Damage Control

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2005;87:434-449. J Bone Joint Surg Am.
Giannoudis
Craig S. Roberts, Hans-Christoph Pape, Alan L. Jones, Arthur L. Malkani, Jorge L. Rodriguez and Peter V.

Patients Who Have Sustained Orthopaedic Trauma
Damage Control Orthopaedics. Evolving Concepts in the Treatment of
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The Journal of Bone and Joint Surgery
,
THE JOURNAL OF BONE & JOI NT SURGERY J BJ S. ORG
VOLUME 87-A NUMBER 2 FEBRUARY 2005
DAMAGE CONTROL
ORTHOPAEDI CS
Damage Control
Orthopaedics
EVOLVING CONCEPTS IN THE TREATMENT OF PATIENTS
WHO HAVE SUSTAINED ORTHOPAEDIC TRAUMA
BY CRAIG S. ROBERTS, MD, HANS-CHRISTOPH PAPE, MD, ALAN L. JONES, MD, ARTHUR L. MALKANI, MD,
JORGE L. RODRIGUEZ, MD, AND PETER V. GIANNOUDIS, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Many orthopaedic patients who have
sustained multiple injuries benefit from
the early total care of major bone frac-
tures. However, the strategy is not the
best option, and indeed might be harm-
ful, for some multiply injured patients.
Since foregoing all early surgery is not
the optimal approach for those patients,
the concept of damage control ortho-
paedics has evolved. Damage control
orthopaedics emphasizes the stabiliza-
tion and control of the injury, often
with use of spanning external fixation,
rather than immediate fracture repair.
The concept of damage control ortho-
paedics is not new; it has evolved out of
the rich history of fracture care and ab-
dominal surgery. This article traces the
roots of damage control orthopaedics,
reviews the physiologic basis for it, de-
scribes the subgroups of patients and
injury complexes that are best treated
with damage control orthopaedics, re-
ports the early clinical results, and pro-
vides a rationale for modern fracture
care for the multiply injured patient.
Definition of Damage
Control Orthopaedics
Damage control orthopaedics is an ap-
proach that contains and stabilizes or-
thopaedic injuries so that the patients
overall physiology can improve. Its pur-
pose is to avoid worsening of the pa-
tients condition by the second hit of a
major orthopaedic procedure and to
delay definitive fracture repair until a
time when the overall condition of the
patient is optimized. Minimally invasive
surgical techniques such as external fix-
ation are used initially. Damage control
focuses on control of hemorrhage,
management of soft-tissue injury, and
achievement of provisional fracture sta-
bility, while avoiding additional insults
to the patient.
History of Fracture Surgery
and Birth of Damage Control
Orthopaedics
We previously stated that: Informa-
tion illustrating the benefits of fracture
stabilization after multiple trauma has
been gathering for almost a century.
1

We also noted that during this time
fears of the fat embolism syndrome
also dominated the philosophy in man-
aging polytrauma patients. Early ma-
nipulation of long-bone fractures was
considered unsafe
2
.
External fixation, an essential
component of damage control ortho-
paedics, developed slowly and was out-
paced by the development of internal
fixation. In Switzerland in 1938, Roul
Hoffmann produced an external fixator
frame that allowed the fracture to be
mechanically manipulated and re-
duced
3
. In 1942, Roger Anderson advo-
cated castless ambulatory treatment of
fractures with use of a versatile linkage
system, but the device was banned in
World War II for being too elaborate
3
.
In 1950, a survey by the Committee on
Fractures and Traumatic Surgery of the
American Academy of Orthopaedic
Surgeons (AAOS) concluded that the
complications of external fixation fre-
quently exceed any advantages of the
procedure
3
. Also in 1950, Gavril Abra-
movich Ilizarov developed the ring sys-
tem for fractures and deformities, but
his device did not reach the West until
the late 1970s. On March 15, 1958,
Maurice Mller, Hans Willenegger, and
Martin Allgwer convened a group of
interested Swiss general and ortho-
paedic surgeons, including Robert
Schneider and Walter Bandi at the Kan-
tonsspital, Chur, Switzerland, to dis-
cuss the status of fracture treatment,
which usually included traction and
prolonged bed rest and led to poor
functional results in a high percentage
of patients
4
. On November 6, 1958,
these pioneering surgeons established
,,
DAMAGE CONTROL
ORTHOPAEDI CS
the Arbeitsgemeinschaft fr Osteosyn-
thesefragen (the Association for the
Study of Internal Fixation, or ASIF), or
AO, in Biel, Switzerland
4
. The key ob-
jective of the AO was the early restora-
tion of function, whether a patient was
being treated for an isolated fracture or
for multiple injuries
4
. Matter noted that
this strategy led to aggressive trauma-
tology involving early total care of the
trauma victim, culminating in the state-
ment: This patient is too sick not to be
treated surgically.
4
By the 1980s, the accepted care of
a major fracture was early or immediate
fixation
5
. Substantiating this approach
were eleven studies (ten retrospective
and one prospective), with the one by
Bone et al.
