to control rather than definitely repair
injuries13.
In the 1940s and 1950s, Arnold Griswold, of Kentucky, used a damage control
approach to penetrating injuries of the abdominal
cavity14. In 1981,
Feliciano et al. reported that nine of ten patients who had undergone hepatic
packing for the treatment of exsanguinating hemorrhage
survived15. Stone
et al., in 1983, described a stepwise approach involving intra-abdominal
packing and a laparotomy that was terminated
rapidly16. In 1992,
Burch et al. reported a 33% survival rate in a group of 200 patients treated
with abbreviated laparotomy and a planned
reoperation17.
Rotondo and Zonies, in 1993, coined the term "damage control" and
reported a 58% rate of survival of patients treated with a standardized
protocol18. In
short, the concept of damage control was first used in abdominal surgery to
describe a systematic threephase approach designed to disrupt a lethal cascade
of events leading to death by
exsanguination13.
Phase one involved an immediate laparotomy to control hemorrhage and
contamination18.
Phase two was resuscitation in the intensive care unit with improvement of
hemodynamics, rewarming, correction of coagulopathy, ventilatory support, and
continued identification of injuries. Phase three consisted of a reoperation
for removal of intra-abdominal packing, definitive repair of abdominal
injuries, and closure and possible repair of extra-abdominal injuries. Damage
control surgery in the abdomen has gained widespread acceptance throughout
North America and
Israel18,19.
The physiologic basis of damage control orthopaedics is beginning to be
understood. Traumatic injury leads to systemic inflammation (systemic
inflammatory response syndrome) followed by a period of recovery mediated by a
counter-regulatory anti-inflammatory response
(Fig.
1)20.
Severe inflammation may lead to acute organ failure and early death after an
injury. A lesser inflammatory response followed by an excessive compensatory
anti-inflammatory response syndrome may induce a prolonged immunosuppressed
state that can be deleterious to the host. This conceptual framework may
explain why multiple organ dysfunction syndrome develops early after trauma in
some patients and much later in others.
Within this inflammatory process, there is a fine balance between the
beneficial effects of inflammation and the potential for the process to cause
and aggravate tissue injury leading to adult respiratory distress syndrome and
multiple organ dysfunction syndrome. The key players in the host response
appear to be the cytokines, the leukocytes, the endothelium, and subsequent
leukocyte-endothelial cell
interactions21.
Reactive oxygen species, eicosanoids, and microcirculatory disturbances also
play pivotal
roles22. The
development of this inflammatory response and its subsequent, often fatal
consequences are part of the normal response to injury.
When the initial massive injury and shock give rise to an intense systemic
inflammatory syndrome with the potential to cause remote organ injury, this
"one hit" can cause an excessive inflammatory response that
activates the innate immune system, including macrophages, leukocytes, natural
killer cells, and inflammatory cell migration enhanced by interleukin-8 (IL-8)
production and complement components (C5a and C3a). When the stimulus is less
intense and would normally resolve without consequence, the patient is
vulnerable to secondary inflammatory insults that can reactivate the systemic
inflammatory response syndrome and precipitate late multiple organ dysfunction
syndrome. The second insult may take many forms as a result of a variety of
circumstances, such as sepsis and surgical procedures, and is the basis for
the decision-making process regarding when and how much to do for a
"borderline" multiply injured patient (as will be defined later).
Hyperstimulation of the inflammatory system, by either single or multiple
hits, is considered by many to be the key element in the pathogenesis of adult
respiratory distress syndrome and multiple organ dysfunction
syndrome23.
The First and Second-Hit Phenomena
Numerous studies have demonstrated that stimulation of a variety of
inflammatory mediators takes place in the immediate aftermath of
trauma24-27.
This response initially corresponds to the first-hit
phenomenon25. Hoch
et al. reported elevation in plasma concentrations of IL-6 and IL-8 in
patients with an injury severity score of =25
points28. An
immediate increase in expression of neutrophil L-selectin was reported in
patients with an injury severity score of =16
points29.
Similarly, a significant (p < 0.05) increase in the expression of the
integrin CD11b was noted in more severely injured
patients29. The
development of multiple organ dysfunction syndrome has also been associated
with a persistent elevation of CD11b expression on both neutrophils and
lymphocytes for 120 hours, a finding that is suggestive of neutrophil
activation in the early development of leukocyte-mediated end-organ injury.
Several other studies have clearly demonstrated the effect of injury severity
on the degree of stimulation of the inflammatory
markers8,30.
While selective immunostimulation may play a critical role in the
development of severe complications after injuries, it is also clear that the
governing effect of surgical or accidental trauma on immune function is
immunosuppression. Several authors have demonstrated the immunosuppressive
effect of
trauma31,32.
