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Damage control orthopaedics. Evolving concepts


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Article in Instructional course lectures February 2005


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THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG D A M A G E C O N T RO L
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Damage Control
Orthopaedics
EVOLVING CONCEPTS IN THE TREATMENT OF PATIENTS
WHO HAVE SUSTAINED ORTHOPAEDIC TRAUMA
BY CRAIG S. ROBERTS, MD, HANS-CHRISTOPH PAPE, MD, ALAN L. JONES, MD, ARTHUR L. MALKANI, MD,
JORGE L. RODRIGUEZ, MD, AND PETER V. GIANNOUDIS, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Many orthopaedic patients who have overall physiology can improve. Its pur- fixation. In Switzerland in 1938, Roul
sustained multiple injuries benefit from pose is to avoid worsening of the pa- Hoffmann produced an external fixator
the early total care of major bone frac- tients condition by the second hit of a frame that allowed the fracture to be
tures. However, the strategy is not the major orthopaedic procedure and to mechanically manipulated and re-
best option, and indeed might be harm- delay definitive fracture repair until a duced3. In 1942, Roger Anderson advo-
ful, for some multiply injured patients. time when the overall condition of the cated castless ambulatory treatment of
Since foregoing all early surgery is not patient is optimized. Minimally invasive fractures with use of a versatile linkage
the optimal approach for those patients, surgical techniques such as external fix- system, but the device was banned in
the concept of damage control ortho- ation are used initially. Damage control World War II for being too elaborate3.
paedics has evolved. Damage control focuses on control of hemorrhage, In 1950, a survey by the Committee on
orthopaedics emphasizes the stabiliza- management of soft-tissue injury, and Fractures and Traumatic Surgery of the
tion and control of the injury, often achievement of provisional fracture sta- American Academy of Orthopaedic
with use of spanning external fixation, bility, while avoiding additional insults Surgeons (AAOS) concluded that the
rather than immediate fracture repair. to the patient. complications of external fixation fre-
The concept of damage control ortho- quently exceed any advantages of the
paedics is not new; it has evolved out of History of Fracture Surgery procedure3. Also in 1950, Gavril Abra-
the rich history of fracture care and ab- and Birth of Damage Control movich Ilizarov developed the ring sys-
dominal surgery. This article traces the Orthopaedics tem for fractures and deformities, but
roots of damage control orthopaedics, We previously stated that: Informa- his device did not reach the West until
reviews the physiologic basis for it, de- tion illustrating the benefits of fracture the late 1970s. On March 15, 1958,
scribes the subgroups of patients and stabilization after multiple trauma has Maurice Mller, Hans Willenegger, and
injury complexes that are best treated been gathering for almost a century.1 Martin Allgwer convened a group of
with damage control orthopaedics, re- We also noted that during this time interested Swiss general and ortho-
ports the early clinical results, and pro- fears of the fat embolism syndrome paedic surgeons, including Robert
vides a rationale for modern fracture also dominated the philosophy in man- Schneider and Walter Bandi at the Kan-
care for the multiply injured patient. aging polytrauma patients. Early ma- tonsspital, Chur, Switzerland, to dis-
nipulation of long-bone fractures was cuss the status of fracture treatment,
Definition of Damage considered unsafe2. which usually included traction and
Control Orthopaedics External fixation, an essential prolonged bed rest and led to poor
Damage control orthopaedics is an ap- component of damage control ortho- functional results in a high percentage
proach that contains and stabilizes or- paedics, developed slowly and was out- of patients4. On November 6, 1958,
thopaedic injuries so that the patients paced by the development of internal these pioneering surgeons established

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the Arbeitsgemeinschaft fr Osteosyn- tion, those treated initially with external of hemodynamics, rewarming, correc-
thesefragen (the Association for the fixation had more severe injuries, with tion of coagulopathy, ventilatory sup-
Study of Internal Fixation, or ASIF), or higher injury severity scores and trans- port, and continued identification of
AO, in Biel, Switzerland4. The key ob- fusion requirements in the initial injuries. Phase three consisted of a reop-
jective of the AO was the early restora- twenty-four hours. The term damage eration for removal of intra-abdominal
tion of function, whether a patient was control began to be used in the ortho- packing, definitive repair of abdominal
being treated for an isolated fracture or paedic literature over the last six to injuries, and closure and possible re-
for multiple injuries4. Matter noted that seven years1,9-12. pair of extra-abdominal injuries. Dam-
this strategy led to aggressive trauma- age control surgery in the abdomen has
tology involving early total care of the History of Abdominal gained widespread acceptance through-
trauma victim, culminating in the state- Damage Control Surgery out North America and Israel18,19.
ment: This patient is too sick not to be The concept of damage control surgery
treated surgically.4 was developed first in the field of Physiology of Damage
By the 1980s, the accepted care of abdominal surgery. The benefits of Control Orthopaedics
a major fracture was early or immediate controlling hemorrhage and contami- The physiologic basis of damage con-
fixation5. Substantiating this approach nation and leaving the abdomen open, trol orthopaedics is beginning to be
were eleven studies (ten retrospective in lieu of definite repair of injuries and understood. Traumatic injury leads
and one prospective), with the one by closure of the abdomen, improved the to systemic inflammation (systemic
Bone et al.6 being most frequently cited. survival of patients with the lethal triad inflammatory response syndrome)
Bone et al. reported that the incidence of hypothermia, acidosis, and coagul- followed by a period of recovery medi-
of pulmonary complications (adult res- opathy. Abdominal damage control ated by a counter-regulatory anti-
piratory distress syndrome, pneumonia, surgery was described as the sum total inflammatory response (Fig. 1)20. Se-
and fat embolism) was higher and the of all maneuvers required to ensure sur- vere inflammation may lead to acute
stays in the hospital and the intensive vival of a multiply injured patient who organ failure and early death after an
care unit were increased when femoral was exsanguinating; its purpose was to injury. A lesser inflammatory response
fixation was delayed. control rather than definitely repair followed by an excessive compensatory
In 1990, Border reported on a injuries13. anti-inflammatory response syndrome
comprehensive study of patients with In the 1940s and 1950s, Arnold may induce a prolonged immunosup-
blunt trauma that challenged the ac- Griswold, of Kentucky, used a damage pressed state that can be deleterious to
cepted practice of immediate definitive control approach to penetrating inju- the host. This conceptual framework
fixation7. This changed practice in the ries of the abdominal cavity14. In 1981, may explain why multiple organ dys-
early 1990s, and a more selective ap- Feliciano et al. reported that nine of ten function syndrome develops early after
proach to fracture fixation was used; patients who had undergone hepatic trauma in some patients and much later
however, early fixation was still per- packing for the treatment of exsan- in others.
formed in most cases. During the guinating hemorrhage survived15. Stone Within this inflammatory pro-
1990s, more was learned about the pa- et al., in 1983, described a stepwise cess, there is a fine balance between the
rameters associated with adverse out- approach involving intra-abdominal beneficial effects of inflammation and
comes in multiply injured patients and packing and a laparotomy that was ter- the potential for the process to cause
about the systemic inflammatory re- minated rapidly16. In 1992, Burch et al. and aggravate tissue injury leading to
sponse to trauma8. It became clear that reported a 33% survival rate in a group adult respiratory distress syndrome
fracture surgery, especially intramedul- of 200 patients treated with abbreviated and multiple organ dysfunction syn-
lary nailing, has systemic physiologic ef- laparotomy and a planned reopera- drome. The key players in the host re-
fects. These effects became known as tion17. Rotondo and Zonies, in 1993, sponse appear to be the cytokines, the
the second hit phenomenon. coined the term damage control and leukocytes, the endothelium, and sub-
The era of damage control ortho- reported a 58% rate of survival of pa- sequent leukocyte-endothelial cell
paedics started around 1993. Two re- tients treated with a standardized interactions21. Reactive oxygen species,
ports from one institution9,10 described protocol18. In short, the concept of dam- eicosanoids, and microcirculatory dis-
temporary external fixation of femoral age control was first used in abdominal turbances also play pivotal roles22. The
shaft fractures in severely injured pa- surgery to describe a systematic three- development of this inflammatory re-
tients. From 1989 to 1990, the fre- phase approach designed to disrupt a sponse and its subsequent, often fatal
quency of using temporary external lethal cascade of events leading to death consequences are part of the normal
fixation increased from <5% to >10%. by exsanguination13. Phase one in- response to injury.
The mean duration of external fixation volved an immediate laparotomy to When the initial massive injury
until intramedullary nailing was less control hemorrhage and contamina- and shock give rise to an intense sys-
than one week. Compared with patients tion18. Phase two was resuscitation in temic inflammatory syndrome with the
treated with immediate definitive fixa- the intensive care unit with improvement potential to cause remote organ injury,

