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Damage Control
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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, Räoul
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- tient’s 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 Müller, Hans Willenegger, and
injury complexes that are best treated been gathering for almost a century.”1 Martin Allgöwer 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 patient’s paced by the development of internal these pioneering surgeons established
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the Arbeitsgemeinschaft für 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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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-α 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 patient’s susceptibility to posttrau- reactive protein, tumor necrosis factor- its role in predicting outcome is still
matic complications. α (TNF-α), 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-α, 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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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 patient’s 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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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 patient’s 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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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
*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 débridement 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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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 Academy’s 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).
References
1. Pape HC, Giannoudis P, Krettek C. The timing of Hildebrand F, Zech S, Winny M, Lichtinghagen R, duction of plasma elastase, IL-6, sICAM-1, and sE-
fracture treatment in polytrauma patients: rele- Krettek C. Major secondary surgery in blunt trauma selectin. Injury. 1996;27:372.
vance of damage control orthopedic surgery. Am J patients and perioperative cytokine liberation: deter-
25. Giannoudis PV, Smith RM, Banks RE, Windsor
Surg. 2002;183:622-9. mination of the clinical relevance of biochemical
AC, Dickson RA, Guillou PJ. Stimulation of inflam-
markers. J Trauma. 2001;50:989-1000.
2. Bradford DS, Foster RR, Nossel HL. Coagulation matory markers after blunt trauma. Br J Surg.
alterations, hypoxemia, and fat embolism in fracture 13. Rotondo MF, Schwab CW, McGonigal MD, Phil- 1998;85:986-90.
patients. J Trauma. 1970;10:307-21. lips GR 3rd, Fruchterman TM, Kauder DR, Latenser
BA, Angood PA. ‘Damage control’: an approach for 26. Giannoudis PV, Smith RM, Windsor AC, Bellamy
3. Rang M. The story of orthopaedics. Philadelphia: improved survival in exsanguinating penetrating ab- MC, Guillou PJ. Monocyte human leukocyte antigen-
WB Saunders; 2000. dominal injury. J Trauma. 1993;35:375-83. DR expression correlates with intrapulmonary
shunting after major trauma. Am J Surg. 1999;177:
4. Matter P. History of the AO and its global effect on 14. Richardson D, Seligson D. Dudley and Griswold: 454-9.
operative fracture treatment. Clin Orthop. the development of fracture treatment in Kentucky. J
1998;347:11-8. Ky Med Assoc. 1993;91:226-30. 27. Pape HC, Grimme K, Van Griensven M, Sott AH,
Giannoudis P, Morley J, Roise O, Ellingsen E, Hilde-
5. Pape HC, Schmidt RE, Rice J, van Griensven M, 15. Feliciano DV, Mattox KL, Jordan GL Jr. Intra- brand F, Wiese B, Krettek C; EPOFF Study Group. Im-
das Gupta R, Krettek C, Tscherne H. Biochemical abdominal packing for control of hepatic hemor- pact of intramedullary instrumentation versus
changes after trauma and skeletal surgery of the rhage: a reappraisal. J Trauma. 1981;21:285-90. damage control for femoral fractures on immunoin-
lower extremity: quantification of the operative bur-
16. Stone HH, Strom PR, Mullins RJ. Management flammatory parameters: prospective randomized
den. Crit Care Med. 2000;28:3441-8.
of the major coagulopathy with onset during laparot- analysis by the EPOFF Study Group. J Trauma.
6. Bone LB, Johnson KD, Weigelt J, Scheinberg R. omy. Ann Surg. 1983;197:532-5. 2003;55:7-13.
Early versus delayed stabilization of femoral frac-
17. Burch JM, Ortiz VB, Richardson RJ, Martin RR, 28. Hoch RC, Rodriguez R, Manning T, Bishop M,
tures. A prospective randomized study. J Bone Joint
Mattox KL, Jordan GL Jr. Abbreviated laparotomy Mead P, Shoemaker WC, Abraham E. Effects of acci-
Surg Am. 1989;71:336-40.
and planned reoperation for critically injured pa- dental trauma on cytokine and endotoxin produc-
7. Border JR. Blunt multiple trauma: comprehensive tients. Ann Surg. 1992;215:476-84. tion. Crit Care Med. 1993;21:839-45.