Following trauma, the production of immunoglobulins and interferon decreases
and many patients become anergic, as assessed with delayed hypersensitivity
skin-testing, and are thus exposed to an increased risk of posttraumatic
sepsis33. Defects
in neutrophil chemotaxis, phagocytosis, lysosomal enzyme content, and
respiratory burst have also been reported. Immunosuppression contributes to
the etiology of infection and sepsis after
trauma34.
The biological profile of the first hit in trauma patients is being
defined. Obertacke et al. demonstrated the importance of the first hit by
using bron-chopulmonary lavage to assess changes in pulmonary microvascular
permeability in patients who had sustained multiple
trauma35. The
permeability of the pulmonary capillaries increased following multiple trauma,
and patients in whom adult respiratory distress syndrome later developed had a
high correlation (r = 0.81) with increased permeability within just six hours
after admission than did those who had had an uneventful recovery. The
development of a massive immune reaction in a patient with bilateral femoral
fracture who showed a massive inflammatory reaction, which was subsequently
hyperstimulated by the surgical procedure itself (bilateral reamed femoral
nailing), further supports the importance of the first-hit
phenomenon36.
Although there was no obvious additional risk factor present (i.e., no chest
injury), the patient died from full-blown adult respiratory distress syndrome
three days after the injury. This case not only clearly illustrates the
existence of biological variation in the inflammatory response to injury, but
also confirms the importance of the degree of the response to the first hit
and the response to the second (surgical) hit that created the final fatal
event. The above studies suggest that the degree of the initial injury is
important in determining a patient's susceptibility to posttraumatic
complications.
The concept that a secondary surgical procedure creates an additional
inflammatory insult (a second hit) was specifically addressed in a prospective
study of 106 patients with an average injury severity score of 40.6
points37. Forty
patients in whom respiratory, renal, or hepatic failure developed, alone or in
combination, following a secondary surgical procedure were compared with
patients in whom no such complications developed. There was a significant (p
< 0.05) elevation of the neutrophil elastase and C-reactive protein levels
and a reduction in the platelet counts in the forty patients with systemic
complications. Abnormality of those three parameters predicted postoperative
organ failure with an accuracy of
79%37.
The first and second-hit phenomena in trauma patients were demonstrated in
a study in which femoral nailing was considered to be the second hit
(Fig.
2)8.
That study demonstrated similar responses to reamed and unreamed nailing in
terms of neutrophil activation, elastase release, and expression of adhesion
molecules. These concepts of biological responses to different stimuli (first
and second hits) have now become the basis of our treatment plans and
illustrate the impact of the operative procedure on trauma patients at risk
for exhaustion of their biological reserve
(Fig. 3).
Markers of Immune Reactivity
Inflammatory markers may hold the key to identifying patients at risk for
the development of posttraumatic complications such as multiple organ
dysfunction syndrome (Table I).
Common serum markers can be divided into markers of mediator activity such as
C-reactive protein, tumor necrosis factor-a (TNF-a), IL-1, IL-6,
IL-8, IL-10, and procalcitonin and markers of cellular activity such as CD11b
surface receptor on leukocytes, endothelial adhesion molecules (intercellular
adhesion molecule-1 [ICAM-1] and e-selectin), and HLA-DR class-II molecules on
peripheral mononuclear cells.
C-reactive protein, procalcitonin, TNF-a, IL-1, and IL-8 have not
been shown to be reliable
markers38-43.
However, IL-6 correlates well with the degree of injury, appears to be a
reliable index of the magnitude of systemic inflammation, and correlates with
the outcome12.
IL-10 inhibits the activity of TNF-a and IL-1, and the levels detectable
in the circulation correlate with the initial degree of injury. Persistently
high levels of IL-10 also correlate with sepsis. However, its role in
predicting outcome is still
debatable44.
Regarding the markers of cellular activity, mixed results have been
reported in the literature about the efficacy of endothelial adhesion
molecules (ICAM-1 and e-selectin) and the CD11b receptor of
leukocytes45.
HLA-DR class-II molecules mediate the processing of antigen to allow for
cellular immunity. They are considered to be reliable markers of immune
reactivity and a predictor of outcome following
trauma46,47.
Napolitano et al. reported that the severity of the systemic inflammatory
response syndrome at admission may be an accurate predictor of mortality and
the length of stay in the hospital by trauma
patients48. In
another study, the ratio of IL-6 to IL-10 was found to correlate with injury
severity after major trauma, and this ratio was recommended as a useful marker
to predict the degree of injury following
trauma49. The level
of plasma DNA has been found to increase after major trauma and has also been
suggested as a potentially valuable prognostic marker for patients at
risk50.
It appears that, at present, only two markers, IL-6 and HLA-DR class-II
molecules, accurately predict the clinical course and outcome after trauma.
