damage control orthopaedics by dr navin kr singh;aiims new delhidco
TRANSCRIPT
ModeratorDr Vijay Kumar
Co-ModeratorDr Venketish
PresenterDr Navin Singh
All India Institute of Medical Sciences
New Delhi
Objectives- Polytrauma
Historical perspetive
Introduction of DCO
Pathophysiology of DCO
Literature on DCO
Polytrauma As patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 times AIS score gt 2)
The Journal of Trauma and Acute Care Surgery [2014 77(4)620-623
To describe the overall condition of the pt many trauma scoring systems have been developed like-
1 Abbrevieted injury scale(AIS)
2 Injury severity scale(ISS)
3 Revised trauma score
4 Anatomic profile
5 Glasgow coma scale
ABBREVIATED INJURY SCALE(AIS)
AIS is an anatomical scoring system first introduced in 1969
Injuries are ranked on a scale of 1 to 6
with 1 being minor 5 severe and 6 a nonsurvivable injury
Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall
score for patients with multiple injuries
Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)
Only the highest AIS score in each body region is used
The 3 most severely injured body regions have their score squared and added together to produce the ISS score
The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75
Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship
Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Objectives- Polytrauma
Historical perspetive
Introduction of DCO
Pathophysiology of DCO
Literature on DCO
Polytrauma As patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 times AIS score gt 2)
The Journal of Trauma and Acute Care Surgery [2014 77(4)620-623
To describe the overall condition of the pt many trauma scoring systems have been developed like-
1 Abbrevieted injury scale(AIS)
2 Injury severity scale(ISS)
3 Revised trauma score
4 Anatomic profile
5 Glasgow coma scale
ABBREVIATED INJURY SCALE(AIS)
AIS is an anatomical scoring system first introduced in 1969
Injuries are ranked on a scale of 1 to 6
with 1 being minor 5 severe and 6 a nonsurvivable injury
Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall
score for patients with multiple injuries
Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)
Only the highest AIS score in each body region is used
The 3 most severely injured body regions have their score squared and added together to produce the ISS score
The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75
Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship
Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Polytrauma As patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 times AIS score gt 2)
The Journal of Trauma and Acute Care Surgery [2014 77(4)620-623
To describe the overall condition of the pt many trauma scoring systems have been developed like-
1 Abbrevieted injury scale(AIS)
2 Injury severity scale(ISS)
3 Revised trauma score
4 Anatomic profile
5 Glasgow coma scale
ABBREVIATED INJURY SCALE(AIS)
AIS is an anatomical scoring system first introduced in 1969
Injuries are ranked on a scale of 1 to 6
with 1 being minor 5 severe and 6 a nonsurvivable injury
Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall
score for patients with multiple injuries
Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)
Only the highest AIS score in each body region is used
The 3 most severely injured body regions have their score squared and added together to produce the ISS score
The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75
Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship
Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
To describe the overall condition of the pt many trauma scoring systems have been developed like-
1 Abbrevieted injury scale(AIS)
2 Injury severity scale(ISS)
3 Revised trauma score
4 Anatomic profile
5 Glasgow coma scale
ABBREVIATED INJURY SCALE(AIS)
AIS is an anatomical scoring system first introduced in 1969
Injuries are ranked on a scale of 1 to 6
with 1 being minor 5 severe and 6 a nonsurvivable injury
Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall
score for patients with multiple injuries
Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)
Only the highest AIS score in each body region is used
The 3 most severely injured body regions have their score squared and added together to produce the ISS score
The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75
Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship
Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
ABBREVIATED INJURY SCALE(AIS)
AIS is an anatomical scoring system first introduced in 1969
Injuries are ranked on a scale of 1 to 6
with 1 being minor 5 severe and 6 a nonsurvivable injury
Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall
score for patients with multiple injuries
Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)
Only the highest AIS score in each body region is used
The 3 most severely injured body regions have their score squared and added together to produce the ISS score
The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75
Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship
Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall
score for patients with multiple injuries
Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)
Only the highest AIS score in each body region is used
The 3 most severely injured body regions have their score squared and added together to produce the ISS score
The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75
Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship
Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75
Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship
Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship
Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Before 1950s The multi trauma patient-too sick for an operation
The surgical stabilization of the fractures of the long bones was not routinely performed
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Treatment preferred-cast and skeletal traction
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
1970- Studies shows that early stabilization of femoral
fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Late 1980- There is a beneficial effect of early stabilization of
fractures on both morbiditymortality and hospital stay
Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named
EARLY TOTAL CARE(ETC)
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest
J Trauma 198525375-84 J Trauma 199030792-8