pathophysiology and care. New York: Marcel Dekker;
18. Rotondo MF, Zonies DH. The damage control se- 29. Maekawa K, Futami S, Nishida M, Terada T, Ina-
1990.
quence and underlying logic. Surg Clin North Am. gawa H, Suzuki S, Ono K. Effects of trauma and sep-
8. Giannoudis PV, Smith RM, Bellamy MC, Morrison 1997;77:761-77. sis on soluble L-selectin and cell surface expression
JF, Dickson RA, Guillou PJ. Stimulation of the inflam- of L-selectin and CD11b. J Trauma. 1998;44:460-8.
matory system by reamed and unreamed nailing of 19. Mattox KL. Introduction, background, and fu-
ture projections of damage control surgery. Surg 30. Smith RM, Giannoudis PV, Bellamy MC, Perry
femoral fractures. An analysis of the second hit. J
Clin North Am. 1997;77:753-9. SL, Dickson RA, Guillou PJ. Interleukin-10 release
Bone Joint Surg Br. 1999;81:356-61.
and monocyte human leukocyte antigen-DR ex-
9. Nowotarski PJ, Turen CH, Brumback RJ, Scarboro 20. Smith RM, Giannoudis PV. Trauma and the im- pression during femoral nailing. Clin Orthop.
JM. Conversion of external fixation to intramedul- mune response. J R Soc Med. 1998;91:417-20. 2000;373:233-40.
lary nailing for fractures of the shaft of the femur in 21. Granger DN, Kubes P. The microcirculation and 31. Ertel W, Keel M, Bonaccio M, Steckholzer U,
multiply injured patients. J Bone Joint Surg Am. inflammation: modulation of leukocyte-endothelial Gallati H, Kenney JS, Trentz O. Release of anti-
2000;82:781-8. cell adhesion. J Leukoc Biol. 1994;55:662-75. inflammatory mediators after mechanical trauma
10. Scalea TM, Boswell SA, Scott JD, Mitchell KA, 22. Cipolle MD, Pasquale MD, Cerra FB. Secondary correlates with severity of injury and clinical out-
Kramer ME, Pollak AN. External fixation as a bridge organ dysfunction. From clinical perspectives to mo- come. J Trauma. 1995;39:879-87.
to intramedullary nailing for patients with multiple lecular mediators. Crit Care Clin. 1993;9:261-98. 32. Tan LR, Waxman K, Scannell G, Ioli G, Granger
injuries and with femur fractures: damage control or-
thopedics. J Trauma. 2000;48:613-23. 23. Anderson BO, Harken AH. Multiple organ failure: GA. Trauma causes early release of soluble re-
inflammatory priming and activation sequences pro- ceptors for tumor necrosis factor. J Trauma.
11. Townsend RN, Lheureau T, Protech J, Riemer B, mote autologous tissue injury. J Trauma. 1993;34:634-8.
Simon D. Timing fracture repair in patients with se- 1990;30(12 Suppl):S44-9.
vere brain injury (Glasgow Coma Scale score <9). J 33. Meakins JL, Pietsch JB, Bubenick O, Kelly R,
Trauma. 1998;44:977-83. 24. Giannoudis PV, Smith RM, Ramsden CW, Sharp- Rode H, Gordon J, MacLean LD. Delayed hypersensi-
les D, Dickson RA, Guillou PJ. Molecular mediators tivity: indicator of acquired failure of host defenses
12. Pape HC, van Griensven M, Rice J, Gansslen A, and trauma: effects of accidental trauma on the pro- in sepsis and trauma. Ann Surg. 1977;186:241-50.
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG D A M A G E C O N T RO L
VO L U M E 87-A · N U M B E R 2 · F E B R U A R Y 2005 ORTHOPAEDICS
34. Polk HC Jr. Non-specific host defence stimula- Suzaki S, Kurokawa A. The ratio of interleukin-6 to 65. Jouanguy E, Altare F, Lamhamedi S, Revy P,
tion in the reduction of surgical infection in man. Br interleukin-10 correlates with severity in patients Emile JF, Newport M, Levin M, Blanche S, Seboun E,
J Surg. 1987;74:969-70. with chest and abdominal trauma. Am J Emerg Med. Fischer A, Casanova JL. Interferon-gamma-receptor
1999;17:548-51. deficiency in an infant with fatal bacille Calmette-
35. Obertacke U, Kleinschmidt C, Dresing K,
Guerin infection. N Engl J Med. 1996;335:1956-61.