IL-6 measurement has already been implemented as a routine laboratory test in
several trauma centers. Because of the additional laboratory processing
required for tests of HLA-DR class-II molecules (antibody staining of cells
and flow cytometric analysis), the use of such tests has not found great
clinical acceptance.
Genetic Predisposition and Adverse Outcomes
Biological variation and genetic predisposition are increasingly mentioned
as explanations of why serious posttraumatic complications develop in some
patients and not in
others51. Some
individuals may be "preprogrammed" to have a hyperreaction to a
given traumatic insult. Genetic polymorphism of the neutrophil receptor for
immunoglobulin G, CD16, has been reported and is associated with functional
differences in neutrophil
phagocytosis52. An
inherited predisposition toward high or low levels of HLA-DR expression is
further evidence of a genetic component in the immune response to
injury46.
Additional evidence of genetic predisposition is found in the cytokine
genes. The single base pair polymorphism at position -308 in the TNF gene was
associated with an increased incidence of sepsis and with a worse outcome
after major trauma, postoperative sepsis, and sepsis in a medical intensive
care
unit53-55.
This association depends on the presence of the TNF2 allele. Homozygosity for
the TNFB2 allele is associated with an increased incidence of severe sepsis
and a worse outcome. The risk of posttraumatic sepsis developing is 5.22 times
higher in patients who are homozygous for
TNFB256. Homozygous
patients also have higher circulating TNF-a concentrations and higher
multiple organ dysfunction syndrome scores compared with
heterozygotes57.
IL-6 polymorphisms have been reported and were detected in both the
3' and the 5' flanking regions and exon
558,59.
The SfaNI polymorphism is located at position 174. A homozygotic
constellation of this polymorphism coincided with decreased IL-6 serum levels
during
inflammation60,61.
Polymorphisms in the IL-10 gene have also been
demonstrated62.
Eskdale et al. reported that stimulation of human blood cultures with
bacterial lipopolysaccharide showed large interindividual variation in IL-10
secretion63. They
concluded that the ability to secrete IL-10 can vary in humans according to
the genetic composition of the IL-10 locus.
Recently, isolated case reports of germline defects in the cellular
receptor for interferon-gamma (IFN-?) were described, and the mutations
were
characterized64,65.
Davis et al. conducted a pilot study of thirty-eight patients who had
sustained blunt trauma and found that the microsatellite polymorphism AA
correlated strongly with
infection66. These
findings portend polymorphism in the receptor itself and thus represent a
genetic basis for the development of the infection.
Early identification of patients at risk for adverse outcomes and
complications may allow directed intervention with biological response
modifiers in order to improve morbidity and mortality rates. Use of
biochemical and genetic markers to identify patients "at risk"
after orthopaedic trauma may facilitate clinical decision-making regarding
when to switch from early total care to damage control orthopaedics.
Because biomechanical and genetic testing is currently not practical, it
remains a clinical decision when to shift from early total care to damage
control orthopaedics. Which patient should be treated with damage control
orthopaedics instead of early total care after orthopaedic trauma should be
decided on the basis of the patient's overall physiologic status and injury
complexes. Many trauma scoring systems (e.g., the abbreviated injury
scale67, injury
severity
score68,69,
revised trauma
score70, anatomic
profile71, and
Glasgow coma
scale72) have been
developed in an attempt to describe the overall condition of the trauma
patient. However, Bosse et
al.73 noted that
"there is no score that assists in decision-making during the acute
resuscitation phase." Therefore, it may be that one cannot rely
exclusively on a scoring system.
Additional data must be synthesized, and the overall status of the patient
should be stratified into one of four categories. Patients who have sustained
orthopaedic trauma have been divided into four groups: stable, borderline,
unstable, and in
extremis74. Stable
patients, unstable patients, and patients in extremis are fairly easy to
define. Stable patients should be treated with the local preferred method for
managing their orthopaedic injuries. Unstable patients and patients in
extremis should be treated with damage control orthopaedics for their
orthopaedic injuries. Borderline patients are more difficult to define. One of
us (H.-C.P.) and colleagues defined them as patients with polytrauma and an
injury severity score of >40 points in the absence of thoracic injury, or
an injury severity score of >20 points with thoracic injury (an abbreviated
injury score of >2 points); polytrauma with abdominal trauma (a Moore
score75 of >3
points); a chest radiograph showing bilateral lung contusions; an initial mean
pulmonary artery pressure of >24 mm Hg; or an increase in pulmonary artery
pressure of >6 mm Hg during nailing
(Table
II)74.
Borderline orthopaedic trauma patients are probably best treated with damage
control orthopaedics.
The term "borderline patient" describes a predisposition for
deterioration74.
