Damage Control Orthopedics
Purpose of Review
This review focuses on the concept of damage control orthopedics (DCO), the staged procedure to prevent the multiple injury patients from additional unnecessary trauma by postponable extensive surgery.
The principles of damage control orthopedics are staged procedures and, in the first surgical step, the main principles are to stop the bleeding, to restore perfusion with a limited surgical burden, and to stop the contamination. Criteria for damage control orthopedics correspond those for damage control surgery in general, including hypothermia, evidence for persistent minor perfusion, and coagulation disorders.
Skeletal injuries are very common in multiple injury patients. However, most of these injuries have to be treated surgically, which may be time-consuming, cause further blood loss, increase hypothermia, and also results in an inflammatory response due to the surgical trauma. The concept of damage control orthopedics (DCO) is a staged procedure to prevent the multiple injury patients from additional unnecessary trauma by postponable extensive surgery. The article gives an overview about this concept including the indications and the available evidence.
KeywordsSkeletal injury Orthopedic trauma Damage control Damage control surgery
Compliance with Ethical Standards
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.• Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48(4):613–21. discussion 21–3. The referenced article introduces the concept of DCO in the international literature und and describes the bridging opportunities.CrossRefPubMedGoogle Scholar
- 3.• Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246(3):491–9. https://doi.org/10.1097/SLA.0b013e3181485750. discussion 9–501. The referenced article describes groups of patients which can profit from the concept of DCO.CrossRefPubMedPubMedCentralGoogle Scholar
- 4.• Harwood PJ, Giannoudis PV, van Griensven M, Krettek C, Pape HC. Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma. 2005;58(3):446–52. discussion 52–4. The article shows the difference in the inflammatory response using the concept of DCO instead of femoral nailing.CrossRefPubMedGoogle Scholar
- 5.Pape HC, Grimme K, Van Griensven M, Sott AH, Giannoudis P, Morley J, et al. Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. J Trauma. 2003;55(1):7–13. https://doi.org/10.1097/01.ta.0000075787.69695.4e.CrossRefPubMedGoogle Scholar
- 7.Pell AC, Christie J, Keating JF, Sutherland GR. The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. The Journal of Bone and Joint Surgery British Volume. 1993;75(6):921–5.CrossRefPubMedGoogle Scholar
- 10.•• Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma. 2005;19(8):551–62. The referenced article shows indicators which can be used in decision making unsing DCO.CrossRefPubMedGoogle Scholar
- 11.Rixen D, Sauerland S, Oestern HJ, Bouillon B. Management strategies in the first operative phase after long-bone injury of the lower extremity in multiple-injured patients. A systematic literature review. Unfallchirurg. 2005;108(10):829–38, 40-2. https://doi.org/10.1007/s00113-005-1012-2.CrossRefPubMedGoogle Scholar
- 12.Gandhi RR, Overton TL, Haut ER, Lau B, Vallier HA, Rohs T, et al. Optimal timing of femur fracture stabilization in polytrauma patients: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2014;77(5):787–95. https://doi.org/10.1097/ta.0000000000000434.CrossRefPubMedGoogle Scholar
- 13.Rixen D, Steinhausen E, Sauerland S, Lefering R, Meier M, Maegele MG, et al. Protocol for a randomized controlled trial on risk adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients. Trials. 2009;10:72. https://doi.org/10.1186/1745-6215-10-72.CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Steinhausen E, Bouillon B, Rixen D. Are large fracture trials really possible? What we have learned from the randomized controlled damage control study? Eur J Trauma Emerg Surg. 2017. https://doi.org/10.1007/s00068-017-0891-6.
- 15.Rixen D, Steinhausen E, Sauerland S, Lefering R, Maegele MG, Bouillon B, et al. Randomized, controlled, two-arm, interventional, multicenter study on risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple-trauma patients. Trials. 2016;17:47. https://doi.org/10.1186/s13063-016-1162-2.CrossRefPubMedPubMedCentralGoogle Scholar
- 19.Bliemel C, Lefering R, Buecking B, Frink M, Struewer J, Krueger A, et al. Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients. J Trauma Acute Care Surg. 2014;76(2):366–73. https://doi.org/10.1097/TA.0b013e3182aafd7a.CrossRefPubMedGoogle Scholar
- 21.•• Lubelski D, Tharin S, Como JJ, Steinmetz MP, Vallier H, Moore T. Surgical timing for cervical and upper thoracic injuries in patients with polytrauma. J Neurosurg Spine. 2017;27(6):633–7. https://doi.org/10.3171/2017.4.spine16933. The referenced article shows factors that influences the results managing spine fractures CrossRefPubMedGoogle Scholar
- 22.• Charles YP, Steib JP. Management of thoracolumbar spine fractures with neurologic disorder. Orthopaedics & Traumatology, Surgery & Research. 2015;101(1 Suppl):S31–40. https://doi.org/10.1016/j.otsr.2014.06.024. The referenced article shows factors that influences the results managing spine fractures CrossRefGoogle Scholar
- 24.Bumbasirevic M, Lesic A, Mitkovic M, Bumbasirevic V. Treatment of blast injuries of the extremity. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S77-S81.Google Scholar
- 32.Friemert B, Franke A, Bieler D, Achatz A, Hinck D, Engelhardt M. Treatment strategies for mass casualty incidents and terrorist attacks in trauma and vascular surgery : presentation of a treatment concept. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2017;88(10):856–62. https://doi.org/10.1007/s00104-017-0490-4.CrossRefPubMedGoogle Scholar
- 35.Vetter SY, Keil C, von Recum J, Wendl K, Grutzner PA, Franke J. Postoperative malrotation after closed reduction and intramedullary nailing of the femur: a retrospective 5-year analysis. Zeitschrift fur Orthopadie und Unfallchirurgie. 2014;152(5):498–503. https://doi.org/10.1055/s-0034-1383011.CrossRefPubMedGoogle Scholar