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Early 1990 Outcome after ETC-increased incidence of ARDS and
MOF
Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma
J Trauma 199334540-8
J Bone Joint Surg [Br] 199981-B356-6120
This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
(ISS)gt25 Higher infammatory burden acute lung
injury and increased mortality rate
Some patients who are so severely injured that they
cannot tolerate long operations blood loss and
especially medullary canal manipulation without a
signifcant life threatening deterioration of pulmonary
function and overall homeostasis
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
ldquoDAMAGE CONTROL ERArdquo
Clinical Course-Three factors
1Trauma load(First hit)
2Biological response
3Treatment(Surgical LoadSecond hit)
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Damage Control Orthopaedics
-Damage control orthopaedics(DCO)is a strategy that
focuses on managing and stabilising major orthopae
dic injuries in selected polytrauma patients who are
in an unstable or extremis physiological state(1)
Its priorities are ndash
- control of haemorrhage
- provisional stabilisation of major skeletal fractures
-management of soft-tissue injuries
-minimising the degree of surgical insult to the patient
1 Injury Int J Care Injured (2009) 40S4 S47ndashS52
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Staged Treatment
Stage 1 early temporary external
fixation stabilization
Stage2
resuscitation of the patient in ICU and optimization of his
condition
Stage 3 delayed definitive
management of the fracture
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Physiology-
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
The cytokine response evidenced by fever leukocytosis
hyperventilation tachycardia commonly seen in injury is referred
to as systemic inflammatory response syndrome (SIRS)
This inflammatory reaction has been implicated in the
development of ARDS and MOF
Jbone jt surg199981(Br)256-61
J Trauma 2003557-13
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
First and second hit phenomenon
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Damage control philosophy in polytruma
Surg Cdr us Dadhwar Maj N Pathak
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Patients who have sustained orthopaedic trauma have been divided into four groups
-stable- Borderline- unstable and - in extremis
Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd
Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery
J Trauma 200253452-62
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Stable patients-ETC
Unstable and in extremis-DCO
Borderline-
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Basic strategies of DCO- Immediate and rapid stabilization of long bone
fractures typically with external fxation
Release of tight soft tissue compartments (compartment syndrome)
Reductions of dislocations
Surgical debridement of open wounds
Amputation in cases of unsalvageable extremities
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Treatment goals
Stop the ongoing injury
Facilitate patient care
Restore function
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Stop the ongoing injury
Remote organ injury occurs as a consequence
of musculoskeletal injury
Mediators
bull activated neutrophils
bull chemical mediators
bull fat emboli
bull marrow contents
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Remote organ injury
- long bone fractures
- Soft tissue injury
- Compartment syndrome
- Infection
- Ischemiareperfusion
Primay target lungs
Secondary targets gut kidney brain etc
Resultant injury is progressive ARDSMODS
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Stop the ongoing injury
Release compartments
Reduce dislocations
Debride open wounds
Stabilize long
bones
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Stabilize long bones
Splints amp traction
Ex-fix
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Splints amp traction
Best reserved for
Essentially stable
fractures
Isolated extremity fractures
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
ldquoExternal Fixator is a device uses for
stabilization and immobilization of long bone
open fracturesrdquo
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Minimally invasive operations
External fixation of femur ndash 35 minutes 90 ml blood loss
Intramedully nailing of femur -130 minutes 400 ml blood loss
Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo
JTrauma 200048 613-23
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
47
Biomechanics of External Fixator
Intrinsic stability of frame (S)
EX I
S = -----------
L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
48
Thus Stiffness is inversely proportional to the distance of the assembly from the bone
(closer the frame to bone -more stable assembly)
Biomechanics
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
49
Mechanics of Bone Pin Interface
To increase stability of bone ndashpin interface
1 Adequate no of pins in each fragments
( 2 for most bone amp 3 for femur)
2 Increase pin pitch
3 Increase size of pin
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Indications for Rapid Ex Fix
Patient in extremis
Massive open injury (degloving injury)
Vascular damagerepair
Mass casualities
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Patient in Extremis
Multiple other severe injuries
Extreme hypotension
Coagulopathy
Massive head injury
Aortic transection
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Early skeletal stabilization
Reduce blood loss
Minimize mediator release
Improve pulmonary
function
Decrease sepsis and
pain
Improved treatment
of head injured
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
Issues while applying DCO-1 Safety
2 Timing of definitive fixation
3 Is DCO associated with high rate of infection
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
They concluded that immediate external fixation followed by early closed
intramedullary nailing is a safe treatment method for fractures of the shaft the femur in
selected multiply injured patients
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days
When is the right time to perform secondary definitive surgery
In a study by Pape et al-compared two group having same ISS and GCS
group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6
group 2-late definitive surgery 5-8 days (157)
Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days