Bardenheuer M, Bruch J. [Repeated routine determi- 50. Lo YM, Rainer TH, Chan LY, Hjelm NM, Cocks
nation of pulmonary microvascular permeability af- RA. Plasma DNA as a prognostic marker in trauma 66. Davis EG, Eichenberger MR, Grant BS, Polk HC
ter polytrauma]. Unfallchirurg. 1993;96:142-9. patients. Clin Chem. 2000;46:319-23. Jr. Microsatellite marker of interferon-gamma recep-
German. tor 1 gene correlates with infection following major
51. Guillou PJ. Biological variation in the develop-
trauma. Surgery. 2000;128:301-5.
36. Giannoudis PV, Abbott C, Stone M, Bellamy MC, ment of sepsis after surgery or trauma. Lancet.
Smith RM. Fatal systemic inflammatory response 1993;342:217-20. 67. Association for the Advancement of Automotive
syndrome following early bilateral femoral nailing. In- Medicine. The abbreviated injury scale. 1990 revi-
52. Salmon JE, Edberg JC, Brogle NL, Kimberly RP.
tensive Care Med. 1998;24:641-2. sion. Des Plaines, IL: Association for the Advance-
Allelic polymorphisms of human Fc gamma receptor
ment of Automotive Medicine; 1990.
37. Waydhas C, Nast-Kolb D, Trupka A, Zettl R, Kick IIA and Fc gamma receptor IIIB. Independent mecha-
M, Wiesholler J, Schweiberer L, Jochum M. Posttrau- nisms for differences in human phagocyte function. 68. Baker SP, O’Neill B, Haddon W Jr, Long WB. The
matic inflammatory response, secondary opera- J Clin Invest. 1992;89:1274-81. injury severity score: a method for describing pa-
tions, and late multiple organ failure. J Trauma. tients with multiple injuries and evaluating emer-
53. O’Keefe GE, Hybki DL, Munford RS. The G—>A
1996;40:624-31. gency care. J Trauma. 1974;14:187-96.
single nucleotide polymorphism at the -308 position
38. Giannoudis PV, Smith MR, Evans RT, Bellamy in the tumor necrosis factor-alpha promoter in- 69. Copes WS, Champion HR, Sacco WJ, Lawnick
MC, Guillou PJ. Serum CRP and IL-6 levels after creases the risk for severe sepsis after trauma. J MM, Keast SL, Bain LW. The Injury Severity Score re-
trauma. Not predictive of septic complications in 31 Trauma. 2002;52:817-26. visited. J Trauma. 1988;28:69-77.
patients. Acta Orthop Scand. 1998;69:184-8.
54. Tang GJ, Huang SL, Yien HW, Chen WS, Chi CW, 70. Champion HR, Sacco WJ, Copes WS, Gann DS,
39. Mimoz O, Benoist JF, Edouard AR, Assicot M, Wu CW, Lui WY, Chiu JH, Lee TY. Tumor necrosis fac- Gennarelli TA, Flanagan ME. A revision of the
Bohuon C, Samii K. Procalcitonin and C-reactive pro- tor gene polymorphism and septic shock in surgical Trauma Score. J Trauma. 1989;29:623-9.
tein during the early posttraumatic systemic inflam- infection. Crit Care Med. 2000;28:2733-6.
71. Copes WS, Champion HR, Sacco WJ, Lawnick
matory response syndrome. Intensive Care Med.
55. Mira JP, Cariou A, Grall F, Delclaux C, Losser MR, MM, Gann DS, Gennarelli T, MacKenzie E, Schwait-
1998;24:185-8.
Heshmati F, Cheval C, Monchi M, Teboul JL, Riche F, zberg S. Progress in characterizing anatomic injury. J
40. Andermahr J, Greb A, Hensler T, Helling HJ, Leleu G, Arbibe L, Mignon A, Delpech M, Dhainaut Trauma. 1990;30:1200-7.
Bouillon B, Sauerland S, Rehm KE, Neugebauer E. JF. Association of TNF2, a TNF-alpha promoter poly-
72. Teasdale G, Jennett B. Assessment of coma
Pneumonia in multiple injured patients: a prospec- morphism, with septic shock susceptibility and mor-
and impaired consciousness. A practical scale. Lan-
tive controlled trial on early prediction using clinical tality: a multicenter study. JAMA. 1999;282:561-8.
cet. 1974;2:81-4.
and immunological parameters. Inflamm Res.
