Damage Control Orthopaedics (2005)

Many orthopaedic patients who have sustained multiple injuries benefit from the early total care of major bone fractures. However, the strategy is not the best option, and indeed might be harmful, for some multiply injured patients. Since foregoing all early surgery is not the optimal approach for those patients, the concept of damage control orthopaedics has evolved. Damage control orthopaedics emphasizes the stabilization and control of the injury, often with use of spanning external fixation, rather than immediate fracture repair. The concept of damage control orthopaedics is not new; it has evolved out of the rich history of fracture care and abdominal surgery. This article traces the roots of damage control orthopaedics, reviews the physiologic basis for it, describes the subgroups of patients and injury complexes that are best treated with damage control orthopaedics, reports the early clinical results, and provides a rationale for modern fracture care for the multiply injured patient. Definition of Damage Control Orthopaedics Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology can improve. Its purpose is to avoid worsening of the patient's condition by the “second hit” of a major orthopaedic procedure and to delay definitive fracture repair until a time when the overall condition of the patient is optimized. Minimally invasive surgical techniques such as external fixation are used initially. Damage control focuses on control of hemorrhage, management of soft-tissue injury, and achievement of provisional fracture stability, while avoiding additional insults to the patient. History of Fracture Surgery and Birth of Damage Control Orthopaedics We previously stated that: “Information illustrating the benefits of fracture stabilization after multiple trauma has been gathering for almost a century.”1 We also noted that during this time “fears of the `fat embolism syndrome' also dominated the philosophy in managing polytrauma patients.” Early manipulation of long-bone fractures was considered unsafe2. External fixation, an essential component of damage control orthopaedics, developed slowly and was outpaced by the development of internal fixation. In Switzerland in 1938, Räoul Hoffmann produced an external fixator frame that allowed the fracture to be mechanically manipulated and reduced3. In 1942, Roger Anderson advocated castless ambulatory treatment of fractures with use of a versatile linkage system, but the device was banned in World War II for being too elaborate3. In 1950, a survey by the Committee on Fractures and Traumatic Surgery of the American Academy of Orthopaedic Surgeons (AAOS) concluded that the complications of external fixation frequently exceed any advantages of the procedure3. Also in 1950, Gavril Abramovich Ilizarov developed the ring system for fractures and deformities, but his device did not reach the West until the late 1970s. On March 15, 1958, Maurice Müller, Hans Willenegger, and Martin Allgöwer convened a group of interested Swiss general and orthopaedic surgeons, including Robert Schneider and Walter Bandi at the Kantonsspital, Chur, Switzerland, to discuss the status of fracture treatment, which usually included traction and prolonged bed rest and led to poor functional results in a high percentage of patients4. On November 6, 1958, these pioneering surgeons established the Arbeitsgemeinschaft für Osteosynthesefragen (the Association for the Study of Internal Fixation, or ASIF), or AO, in Biel, Switzerland4. The key objective of the AO was the early restoration of function, whether a patient was being treated for an isolated fracture or for multiple injuries4. Matter noted that this strategy led to “aggressive traumatology involving early total care of the trauma victim, culminating in the statement: This patient is too sick not to be treated surgically.”4 By the 1980s, the accepted care of a major fracture was early or immediate fixation5. Substantiating this approach were eleven studies (ten retrospective and one prospective), with the one by Bone et al.6 being most frequently cited. Bone et al. reported that the incidence of pulmonary complications (adult respiratory distress syndrome, pneumonia, and fat embolism) was higher and the stays in the hospital and the intensive care unit were increased when femoral fixation was delayed. In 1990, Border reported on a comprehensive study of patients with blunt trauma that challenged the accepted practice of immediate definitive fixation7. This changed practice in the early 1990s, and a more selective approach to fracture fixation was used; however, early fixation was still performed in most cases. During the 1990s, more was learned about the parameters associated with adverse outcomes in multiply injured patients and about the systemic inflammatory response to trauma8. It became clear that fracture surgery, especially intramedullary nailing, has systemic physiologic effects. These effects became known as the “second hit” phenomenon. The era of damage control orthopaedics started around 1993. Two reports from one institution9,10 described temporary external fixation of femoral shaft fractures in severely injured patients. From 1989 to 1990, the frequency of using temporary external fixation increased from <5% to >10%. The mean duration of external fixation until intramedullary was than one with patients treated with immediate definitive fixation, those treated with external fixation more with higher injury and in the The to be used in the orthopaedic the to History of Damage Control Surgery The concept of damage control surgery was developed in the of abdominal surgery. The benefits of and and the in of repair of injuries and of the the of patients with the of and damage control surgery was described as the total of all to of a multiply injured patient who was purpose was to control rather than repair In the and of used a damage control approach to injuries of the abdominal In et al. reported that of patients who for the treatment of et in described a approach involving and a that was In et al. reported a in a group of patients treated with and a and in the and reported a of of patients treated with a In the concept of damage control was used in abdominal surgery to a approach to a of to by one an immediate to control and was in the intensive care unit with of of and of of a for of definitive repair of abdominal and and repair of Damage control surgery in the has and of Damage Control Orthopaedics The physiologic basis of damage control orthopaedics is to be