Among other factors, thoracic trauma appears to play a crucial role in this
predisposition. However, whether femoral fractures in patients with chest
trauma should be treated with definitive stabilization or should be stabilized
with a temporary external fixator remains a subject of debate. The clinical
situation, including the presence or absence of a criterion indicating
borderline status (Table II)
and factors associated with a high risk of adverse outcomes
(Table III), should determine
how the patient is treated. In Louisville, some of the additional clinical
criteria that we have used as a basis for shifting to damage control
orthopaedics include a pH of <7.24, a temperature of <35°C,
operative times of more than ninety minutes, coagulopathy, and transfusion of
more than ten units of packed red blood cells. Furthermore, certain specific
orthopaedic injury complexes appear to be more amenable to damage control
orthopaedics; these include, for example, femoral fractures in a multiply
injured patient, pelvic ring injuries with exsanguinating hemorrhage, and
polytrauma in a geriatric patient.
Femoral Fractures
Femoral fractures in a multiply injured patient are not automatically
treated with intramedullary nailing because of concerns about the second hit
of such a procedure. In addition to the second hit, which results in an
additional systemic inflammatory response, embolic fat from use of
instrumentation in the medullary canal will worsen the pulmonary status.
Patients with a chest injury (an abbreviated injury score of >2 points) are
most prone to deterioration after an intramedullary nailing
procedure76.
Bilateral femoral fracture is a unique scenario in polytrauma that is
associated with a higher mortality rate and incidence of adult respiratory
distress syndrome than is a unilateral femoral
fracture77.
Copeland et al. noted that the increase in mortality may be more closely
related to associated injuries and physiologic parameters than to the
bilateral femoral fracture
itself77. Wu and
Shih78 noted that
bilateral femoral fracture indicates severe systemic and local injuries. Thus,
such injuries are ideal for damage control orthopaedics.
Pelvic Ring Injuries
Exsanguinating hemorrhage associated with pelvic fracture is another injury
complex suitable for damage control orthopaedics. Hemorrhage can result from a
combination of osseous, venous, and arterial bleeding. Although the most
common arterial injuries involve the internal iliac artery or its branches
(e.g., the superior gluteal artery), injuries to the common and external iliac
arteries have been reported and are associated with a poor
outcome79. The
specific radiographic pattern of the pelvic ring injury and the mechanism of
the injury can help one to anticipate the amount of bleeding, but there is no
precise injury pattern that predicts hemorrhage consistently. An additional
complicating factor can be the presence of a pelvic binder put in place by
emergency medical responders, as it may decrease the pelvic volume, realign
the pelvic ring, and contribute to a benign-looking pelvic radiograph.
There are nonetheless some consistent findings associated with a higher
likelihood of hemorrhage. Posterior pelvic ring injuries are associated with a
two to threefold increase in blood replacement requirements compared with
anterior
injuries80,81.
Anterior-posterior compression type-III injuries and lateral compression
injuries are associated with a high prevalence of vascular injury (22% and
23%,
respectively)82.
Finally, pelvic fractures in patients over fifty-five years old are more
likely to produce hemorrhage and require
angiography83.
The main controversy regarding the treatment of patients with profuse,
exsanguinating hemorrhage relates to the role of angiography and embolization.
In North America, both are most commonly utilized in the initial treatment of
pelvic fractures with associated hypotension that have not responded to the
placement of a pelvic binder, external fixator, pelvic c-clamp, or pelvic
stabilizer and transfusion of four units or more of blood. Additional
indications for angiography are an expanding retroperitoneal hematoma, a
vascular blush seen on computed tomography, and a massive retroperitoneal
hematoma observed on computed tomography. The timing of embolization is also
important. Agolini et
al.84 reported that
embolization later than three hours after injury increased the risk of
mortality fivefold and that the average procedure time for embolization was
ninety minutes.
Alternatively, pelvic packing for the control of hemorrhage has been
advocated at some centers in
Europe85. This
technique appears to be used for patients with severe hypotension and a pelvic
fracture that is unresponsive to other initial treatment measures and that is
associated with the imminent risk of death and thus a high likelihood that the
patient will not survive the trip to the angiography suite. However, there are
limited data to support the use of pelvic packing.
Damage control orthopaedics for a pelvic ring injury with exsanguinating
hemorrhage involves rapid clinical decision-making and multiple teams for
resuscitation and minimally invasive pelvic stabilization (e.g., with a pelvic
binder, external fixator, pelvic c-clamp, or pelvic stabilizer). Patients who
do not respond to these measures should be considered for angiography and
embolization if they are likely to survive the trip to the angiography suite;
otherwise, they should be considered for pelvic packing once any underlying
coagulopathy has been corrected.