56. Majetschak M, Flohe S, Obertacke U, Schroder
2002;51:265-72. 73. Bosse MJ, MacKenzie EJ, Riemer BL, Brum-
J, Staubach K, Nast-Kolb D, Schade FU, Stuber F.
back RJ, McCarthy ML, Burgess R, Gens DR, Yasui
41. Wanner GA, Keel M, Steckholzer U, Beier W, Relation of a TNF gene polymorphism to severe
Y. Adult respiratory distress syndrome, pneumonia,
Stocker R, Ertel W. Relationship between procalci- sepsis in trauma patients. Ann Surg. 1999;230:
and mortality following thoracic injury and a femoral
tonin plasma levels and severity of injury, sepsis, or- 207-14.
fracture treated either with intramedullary nailing
gan failure, and mortality in injured patients. Crit
57. Stüber F, Petersen M, Bokelmann F, Schade U. A with reaming or with a plate. A comparative study. J
Care Med. 2000;28:950-7.
genomic polymorphism within the tumor necrosis Bone Joint Surg Am. 1997;79:799-809.
42. Oberhoffer M, Karzai W, Meier-Hellmann A, Bo- factor locus influences plasma tumor necrosis fac-
74. Pape HC, Hildebrand F, Pertschy S, Zelle B, Ga-
gel D, Fassbinder J, Reinhart K. Sensitivity and spe- tor-alpha concentrations and outcome of patients
rapati R, Grimme K, Krettek C, Reed RL 2nd.
cificity of various markers of inflammation for the with severe sepsis. Crit Care Med. 1996;24:381-4.
Changes in the management of femoral shaft frac-
prediction of tumor necrosis factor-alpha and inter-
58. Bowcock AM, Ray A, Erlich H, Sehgal PB. Rapid tures in polytrauma patients: from early total care to
leukin-6 in patients with sepsis. Crit Care Med.
detection and sequencing of alleles in the 3′ flank- damage control orthopedic surgery. J Trauma.
1999;27:1814-8.
ing region of the interleukin-6 gene. Nucleic Acids 2002;53:452-62.
43. Abraham E. Why immunomodulatory therapies Res. 1989;17:6855-64.
75. Moore EE, Cogbill TH, Malangoni MA, Jurkovich
have not worked in sepsis. Intensive Care Med.
59. Fishman D, Faulds G, Jeffery R, Mohamed-Ali V, GJ, Shackford SR, Champion HR, McAninch JW. Or-
1999;25:556-66.
Yudkin JS, Humphries S, Woo P. The effect of novel gan injury scaling. Surg Clin North Am. 1995;75:
44. Giannoudis PV, Smith RM, Perry SL, Windsor AJ, polymorphisms in the interleukin-6 (IL-6) gene on IL- 293-303.
Dickson RA, Bellamy MC. Immediate IL-10 expres- 6 transcription and plasma IL-6 levels, and an asso-
76. Pape HC, Auf’m’Kolk M, Paffrath T, Regel G,
sion following major orthopaedic trauma: relation- ciation with systemic-onset juvenile chronic arthritis.
Sturm JA, Tscherne H. Primary intramedullary femur
ship to anti-inflammatory response and subsequent J Clin Invest. 1998;102:1369-76.
fixation in multiple trauma patients with associated
development of sepsis. Intensive Care Med.
60. Osiri M, McNicholl J, Moreland LW, Bridges SL lung contusion—a cause of posttraumatic ARDS? J
2000;26:1076-81.
Jr. A novel single nucleotide polymorphism and five Trauma. 1993;34:540-8.
45. Weigand MA, Schmidt H, Pourmahmoud M, probable haplotypes in the 5¢ flanking region of the
77. Copeland CE, Mitchell KA, Brumback RJ, Gens
Zhao Q, Martin E, Bardenheuer HJ. Circulating intra- IL-6 gene in African-Americans. Genes Immun.