Traumatic injury to systemic inflammatory response by a of by a response to and early after an inflammatory response by an response a prolonged that can be to the This multiple early after trauma in some patients and in is a the systemic inflammatory response and the can to and early inflammatory response with an response also a prolonged that can be to the systemic inflammatory response syndrome, and response this inflammatory is a the effects of and the for the to and injury to respiratory distress and multiple The key in the response to be the the the and and also The development of this inflammatory response and often are of the response to the injury and to an systemic inflammatory with the to injury, this hit” can an inflammatory response that the system, including and inflammatory by and and the is and the patient is to inflammatory insults that can the systemic inflammatory response and late multiple The as a of a of such as and surgical and is the basis for the when and to for a multiply injured patient be of the inflammatory system, by or multiple is considered by to be the key in the of respiratory distress and multiple The and studies have that of a of inflammatory in the immediate of This response to the et al. reported in of and in patients with an injury of immediate in of was reported in patients with an injury of a in the of the was noted in more severely injured The development of multiple has also been associated with a of on and for a that is of in the early development of studies have the of injury on the of of the inflammatory selective a in the development of complications after it is also clear that the of surgical or trauma on is have the of the of and and patients as with and are to an increased of in and respiratory have also been to the of and after The of the in trauma patients is being et al. the of the by using to in pulmonary in patients who sustained multiple The of the pulmonary increased multiple and patients in respiratory distress developed a high with increased after than did those who an The development of a in a patient with femoral fracture who a inflammatory which was by the surgical procedure femoral the of the was additional the patient from respiratory distress after the This not the of in the inflammatory response to injury, but also the of the of the response to the and the response to the that the The studies that the of the injury is in a patient's to The concept that a surgical procedure an additional inflammatory was in a study of patients with an injury of patients in or or in a surgical procedure were with patients in such complications was a of the and and a in the in the patients with systemic of those parameters with an of The and in trauma patients were in a study in which femoral was considered to be the study to and in of and of These of to and have the basis of treatment and the of the procedure on trauma patients at for of and after intramedullary of the from the time of to the to after The control group is by the of and with from of the inflammatory system by and of femoral fractures. of the Bone The is The is the and the is the definitive orthopaedic usually femoral multiple syndrome, and respiratory distress of the key to patients at for the development of complications such as multiple can be of such as and and of such as on and and on and have not been to be However, with the of injury, to be a of the of systemic and with the the of and and the in the with the of high of also with However, in is still the of results have been reported in the about the of and and the of the of to for are considered to be of and a of et al. reported that the of the systemic inflammatory response at be an of and the of in the hospital by trauma In the of to was to with injury after major and this was as a to the of injury The of has been to after major trauma and has also been as a for patients at It at and the clinical and after has been as a in trauma of the additional for of of and the use of such has not clinical and and are as of complications in some patients and not in be to have a to a of the for has been reported and is associated with functional in high or of is of a component in the response to of is in the The at in the was associated with an increased incidence of and with a after major and in a intensive care This on the of the for the is associated with an increased incidence of and a The of is higher in patients who are for patients also have higher and higher multiple with have been reported and were in the and the and The is at of this with during in the have also been et al. reported that of with in concluded that the to can in to the of the isolated reports of in the for were and the were et al. a study of patients who sustained blunt trauma and that the with These in the and a basis for the development of the Early of patients at for adverse outcomes and complications with response in to and of and to patients after orthopaedic trauma clinical when to from early total care to damage control for Damage Control Orthopaedics and is not it a clinical when to from early total care to damage control patient be treated with damage control orthopaedics of early total care after orthopaedic trauma be on the basis of the patient's overall physiologic status and injury Many trauma the injury injury trauma and have been developed in an to the overall condition of the trauma patient. However, et noted that is that in during the it be that one on a be and the overall status of the patient be one of who have sustained orthopaedic trauma have been and in patients, patients, and patients in are to patients be treated with the for managing orthopaedic patients and patients in be treated with damage control orthopaedics for orthopaedic patients are more to of and as patients with polytrauma and an injury of in the of injury, or an injury of with injury injury of polytrauma with abdominal trauma of a an mean pulmonary of or an in pulmonary of during orthopaedic trauma patients are best treated with damage control II in to the for Damage Control Orthopaedics injury of and additional trauma injury with trauma and of in the of additional injury of mean pulmonary of of in pulmonary during intramedullary The describes a for trauma to a in this However, whether femoral fractures in patients with trauma be treated with definitive stabilization or be with a temporary external fixator a of The clinical including the or of a status and associated with a high of adverse outcomes the patient is In some of the additional clinical that have used as a