6
being most frequently cited.
Bone et al. reported that the incidence
of pulmonary complications (adult res-
piratory distress syndrome, pneumonia,
and fat embolism) was higher and the
stays in the hospital and the intensive
care unit were increased when femoral
fixation was delayed.
In 1990, Border reported on a
comprehensive study of patients with
blunt trauma that challenged the ac-
cepted practice of immediate definitive
fixation
7
. This changed practice in the
early 1990s, and a more selective ap-
proach to fracture fixation was used;
however, early fixation was still per-
formed in most cases. During the
1990s, more was learned about the pa-
rameters associated with adverse out-
comes in multiply injured patients and
about the systemic inflammatory re-
sponse to trauma
8
. It became clear that
fracture surgery, especially intramedul-
lary nailing, has systemic physiologic ef-
fects. These effects became known as
the second hit phenomenon.
The era of damage control ortho-
paedics started around 1993. Two re-
ports from one institution
9,10
described
temporary external fixation of femoral
shaft fractures in severely injured pa-
tients. From 1989 to 1990, the fre-
quency of using temporary external
fixation increased from <5% to >10%.
The mean duration of external fixation
until intramedullary nailing was less
than one week. Compared with patients
treated with immediate definitive fixa-
tion, those treated initially with external
fixation had more severe injuries, with
higher injury severity scores and trans-
fusion requirements in the initial
twenty-four hours. The term damage
control began to be used in the ortho-
paedic literature over the last six to
seven years
1,9-12
.
History of Abdominal
Damage Control Surgery
The concept of damage control surgery
was developed first in the field of
abdominal surgery. The benefits of
controlling hemorrhage and contami-
nation and leaving the abdomen open,
in lieu of definite repair of injuries and
closure of the abdomen, improved the
survival of patients with the lethal triad
of hypothermia, acidosis, and coagul-
opathy. Abdominal damage control
surgery was described as the sum total
of all maneuvers required to ensure sur-
vival of a multiply injured patient who
was exsanguinating; its purpose was to
control rather than definitely repair
injuries
13
.
In the 1940s and 1950s, Arnold
Griswold, of Kentucky, used a damage
control approach to penetrating inju-
ries of the abdominal cavity
14
. In 1981,
Feliciano et al. reported that nine of ten
patients who had undergone hepatic
packing for the treatment of exsan-
guinating hemorrhage survived
15
. Stone
et al., in 1983, described a stepwise
approach involving intra-abdominal
packing and a laparotomy that was ter-
minated rapidly
16
. In 1992, Burch et al.
reported a 33% survival rate in a group
of 200 patients treated with abbreviated
laparotomy and a planned reopera-
tion
17
. Rotondo and Zonies, in 1993,
coined the term damage control and
reported a 58% rate of survival of pa-
tients treated with a standardized
protocol
18
. In short, the concept of dam-
age control was first used in abdominal
surgery to describe a systematic three-
phase approach designed to disrupt a
lethal cascade of events leading to death
by exsanguination
13
. Phase one in-
volved an immediate laparotomy to
control hemorrhage and contamina-
tion
18
. Phase two was resuscitation in
the intensive care unit with improvement
of hemodynamics, rewarming, correc-
tion of coagulopathy, ventilatory sup-
port, and continued identification of
injuries. Phase three consisted of a reop-
eration for removal of intra-abdominal
packing, definitive repair of abdominal
injuries, and closure and possible re-
pair of extra-abdominal injuries. Dam-
age control surgery in the abdomen has
gained widespread acceptance through-
out North America and Israel
18,19
.
Physiology of Damage
The physiologic basis of damage con-
trol orthopaedics is beginning to be
understood. Traumatic injury leads
to systemic inflammation (systemic
inflammatory response syndrome)
followed by a period of recovery medi-
ated by a counter-regulatory anti-
inflammatory response (Fig. 1)
20
. Se-
vere inflammation may lead to acute
organ failure and early death after an
injury. A lesser inflammatory response
followed by an excessive compensatory
anti-inflammatory response syndrome
may induce a prolonged immunosup-
pressed state that can be deleterious to
the host. This conceptual framework
may explain why multiple organ dys-
function syndrome develops early after
trauma in some patients and much later
in others.
Within this inflammatory pro-
cess, there is a fine balance between the
beneficial effects of inflammation and
the potential for the process to cause
and aggravate tissue injury leading to
adult respiratory distress syndrome
and multiple organ dysfunction syn-
drome. The key players in the host re-
sponse appear to be the cytokines, the
leukocytes, the endothelium, and sub-
sequent leukocyte-endothelial cell
interactions
21
. Reactive oxygen species,
eicosanoids, and microcirculatory dis-
turbances also play pivotal roles
22
. The
development of this inflammatory re-
sponse and its subsequent, often fatal
consequences are part of the normal
response to injury.