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gree of stimulation of the inflamma-


tory markers8,30.
While selective immunostimula-
tion may play a critical role in the devel-
opment of severe complications after
injuries, it is also clear that the govern-
ing effect of surgical or accidental
trauma on immune function is immu-
nosuppression. Several authors have
demonstrated the immunosuppressive
effect of trauma31,32. Following trauma,
the production of immunoglobulins
and interferon decreases and many pa-
tients 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 respira-
Fig. 1 tory burst have also been reported. Im-
After trauma, there is a balance between the systemic inflammatory response and the counter- munosuppression contributes to the
regulatory anti-inflammatory response. Severe inflammation can lead to acute organ failure and etiology of infection and sepsis after
early death. A lesser inflammatory response coupled with an excessive counter-regulatory anti- trauma34.
inflammatory response may also induce a prolonged immunosuppressed state that can be dele-
The biological profile of the first
terious to the host. SIRS = systemic inflammatory response syndrome, and CARS = counter-
hit in trauma patients is being defined.
Obertacke et al. demonstrated the im-
regulatory anti-inflammatory response syndrome.
portance of the first hit by using bron-
chopulmonary lavage to assess changes
this one hit can cause an excessive in- The First and Second-Hit in pulmonary microvascular perme-
flammatory response that activates the Phenomena ability in patients who had sustained
innate immune system, including mac- Numerous studies have demonstrated multiple trauma35. The permeability of
rophages, leukocytes, natural killer that stimulation of a variety of inflam- the pulmonary capillaries increased
cells, and inflammatory cell migration matory mediators takes place in the im- following multiple trauma, and patients
enhanced by interleukin-8 (IL-8) pro- mediate aftermath of trauma24-27. This in whom adult respiratory distress
duction and complement components response initially corresponds to the syndrome later developed had a high
(C5a and C3a). When the stimulus is first-hit phenomenon25. Hoch et al. re- correlation (r = 0.81) with increased
less intense and would normally resolve ported elevation in plasma concentra- permeability within just six hours after
without consequence, the patient is vul- tions of IL-6 and IL-8 in patients with admission than did those who had had
nerable to secondary inflammatory in- an injury severity score of 25 points28. an uneventful recovery. The develop-
sults that can reactivate the systemic An immediate increase in expression of ment of a massive immune reaction in a
inflammatory response syndrome and neutrophil L-selectin was reported in patient with bilateral femoral fracture
precipitate late multiple organ dysfunc- patients with an injury severity score of who showed a massive inflammatory
tion syndrome. The second insult may 16 points29. Similarly, a significant (p < reaction, which was subsequently hy-
take many forms as a result of a variety 0.05) increase in the expression of the perstimulated by the surgical proce-
of circumstances, such as sepsis and integrin CD11b was noted in more se- dure itself (bilateral reamed femoral
surgical procedures, and is the basis for verely injured patients29. The develop- nailing), further supports the impor-
the decision-making process regarding ment of multiple organ dysfunction tance of the first-hit phenomenon36. Al-
when and how much to do for a bor- syndrome has also been associated with though there was no obvious additional
derline multiply injured patient (as a persistent elevation of CD11b expres- risk factor present (i.e., no chest in-
will be defined later). Hyperstimula- sion on both neutrophils and lympho- jury), the patient died from full-blown
tion of the inflammatory system, by cytes for 120 hours, a finding that is adult respiratory distress syndrome
either single or multiple hits, is consid- suggestive of neutrophil activation in three days after the injury. This case not
ered by many to be the key element in the early development of leukocyte- only clearly illustrates the existence of
the pathogenesis of adult respiratory mediated end-organ injury. Several biological variation in the inflamma-
distress syndrome and multiple organ other studies have clearly demonstrated tory response to injury, but also con-
dysfunction syndrome23. the effect of injury severity on the de- firms the importance of the degree of