DR, Burgess AR. Mortality in patients with bilateral
cellular adhesion molecule-1 as an early predictor of 1999;1:166-7.
femoral fractures. J Orthop Trauma. 1998;12:
hepatic failure in patients with septic shock. Crit
61. Fernandez-Real JM, Broch M, Vendrell J, Gutier- 315-9.
Care Med. 1999;27:2656-61.
rez C, Casamitjana R, Pugeat M, Richart C, Ricart
78. Wu CC, Shih CH. Simultaneous bilateral femoral
46. Cheadle WG, Hershman MJ, Wellhausen SR, W. Interleukin-6 gene polymorphism and insulin sen-
shaft fractures. J Trauma. 1992;32:289-93.
Polk HC Jr. HLA-DR antigen expression on periph- sitivity. Diabetes. 2000;49:517-20.
eral blood monocytes correlates with surgical infec- 79. Carrillo EH, Wohltmann CD, Spain DA, Schmieg
62. Turner DM, Williams DM, Sankaran D, Lazarus
tion. Am J Surg. 1991;161:639-45. RE Jr, Miller FB, Richardson JD. Common and exter-
M, Sinnott PJ, Hutchinson IV. An investigation of
nal iliac artery injuries associated with pelvic frac-
47. Giannoudis PV, Smith RM, Windsor AC, Bellamy polymorphism in the interleukin-10 gene promoter.
tures. J Orthop Trauma. 1999;13:351-5.
MC, Guillou PJ. Monocyte human leukocyte Eur J Immunogenet. 1997;24:1-8.
antigen-DR expression correlates with intrapulmo- 80. McMurtry R, Walton D, Dickinson D, Kellam J,
63. Eskdale J, Gallagher G, Verweij CL, Keijsers V,
nary shunting after major trauma. Am J Surg. 1999; Tile M. Pelvic disruption in the polytraumatized pa-
Westendorp RG, Huizinga TW. Interleukin 10 secre-
177:454-9. tient: a management protocol. Clin Orthop.
tion in relation to human IL-10 locus haplotypes.
1980;151:22-30.
48. Napolitano LM, Ferrer T, McCarter RJ Jr, Scalea Proc Natl Acad Sci USA. 1998;95:9465-70.
TM. Systemic inflammatory response syndrome 81. Gilliland MD, Ward RE, Barton RM, Miller PW,
64. Newport MJ, Huxley CM, Huston S, Hawrylowicz
score at admission independently predicts mortal- Duke JH. Factors affecting mortality in pelvic frac-
CM, Oostra BA, Williamson R, Levin M. A mutation
ity and length of stay in trauma patients. J Trauma. tures. J Trauma. 1982;22:691-3.
in the interferon-gamma-receptor gene and suscepti-
2000;49:647-53.
bility to mycobacterial infection. N Engl J Med. 82. Hak DJ. Pelvic ring injuries. In: Brinker MR,
49. Taniguchi T, Koido Y, Aiboshi J, Yamashita T, 1996;335:1941-9. editor. Review of orthopaedic trauma. Philadelphia:
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG D A M A G E C O N T RO L
VO L U M E 87-A · N U M B E R 2 · F E B R U A R Y 2005 ORTHOPAEDICS
WB Saunders; 2001. p 188. shaft treated surgically. Comparative results of early 113. Helfet DL, Howey T, Sanders R, Johansen K.
and delayed operative stabilization. J Bone Joint Limb salvage versus amputation. Preliminary results
83. Henry SM, Pollak AN, Jones AL, Boswell S,
Surg Am. 1978;60:489-91. of the Mangled Extremity Severity Score. Clin Or-
Scalea TM. Pelvic fracture in geriatric patients: a
thop. 1990;256:80-6.
distinct clinical entity. J Trauma. 2002;53:15-20. 98. Beck JP, Collins JA. Theoretical and clinical as-
pects of posttraumatic fat embolism syndrome. 114. Georgiadis GM, Behrens FF, Joyce MJ, Earle
84. Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes
Instr Course Lect. 1973;22:38-87. AS, Simmons AL. Open tibial fractures with severe
M, Reed JF 3rd. Arterial embolization is a rapid and
soft-tissue loss. Limb salvage compared with below-
effective technique for controlling pelvic fracture 99. Wald SL, Shackford SR, Fenwick J. The effect of
the-knee amputation. J Bone Joint Surg Am.
hemorrhage. J Trauma. 1997;43:395-9. secondary insults on mortality and long-term disabil-
1993;75:1431-41.
ity after severe head injury in a rural region without
85. Pohlemann T, Gänsslen A, Bosch U, Tscherne H.
a trauma system. J Trauma. 1993;34:377-82. 115. Gilson BS, Bergner M, Bobbitt RA, Carter WB.