Geriatric Trauma
Elderly trauma patients require special evaluation and treatment because of
their higher mortality rate following trauma, even minor trauma. Greenspan et
al. reported that the average LD (Lethal Dose) 50 injury severity score was 20
points for individuals more than sixty-five years of
age86. This value
is essentially half of the LD 50 injury severity score for individuals between
twenty-four and forty-four years of
age85. In addition,
pelvic ring fractures in individuals more than fifty-five years old are
associated with an increased chance of arterial injuries and higher
transfusion
requirements83. In
a study of patients who were more than sixty years old, Tornetta et al. noted
that increased mortality was associated with a lower Glasgow coma score (11.5
points for the patients who died compared with 13.9 points for the patients
who survived), greater transfusion requirements (10.9 units for the patients
who died compared with 2.9 units for those who survived), and greater fluid
infusion (12.4 L for the patients who died compared with 4.9 L for those who
survived)87. These
differences highlight the importance of considering damage control
orthopaedics for elderly patients. In addition, treatment should be directed
toward measures that enhance immediate mobilization and the avoidance of
prolonged bed rest in this patient population.
Chest Injuries
Traditionally, there have been two divergent schools of thought related to
the treatment of multiply injured patients with long-bone fractures and a
chest injury (Figs. 4-A, 4-B,
4-C, 4-D,
4-E), with some believing that
early fracture stabilization is safe and maybe even
beneficial6,88-91
and others believing that early fracture stabilization is not safe and may be
harmful76. The
classic paper by Bone et al. has probably had the most influence on the care
and treatment of orthopaedic trauma patients in the United
States6. More
recently, Boulanger et al. reported no increase in morbidity or mortality in
association with early intramedullary nailing (within twenty-four hours) of
femoral fractures in patients who had sustained blunt thoracic
trauma92.
The Eastern Association for the Surgery of Trauma Practice Management
Guidelines Work Group reviewed the current literature and found no randomized
clinical trials of the treatment of patients with chest injuries with
immediate long-bone stabilization (within forty-eight
hours)93. They
noted that available prospective studies or retrospective analyses comparing
long-bone stabilization within forty-eight hours with later stabilization in
patients with a chest injury showed that the two groups had similar rates of
mortality and adult respiratory distress syndrome, mechanical ventilation
requirements, lengths of stay in the intensive care unit, and total lengths of
stay in the hospital. The authors indicated that five clinical parameters may
be helpful in determining the appropriateness of early long-bone
stabilization: severity of pulmonary dysfunction, hemodynamic status,
estimated operative time, estimated blood loss, and fracture status (open or
closed).
A selective approach should be used for patients with long-bone fractures
and a chest injury. Defining the subgroup of patients for whom early nailing
would increase the risk of early complications is the goal of damage control
orthopaedics. Treatment ought to be individualized. When early intramedullary
nailing is not deemed to be the best alternative, damage control orthopaedics,
with short-term external fixation of the femur followed by staged conversion
to an intramedullary nail in the first week after injury, can be utilized.
Head Injuries
The Eastern Association for the Surgery of Trauma Practice Management
Guidelines Work Group also searched the literature for studies regarding the
timing of long-bone fracture stabilization in a multiply injured patient with
a head injury93.
The group found no Level-I studies (randomized clinical trials). On the basis
of Level-II studies (prospective, noncomparative clinical studies or
retrospective analyses of reliable data) and Level-III studies (retrospective
case series or database reviews), it was concluded that patients with mild,
moderate, or severe brain injury who underwent long-bone stabilization within
forty-eight hours were similar to those treated with later stabilization with
regard to mortality rate, length of stay in the intensive care unit, need for
mechanical ventilation, and total length of stay in the hospital. The overall
conclusion was that there was no compelling evidence that early longbone
stabilization either enhances or worsens the outcome in patients with a mild,
moderate, or severe head injury.
Many clinical issues arise during an examination of the available
literature on patients with a head injury and long-bone fractures. Early
definitive fracture stabilization is potentially beneficial in this situation
because it reduces persistent pain at the fracture site by minimizing
involuntary movements by an unconscious or not yet cooperative patient.
Fracture stabilization also has a positive effect on the patient's metabolism,
muscle tone, and body temperature, and, as a result, cerebral
function94.
Furthermore, unstabilized fractures may cause physiologic deterioration in
these patients as a result of increased soft-tissue damage, fat embolism, and
respiratory
insufficiency95-99.
In recent years, some authors have reported a worse outcome in patients
with secondary brain injury resulting from hypotension, hypoxia, and increased
intraoperative administration of fluid related to early operative fracture
fixation100,101.