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TABLE I Cytokines That Are Important Inflammatory Mediators

Group Examples
Interleukins (IL) IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-11, IL-12, IL-13, IL-18
Tumor necrosis factors (TNF) TNF, lymphotoxin (LT)
Interferons (IFN) IFN-alpha, IFN-beta, IFN-gamma
Colony stimulating factors (CSF) G-CSF, M-CSF, GM-CSF

the response to the first hit and the re- development of posttraumatic compli- IL-10 inhibits the activity of TNF- and
sponse to the second (surgical) hit that cations such as multiple organ dysfunc- IL-1, and the levels detectable in the cir-
created the final fatal event. The above tion syndrome (Table I). Common culation correlate with the initial degree
studies suggest that the degree of the serum markers can be divided into of injury. Persistently high levels of IL-
initial injury is important in determin- markers of mediator activity such as C- 10 also correlate with sepsis. However,
ing a patients susceptibility to posttrau- reactive protein, tumor necrosis factor- its role in predicting outcome is still
matic complications. (TNF-), IL-1, IL-6, IL-8, IL-10, and debatable44.
The concept that a secondary sur- procalcitonin and markers of cellular Regarding the markers of cellular
gical procedure creates an additional in- activity such as CD11b surface receptor activity, mixed results have been re-
flammatory insult (a second hit) was on leukocytes, endothelial adhesion ported in the literature about the effi-
specifically addressed in a prospective molecules (intercellular adhesion mole- cacy of endothelial adhesion molecules
study of 106 patients with an average cule-1 [ICAM-1] and e-selectin), and (ICAM-1 and e-selectin) and the
injury severity score of 40.6 points37. HLA-DR class-II molecules on periph- CD11b receptor of leukocytes45. HLA-
Forty patients in whom respiratory, re- eral mononuclear cells. DR class-II molecules mediate the pro-
nal, or hepatic failure developed, alone C-reactive protein, procalcitonin, cessing of antigen to allow for cellular
or in combination, following a second- TNF-, IL-1, and IL-8 have not been immunity. They are considered to be re-
ary surgical procedure were compared shown to be reliable markers38-43. How- liable markers of immune reactivity and
with patients in whom no such compli- ever, IL-6 correlates well with the degree a predictor of outcome following
cations developed. There was a signifi- of injury, appears to be a reliable index trauma46,47.
cant (p < 0.05) elevation of the of the magnitude of systemic inflamma- Napolitano et al. reported that
neutrophil elastase and C-reactive pro- tion, and correlates with the outcome12. the severity of the systemic inflamma-
tein levels and a reduction in the plate-
let counts in the forty patients with
systemic complications. Abnormality of
those three parameters predicted post-
operative organ failure with an accuracy
of 79%37.
The first and second-hit phenom-
ena in trauma patients were demon-
strated 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 un-
reamed nailing in terms of neutrophil
activation, elastase release, and expres-
sion of adhesion molecules. These con-
cepts of biological responses to different
stimuli (first and second hits) have now
become the basis of our treatment plans
Fig. 2
and illustrate the impact of the opera-
Mean plasma elastase concentrations (and 95% confidence intervals) before and after intramed-
tive procedure on trauma patients at
risk for exhaustion of their biological ullary nailing of the femur from the time of admission to the emergency room (A&E) to 168 hours
reserve (Fig. 3). after surgery8. The control group is shown by the dotted line. Ind = induction of anesthesia, and
Nail Ins. = nail insertion. (Reprinted, with permission, from Giannoudis PV, Smith RM, Bellamy
Markers of Immune Reactivity MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and
Inflammatory markers may hold the unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br.
key to identifying patients at risk for the 1999;81:359.)

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tory response syndrome at admission


may be an accurate predictor of mortal-
ity 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 ma-
jor trauma, and this ratio was recom-
mended 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 poten-
tially 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 clini-
cal course and outcome after trauma. Fig. 3
IL-6 measurement has already been im- The two-hit theory is shown schematically. The first hit is the initial traumatic event, and the sec-
plemented as a routine laboratory test ond hit is the definitive orthopaedic procedure, usually femoral nailing. MODS = multiple organ
in several trauma centers. Because of dysfunction syndrome, and ARDS = adult respiratory distress syndrome.
the additional laboratory processing re-
quired for tests of HLA-DR class-II
molecules (antibody staining of cells mozygosity for the TNFB2 allele is asso- a pilot study of thirty-eight patients
and flow cytometric analysis), the use of ciated with an increased incidence of who had sustained blunt trauma and
such tests has not found great clinical severe sepsis and a worse outcome. The found that the microsatellite polymor-
acceptance. risk of posttraumatic sepsis developing phism AA correlated strongly with
is 5.22 times higher in patients who are infection66. These findings portend
Genetic Predisposition and homozygous for TNFB256. Homozy- polymorphism in the receptor itself and
Adverse Outcomes gous patients also have higher circulat- thus represent a genetic basis for the de-
Biological variation and genetic predis- ing TNF- concentrations and higher velopment of the infection.
position are increasingly mentioned as multiple organ dysfunction syndrome Early identification of patients at
explanations of why serious posttrau- scores compared with heterozygotes57. risk for adverse outcomes and compli-
matic complications develop in some IL-6 polymorphisms have been cations may allow directed intervention
patients and not in others51. Some indi- reported and were detected in both the with biological response modifiers in
viduals may be preprogrammed to 3 and the 5 flanking regions and exon order to improve morbidity and mor-
have a hyperreaction to a given trau- 558,59. The SfaNI polymorphism is lo- tality rates. Use of biochemical and ge-
matic insult. Genetic polymorphism of cated at position 174. A homozygotic netic markers to identify patients at
the neutrophil receptor for immuno- constellation of this polymorphism risk after orthopaedic trauma may fa-
globulin G, CD16, has been reported coincided with decreased IL-6 serum cilitate clinical decision-making regard-
and is associated with functional differ- levels during inflammation60,61. Poly- ing when to switch from early total care
ences in neutrophil phagocytosis52. An morphisms in the IL-10 gene have also to damage control orthopaedics.
inherited predisposition toward high or been demonstrated62. Eskdale et al.
low levels of HLA-DR expression is fur- reported that stimulation of human Patient Selection for
ther evidence of a genetic component in blood cultures with bacterial li- Damage Control Orthopaedics
the immune response to injury46. popolysaccharide showed large inter- Because biomechanical and genetic
Additional evidence of genetic individual variation in IL-10 secretion63. testing is currently not practical, it re-
predisposition is found in the cytokine They concluded that the ability to se- mains a clinical decision when to shift
genes. The single base pair polymor- crete IL-10 can vary in humans accord- from early total care to damage control
phism at position 308 in the TNF gene ing to the genetic composition of the orthopaedics. Which patient should be
was associated with an increased inci- IL-10 locus. treated with damage control ortho-
dence of sepsis and with a worse out- Recently, isolated case reports of paedics instead of early total care after
come after major trauma, postoperative germline defects in the cellular receptor orthopaedic trauma should be decided
sepsis, and sepsis in a medical intensive for interferon-gamma (IFN-) were on the basis of the patients overall
care unit53-55. This association depends described, and the mutations were physiologic status and injury com-
on the presence of the TNF2 allele. Ho- characterized64,65. Davis et al. conducted plexes. Many trauma scoring systems