When the initial massive injury
and shock give rise to an intense sys-
temic inflammatory syndrome with the
potential to cause remote organ injury,
,o
DAMAGE CONTROL
ORTHOPAEDI CS
this one hit can cause an excessive in-
flammatory response that activates the
innate immune system, including mac-
rophages, leukocytes, natural killer
cells, and inflammatory cell migration
enhanced by interleukin-8 (IL-8) pro-
duction and complement components
(C5a and C3a). When the stimulus is
less intense and would normally resolve
without consequence, the patient is vul-
nerable to secondary inflammatory in-
sults that can reactivate the systemic
inflammatory response syndrome and
precipitate late multiple organ dysfunc-
tion syndrome. The second insult may
take many forms as a result of a variety
of circumstances, such as sepsis and
surgical procedures, and is the basis for
the decision-making process regarding
when and how much to do for a bor-
derline multiply injured patient (as
will be defined later). Hyperstimula-
tion of the inflammatory system, by
either single or multiple hits, is consid-
ered by many to be the key element in
the pathogenesis of adult respiratory
distress syndrome and multiple organ
dysfunction syndrome
23
.
The First and Second-Hit
Phenomena
Numerous studies have demonstrated
that stimulation of a variety of inflam-
matory mediators takes place in the im-
mediate aftermath of trauma
24-27
. This
response initially corresponds to the
first-hit phenomenon
25
. Hoch et al. re-
ported elevation in plasma concentra-
tions of IL-6 and IL-8 in patients with
an injury severity score of 25 points
28
.
An immediate increase in expression of
neutrophil L-selectin was reported in
patients with an injury severity score of
16 points
29
. Similarly, a significant (p <
0.05) increase in the expression of the
integrin CD11b was noted in more se-
verely injured patients
29
. The develop-
ment of multiple organ dysfunction
syndrome has also been associated with
a persistent elevation of CD11b expres-
sion on both neutrophils and lympho-
cytes for 120 hours, a finding that is
suggestive of neutrophil activation in
the early development of leukocyte-
mediated end-organ injury. Several
other studies have clearly demonstrated
the effect of injury severity on the de-
gree of stimulation of the inflamma-
tory markers
8,30
.
While selective immunostimula-
tion may play a critical role in the devel-
opment of severe complications after
injuries, it is also clear that the govern-
ing effect of surgical or accidental
trauma on immune function is immu-
nosuppression. Several authors have
demonstrated the immunosuppressive
effect of trauma
31,32
. Following trauma,
the production of immunoglobulins
and interferon decreases and many pa-
tients become anergic, as assessed with
delayed hypersensitivity skin-testing,
and are thus exposed to an increased
risk of posttraumatic sepsis
33
. Defects in
neutrophil chemotaxis, phagocytosis,
lysosomal enzyme content, and respira-
tory burst have also been reported. Im-
munosuppression contributes to the
etiology of infection and sepsis after
trauma
34
.
The biological profile of the first
hit in trauma patients is being defined.
Obertacke et al. demonstrated the im-
portance of the first hit by using bron-
chopulmonary lavage to assess changes
in pulmonary microvascular perme-
ability in patients who had sustained
multiple trauma
35
. The permeability of
the pulmonary capillaries increased
following multiple trauma, and patients
in whom adult respiratory distress
syndrome later developed had a high
correlation (r = 0.81) with increased
permeability within just six hours after
admission than did those who had had
an uneventful recovery. The develop-
ment of a massive immune reaction in a
patient with bilateral femoral fracture
who showed a massive inflammatory
reaction, which was subsequently hy-
perstimulated by the surgical proce-
dure itself (bilateral reamed femoral
nailing), further supports the impor-
tance of the first-hit phenomenon
36
. Al-
though there was no obvious additional
risk factor present (i.e., no chest in-
jury), the patient died from full-blown
adult respiratory distress syndrome
three days after the injury. This case not
only clearly illustrates the existence of
biological variation in the inflamma-
tory response to injury, but also con-
firms the importance of the degree of
Fig. 1
After trauma, there is a balance between the systemic inflammatory response and the counter-
regulatory anti-inflammatory response. Severe inflammation can lead to acute organ failure and
early death. A lesser inflammatory response coupled with an excessive counter-regulatory anti-
inflammatory response may also induce a prolonged immunosuppressed state that can be dele-
terious to the host. SIRS = systemic inflammatory response syndrome, and CARS = counter-
regulatory anti-inflammatory response syndrome.
,,
DAMAGE CONTROL
ORTHOPAEDI CS
the response to the first hit and the re-
sponse to the second (surgical) hit that
created the final fatal event. The above
studies suggest that the degree of the
initial injury is important in determin-
ing a patients susceptibility to posttrau-
matic complications.
The concept that a secondary sur-
gical procedure creates an additional in-
flammatory insult (a second hit) was
specifically addressed in a prospective
study of 106 patients with an average
injury severity score of 40.6 points
37
.
Forty patients in whom respiratory, re-
nal, or hepatic failure developed, alone
or in combination, following a second-
ary surgical procedure were compared
with patients in whom no such compli-
cations developed. There was a signifi-
cant (p < 0.05) elevation of the
neutrophil elastase and C-reactive pro-
tein levels and a reduction in the plate-
let counts in the forty patients with
systemic complications. Abnormality of
those three parameters predicted post-
operative organ failure with an accuracy
of 79%
37
.