In a study of multiply injured patients with fractures of the femur, tibia,
and pelvis, Martens and Ectors reported a 38% prevalence of early neurological
deterioration in a group treated with early fixation but no early neurological
deterioration in a group treated with late
fixation102. McKee
et al. reported that neurological complications developed in the postoperative
period in three patients treated with early fixation, but they did not
attribute any of these complications to the femoral fracture or its
fixation103. Also,
they found no difference in the long-term neurological outcome between the
patients treated with early fixation and those treated with delayed
fixation.
In contrast, in a study of patients with a head injury and a fracture of
the neck or shaft of the femur or the shaft of the tibia, Poole et al. found
that those who had undergone early definitive fracture fixation had a
significantly (p < 0.0001) lower prevalence of perioperative neurological
complications compared with those who had been treated with late
fixation104.
Brundage et al. reported that, in a series of multiply injured patients with
head injuries, femoral shaft fractures, and an injury severity score of >15
points, those treated with fixation within twenty-four hours after the injury
had the highest Glasgow coma scale scores at the time of
discharge105.
However, since only the mean head abbreviated injury scale score, and not the
Glasgow coma scale score on admission, was reported, these results are very
difficult to interpret accurately. Hofman and Goris found that the Glasgow
coma scale score was better in a group treated with early fixation than it was
in a group treated with late fixation, but the difference did not reach
significance106.
The initial management of a patient with a head injury should be similar to
that of other trauma patients, with a focus on the rapid control of hemorrhage
and restoration of vital signs and tissue perfusion. A brain injury can be
made worse if resuscitation is inadequate or if operative intervention such as
long-bone fixation decreases mean arterial pressure or increases intracranial
pressure. The treatment protocol for unstable patients should be based on the
individual clinical assessment and treatment requirements rather than on
mandatory policies with respect to the timing of fixation of long-bone
fractures. In such cases, damage control orthopaedics can provide temporary
osseous stability to an injured extremity, functioning as a temporary bridge
to staged definitive osteosynthesis, without worsening the patient's head
injury or overall condition. Intracranial pressure monitoring should be
utilized in the intensive care unit as well as during surgical procedures in
the operating room. Aggressive management of intracranial pressure appears to
be related to an improved outcome. Maintenance of cerebral perfusion pressure
at >70 mm Hg and intracranial pressure at <20 mm Hg should be mandatory
before, during, and after surgical procedures. Orthopaedic injuries should be
managed aggressively with the assumption that full neurological recovery will
occur.
Mangled Extremities
Prior to the Lower Extremity Assessment Project (LEAP)
study107-109,
there were limited data on the contemporary treatment of severely injured or
mangled lower extremities.
Lange110 performed
a retrospective study of twenty-three Gustilo and Anderson Type-IIIC tibial
fractures (severe open fractures with limb-threatening vascular compromise
requiring repair), fourteen of which eventually led to amputation (five of the
amputations were primary and nine, delayed). The absolute indications for
amputation in that study included anatomic disruption of the tibial nerve and
a crush injury with a warm ischemia time of more than six hours, or the
presence of two of three relative indications (serious polytrauma, severe
injury of the ipsilateral foot, and anticipation of a protracted course to
obtain soft-tissue coverage and tibial reconstruction). Caudle and
Stern111 reported
that seven of nine Type-III open tibial fractures required secondary
amputation.
Hansen112
called for a multicenter study to develop guidelines to "avoid
prolonged, costly, and fruitless salvage procedures when such a course is not
indicated." Helfet et
al.113 reported
that a mangled extremity severity score (MESS) of =7 points was associated
with a 100% rate of amputation. Georgiadis et
al.114 reported
that, of forty-five patients with a severe open tibial fracture requiring free
tissue transfer for soft-tissue coverage, twenty-seven were treated with limb
salvage and eighteen were treated with early amputation. The patients in the
limb salvage group had an average of three complications, whereas there was a
total of seventeen complications in the early amputation group.
Renewed interest in treatment of the mangled lower extremity has been
generated by the dissemination of the results from the LEAP study, a
prospective, longitudinal, observational, outcomes study at eight Level-I
American trauma
centers107-109.
In this study, the attending surgeons directed all evaluations, decisions, and
extremity treatment. There were 656 eligible patients ranging in age from
sixteen to sixty-nine years. Fifty-five patients were excluded from the study:
thirty-six refused to participate, thirteen died in the hospital, and six were
not enrolled because of administrative failure, which left a study group of
601 patients. In that group, thirty-two patients had bilateral injuries, which
were analyzed separately, and 569 had a unilateral injury.
The main hypothesis of the study was that, after the investigators
controlled for the severity of the limb injury, the presence and severity of
other injuries, and patient characteristics, amputation would prove to have a
better functional outcome than reconstruction for the treatment of traumatic
amputations, Type-IIIB and IIIC open tibial fractures, selected Type-IIIA open
tibial fractures, vascular injuries, major soft-tissue injuries, and severe
foot injuries.