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(e.g., the abbreviated injury scale67, in-


jury severity score68,69, revised trauma TABLE II Clinical Parameters Used in Hannover, Germany, to Define the
Borderline Patient for Whom Damage Control Orthopaedics
score70, anatomic profile71, and Glasgow Is Often Preferred
coma scale72) have been developed in an
attempt to describe the overall condi- Polytrauma + injury severity score of >20 points and additional thoracic trauma
tion of the trauma patient. However, (abbreviated injury score >2 points)
Bosse et al.73 noted that there is no Polytrauma with abdominal/pelvic trauma (Moore score75 >3 points) and hemorrhagic
score that assists in decision-making shock (initial blood pressure <90 mm Hg)
during the acute resuscitation phase. Injury severity score of 40 points in the absence of additional thoracic injury
Therefore, it may be that one cannot Radiographic findings of bilateral lung contusion
rely exclusively on a scoring system.
Initial mean pulmonary arterial pressure of >24 mm Hg
Additional data must be synthe-
sized, and the overall status of the pa- Increase of >6 mm Hg in pulmonary arterial pressure during intramedullary nailing
tient should be stratified into one of
four categories. Patients who have sus- indicating borderline status (Table II) that the increase in mortality may be
tained orthopaedic trauma have been and factors associated with a high risk more closely related to associated inju-
divided into four groups: stable, bor- of adverse outcomes (Table III), should ries and physiologic parameters than to
derline, unstable, and in extremis74. Sta- determine how the patient is treated. In the bilateral femoral fracture itself 77. Wu
ble patients, unstable patients, and Louisville, some of the additional clini- and Shih78 noted that bilateral femoral
patients in extremis are fairly easy to de- cal criteria that we have used as a basis fracture indicates severe systemic and
fine. Stable patients should be treated for shifting to damage control ortho- local injuries. Thus, such injuries are
with the local preferred method for paedics include a pH of <7.24, a tem- ideal for damage control orthopaedics.
managing their orthopaedic injuries. perature of <35C, operative times of
Unstable patients and patients in extre- more than ninety minutes, coagulopa- Pelvic Ring Injuries
mis should be treated with damage con- thy, and transfusion of more than ten Exsanguinating hemorrhage associated
trol orthopaedics for their orthopaedic units of packed red blood cells. Further- with pelvic fracture is another injury
injuries. Borderline patients are more more, certain specific orthopaedic in- complex suitable for damage control
difficult to define. One of us (H.-C.P.) jury complexes appear to be more orthopaedics. Hemorrhage can result
and colleagues defined them as patients amenable to damage control ortho- from a combination of osseous, venous,
with polytrauma and an injury severity paedics; these include, for example, and arterial bleeding. Although the
score of >40 points in the absence of femoral fractures in a multiply injured most common arterial injuries involve
thoracic injury, or an injury severity patient, pelvic ring injuries with exsan- the internal iliac artery or its branches
score of >20 points with thoracic in- guinating hemorrhage, and poly- (e.g., the superior gluteal artery), inju-
jury (an abbreviated injury score of >2 trauma in a geriatric patient. ries to the common and external iliac
points); polytrauma with abdominal arteries have been reported and are as-
trauma (a Moore score75 of >3 points); a Femoral Fractures sociated with a poor outcome79. The
chest radiograph showing bilateral lung Femoral fractures in a multiply injured specific radiographic pattern of the pel-
contusions; an initial mean pulmonary patient are not automatically treated vic ring injury and the mechanism of
artery pressure of >24 mm Hg; or an in- with intramedullary nailing because of the injury can help one to anticipate the
crease in pulmonary artery pressure of concerns about the second hit of such a amount of bleeding, but there is no pre-
>6 mm Hg during nailing (Table II)74. procedure. In addition to the second cise injury pattern that predicts hemor-
Borderline orthopaedic trauma pa- hit, which results in an additional sys- rhage consistently. An additional
tients are probably best treated with temic inflammatory response, embolic complicating factor can be the presence
damage control orthopaedics. fat from use of instrumentation in the of a pelvic binder put in place by emer-
The term borderline patient medullary canal will worsen the pulmo- gency medical responders, as it may de-
describes a predisposition for nary status. Patients with a chest injury crease the pelvic volume, realign the
deterioration74. Among other factors, (an abbreviated injury score of >2 pelvic ring, and contribute to a benign-
thoracic trauma appears to play a cru- points) are most prone to deterioration looking pelvic radiograph.
cial role in this predisposition. How- after an intramedullary nailing There are nonetheless some con-
ever, whether femoral fractures in procedure76. sistent findings associated with a higher
patients with chest trauma should be Bilateral femoral fracture is a likelihood of hemorrhage. Posterior
treated with definitive stabilization or unique scenario in polytrauma that is pelvic ring injuries are associated with a
should be stabilized with a temporary associated with a higher mortality rate two to threefold increase in blood re-
external fixator remains a subject of de- and incidence of adult respiratory dis- placement requirements compared with
bate. The clinical situation, including tress syndrome than is a unilateral fem- anterior injuries80,81. Anterior-posterior
the presence or absence of a criterion oral fracture77. Copeland et al. noted compression type-III injuries and lat-

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survived), greater transfusion require-