basis for to damage control orthopaedics a of a of of more than and of more than of orthopaedic injury complexes to be more to damage control these for femoral fractures in a multiply injured ring injuries with hemorrhage, and polytrauma in a patient. with in as in condition or and of on long-bone injuries and injury of time injury and inflammatory response Fractures fractures in a multiply injured patient are not treated with intramedullary of about the of such a In to the which results in an additional systemic inflammatory fat from use of in the the pulmonary with a injury injury of are most to after an intramedullary femoral fracture is a in polytrauma that is associated with a higher and incidence of respiratory distress than is a femoral et al. noted that the in be more to associated injuries and physiologic parameters than to the femoral fracture and noted that femoral fracture systemic and such injuries are for damage control associated with fracture is injury for damage control can from a of and the most injuries the internal or the injuries to the and external have been reported and are associated with a poor The of the ring injury and the of the injury can one to the of but is injury that additional can be the of a in by as it the the and to a are some associated with a higher of ring injuries are associated with a to in with injuries and injuries are associated with a high of injury and fractures in patients are more to and The the treatment of patients with to the of and In are most in the treatment of fractures with associated that have not to the of a external or and of or more of for are an a on and a on The of is also et reported that than after injury increased the of and that the procedure time for was for the control of has been advocated at some in This to be used for patients with and a fracture that is to treatment and that is associated with the of and a high that the patient not the to the However, are to the use of Damage control orthopaedics for a ring injury with clinical and multiple for and invasive stabilization with a external or who not to these be considered for and are to the to the be considered for any has been trauma patients and treatment of higher et al. reported that the injury was for more than of This is of the injury for and of In ring fractures in more than are associated with an increased of injuries and higher In a study of patients who were more than et al. noted that increased was associated with a for the patients who with for the patients who for the patients who with for those who and for the patients who with for those who These the of damage control orthopaedics for patients. In treatment be that immediate and the of prolonged bed rest in this patient in Damage Control Orthopaedics have been of to the treatment of multiply injured patients with long-bone fractures and a injury with some that early fracture stabilization is and and that early fracture stabilization is not and be The by Bone et al. has the most on the care and treatment of orthopaedic trauma patients in the et al. reported in or in with early intramedullary of femoral fractures in patients who sustained blunt and a and a femoral fracture in a multiply injured patient. and external fixation was performed at the time of the intramedullary was performed on Association for the Surgery of the and clinical of the treatment of patients with injuries with immediate long-bone stabilization noted that studies or retrospective long-bone stabilization with stabilization in patients with a injury that the of and respiratory distress syndrome, of in the intensive care and total of in the The that clinical parameters be in the of early long-bone of pulmonary and fracture status or selective approach be used for patients with long-bone fractures and a the of patients for early the of early complications is the of damage control to be early intramedullary is not to be the best damage control orthopaedics, with external fixation of the by to an intramedullary in the after injury, can be The Association for the Surgery of also the for studies the of long-bone fracture stabilization in a multiply injured patient with a The group studies clinical On the basis of studies clinical studies or retrospective of and studies or it was concluded that patients with or injury who long-bone stabilization were to those treated with stabilization with to of in the intensive care for and total of in the The overall was that was that early stabilization or the in patients with a or Many clinical during an of the on patients with a injury and long-bone fractures. Early definitive fracture stabilization is in this it at the fracture by by an or not patient. Fracture stabilization also has a on the patient's and as a fractures physiologic in these patients as a of increased soft-tissue fat and respiratory In some have reported a in patients with injury from and increased of to early fracture In a study of multiply injured patients with fractures of the and and reported a of early in a group treated with early fixation but early in a group treated with late et al. reported that complications developed in the in patients treated with early fixation, but did not any of these complications to the femoral fracture or in the the patients treated with early fixation and those treated with fixation. In in a study of patients with a injury and a fracture of the or shaft of the or the shaft of the et al. that those who early definitive fracture fixation a of complications with those who been treated with late et al. reported in a of multiply injured patients with femoral shaft and an injury of those treated with fixation after the injury the at the time of However, the mean injury and not the on was these results are to and that the was in a group treated with early fixation than it was in a group treated with late fixation, but the did not reach The management of a patient with a injury be to that of trauma patients, with a on the control of and restoration of and injury can be is or such as long-bone fixation mean or The treatment for patients be on the clinical and treatment rather than on with to the of fixation of long-bone fractures. In such damage control orthopaedics can temporary to an injured as a temporary to definitive worsening the patient's injury or overall be in the intensive care unit as as during surgical in the management of to be to an of at and at be and after surgical Orthopaedic injuries be with the that to the were on the treatment of severely injured or performed a retrospective study