Elsevier

Injury

Volume 35, Issue 7, July 2004, Pages 678-689
Injury

Damage control: extremities

https://doi.org/10.1016/j.injury.2004.03.004Get rights and content

Abstract

The principles of fracture management in polytrauma patients continue to be of crucial importance. Over the last five decades, various strategies of fracture treatment in the multiply injured patient have evolved. The various new methodologies remain controversial. In the beginning, early surgical fracture treatment of long bone fractures after multiple trauma was not routinely advocated. It was believed that the polytraumatised patient did not have the physiological reserve to withstand prolonged operations. The introduction of standardised, definitive surgical protocols, led to the concept of early total care (ETC) in the 1980s. This concept was subsequently applied universally, in all patient groups, regardless of injury severity and distribution. Later, it became apparent that certain patients did not appear to benefit from ETC. Indeed, extended operative procedures, during the early phase of multiple trauma recovery, were associated with adverse outcome. This applied for patients with significant thoracic, abdominal and head injuries and those with high injury severity scores (ISS). In response, the concept of damage control orthopaedics (DCO) was developed in the 1990s. DCO methodology is characterised by primary, rapid, temporary fracture stabilization. Secondary definitive management follows, once the acute phase of systemic recovery has passed. We explore the processes underlying the systemic biological impact of fracture fixation, the evolution of operative treatment strategies for major fractures in polytrauma and the current trends toward staged management of these patients.

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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