TABLE III Clinical Parameters Associated with Adverse Outcomes in Multiply ments (10.9 units for the patients who
Injured Patients as Reported in Hannover, Germany
died compared with 2.9 units for those
Unstable condition or resuscitation difficult (borderline patient) who survived), and greater fluid infu-
Coagulopathy (platelet count <90,000)
sion (12.4 L for the patients who died
compared with 4.9 L for those who sur-
Hypothermia (<32C)
vived)87. These differences highlight the
Shock and >25 units of blood needed importance of considering damage
Bilateral lung contusion on first plain radiograph control orthopaedics for elderly pa-
Multiple long-bone injuries and truncal injury; abbreviated injury score of 2 points tients. In addition, treatment should be
directed toward measures that enhance
Presumed operation time >6 hr
immediate mobilization and the avoid-
Arterial injury and hemodynamic instability (blood pressure <90 mm Hg) ance of prolonged bed rest in this pa-
Exaggerated inflammatory response (e.g., IL-6 >800 pg/mL) tient population.

eral compression injuries are associated there are limited data to support the use Special Situations in
with a high prevalence of vascular in- of pelvic packing. Damage Control Orthopaedics
jury (22% and 23%, respectively)82. Fi- Damage control orthopaedics for Chest Injuries
nally, pelvic fractures in patients over a pelvic ring injury with exsanguinat- Traditionally, there have been two di-
fifty-five years old are more likely to ing hemorrhage involves rapid clinical vergent schools of thought related to
produce hemorrhage and require decision-making and multiple teams the treatment of multiply injured pa-
angiography83. for resuscitation and minimally invasive tients with long-bone fractures and a
The main controversy regarding pelvic stabilization (e.g., with a pelvic chest injury (Figs. 4-A through 4-E),
the treatment of patients with profuse, binder, external fixator, pelvic c-clamp, with some believing that early fracture
exsanguinating hemorrhage relates to the or pelvic stabilizer). Patients who do stabilization is safe and maybe even
role of angiography and embolization. not respond to these measures should beneficial6,88-91 and others believing that
In North America, both are most com- be considered for angiography and em- early fracture stabilization is not safe
monly utilized in the initial treatment of bolization if they are likely to survive and may be harmful76. The classic paper
pelvic fractures with associated hypoten- the trip to the angiography suite; other- by Bone et al. has probably had the
sion that have not responded to the wise, they should be considered for pel- most influence on the care and treat-
placement of a pelvic binder, external fix- vic packing once any underlying ment of orthopaedic trauma patients in
ator, pelvic c-clamp, or pelvic stabilizer coagulopathy has been corrected. the United States6. More recently, Bou-
and transfusion of four units or more of langer et al. reported no increase in
blood. Additional indications for angiog- Geriatric Trauma morbidity or mortality in association
raphy are an expanding retroperitoneal Elderly trauma patients require special with early intramedullary nailing
hematoma, a vascular blush seen on evaluation and treatment because of (within twenty-four hours) of femoral
computed tomography, and a massive their higher mortality rate following fractures in patients who had sustained
retroperitoneal hematoma observed on trauma, even minor trauma. Green- blunt thoracic trauma92.
computed tomography. The timing of span et al. reported that the average LD The Eastern Association for the
embolization is also important. Agolini (Lethal Dose) 50 injury severity score Surgery of Trauma Practice Manage-
et al.84 reported that embolization later was 20 points for individuals more than ment Guidelines Work Group reviewed
than three hours after injury increased sixty-five years of age86. This value is the current literature and found no ran-
the risk of mortality fivefold and that the essentially half of the LD 50 injury se- domized clinical trials of the treatment
average procedure time for embolization verity score for individuals between of patients with chest injuries with im-
was ninety minutes. twenty-four and forty-four years of mediate long-bone stabilization (within
Alternatively, pelvic packing for age85. In addition, pelvic ring fractures forty-eight hours)93. They noted that
the control of hemorrhage has been ad- in individuals more than fifty-five years available prospective studies or retro-
vocated at some centers in Europe85. old are associated with an increased spective analyses comparing long-bone
This technique appears to be used for chance of arterial injuries and higher stabilization within forty-eight hours
patients with severe hypotension and a transfusion requirements83. In a study with later stabilization in patients with
pelvic fracture that is unresponsive to of patients who were more than sixty a chest injury showed that the two
other initial treatment measures and years old, Tornetta et al. noted that in- groups had similar rates of mortality
that is associated with the imminent creased mortality was associated with a and adult respiratory distress syn-
risk of death and thus a high likelihood lower Glasgow coma score (11.5 points drome, mechanical ventilation require-
that the patient will not survive the trip for the patients who died compared ments, lengths of stay in the intensive
to the angiography suite. However, with 13.9 points for the patients who care unit, and total lengths of stay in the

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hospital. The authors indicated that five the literature for studies regarding the fracture stabilization is potentially ben-
clinical parameters may be helpful in timing of long-bone fracture stabiliza- eficial in this situation because it re-
determining the appropriateness of tion in a multiply injured patient with a duces persistent pain at the fracture site
early long-bone stabilization: severity of head injury93. The group found no by minimizing involuntary movements
pulmonary dysfunction, hemodynamic Level-I studies (randomized clinical tri- by an unconscious or not yet coopera-
status, estimated operative time, esti- als). On the basis of Level-II studies tive patient. Fracture stabilization also
mated blood loss, and fracture status (prospective, noncomparative clinical has a positive effect on the patients me-
(open or closed). studies or retrospective analyses of tabolism, muscle tone, and body tem-
A selective approach should be reliable data) and Level-III studies (ret- perature, and, as a result, cerebral
used for patients with long-bone frac- rospective case series or database re- function94. Furthermore, unstabilized
tures and a chest injury. Defining the views), it was concluded that patients fractures may cause physiologic deteri-
subgroup of patients for whom early with mild, moderate, or severe brain in- oration in these patients as a result of
nailing would increase the risk of early jury who underwent long-bone stabili- increased soft-tissue damage, fat embo-
complications is the goal of damage zation within forty-eight hours were lism, and respiratory insufficiency95-99.
control orthopaedics. Treatment ought similar to those treated with later stabi- In recent years, some authors
to be individualized. When early in- lization with regard to mortality rate, have reported a worse outcome in pa-
tramedullary nailing is not deemed to length of stay in the intensive care unit, tients with secondary brain injury re-
be the best alternative, damage control need for mechanical ventilation, and to- sulting from hypotension, hypoxia, and
orthopaedics, with short-term external tal length of stay in the hospital. The increased intraoperative administra-
fixation of the femur followed by overall conclusion was that there was no tion of fluid related to early operative
staged conversion to an intramedul- compelling evidence that early long- fracture fixation100,101. In a study of mul-
lary nail in the first week after injury, bone stabilization either enhances or tiply injured patients with fractures of
can be utilized. worsens the outcome in patients with a the femur, tibia, and pelvis, Martens
mild, moderate, or severe head injury. and Ectors reported a 38% prevalence
Head Injuries Many clinical issues arise during of early neurological deterioration in a
The Eastern Association for the Sur- an examination of the available litera- group treated with early fixation but no
gery of Trauma Practice Management ture on patients with a head injury and early neurological deterioration in a
Guidelines Work Group also searched long-bone fractures. Early definitive group treated with late fixation102. Mc-