The technique of packing for control of hemorrhage
The Sickness Impact Profile: final development and
in complex pelvic fractures. Tech Orthop. 1995;9: 100. Bhandari M, Guyatt GH, Khera V, Kulkarni AV,
testing. Seattle: Department of Health Services,
267-70. Sprague S, Schemitsch EH. Operative management
University of Washington School of Public Health
of lower extremity fractures in patients with head in-
86. Greenspan L, McLellan BA, Greig H. Abbreviated and Community Medicine; 1979.
juries. Clin Orthop. 2003;407:187-98.
Injury Scale and Injury Severity Score: a scoring
116. Webb LX, Bosse MJ, Castillo RC, MacKenzie
chart. J Trauma. 1985;25:60-4. 101. Jaicks RR, Cohn SM, Moller BA. Early fracture
EJ; The LEAP Study Group. Outcomes in patients
fixation may be deleterious after head injury. J
87. Tornetta P 3rd, Mostafavi H, Riina J, Turen C, with limb-threatening grade III open tibial diaphy-
Trauma. 1997;42:1-6.
Reimer B, Levine R, Behrens F, Geller J, Ritter C, seal fractures. Read at the Annual Meeting of the
Homel P. Morbidity and mortality in elderly trauma 102. Martens F, Ectors P. Priorities in the manage- Orthopaedic Trauma Association; 2003 Oct 9-11;
patients. J Trauma. 1999;46:702-6. ment of polytraumatised patients with head injury: Salt Lake City, UT.
partially resolved problems. Acta Neurochir (Wien).
88. Meek RN, Vivoda EE, Pirani S. Comparison of 117. Smith DG, Castillo RC, MacKenzie EJ, Bosse
1988;94:70-3.
mortality of patients with multiple injuries according MJ; The LEAP Study Group. Functional outcomes of
to type of fracture treatment—a retrospective age- 103. McKee MD, Schemitsch EH, Vincent LO, Sulli- patients who have late amputation after trauma is
and injury-matched series. Injury. 1986;17:2-4. van I, Yoo D. The effect of a femoral fracture on con- significantly worse than for those who have early
comitant closed head injury in patients with multiple amputation. Read at the Annual Meeting of the Or-
89. Goris RJ, Gimbrére JS, van Niekerk JL, Schoots
injuries. J Trauma. 1997;42:1041-5. thopaedic Trauma Association; 2003 Oct 9-11; Salt
FJ, Booy LH. Early osteosynthesis and prophylactic
Lake City, UT.
mechanical ventilation in the multitrauma patient. J 104. Poole GV, Miller JD, Agnew SG, Griswold JA.
Trauma. 1982;22:895-903. Lower extremity fracture fixation in head-injured pa- 118. Goodell JA, Flick AB, Hebert JC, Howe JG. Prep-
tients. J Trauma. 1992;32:654-9. aration and release characteristics of tobramycin-
90. Johnson KD, Cadambi A, Seibert GB. Incidence
impregnated polymethylmethacrylate beads. Am J
of adult respiratory distress syndrome in patients 105. Brundage SI, McGhan R, Jurkovich GJ, Mack
Hosp Pharm. 1986;43:1454-61.
with multiple musculoskeletal injuries: effect of CD, Maier RV. Timing of femur fracture fixation: ef-
early operative stabilization of fractures. J Trauma. fect on outcome in patients with thoracic and head 119. Flick AB, Herbert JC, Goodell J, Kristiansen T.
1985;25:375-84. injuries. J Trauma. 2002;52:299-307. Noncommercial fabrication of antibiotic-impregnated
polymethylmethacrylate beads. Technical note. Clin
91. Riska EB, von Bonsdorff H, Hakkinen S, Jaroma 106. Hofman PA, Goris RJ. Timing of osteosynthesis
Orthop. 1987;223:282-6.
H, Kiviluoto O, Paavilainen T. Prevention of fat embo- of major fractures in patients with severe brain in-
lism by early internal fixation of fractures in patients jury. J Trauma. 1991;31:261-3. 120. Seligson D. Antibiotic-impregnated beads in or-
with multiple injuries. Injury. 1976;8:110-6. thopedic infectious problems. J Ky Med Assoc.