of and Anderson fractures fractures with of which led to of the were and The for in that study included of the and a injury with a time of more than or the of of injury of the and of a to soft-tissue and and reported that of fractures for a study to to and when such a is not et reported that a of was associated with a of et reported of patients with a fracture for soft-tissue were treated with and were treated with early The patients in the group an of was a total of complications in the early in treatment of the has been by the of the results from the a outcomes study at American trauma In this the surgeons all and were patients in from to patients were from the to in the and were not of which a study group of patients. In that patients which were and a The of the study was after the for the of the injury, the and of and patient to have a functional than for the treatment of and major soft-tissue and The study patients from the general with to were more to be were were more often were were more to be and were and a with a injury of the and at the time of at and treated with did not have outcomes than those treated with did not the of at the injury the and of or injuries with the outcomes as with the with a and than did patients with a or an who been for a major also of a poor were a or a the being a of a poor and in the system for injury of the patients who not by of those patients did not have and were to additional surgery. The in the study were higher than was time for all of the for The percentage of patients with a was higher in the group than in the group was the in of for or the percentage who to The patients who to and more and hospital to the the outcomes the were not than those the However, a higher additional surgical and more hospital the of late was a of this that an or a a et al. reported that patients with a shaft fracture with outcomes that were to those of patients who an The noted that to the of the fracture and the patient with results than external fixation and results than and performed after the injury a for a than did that was In et al. that the of and of soft-tissue did not the and the most complications were and et al. reported that patients treated with late after a injury reported higher of than did those who an during the or the after the These noted a high of for complications a high of and a high of surgical in the group stated that trauma an at of is in that in a The an rather than immediate for damage control orthopaedics approach to the it to that to be to The use of spanning external fixation, and and the a to and soft-tissue the bed to by of a system and from the and for treatment of an fracture with a to the are and that have been external fixation the for management of the fracture and a femoral traction for management of an fracture were also in this patient. isolated injury than a is a for a of damage control orthopaedics that have damage control injuries that are to this approach and fractures and fractures. These clinical usually a fracture or with a soft-tissue damage control orthopaedics is for soft-tissue complications by spanning the with an external fixator and avoiding of invasive can be performed at a when the condition of the is optimized. Orthopaedic of the most in damage control orthopaedics is the of the surgical and are not for definitive surgery. During this are and increased is study that multiply injured patients to definitive surgery and a increased inflammatory response with that in patients on and It was concluded in inflammatory to are This to the in clinical a higher incidence of multiple that have been In all patients have been with a treatment that a of clinical and parameters in the after the On the basis of this can be for of patients in the of an The treatment from for the use of damage control orthopaedics is on a and of whether the patient is or in for early total damage control orthopaedics, and intensive care of Damage Control Orthopaedics In the early 1990s, the approach in changed from definitive surgery in all patients to using an external fixator as a temporary to the fracture and out definitive internal In a retrospective were In the early total care and the for the treatment of a femoral shaft fracture was early definitive stabilization than In the 1990, and the for a femoral shaft fracture in a multiply injured patient at for complications changed from early definitive stabilization to early temporary fixation. In the damage control orthopaedics in the for such an injury in such a patient was early temporary stabilization by to intramedullary The of and respiratory distress were to be higher in the In during the patients who were treated with damage control orthopaedics a of respiratory distress than those treated with intramedullary of to of Fixation, with to of a in with Early Damage Control Orthopaedics intramedullary external fixation, intramedullary fixation are as the of patients with the percentage in early total care and damage control The of respiratory distress was with the damage control orthopaedics a intramedullary and external fixation with intramedullary of with Damage Control Orthopaedics The use of spanning external fixation the of In the in the of definitive intramedullary was not than that in studies of patients who intramedullary stabilization after external of are still but are when the duration of external fixation is on During the of Fracture in with Early Damage Control Orthopaedics of patients with a of patients. not for Damage Control Orthopaedics for spanning external fixation the use of an external fixation system that is and can be which can be can be with a for time can be by multiple on of the or on External fixation that can be In a system that in is so that of can be and Damage control orthopaedics is for an patient or a patient in and it has some for the patient as injury complexes for which damage control orthopaedics be considered are femoral fractures ring injuries with hemorrhage, and multiple injuries in patients. subgroups of multiply injured orthopaedic patients who benefit from damage control orthopaedics are those with a injury, or a of damage control orthopaedics damage control is a for the treatment of and in to to the of when orthopaedic surgeons use a damage control orthopaedics studies to the be to the of damage control orthopaedics in the treatment of patients who have sustained orthopaedic especially those with injuries to the and the of clinical trauma have approach to the treatment of orthopaedic patients with multiple injuries by the of damage control