damage control orthopedics
TRANSCRIPT
Damage Control Orthopaedics
Definition
• is an approach that contains and stabilizes orthopaedic injuries so that the patient’s overall physiology can improve.
• purpose :
- avoid worsening of the patient's condition by the “second hit” of a major orthopaedic procedure
- delay definitive fracture repair until a time when the overall condition of the patient is optimized
Physiology
SIRS = systemic inflammatory response syndromeCARS = counter-regulatory anti-inflammatory response syndrome
The First and Second-Hit Phenomena
MODS = multiple organ dysfunction syndromeARDS = adult respiratory distress syndrome
Markers of Immune ReactivityGroup Examples
Interleukins (IL)IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-11, IL-12, IL-13, IL-18
Tumor necrosis factors (TNF) TNF, lymphotoxin (LT)
Interferons (IFN) IFN-alpha, IFN-beta, IFN-gamma
Colony stimulating factors (CSF) G-CSF, M-CSF, GM-CSF
• C-reactive protein, procalcitonin, TNF-α, IL-1, and IL-8 are not reliable markers
• IL-6 reliable index of the magnitude of systemic inflammation and correlates with the outcome
• IL-10 correlate with the initial degree of injury and persistently high levels of IL-10 correlate with sepsis.
• HLA-DR class-II molecules markers of immune reactivity and a predictor of outcome following trauma
• ratio of IL-6 to IL-10 correlate with injury severity after major trauma and is used to predict the degree of injury following trauma
• level of plasma DNA suggested as a potentially valuable prognostic marker for patients at risk
• at present, IL-6 and HLA-DR class-II molecules, accurately predict the clinical course and outcome after trauma.
Patient Selection for Damage Control Orthopaedics
• Patients who have sustained orthopaedic trauma are divided into :
a)Stable - local preferred method
b)Borderline - damage control orthopaedics often preferred
c) Unstable - damage control orthopaedics
d)In extremis - damage control orthopaedics
Clinical grading criteria ( Pape et al)
Injury complexes suitable for damage control orthopaedics
Femoral Fracture
• Femoral fractures in a multiply injured patient are not automatically treated with intramedullary nailing because :
- ‘second hit’- fat emboli• Patients with a chest injury are most prone to deterioration
after an intramedullary nailing procedure• Bilateral femoral fracture is associated with a higher
mortality rate and incidence of adult respiratory distress syndrome than is a unilateral femoral fracture
• Increase in mortality may be more closely related to associated injuries and physiologic parameters than to the bilateral femoral fracture itself
Pelvic Ring Injuries
• Exsanguinating haemorrhage associated with pelvic fracture
• Conditions where haemorrhage can be expected, when there is pelvic injury :
-Posterior pelvic ring injuries
-Anterior-posterior compression type III injuries, lateral compression injuries
-Pelvic fracture in patients over 55 years old
What is done?• Minimally invasive pelvic stabilisation- Pelvic binder- External fixator- Pelvic c-clamp- Pelvic stabilizer
• Angiography and embolisationIndications :1.Initial treatment of pelvic fractures associated with
hypotension that have not responded to the placement of a pelvic binder, external fixator, pelvic c-clamp, or pelvic stabilizer and transfusion of four units or more of blood
2. expanding retroperitoneal hematoma,3. a vascular blush seen on CT 4. a massive retroperitoneal hematoma observed on CT- Timing is important- Embolisation later than 3 hours after injury increased
risk of mortality-Average procedure time is 90 minutes
• Pelvic PackingIndication :1. Patient with severe hypotension and a pelvic fracture
that is unresponsive to other initial treatment measures, associated with imminent risk of death
Chest Injuries
Treatment of multiply injured patients with long bone fractures and a chest injury:
• early fracture stabilisation (within 48 hours)is safe and may be beneficial
• early fracture stabilisation is safe and maybe beneficial
Chest radiograph showing a ruptured left hemidiaphragm and femoral fracture in a multiply injured patient
Initial external fixation was performed at the time of the diaphragmatic repair
Staged intramedullary nailing was performed on post-injury day 2
Head Injuries• Early stabilisation doesn’t enhance or worsen the
outcome in patients with head injury.
Management :• Based on the individual clinical assessment and
treatment requirements• Damage control orthopaedics can provide temporary
osseous stability to an injured extremity, functioning as a temporary bridge to staged definitive osteosynthesis, without worsening the patient's head injury or overall condition.
• Aggressive management of intracranial pressure• Maintenance of cerebral perfusion pressure at >70 mm
Hg and intracranial pressure at <20 mm Hg
Mangled Extremities
• DCO approach to save the limb :
a) Spanning external fixator
b) Antibiotic bead pouches
c) Vacuum assisted wound closure
Antibiotic bead pouch for treatment of an open proximal tibial fracture
Isolated Complex Lower-Extremity Trauma
• “limb damage control orthopaedics”• Proximal tibial articular and metaphyseal
fractures, metaphyseal fractures, distal tibial pilon fractures
• Useful for preventing soft-tissue complications by spanning the articular segment with an external fixator and avoiding areas of future incisions.
• Then minimally invasive plate osteosynthesis can be performed at a stage when the condition of the soft tissue envelope is optimized.
When can secondary orthopaedic procedures be performed?
• Days 2, 3 and 4 are not safe ( marked immune reactions and increased generalised oedema)
• Days 6 to 8 less risk
The current treatment algorithm from Hannover, Germany, for the use of damage control orthopaedics. ER = emergency room, ABG = arterial blood gases, FAST = focused assessment sonography for trauma, I/O ratio = intake/output ratio, ABP = arterial blood pressure, IL-6 = interleukin-6