The first and second-hit phenom-
ena in trauma patients were demon-
strated in a study in which femoral
nailing was considered to be the second
hit (Fig. 2)
8
. That study demonstrated
similar responses to reamed and un-
reamed nailing in terms of neutrophil
activation, elastase release, and expres-
sion of adhesion molecules. These con-
cepts of biological responses to different
stimuli (first and second hits) have now
become the basis of our treatment plans
and illustrate the impact of the opera-
tive procedure on trauma patients at
risk for exhaustion of their biological
reserve (Fig. 3).
Markers of Immune Reactivity
Inflammatory markers may hold the
key to identifying patients at risk for the
development of posttraumatic compli-
cations such as multiple organ dysfunc-
tion syndrome (Table I). Common
serum markers can be divided into
markers of mediator activity such as C-
reactive protein, tumor necrosis factor-
(TNF-), IL-1, IL-6, IL-8, IL-10, and
procalcitonin and markers of cellular
activity such as CD11b surface receptor
on leukocytes, endothelial adhesion
molecules (intercellular adhesion mole-
cule-1 [ICAM-1] and e-selectin), and
HLA-DR class-II molecules on periph-
eral mononuclear cells.
C-reactive protein, procalcitonin,
TNF-, IL-1, and IL-8 have not been
shown to be reliable markers
38-43
. How-
ever, IL-6 correlates well with the degree
of injury, appears to be a reliable index
of the magnitude of systemic inflamma-
tion, and correlates with the outcome
12
.
IL-10 inhibits the activity of TNF- and
IL-1, and the levels detectable in the cir-
culation correlate with the initial degree
of injury. Persistently high levels of IL-
10 also correlate with sepsis. However,
its role in predicting outcome is still
debatable
44
.
Regarding the markers of cellular
activity, mixed results have been re-
ported in the literature about the effi-
cacy of endothelial adhesion molecules
(ICAM-1 and e-selectin) and the
CD11b receptor of leukocytes
45
. HLA-
DR class-II molecules mediate the pro-
cessing of antigen to allow for cellular
immunity. They are considered to be re-
liable markers of immune reactivity and
a predictor of outcome following
trauma
46,47
.
Napolitano et al. reported that
the severity of the systemic inflamma-
Fig. 2
Mean plasma elastase concentrations (and 95% confidence intervals) before and after intramed-
ullary nailing of the femur from the time of admission to the emergency room (A&E) to 168 hours
after surgery
8
. The control group is shown by the dotted line. Ind = induction of anesthesia, and
Nail Ins. = nail insertion. (Reprinted, with permission, from Giannoudis PV, Smith RM, Bellamy
MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and
unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br.
1999;81:359.)
TABLE I Cytokines That Are Important Inflammatory Mediators
Group 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
,8
DAMAGE CONTROL
ORTHOPAEDI CS
tory response syndrome at admission
may be an accurate predictor of mortal-
ity and the length of stay in the hospital
by trauma patients
48
. In another study,
the ratio of IL-6 to IL-10 was found to
correlate with injury severity after ma-
jor trauma, and this ratio was recom-
mended as a useful marker to predict
the degree of injury following trauma
49
.
The level of plasma DNA has been
found to increase after major trauma
and has also been suggested as a poten-
tially valuable prognostic marker for
patients at risk
50
.
It appears that, at present, only
two markers, IL-6 and HLA-DR class-II
molecules, accurately predict the clini-
cal course and outcome after trauma.
IL-6 measurement has already been im-
plemented as a routine laboratory test
in several trauma centers. Because of
the additional laboratory processing re-
quired for tests of HLA-DR class-II
molecules (antibody staining of cells
and flow cytometric analysis), the use of
such tests has not found great clinical
acceptance.
Genetic Predisposition and
Adverse Outcomes
Biological variation and genetic predis-
position are increasingly mentioned as
explanations of why serious posttrau-
matic complications develop in some
patients and not in others
51
. Some indi-
viduals may be preprogrammed to
have a hyperreaction to a given trau-
matic insult. Genetic polymorphism of
the neutrophil receptor for immuno-
globulin G, CD16, has been reported
and is associated with functional differ-
ences in neutrophil phagocytosis
52
. An
inherited predisposition toward high or
low levels of HLA-DR expression is fur-
ther evidence of a genetic component in
the immune response to injury
46
.
Additional evidence of genetic
predisposition is found in the cytokine
genes. The single base pair polymor-
phism at position 308 in the TNF gene
was associated with an increased inci-
dence of sepsis and with a worse out-
come after major trauma, postoperative
sepsis, and sepsis in a medical intensive
care unit
53-55
. This association depends
on the presence of the TNF2 allele. Ho-
mozygosity for the TNFB2 allele is asso-
ciated with an increased incidence of
severe sepsis and a worse outcome. The
risk of posttraumatic sepsis developing
is 5.22 times higher in patients who are
homozygous for TNFB2
56
. Homozy-
gous patients also have higher circulat-
ing TNF- concentrations and higher
multiple organ dysfunction syndrome
scores compared with heterozygotes
57
.