The LEAP study patients differed from the general population with regard to
many characteristics. They were more likely to be male; they were less
educated; they were more often blue collar workers; they were less insured
(38% had no insurance); they were more likely to be healthy, heavy drinkers,
smokers, neurotic, and extroverted; they were less agreeable; and they had a
lower income.
Patients with a severe injury of the lower extremity and absent plantar
sensation at the time of admission had substantial impairment at twenty and
twenty-four months. Patients treated with limb salvage did not have poorer
outcomes than those treated with amputation. Absent plantar sensation did not
even predict the state of plantar sensation at twenty-four months. Neither the
injury characteristics nor the presence and severity of ipsilateral or
contralateral limb injuries significantly correlated with the outcomes as
assessed with the Sickness Impact Profile (SIP). Patients with a
through-the-knee amputation had worse regression-adjusted SIP scores (p =
0.05) and slower self-selected walking speeds (p = 0.004) than did patients
with either a below-the-knee or an above-the-knee
amputation109.
Patients who had been rehospitalized for a major complication also had poorer
outcomes. Significant (p = 0.05) predictors of a poor outcome were a
high-school education or less, a household income below the federal poverty
line, being nonwhite, a lack of insurance, receiving Medicaid benefits, a poor
social support network, low self-efficacy, smoking, and involvement in the
legal system for injury compensation. A proportion of the patients who had
undergone limb reconstruction had not fully recovered by two years; 10.8% of
those patients had nonunion, 4.7% did not have softtissue healing, and 15%
were judged to need additional surgery.
The SIP scores in the LEAP study were significantly higher (p < 0.01)
than published population
scores115.
Significant (p < 0.05) improvement was observed over time for all
dimensions of the SIP except for psychosocial functioning. The percentage of
patients with a slower walking speed was higher in the amputation group than
in the reconstruction group (p < 0.05). There was no difference between the
two groups in terms of SIP scores for disability or the percentage who
returned to work. The patients who had undergone reconstruction took longer to
achieve full weight-bearing, and they had more rehospitalizations and hospital
days (p < 0.01). Contrary to the study's hypothesis, the two-year outcomes
following the reconstructions were not significantly worse (or better) than
those following the amputations. However, reconstruction involves a higher
complication risk, additional surgical procedures, and more hospital
readmissions. Also, the risk of late amputation was 6.4%. As a result of this
study, we cannot assume that either an amputation or a successful
reconstruction will provide a superior result.
Webb et al. reported that patients with a limb-threatening Type-III open
tibial shaft fracture managed with limb salvage had outcomes that were similar
to those of patients who had undergone an
amputation116. The
authors noted several surgeon-controlled variables that appeared to influence
the course of the fracture and the patient outcome. Wound coverage with simple
methods provided better results than flap coverage, external fixation and flap
coverage provided worse results than amputations, and bone-grafting performed
within three months after the injury had a trend for a better outcome than did
bone-grafting that was accomplished later. In addition, Webb et al. found that
the timing of débridement and of soft-tissue coverage did not influence
the outcome, and the most common complications warranting readmission were
nonunion and infection.
Smith et al. reported that patients treated with late amputation after a
complex lower-extremity injury reported significantly (p < 0.05) higher
levels of disability than did those who had had an amputation either during
the first hospitalization or within the first three months after the
injury117. These
investigators noted a high number of hospitalizations for complications (p
< 0.0001), a high number of infections (p < 0.001), and a high number of
surgical procedures in the late-amputation group (p < 0.0001). They stated
that "when severe lower limb trauma places an individual at risk of
amputation there is value in making that difficult decision in a timely
fashion."
The LEAP data suggest an increasing trend toward limb salvage rather than
immediate amputation for complex open lower-extremity injuries. A damage
control orthopaedics approach to saving the limb may make it possible to
improve surgeon-controlled variables that appear to be related to better
outcomes. The use of spanning external fixation, antibiotic bead
pouches118-120
(Figs. 5-A and 5-B), and the
vacuum-assisted wound closure technique may provide a bridge to staged osseous
reconstruction and soft-tissue coverage
procedures121.
Vacuum-assisted wound closure subjects the wound bed to negative pressure by
way of a closed system and thereby removes edema from the extravascular
space121.
Isolated Complex Lower-Extremity Trauma
An isolated complex extremity injury (other than a mangled limb) is a
possible indication for a limited form of damage control orthopaedics that we
have termed "limb damage control orthopaedics." Specific injuries
that are amenable to this approach include complex proximal tibial articular
and metaphyseal fractures and distal tibial pilon fractures. These clinical
situations usually combine a complex fracture pattern, either open or closed,
with a substantial soft-tissue injury. Limb damage control orthopaedics is
useful for preventing soft-tissue complications by spanning the articular
segment with an external fixator and avoiding areas of future incisions. Then
minimally invasive plate osteosynthesis can be performed at a stage when the
condition of the soft tissue envelope is optimized.