Fig. 4-A

Chest radiograph demonstrating a ruptured left hemidiaphragm (Fig. 4-A) and ra-
diograph showing a Grade-II open femoral fracture (Fig. 4-B) in a multiply injured
patient.
Fig. 4-B

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Fig. 4-C Fig. 4-D


Figs. 4-C and 4-D Initial external fixation was performed at the time of the diaphragmatic repair.

Kee et al. reported that neurological treated with fixation within twenty- treatment protocol for unstable patients
complications developed in the postop- four hours after the injury had the should be based on the individual clini-
erative period in three patients treated highest Glasgow coma scale scores at cal assessment and treatment require-
with early fixation, but they did not at- the time of discharge105. However, since ments rather than on mandatory
tribute any of these complications to only the mean head abbreviated injury policies with respect to the timing of
the femoral fracture or its fixation103. scale score, and not the Glasgow coma fixation of long-bone fractures. In such
Also, they found no difference in the scale score on admission, was reported, cases, damage control orthopaedics can
long-term neurological outcome be- these results are very difficult to inter- provide temporary osseous stability to
tween the patients treated with early pret accurately. Hofman and Goris an injured extremity, functioning as a
fixation and those treated with delayed found that the Glasgow coma scale temporary bridge to staged definitive
fixation. score was better in a group treated with osteosynthesis, without worsening the
In contrast, in a study of patients early fixation than it was in a group patients head injury or overall condi-
with a head injury and a fracture of the treated with late fixation, but the differ- tion. Intracranial pressure monitoring
neck or shaft of the femur or the shaft ence did not reach significance106. should be utilized in the intensive care
of the tibia, Poole et al. found that those The initial management of a pa- unit as well as during surgical proce-
who had undergone early definitive tient with a head injury should be simi- dures in the operating room. Aggres-
fracture fixation had a significantly (p < lar to that of other trauma patients, sive management of intracranial
0.0001) lower prevalence of periopera- with a focus on the rapid control of pressure appears to be related to an im-
tive neurological complications com- hemorrhage and restoration of vital proved outcome. Maintenance of cere-
pared with those who had been treated signs and tissue perfusion. A brain in- bral perfusion pressure at >70 mm Hg
with late fixation104. Brundage et al. re- jury can be made worse if resuscitation and intracranial pressure at <20 mm
ported that, in a series of multiply in- is inadequate or if operative interven- Hg should be mandatory before, dur-
jured patients with head injuries, tion such as long-bone fixation de- ing, and after surgical procedures. Or-
femoral shaft fractures, and an injury creases mean arterial pressure or thopaedic injuries should be managed
severity score of >15 points, those increases intracranial pressure. The aggressively with the assumption that

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comes study at eight Level-I American


trauma centers107-109. In this study, the
attending surgeons directed all eval-
uations, decisions, and extremity treat-
Staged intramedullary nailing was
ment. There were 656 eligible patients
ranging in age from sixteen to sixty-nine
performed on post-injury day 2.
years. Fifty-five patients were excluded
from the study: thirty-six refused to par-
ticipate, thirteen died in the hospital,
and six were not enrolled because of ad-
ministrative 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 con-
trolled for the severity of the limb in-
jury, 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, vascu-
lar injuries, major soft-tissue injuries,
Fig. 4-E and severe foot injuries.
The LEAP study patients differed
from the general population with re-
full neurological recovery will occur. Stern111 reported that seven of nine gard to many characteristics. They were
Type-III open tibial fractures required more likely to be male; they were less
Mangled Extremities secondary amputation. educated; they were more often blue
Prior to the Lower Extremity Assess- Hansen112 called for a multicenter collar workers; they were less insured
ment Project (LEAP) study107-109, there study to develop guidelines to avoid (38% had no insurance); they were
were limited data on the contemporary prolonged, costly, and fruitless salvage more likely to be healthy, heavy drink-
treatment of severely injured or man- procedures when such a course is not ers, smokers, neurotic, and extroverted;
gled lower extremities. Lange110 per- indicated. Helfet et al.113 reported that they were less agreeable; and they had a
formed a retrospective study of twenty- a mangled extremity severity score lower income.
three Gustilo and Anderson Type-IIIC (MESS) of 7 points was associated with Patients with a severe injury of
tibial fractures (severe open fractures a 100% rate of amputation. Georgiadis the lower extremity and absent plantar
with limb-threatening vascular com- et al.114 reported that, of forty-five patients sensation at the time of admission had
promise requiring repair), fourteen of with a severe open tibial fracture requir- substantial impairment at twenty and
which eventually led to amputation ing free tissue transfer for soft-tissue twenty-four months. Patients treated
(five of the amputations were primary coverage, twenty-seven were treated with limb salvage did not have poorer
and nine, delayed). The absolute indi- with limb salvage and eighteen were outcomes than those treated with am-
cations for amputation in that study in- treated with early amputation. The pa- putation. Absent plantar sensation did
cluded anatomic disruption of the tients in the limb salvage group had an not even predict the state of plantar
tibial nerve and a crush injury with a average of three complications, whereas sensation at twenty-four months. Nei-
warm ischemia time of more than six there was a total of seventeen complica- ther the injury characteristics nor the
hours, or the presence of two of three tions in the early amputation group. presence and severity of ipsilateral or
relative indications (serious poly- Renewed interest in treatment of contralateral limb injuries significantly
trauma, severe injury of the ipsilateral the mangled lower extremity has been correlated with the outcomes as as-
foot, and anticipation of a protracted generated by the dissemination of the sessed with the Sickness Impact Profile
course to obtain soft-tissue coverage results from the LEAP study, a prospec- (SIP). Patients with a through-the-knee
and tibial reconstruction). Caudle and tive, longitudinal, observational, out- amputation had worse regression-

