Damage control: extremities
Introduction
It has long been recognised that, in patients with severe abdominal injuries initial management should avoid complex operative procedures. Performed under emergency conditions, such interventions should be rapid and minimally traumatic to the patient. The primary focus is haemorrhage control and other life saving measures. Complex reconstructive work is delayed until the patient is better able to withstand the additional trauma. This approach was adopted in patients with extremity injuries as it became apparent that patients undergoing drawn out operations following major trauma suffered an excess of complications. Homeostatic anomalies, the systemic inflammatory response, multiple organ dysfunction and an increased mortality were observed.6., 9., 52.
Specific criteria have been developed, which should be fulfilled in order to apply this new concept (damage control orthopaedics, DCO) (Table 1).77
In the following document we discuss the potential advantages of applying damage control methodology to major extremity injuries.
Section snippets
Systemic impact of extremity injuries
All extremity fractures must be considered with the associated haemorrhage and local soft tissue injuries.28 The injury initiates a local inflammatory response with increased systemic concentrations of pro-inflammatory cytokines. Cytokine levels correlate with the degree of tissue damage and the incidence of osseous fractures. This suggests that injury plays a major role in determining the release of these pro-inflammatory mediators.28 Concentrations of inflammatory cytokines in injured tissue
The era of secondary fracture stabilization
Until the middle of the last century, early definitive fracture stabilization was performed only as an exception, as it was believed that multiply injured patients were too unstable to survive surgical intervention. Complex laboratory investigations and monitoring facilities were not available. Consequently estimation of the patient’s status was, on the whole, performed by clinical assessment only. Thus, complications were usually only identified in their late stages. Signs of MODS in the first
DCO: a current concept
The impact of surgery on the immune response that occurs in polytraumatised patients, in addition to that caused by the primary insult, has been clearly demonstrated.58 Sub-clinical consequences of the initial trauma and subsequent operative treatment are compound and manifest as abnormalities in organ function, leading to MODS. It is clear that the burden of the second hit should be minimised in multiple injured patients with a high risk of adverse outcome.
Different studies report favourable
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2020, InjuryCitation Excerpt :Modern day intramedullary nailing systems have now superseded traditional plating techniques. Benefits include reduced soft tissue stripping, reduced rates of infection, reduced incidence of non-union and improved biomechanical function [15,29,44]. Prospective clinical trials have found no significant effect of reamed versus un-reamed femoral nails on the incidence of ARDS and death. [14,15,22,29,43–45].