107. MacKenzie EJ, Bosse MJ, Kellam JF, Burgess
1984;82:25-9.
92. Boulanger BR, Stephen D, Brenneman FD. Tho- AR, Webb LX, Swiontkowski MF, Sanders R, Jones
racic trauma and early intramedullary nailing of fe- AL, McAndrew MP, Patterson B, McCarthy ML, Rohde 121. Webb LX. New techniques in wound manage-
mur fractures: are we doing harm? J Trauma. CA; LEAP Study Group. Factors influencing the deci- ment: vacuum-assisted wound closure. J Am Acad
1997;43:24-8. sion to amputate or reconstruct after high-energy Orthop Surg. 2002;10:303-11.
lower extremity trauma. J Trauma. 2002;52:641-9.
93. Dunham CM, Bosse MJ, Clancy TV, Cole FJ Jr, 122. Pape H, Stalp M, v Griensven M, Weinberg A,
Erratum in: J Trauma. 2002;53:48.
Coles MJ, Knuth T, Luchette FA, Ostrum R, Plaisier Dahlweit M, Tscherne H. [Optimal timing for second-
B, Poka A, Simon RJ; EAST Practice Management 108. McCarthy ML, MacKenzie EJ, Edwin D, Bosse ary surgery in polytrauma patients: an evaluation of
Guidelines Work Group. Practice guidelines for the MJ, Castillo RC, Starr A; LEAP study group. Psycho- 4,314 serious-injury cases]. Chirurg. 1999;70:
optimal timing of long-bone fracture stabilization in logical distress associated with severe lower-limb in- 1287-93. German.
polytrauma patients: the EAST Practice Manage- jury. J Bone Joint Surg Am. 2003;85:1689-97.
123. Tornetta P 3rd, DeMarco C. Intramedullary nail-
ment Guidelines Work Group. J Trauma.
109. MacKenzie EJ, Bosse MJ, Castillo RC, Smith ing after external fixation of the tibia. Bull Hosp Jt
2001;50:958-67.
DG, Webb LX, Kellam JF, Burgess AR, Swiontkowski Dis. 1995;54:5-13.
94. Giannoudis PV, Veysi VT, Pape HC, Krettek C, MF, Sanders RW, Jones AL, McAndrew MP, Patter-
124. Blachut PA, Meek RN, O’Brien PJ. External fixa-
Smith MR. When should we operate on major frac- son BM, Travison TG, McCarthy ML. Functional out-
tion and delayed intramedullary nailing of open frac-
tures in patients with severe head injuries? Am J comes following trauma-related lower-extremity
tures of the tibial shaft. A sequential protocol. J
Surg. 2002;183:261-7. amputation. J Bone Joint Surg Am. 2004;86:
Bone Joint Surg Am. 1990;72:729-35.
1636-45.
95. Seibel R, LaDuca J, Hassett JM, Babikian G,
125. Winkler H, Hochstein P, Pfrengle S, Wentz-
Mills B, Border DO, Border JR. Blunt multiple trauma 110. Lange RH. Limb reconstruction versus amputa-
ensen A. [Change in procedure to reamed intramed-
(ISS 36), femur traction, and the pulmonary failure- tion decision making in massive lower extremity
ullary nail in diaphyseal femoral fractures after
septic state. Ann Surg. 1985;202:283-95. trauma. Clin Orthop. 1989;243:92-9.
stabilization with external fixator]. Zentralbl Chir.
96. Rüedi T, Wolff G. [Prevention of post-traumatic 111. Caudle RJ, Stern PJ. Severe open fractures of 1998;123:1239-46. German.
complications through immediate therapy in pa- the tibia. J Bone Joint Surg Am. 1987;69:801-7.
126. Parameswaran AD, Roberts CS, Seligson D,
tients with multiple injuries and fractures]. Helv Chir
112. Hansen ST Jr. The type-IIIC tibial fracture. Sal- Voor M. Pin tract infection with contemporary exter-
Acta. 1975;42:507-12. German.
vage or amputation. J Bone Joint Surg Am. nal fixation: how much of a problem? J Orthop
97. Wilber MC, Evans EB. Fractures of the femoral 1987;69:799-800. Trauma. 2003;17:503-7.