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.

Damage control focuses

Control of hemorrhage

Management of soft tissue injury

Achievement of provisional fracture stability, while avoiding additional insults to the patient.

The term damage control was borrowed from a traditional Navy term and philosophy.

Temporary measures are used to limit further damage and stabilize the ship to allow for a thorough
assessment of the damage and development of a comprehensive strategy for definitive repair.

The advent of DCO in the late 1990s and early 2000s represented a major shift if philosophy for the
treatment of orthopedic injuries in severely injured trauma patients.

SLIDE 6???

Pada tahun 1980, pergeseran mayor terjadi pada penanganan fraktur tulang panjang di pasien dengan
multiply injured trauma
There is a beneficial effect of early stabilization of fractures on both mortality and morbidity and length
of hospital stay.

This new philosophy in the management of the patient with multiple injuries was named Early Total
Care (ETC).

SLIDE 8???

DCO is a surgical strategy that focuses on control of haemorrhage, soft tissue management, early
temporary fracture stabilization and optimization of the patient’s physiology, avoidance of the ‘second
hit’ and the triad of hypothermia, acidosis and coagulopathy

There has, for a relatively long period, been a debate over the management of the polytraumatized
patient. The two sides being early total care and damage control.

Early total care is the process whereby all skeletal injuries are treated definitively at the first surgical
intervention. This is sometimes possible but there is evidence to suggest that this approach may
increase the risk of adverse sequelae such as fat embolism, a worsening SIRS response and significant
increase in the incidence of adult respiratory distress syndrome (ARDS).

POLYTRAUMA

Polytrauma is a syndrome of multiple injuries exceeding a defined severity (ISS >= 17) with sequential
systemic reactions that may lead to dysfunction or failure of remote organs and vital systems, which
have not themselves been directly injured.
Stable patients have no immediatey life-threatening injuries and respond to initial therapy

Borderline patients have stabilized in response to initial resuscitative attempts but sustained injuries
that put them at risk of rapid deterioration.

Unstable patients remain hemodynamically unstable despite initial intervention and are at high risk for
clinical complicaions.

Patients in extremis have ongoing uncontrolled blood loss despite resuscitation and may die if blood loss
is not immediately stopped.
Borderline Patients

Polytrauma + ISS > 20 + thoracic trauma (AIS > 2)

Polytrauma + abdominal/pelvic trauma + hemorrhagic shock (initial SBP < 90 mmHg)

ISS > 40, without additional thoracic trauma

Initial mean pulmonary arterial pressure > 24 mmHg

Increase of pulmonary arterial pressure during intermedullary nailing of > 6 mmHg

Bilateral femoral fractures

Radiographic evidence of pulmonary contusion

Hypothermia (< 35 C)

Additional moderate or severe head injuries (AIS >= 3)

Early Total Care (ETC): a concept implying the primary definitive management of all major injuries within
24 hours after trauma.

Damage Control Orthopaedics (DCO): minimally invasive surgical techniques are used for the primary
stabilization of all major fractures. Based upon the patient’s physiological status, temporary stabilization
with external fixation for certain fractures is used.

PATOFISIOLOGI

Traumatic injury leads to systemic inflammation (SIRS) followed by a period od recovery mediated by a
counter-regulatory anti-inflammatory response.

Within this inflammatory process, there is a fine balance between the inflammation and the potential
for the process to cause and aggravate tissue injury, leading to ARDS dan MODS.

(GAMBAR)

The First and Second-Hit Phenomena

First hit phenomenon: The body response by stimulation of a variety of inflammatory mediators in the
immediate aftermath of trauma

IL-6 and HLA-DR class-II molecules (ICAM-1-e-selectin and CD11b), accurately predict the clinical course
and outcome after trauma.

The ratio of IL-6 to IL-10 was found to correlate with injury severity after major trauma, and this ratio
was recommended as a useful marker to predict the degree of injury following trauma

Second-hit:

Another trauma during the acute phase

 Major surgery
 Adverse event during ICU treatment
 Septic stimulus
SIRS Score
Heart rate > 90 beats / min
WBC count < 4000 cells/ mm3 OR > 12.000 cells/ mm3
RR > 20 x/ min or PaCO2 > 32 mm
Temperature < 36 or > 38

Interpretation
Score of 2 or more meets criteria for SIRS
The general aims and scopes for fracture management are:
Control of hemorrhage
Control of sources of contamination, removal of dead tissue
Prevention of ischemia-reperfusion injury
Pain relief
Facilitation of intensive care

Damage Control and Pelvic Ring Injuries

Exsanguinating hemorrhage is the major cause of death in multiply injured patients with pelvic
ring disruptions
Concomitant bowel injury places these fractures at high risk for infection and the need for
access to the abdomen for visceral or genitourinary system injuries may limit the treatment
options

Damage control treatment in pelvic ring injury

Sheet or pelvic binder, placed at the level of greater trochanters
External Fixator
C-Clamp
Iliosacral Screw
Sacral bar (in stable and borderline patients)
Angiography and embolization
(GAMBAR 3)

Damage Control treatment for long bones fractures

Long bones fractures in a multiply injured patient are not automatically treated with
intramedullary nailing because of concerns about the second-hit of such a procedure.
Patients with pulmonary injury should undergo undreamed nailing yo avoid increased risk of
ARDS
(GAMBAR)

Bilateral femoral fracture is a unique scenario in polytrauma that is associated with a higher
mortality rate and incidence of ARDS than is a unilateral femoral fracture
The use of external fixation as a temporizing measure allows for the advantages of rigid fixation
without the risk of hypotension and hypoxia associated with IMN in seriously injured patients