IL-6 polymorphisms have been
reported and were detected in both the
3 and the 5 flanking regions and exon
5
58,59
. The SfaNI polymorphism is lo-
cated at position 174. A homozygotic
constellation of this polymorphism
coincided with decreased IL-6 serum
levels during inflammation
60,61
. Poly-
morphisms in the IL-10 gene have also
been demonstrated
62
. Eskdale et al.
reported that stimulation of human
blood cultures with bacterial li-
popolysaccharide showed large inter-
individual variation in IL-10 secretion
63
.
They concluded that the ability to se-
crete IL-10 can vary in humans accord-
ing to the genetic composition of the
IL-10 locus.
Recently, isolated case reports of
germline defects in the cellular receptor
for interferon-gamma (IFN-) were
described, and the mutations were
characterized
64,65
. Davis et al. conducted
a pilot study of thirty-eight patients
who had sustained blunt trauma and
found that the microsatellite polymor-
phism AA correlated strongly with
infection
66
. These findings portend
polymorphism in the receptor itself and
thus represent a genetic basis for the de-
velopment of the infection.
Early identification of patients at
risk for adverse outcomes and compli-
cations may allow directed intervention
with biological response modifiers in
order to improve morbidity and mor-
tality rates. Use of biochemical and ge-
netic markers to identify patients at
risk after orthopaedic trauma may fa-
cilitate clinical decision-making regard-
ing when to switch from early total care
to damage control orthopaedics.
Patient Selection for
Damage Control Orthopaedics
Because biomechanical and genetic
testing is currently not practical, it re-
mains a clinical decision when to shift
from early total care to damage control
orthopaedics. Which patient should be
treated with damage control ortho-
paedics instead of early total care after
orthopaedic trauma should be decided
on the basis of the patients overall
physiologic status and injury com-
plexes. Many trauma scoring systems
Fig. 3
The two-hit theory is shown schematically. The first hit is the initial traumatic event, and the sec-
ond hit is the definitive orthopaedic procedure, usually femoral nailing. MODS = multiple organ
dysfunction syndrome, and ARDS = adult respiratory distress syndrome.
,,
DAMAGE CONTROL
ORTHOPAEDI CS
(e.g., the abbreviated injury scale
67
, in-
jury severity score
68,69
, revised trauma
score
70
, anatomic profile
71
, and Glasgow
coma scale
72
) have been developed in an
attempt to describe the overall condi-
tion of the trauma patient. However,
Bosse et al.
73
noted that there is no
score that assists in decision-making
during the acute resuscitation phase.
Therefore, it may be that one cannot
rely exclusively on a scoring system.
Additional data must be synthe-
sized, and the overall status of the pa-
tient should be stratified into one of
four categories. Patients who have sus-
tained orthopaedic trauma have been
divided into four groups: stable, bor-
derline, unstable, and in extremis
74
. Sta-
ble patients, unstable patients, and
patients in extremis are fairly easy to de-
fine. Stable patients should be treated
with the local preferred method for
managing their orthopaedic injuries.
Unstable patients and patients in extre-
mis should be treated with damage con-
trol orthopaedics for their orthopaedic
injuries. Borderline patients are more
difficult to define. One of us (H.-C.P.)
and colleagues defined them as patients
with polytrauma and an injury severity
score of >40 points in the absence of
thoracic injury, or an injury severity
score of >20 points with thoracic in-
jury (an abbreviated injury score of >2
points); polytrauma with abdominal
trauma (a Moore score
75
of >3 points); a
chest radiograph showing bilateral lung
contusions; an initial mean pulmonary
artery pressure of >24 mm Hg; or an in-
crease in pulmonary artery pressure of
>6 mm Hg during nailing (Table II)
74
.
Borderline orthopaedic trauma pa-
tients are probably best treated with
damage control orthopaedics.
The term borderline patient
describes a predisposition for
deterioration
74
. Among other factors,
thoracic trauma appears to play a cru-
cial role in this predisposition. How-
ever, whether femoral fractures in
patients with chest trauma should be
treated with definitive stabilization or
should be stabilized with a temporary
external fixator remains a subject of de-
bate. The clinical situation, including
the presence or absence of a criterion
indicating borderline status (Table II)
and factors associated with a high risk
of adverse outcomes (Table III), should
determine how the patient is treated. In
Louisville, some of the additional clini-
cal criteria that we have used as a basis
for shifting to damage control ortho-
paedics include a pH of <7.24, a tem-
perature of <35C, operative times of
more than ninety minutes, coagulopa-
thy, and transfusion of more than ten
units of packed red blood cells. Further-
more, certain specific orthopaedic in-
jury complexes appear to be more
amenable to damage control ortho-
paedics; these include, for example,
femoral fractures in a multiply injured
patient, pelvic ring injuries with exsan-
guinating hemorrhage, and poly-
trauma in a geriatric patient.