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groups in terms of SIP scores for dis-


ability or the percentage who returned
to work. The patients who had under-
gone reconstruction took longer to
achieve full weight-bearing, and they
had more rehospitalizations and hospi-
tal days (p < 0.01). Contrary to the
studys hypothesis, the two-year out-
comes 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 am-
putation was 6.4%. As a result of this
study, we cannot assume that either an
amputation or a successful reconstruc-
tion will provide a superior result.
Webb et al. reported that patients
with a limb-threatening Type-III open
Fig. 5-A
tibial shaft fracture managed with limb
Antibiotic bead pouch for treatment of an open proximal tibial fracture (Fig. 5-A), with a
salvage had outcomes that were similar
close-up view (Fig. 5-B). Adjacent to the bead pouch are traumatic arthrotomy and fasciot-
to those of patients who had under-
omy wounds that have been closed. Spanning external fixation across the knee for man-
gone an amputation116. The authors
agement of the tibial fracture and a femoral traction pin for management of an ipsilateral
noted several surgeon-controlled vari-
acetabular fracture were also utilized in this patient.
ables that appeared to influence the
course of the fracture and the patient
adjusted SIP scores (p = 0.05) and tioning. The percentage of patients with outcome. Wound coverage with sim-
slower self-selected walking speeds (p = a slower walking speed was higher in ple methods provided better results
0.004) than did patients with either a the amputation group than in the re- than flap coverage, external fixation
below-the-knee or an above-the-knee construction group (p < 0.05). There and flap coverage provided worse
amputation109. Patients who had been was no difference between the two results than amputations, and bone-
rehospitalized for a major complica-
tion also had poorer outcomes. Signifi-
cant (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 net-
work, low self-efficacy, smoking, and
involvement in the legal system for in-
jury compensation. A proportion of the
patients who had undergone limb re-
construction had not fully recovered
by two years; 10.8% of those patients
had nonunion, 4.7% did not have soft-
tissue 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 func- Fig. 5-B

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TABLE IV Prevalence of Adult Respiratory Distress Syndrome, According to Type of Femoral Fixation, Associated with Three
Different Approaches to Treatment of a Multiply Injured Patient in Hannover, Germany

Patients with Adult Respiratory Distress Syndrome*


Early Total Intermediate Damage Control
Care Period Period Orthopaedics Period P Value
Primary intramedullary nailing 77 (32.7) 20 (22.7) 29 (15.1) 0.003
Primary external fixation, secondary intramedullary nailing 38 (16.2) 10 (11.4) 15 (7.8) 0.002
Primary plate fixation 45 (19.1) 14 (15.9) 42 (21.9) 0.001

*The values are given as the number of patients with the percentage in parentheses. P values indicate significant differences between
early total care and damage control orthopaedics. The prevalence of adult respiratory distress syndrome was significantly lower with the
damage control orthopaedics approach. Indicates a significant difference (p < 0.05) between primary intramedullary nailing and primary ex-
ternal fixation with secondary intramedullary nailing.

grafting performed within three technique may provide a bridge to have termed limb damage control or-
months after the injury had a trend staged osseous reconstruction and soft- thopaedics. Specific injuries that are
for a better outcome than did bone- tissue coverage procedures121. Vacuum- amenable to this approach include
grafting that was accomplished later. In assisted wound closure subjects the complex proximal tibial articular and
addition, Webb et al. found that the wound bed to negative pressure by way metaphyseal fractures and distal tibial
timing of dbridement and of soft- of a closed system and thereby removes pilon fractures. These clinical situa-
tissue coverage did not influence the edema from the extravascular space121. tions usually combine a complex frac-
outcome, and the most common com- ture pattern, either open or closed,
plications warranting readmission Isolated Complex with a substantial soft-tissue injury.
were nonunion and infection. Lower-Extremity Trauma Limb damage control orthopaedics is
Smith et al. reported that pa- An isolated complex extremity injury useful for preventing soft-tissue com-
tients treated with late amputation af- (other than a mangled limb) is a possi- plications by spanning the articular
ter a complex lower-extremity injury ble indication for a limited form of segment with an external fixator and
reported significantly (p < 0.05) higher damage control orthopaedics that we avoiding areas of future incisions. Then
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 num-
ber of hospitalizations for complica-
tions (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 in-
creasing trend toward limb salvage
rather than immediate amputation for
complex open lower-extremity injuries.
A damage control orthopaedics ap-
proach to saving the limb may make it Fig. 6
possible to improve surgeon-controlled The current treatment algorithm from Hannover, Germany, for the use of damage control ortho-
variables that appear to be related to paedics is based on a prompt and accurate determination of whether the patient is stable, bor-
better outcomes. The use of spanning derline, unstable, or in extremis. ER = emergency room, ABG = arterial blood gases, FAST =
external fixation, antibiotic bead focused assessment sonography for trauma, I/O ratio = intake/output ratio, ABP = arterial blood
pouches118-120 (Figs. 5-A and 5-B), and pressure, IL-6 = interleukin-6, ETC = early total care, OR = operating room, DCO = damage con-
the vacuum-assisted wound closure trol orthopaedics, and ICU = intensive care unit.