Dari 776 pasien dengan fraktur femur unilateral dan 118 pasien dengan fraktur femur bilateral,
pasien dengan fraktur femur bilateral memiliki skor ISS lebih tinggi (29.5) dibandingkan (25.7)
Ditemukan juga angka insidensi ARDS lebih tinggi sebesar 34.7% berbanding 20.6%, dan angka
mortalitas lebih tinggi sebesar 16.9% berbanding 9.4% (Kobbe et al., 2013)
Early fixation of long-bone fractures especially of the femoral shaft in polytrauma
Facilitation of nursing care
Early mobilization with improved pulmonary function
Shorter time on the ventilator
Reduced morbidity and mortality

External fixation of femur

35 minutes
90 ml blood loss
Intermedullary nailing of femur
130 minutes
400 ml blood loss
(Scales et al., 2000)
Damage Control in Spine Trauma
Spine trauma range from 13% to 30% of spinal injuties in polytraumatized patients
Injuries of the spine originate from motor vehicle accidents and incidentl as well as fall from
height in most cases
DCO adalah approach that contains and stabilizes orthopaedic injuries so that the patient’s overall
physiology can improve

In damage control for trauma patients, the main target is to perform temporary operative procedures to
provide time for physiologic stabilization before definitive surgical care

Acidosis, hypothermia, and coagulopathy are called The Lethal Triad

Measures to prevent and revert those triad are of priority

The use of external fixators, pelvic stabilization, and percutaneous pedicle screw fixation should be
considered in polytraumatized patients in the first 24 hours

Patients with multiple injuries are at high risk for developing posttraumatic systemic
immunoinflammatory responses with organ dysfunction, organ failure, and
death. Despite formal parameters (ISS, AIS, GCS, etc.) indicating the severity of
injury, there are currently no reliable parameters to exactly assess the trauma load
and predict its potential effect on the immune responses or its impact on the further
clinical course.
Early total care is obviously the optimal treatment strategy for orthopedic fracture
treatment. But what is uncertain is the impact of the surgical trauma caused by ETC
on the multiply injured individual. There is consensus that ETC should not be
applied in multiply injured patients with high injury severity score and signs of
hemorrhage, coagulopathy, hypothermia, acidosis with base excess, and metabolic
and organ-related disorders. Also, the complexity of fracture care by intramedullary
nailing must be taken into account when deciding the course of fracture treatment.
DCO has been proven to save time, prevent additional blood loss, and avoid
local complications in the later course. The simplicity of external fixation might
also influence the decision. It seems clear that patients with moderate injuries and
stable conditions should undergo ETC.

In order to assess the clinical condition more precisely, a new patient category has
been added to the three existing classes (stable, unstable, in extremis) [79]. The
term “borderline” has been coined to describe a patient who is in apparently stable
condition preoperatively, but who deteriorates unexpectedly and may develop organ
dysfunction [79]. Once initial assessment and intervention is complete, patients can
be separated into one of these four categories in order to guide the subsequent
approach to their care.
This assessment is done on the basis of overall injury severity, the presence of
specific injuries, and current hemodynamic status as detailed above [79]. Any deterioration
in the clinical state or physiological parameters should prompt rapid reassessment
and adjustment of management approach as appropriate [8].
Achieving end points of resuscitation is of paramount importance for the classification
of the patient into the appropriate category. End points of resuscitation
include: stable hemodynamics, stable oxygen saturation, lactate level <2 mmol/L,
no coagulation disturbances, normal temperature, urinary output >1 mL kg/h, and
no requirement for inotropic support
The management of a polytrauma patient with a significant head injury represents one of the most complicated
clinical scenarios encountered by the trauma team. However, it provides an opportunity to implement innovative and
imaginative management strategies that require communication, coordination, and flexibility among the involved
subspecialties. Primary intracranial pathologies need to be treated aggressively, and secondary injuries need to be
avoided. Head injuries, spine injuries, orthopedic injuries, and craniofacial injuries with CSF leaks need to be
assessed and treated simultaneously if possible. The definitive treatment of the extra-cranial injuries can often be
delayed, with the initial therapy designed to stabilize spine, pelvis, and long bone injuries as well as to repair CSF
leaks associated with cranial facial injuries. This facilitates management in the ICU and helps prevent pulmonary
complications, which are a major source of morbidity and mortality. Additionally, neurocritical care, provided in the
ICU, needs to be extended to the OR to avoid secondary brain injury. Subsequently, with stabilization and
improvement of the head injury, the extra-cranial injuries can be readdressed.

Bone LB, Johnson KD, Weigert J, Scheinberg R. Early versus delayed

stabilization of fractures: a prospective randomized study. J Bone Joint
Surg [Am] 1989; 71-A: 336e40.
Brazzel C. Thromboelastography-guided transfusion therapy in the trauma
patient. AANA J 2013 Apr; 81: 127e32.
Fries CA, Midwinter Mark J. Trauma resuscitation and damage control
surgery. Surgery 2010; 28: 563e7.
Giannoudis PV. Surgical priorities in damage control in poly trauma.
J Bone Joint Surg [Br] 2003; 85-B: 478e83.
Giannoudis PV, Giannoudi M, Stavlas P. Damage control orthopaedics:
lessons learned. Injury 2009 Nov; 40(suppl 4): S47e52.
Ratto N. Early total care versus damage control: current concepts in the
orthopedic care of polytrauma patients. ISRN Orthopedics 2013; 2013:
9. Article ID 329452.
Roberts Craig S, Pape Hans-Christoph, Jones Alan L, Malkani Arthur L,
Rodriguez Jorge L, Giannoudis Peter V. Damage control orthopaedics
evolving concepts in the treatment of patients who have sustained
orthopaedic trauma. J Bone Joint Surg Am 2005 Feb; 87: 434e49.