Femoral Fractures
Femoral fractures in a multiply injured
patient are not automatically treated
with intramedullary nailing because of
concerns about the second hit of such a
procedure. In addition to the second
hit, which results in an additional sys-
temic inflammatory response, embolic
fat from use of instrumentation in the
medullary canal will worsen the pulmo-
nary status. Patients with a chest injury
(an abbreviated injury score of >2
points) are most prone to deterioration
after an intramedullary nailing
procedure
76
.
Bilateral femoral fracture is a
unique scenario in polytrauma that is
associated with a higher mortality rate
and incidence of adult respiratory dis-
tress syndrome than is a unilateral fem-
oral fracture
77
. Copeland et al. noted
that the increase in mortality may be
more closely related to associated inju-
ries and physiologic parameters than to
the bilateral femoral fracture itself
77
. Wu
and Shih
78
noted that bilateral femoral
fracture indicates severe systemic and
local injuries. Thus, such injuries are
ideal for damage control orthopaedics.
Pelvic Ring Injuries
Exsanguinating hemorrhage associated
with pelvic fracture is another injury
complex suitable for damage control
orthopaedics. Hemorrhage can result
from a combination of osseous, venous,
and arterial bleeding. Although the
most common arterial injuries involve
the internal iliac artery or its branches
(e.g., the superior gluteal artery), inju-
ries to the common and external iliac
arteries have been reported and are as-
sociated with a poor outcome
79
. The
specific radiographic pattern of the pel-
vic ring injury and the mechanism of
the injury can help one to anticipate the
amount of bleeding, but there is no pre-
cise injury pattern that predicts hemor-
rhage consistently. An additional
complicating factor can be the presence
of a pelvic binder put in place by emer-
gency medical responders, as it may de-
crease the pelvic volume, realign the
pelvic ring, and contribute to a benign-
looking pelvic radiograph.
There are nonetheless some con-
sistent findings associated with a higher
likelihood of hemorrhage. Posterior
pelvic ring injuries are associated with a
two to threefold increase in blood re-
placement requirements compared with
anterior injuries
80,81
. Anterior-posterior
compression type-III injuries and lat-
TABLE II Clinical Parameters Used in Hannover, Germany, to Define the
Borderline Patient for Whom Damage Control Orthopaedics
Is Often Preferred
Polytrauma + injury severity score of >20 points and additional thoracic trauma
(abbreviated injury score >2 points)
Polytrauma with abdominal/pelvic trauma (Moore score
75
>3 points) and hemorrhagic
shock (initial blood pressure <90 mm Hg)
Injury severity score of 40 points in the absence of additional thoracic injury
Radiographic findings of bilateral lung contusion
Initial mean pulmonary arterial pressure of >24 mm Hg
Increase of >6 mm Hg in pulmonary arterial pressure during intramedullary nailing
o
DAMAGE CONTROL
ORTHOPAEDI CS
eral compression injuries are associated
with a high prevalence of vascular in-
jury (22% and 23%, respectively)
82
. Fi-
nally, pelvic fractures in patients over
fifty-five years old are more likely to
produce hemorrhage and require
angiography
83
.
The main controversy regarding
the treatment of patients with profuse,
exsanguinating hemorrhage relates to the
role of angiography and embolization.
In North America, both are most com-
monly utilized in the initial treatment of
pelvic fractures with associated hypoten-
sion that have not responded to the
placement of a pelvic binder, external fix-
ator, pelvic c-clamp, or pelvic stabilizer
and transfusion of four units or more of
blood. Additional indications for angiog-
raphy are an expanding retroperitoneal
hematoma, a vascular blush seen on
computed tomography, and a massive
retroperitoneal hematoma observed on
computed tomography. The timing of
embolization is also important. Agolini
et al.
84
reported that embolization later
than three hours after injury increased
the risk of mortality fivefold and that the
average procedure time for embolization
was ninety minutes.
Alternatively, pelvic packing for
the control of hemorrhage has been ad-
vocated at some centers in Europe
85
.
This technique appears to be used for
patients with severe hypotension and a
pelvic fracture that is unresponsive to
other initial treatment measures and
that is associated with the imminent
risk of death and thus a high likelihood
that the patient will not survive the trip
to the angiography suite. However,
there are limited data to support the use
of pelvic packing.
Damage control orthopaedics for
a pelvic ring injury with exsanguinat-
ing hemorrhage involves rapid clinical
decision-making and multiple teams
for resuscitation and minimally invasive
pelvic stabilization (e.g., with a pelvic
binder, external fixator, pelvic c-clamp,
or pelvic stabilizer). Patients who do
not respond to these measures should
be considered for angiography and em-
bolization if they are likely to survive
the trip to the angiography suite; other-
wise, they should be considered for pel-
vic packing once any underlying
coagulopathy has been corrected.