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minimally invasive plate osteosynthe-


sis can be performed at a stage when TABLE V Comparative Data on Postoperative Local Complications During the
the condition of the soft tissue enve- Three Periods of Fracture Care in Hannover, Germany
lope is optimized. Patients with Complication*
Early Total Intermediate Damage Control
When Can Secondary Orthopaedic Care Period Period Orthopaedics Period P Value
Procedures Be Performed? Pin track infection 2/39 3/21 4/68 NS
One of the most important issues in
Wound infection 5/235 2/88 3/191 NS
damage control orthopaedics is the tim-
ing of the secondary surgical procedures Osteomyelitis 2/235 0/88 1/191 NS
(definitive osteosynthesis). Days 2, 3, *Number of patients with a complication/total number of patients. NS = not significant.
and 4 are not safe for performing defini-
tive surgery. During this period, marked
immune reactions are ongoing and in- hours). In the intermediate period, be- external fixation include the use of an
creased generalized edema is observed. A tween January 1, 1990, and December external fixation system that is user-
recent prospective study demonstrated 31, 1992, the usual protocol for treating friendly and can be applied rapidly.
that multiply injured patients subjected a femoral shaft fracture in a multiply Self-drilling pins, which can be manu-
to secondary definitive surgery between injured patient at risk for posttraumatic ally inserted, can be applied quickly
days 2 and 4 had a significantly (p < complications changed from early de- with a limited need for fluoroscopy.
0.0001) increased inflammatory re- finitive stabilization to early temporary Operating time can be decreased by
sponse compared with that in patients fixation. In the damage control ortho- multiple operating teams working on
operated on between days 6 and 812,122. It paedics period, beginning in 1993, the opposite ends of the same limb or on
was concluded that, in different post- protocol for such an injury in such a pa- different extremities. External fixation
traumatic periods, variable inflamma- tient was early temporary stabilization systems that employ snap-and-click
tory responses to comparable stimuli are (within twenty-four hours) followed by clamps can be assembled rapidly. In ad-
observed. This variation may contribute secondary conversion to intramedullary dition, a system that allows flexibility in
to the differences in clinical outcome nailing. The rates of multisystem organ pin placement is preferable so that areas
(e.g., a higher incidence of multiple or- failure and adult respiratory distress of future incisions can be avoided.
gan failure) that have been reported12. syndrome were found to be signifi-
In Hannover, Germany, all high- cantly higher (p < 0.05) in the earlier Overview and Future Directions
risk patients have been managed with a time-periods (Table IV). In addition, Damage control orthopaedics is ideal for
treatment plan that involves a re-evalu- during the latest time-period, patients an unstable patient or a patient in extre-
ation of clinical and laboratory parame- who were treated with damage control mis, and it has some utility for the bor-
ters in the emergency department after orthopaedics demonstrated a lower risk derline patient as well. Specific injury
the primary diagnostic workup1. On the of adult respiratory distress syndrome complexes for which damage control
basis of this re-evaluation, specific rec- than those treated with initial in- orthopaedics should be considered are
ommendations can be made for specific tramedullary nailing. femoral fractures (especially bilateral
groups of patients in the form of an al- fractures), pelvic ring injuries with pro-
gorithm (Fig. 6). Risk of Local Infection with found hemorrhage, and multiple injuries
Damage Control Orthopaedics in elderly patients. Specific subgroups of
Clinical Outcomes of Damage The use of spanning external fixation multiply injured orthopaedic patients
Control Orthopaedics carries the risk of pin-track infection. In who may benefit from damage control
In the early 1990s, the approach in the series in Hannover, the risk of infec- orthopaedics are those with a head injury,
Hannover changed from performing tion following definitive intramedul- chest trauma, or a mangled limb. A lim-
definitive surgery in all patients to using lary nailing (Table V) was not greater ited form of damage control orthopaedics
an external fixator as a temporary than that in other studies of patients (limb damage control orthopaedics) is a
measure to stabilize the fracture and who had undergone intramedullary sta- rational alternative for the treatment of
subsequently carrying out secondary bilization after external fixation123-125. isolated, complex limb injuries.
definitive internal fixation1. In a retro- Contemporary rates of pin-track infec- Clinical data and emerging discov-
spective evaluation, three different tion are still substantial, but they are eries in molecular medicine may con-
time-periods were identified. In the minimized when the duration of exter- tinue to provide answers to the question
early total care period, between January nal fixation is brief126. of when orthopaedic surgeons should
1, 1981, and December 31, 1989, the use a damage control orthopaedics ap-
protocol for the treatment of a femoral Practical Considerations for proach. Prospective, multicenter studies
shaft fracture was early definitive stabi- Damage Control Orthopaedics similar to the Lower Extremity Assess-
lization (within less than twenty-four Practical considerations for spanning ment Project may ultimately be neces-

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sary to better understand the role of Departments of Orthopaedic Surgery (C.S.R The authors did not receive grants or outside
damage control orthopaedics in the and A.L.M.) and Surgery (J.L.R.), University of funding in support of their research or prepa-
treatment of patients who have sustained Louisville, 210 East Gray Street, Suite 1003, ration of this manuscript. They did not receive
Louisville, KY 40202. E-mail address for C.S. payments or other benefits or a commitment
orthopaedic trauma, especially those Roberts: craig.roberts@louisville.edu or agreement to provide such benefits from
with concomitant injuries to the chest a commercial entity. No commercial entity
and head. Despite the lack of prospec- Hans-Christoph Pape, MD paid or directed, or agreed to pay or direct, any
tive clinical studies, many trauma centers Department of Trauma Surgery, Hannover benefits to any research fund, foundation, edu-
have already modified their approach to Medical School, Carl-Neuberg-Strasse 1, cational institution, or other charitable or
the treatment of orthopaedic patients Hannover 30625, Germany nonprofit organization with which the authors
are affiliated or associated.
with multiple injuries by incorporating
Alan L. Jones, MD
the principles of damage control Department of Orthopaedic Surgery, Univer- Printed with permission of the American
orthopaedics1. sity of Texas Southwestern Medical Center at Academy of Orthopaedic Surgeons. This arti-
NOTE: The authors thank Paul Tornetta III, MD, for his encour- Dallas, 5323 Harry Hines Boulevard, Dallas, cle, as well as other lectures presented at the
agement and enthusiasm, which contributed greatly to this
instructional course lecture. They also express their appreci- TX 75390-8883 Academys Annual Meeting, will be available
ation to Timothy E. Hewett, PhD, for his thoughtful review of in February 2005 in Instructional Course Lec-
this manuscript.
Peter V. Giannoudis, MD tures, Volume 54. The complete volume can
Craig S. Roberts, MD Department of Trauma Orthopaedic Surgery, be ordered online at www.aaos.org, or by call-
Arthur L. Malkani, MD University of Leeds, Beckett Street, Leeds LS9 ing 800-626-6726 (8 A.M.-5 P.M., Central
Jorge L. Rodriguez, MD 7TF, United Kingdom time).

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