One of the most important issues in damage control orthopaedics is the
timing of the secondary surgical procedures (definitive osteosynthesis). Days
2, 3, and 4 are not safe for performing definitive surgery. During this
period, marked immune reactions are ongoing and increased generalized edema is
observed. A recent prospective study demonstrated that multiply injured
patients subjected to secondary definitive surgery between days 2 and 4 had a
significantly (p < 0.0001) increased inflammatory response compared with
that in patients operated on between days 6 and
812,122.
It was concluded that, in different posttraumatic periods, variable
inflammatory responses to comparable stimuli are observed. This variation may
contribute to the differences in clinical outcome (e.g., a higher incidence of
multiple organ failure) that have been
reported12.
In Hannover, Germany, all high-risk patients have been managed with a
treatment plan that involves a re-evaluation of clinical and laboratory
parameters in the emergency department after the primary diagnostic
workup1. On the
basis of this re-evaluation, specific recommendations can be made for specific
groups of patients in the form of an algorithm
(Fig. 6).
In the early 1990s, the approach in Hannover changed from performing
definitive surgery in all patients to using an external fixator as a temporary
measure to stabilize the fracture and subsequently carrying out secondary
definitive internal
fixation1. In a
retrospective evaluation, three different time-periods were identified. In the
early total care period, between January 1, 1981, and December 31, 1989, the
protocol for the treatment of a femoral shaft fracture was early definitive
stabilization (within less than twenty-four hours). In the intermediate
period, between January 1, 1990, and December 31, 1992, the usual protocol for
treating a femoral shaft fracture in a multiply injured patient at risk for
posttraumatic complications changed from early definitive stabilization to
early temporary fixation. In the damage control orthopaedics period, beginning
in 1993, the protocol for such an injury in such a patient was early temporary
stabilization (within twenty-four hours) followed by secondary conversion to
intramedullary nailing. The rates of multisystem organ failure and adult
respiratory distress syndrome were found to be significantly higher (p <
0.05) in the earlier time-periods (Table
IV). In addition, during the latest time-period, patients who were
treated with damage control orthopaedics demonstrated a lower risk of adult
respiratory distress syndrome than those treated with initial intramedullary
nailing.
The use of spanning external fixation carries the risk of pin-track
infection. In the series in Hannover, the risk of infection following
definitive intramedullary nailing (Table
V) was not greater than that in other studies of patients who had
undergone intramedullary stabilization after external
fixation123-125.
Contemporary rates of pin-track infection are still substantial, but they are
minimized when the duration of external fixation is
brief126.
Practical considerations for spanning external fixation include the use of
an external fixation system that is user-friendly and can be applied rapidly.
Self-drilling pins, which can be manually inserted, can be applied quickly
with a limited need for fluoroscopy. Operating time can be decreased by
multiple operating teams working on opposite ends of the same limb or on
different extremities. External fixation systems that employ snap-and-click
clamps can be assembled rapidly. In addition, a system that allows flexibility
in pin placement is preferable so that areas of future incisions can be
avoided.
Damage control orthopaedics is ideal for an unstable patient or a patient
in extremis, and it has some utility for the borderline patient as well.
Specific injury complexes for which damage control orthopaedics should be
considered are femoral fractures (especially bilateral fractures), pelvic ring
injuries with profound hemorrhage, and multiple injuries in elderly patients.
Specific subgroups of multiply injured orthopaedic patients who may benefit
from damage control orthopaedics are those with a head injury, chest trauma,
or a mangled limb. A limited form of damage control orthopaedics (limb damage
control orthopaedics) is a rational alternative for the treatment of isolated,
complex limb injuries.
Clinical data and emerging discoveries in molecular medicine may continue
to provide answers to the question of when orthopaedic surgeons should use a
damage control orthopaedics approach. Prospective, multicenter studies similar
to the Lower Extremity Assessment Project may ultimately be necessary to
better understand the role of damage control orthopaedics in the treatment of
patients who have sustained orthopaedic trauma, especially those with
concomitant injuries to the chest and head. Despite the lack of prospective
clinical studies, many trauma centers have already modified their approach to
the treatment of orthopaedic patients with multiple injuries by incorporating
the principles of damage control
orthopaedics1.
Note: The authors thank Paul Tornetta III, MD, for his
encouragement and enthusiasm, which contributed greatly to this instructional
course lecture. They also express their appreciation to Timothy E. Hewett,
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