Geriatric Trauma
Elderly trauma patients require special
evaluation and treatment because of
their higher mortality rate following
trauma, even minor trauma. Green-
span et al. reported that the average LD
(Lethal Dose) 50 injury severity score
was 20 points for individuals more than
sixty-five years of age
86
. This value is
essentially half of the LD 50 injury se-
verity score for individuals between
twenty-four and forty-four years of
age
85
. In addition, pelvic ring fractures
in individuals more than fifty-five years
old are associated with an increased
chance of arterial injuries and higher
transfusion requirements
83
. In a study
of patients who were more than sixty
years old, Tornetta et al. noted that in-
creased mortality was associated with a
lower Glasgow coma score (11.5 points
for the patients who died compared
with 13.9 points for the patients who
survived), greater transfusion require-
ments (10.9 units for the patients who
died compared with 2.9 units for those
who survived), and greater fluid infu-
sion (12.4 L for the patients who died
compared with 4.9 L for those who sur-
vived)
87
. These differences highlight the
importance of considering damage
control orthopaedics for elderly pa-
tients. In addition, treatment should be
directed toward measures that enhance
immediate mobilization and the avoid-
ance of prolonged bed rest in this pa-
tient population.
Special Situations in
Chest Injuries
Traditionally, there have been two di-
vergent schools of thought related to
the treatment of multiply injured pa-
tients with long-bone fractures and a
chest injury (Figs. 4-A through 4-E),
with some believing that early fracture
stabilization is safe and maybe even
beneficial
6,88-91
and others believing that
early fracture stabilization is not safe
and may be harmful
76
. The classic paper
by Bone et al. has probably had the
most influence on the care and treat-
ment of orthopaedic trauma patients in
the United States
6
. More recently, Bou-
langer et al. reported no increase in
morbidity or mortality in association
with early intramedullary nailing
(within twenty-four hours) of femoral
fractures in patients who had sustained
blunt thoracic trauma
92
.
The Eastern Association for the
Surgery of Trauma Practice Manage-
ment Guidelines Work Group reviewed
the current literature and found no ran-
domized clinical trials of the treatment
of patients with chest injuries with im-
mediate long-bone stabilization (within
forty-eight hours)
93
. They noted that
available prospective studies or retro-
spective analyses comparing long-bone
stabilization within forty-eight hours
with later stabilization in patients with
a chest injury showed that the two
groups had similar rates of mortality
and adult respiratory distress syn-
drome, mechanical ventilation require-
ments, lengths of stay in the intensive
care unit, and total lengths of stay in the
TABLE III Clinical Parameters Associated with Adverse Outcomes in Multiply
Injured Patients as Reported in Hannover, Germany
Unstable condition or resuscitation difficult (borderline patient)
Coagulopathy (platelet count <90,000)
Hypothermia (<32C)
Shock and >25 units of blood needed
Bilateral lung contusion on first plain radiograph
Multiple long-bone injuries and truncal injury; abbreviated injury score of 2 points
Presumed operation time >6 hr
Arterial injury and hemodynamic instability (blood pressure <90 mm Hg)
Exaggerated inflammatory response (e.g., IL-6 >800 pg/mL)
I
DAMAGE CONTROL
ORTHOPAEDI CS
hospital. The authors indicated that five
clinical parameters may be helpful in
determining the appropriateness of
early long-bone stabilization: severity of
pulmonary dysfunction, hemodynamic
status, estimated operative time, esti-
mated blood loss, and fracture status
(open or closed).
A selective approach should be
used for patients with long-bone frac-
tures and a chest injury. Defining the
subgroup of patients for whom early
nailing would increase the risk of early
complications is the goal of damage
control orthopaedics. Treatment ought
to be individualized. When early in-
tramedullary nailing is not deemed to
be the best alternative, damage control
orthopaedics, with short-term external
fixation of the femur followed by
staged conversion to an intramedul-
lary nail in the first week after injury,
can be utilized.
Head Injuries
The Eastern Association for the Sur-
gery of Trauma Practice Management
Guidelines Work Group also searched
the literature for studies regarding the
timing of long-bone fracture stabiliza-
tion in a multiply injured patient with a
head injury
93
. The group found no
Level-I studies (randomized clinical tri-
als). On the basis of Level-II studies
(prospective, noncomparative clinical
studies or retrospective analyses of
reliable data) and Level-III studies (ret-
rospective case series or database re-
views), it was concluded that patients
with mild, moderate, or severe brain in-
jury who underwent long-bone stabili-
zation within forty-eight hours were
similar to those treated with later stabi-
lization with regard to mortality rate,
length of stay in the intensive care unit,
need for mechanical ventilation, and to-
tal length of stay in the hospital. The
overall conclusion was that there was no
compelling evidence that early long-
bone stabilization either enhances or
worsens the outcome in patients with a
mild, moderate, or severe head injury.
Many clinical issues arise during
an examination of the available litera-
ture on patients with a head injury and
long-bone fractures. Early definitive
fracture stabilization is potentially ben-
eficial in this situation because it re-
duces persistent pain at the fracture site
by minimizing involuntary movements
by an unconscious or not yet coopera-
tive patient. Fracture stabilization also
has a positive effect on the patients me-
tabolism, muscle tone, and body tem-
perature, and, as a result, cerebral
function
94
. Furthermore, unstabilized
fractures may cause physiologic deteri-
oration in these patients as a result of
increased soft-tissue damage, fat embo-
lism, and respiratory insufficiency
95-99
.
In recent years, some authors
have reported a worse outcome in pa-
tients with secondary brain injury re-
sulting from hypotension, hypoxia, and
increased intraoperative administra-
tion of fluid related to early operative
fracture fixation
100,101
. In a study of mul-
tiply injured patients with fractures of
the femur, tibia, and pelvis, Martens
and Ectors reported a 38% prevalence
of early neurological deterioration in a
group treated with early fixation but no
early neurological deterioration in a
group treated with late fixation
102
. Mc-
Fig. 4-B
Chest radiograph demonstrating a ruptured left hemidiaphragm (Fig. 4-A) and ra-
diograph showing a Grade-II open femoral fracture (Fig. 4-B) in a multiply injured
patient.
Fig. 4-A
:
DAMAGE CONTROL
ORTHOPAEDI CS
Kee et al. reported that neurological
complications developed in the postop-
erative period in three patients treated
with early fixation, but they did not at-
tribute any of these complications to
the femoral fracture or its fixation
103
.
Also, they found no difference in the
long-term neurological outcome be-
tween the patients treated with early
fixation and those treated with delayed
fixation.
In contrast, in a study of patients
with a head injury and a fracture of the
neck or shaft of the femur or the shaft
of the tibia, Poole et al. found that those
who had undergone early definitive
fracture fixation had a significantly (p <
0.0001) lower prevalence of periopera-
tive neurological complications com-
pared with those who had been treated
with late fixation
104
. Brundage et al. re-
ported that, in a series of multiply in-
jured patients with head injuries,
femoral shaft fractures, and an injury
severity score of >15 points, those
treated with fixation within twenty-
four hours after the injury had the
highest Glasgow coma scale scores at
the time of discharge
105
. However, since
only the mean head abbreviated injury
scale score, and not the Glasgow coma
scale score on admission, was reported,
these results are very difficult to inter-
pret accurately. Hofman and Goris
found that the Glasgow coma scale
score was better in a group treated with
early fixation than it was in a group
treated with late fixation, but the differ-
ence did not reach significance
106
.
The initial management of a pa-
tient with a head injury should be simi-
lar to that of other trauma patients,
with a focus on the rapid control of
hemorrhage and restoration of vital
signs and tissue perfusion. A brain in-
jury can be made worse if resuscitation
is inadequate or if operative interven-
tion such as long-bone fixation de-
creases mean arterial pressure or
increases intracranial pressure. The
treatment protocol for unstable patients
should be based on the individual clini-
cal assessment and treatment require-
ments rather than on mandatory
policies with respect to the timing of
fixation of long-bone fractures. In such
cases, damage control orthopaedics can
provide temporary osseous stability to
an injured extremity, functioning as a
temporary bridge to staged definitive
osteosynthesis, without worsening the
patients head injury or overall condi-
tion. Intracranial pressure monitoring
should be utilized in the intensive care
unit as well as during surgical proce-
dures in the operating room. Aggres-
sive management of intracranial
pressure appears to be related to an im-
proved outcome. Maintenance of cere-
bral perfusion pressure at >70 mm Hg
and intracranial pressure at <20 mm
Hg should be mandatory before, dur-
ing, and after surgical procedures. Or-
thopaedic injuries should be managed
aggressively with the assumption that
Fig. 4-D
Figs. 4-C and 4-D Initial external fixation was performed at the time of the diaphragmatic repair.
Fig. 4-C
,
DAMAGE CONTROL
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full neurological recovery will occur.
Mangled Extremities
Prior to the Lower Extremity Assess-
ment Project (LEAP) study
107-109
, there
were limited data on the contemporary
treatment of severely injured or man-
gled lower extremities. Lange
110
per-
formed a retrospective study of twenty-
three Gustilo and Anderson Type-IIIC
tibial fractures (severe open fractures
with limb-threatening vascular com-
promise requiring repair), fourteen of
which eventually led to amputation
(five of the amputations were primary
and nine, delayed). The absolute indi-
cations for amputation in that study in-
cluded anatomic disruption of the
tibial nerve and a crush injury with a
warm ischemia time of more than six
hours, or the presence of two of three
relative indications (serious poly-
trauma, severe injury of the ipsilateral
foot, and anticipation of a protracted
course to obtain soft-tissue coverage
and tibial reconstruction). Caudle and
Stern
111
reported that seven of nine
Type-III open tibial fractures required
secondary amputation.
Hansen
112
called for a multicenter
study to develop guidelines to avoid
prolonged, costly, and fruitless salvage
procedures when such a course is not
indicated. Helfet et al.
113
reported that
a mangled extremity severity score
(MESS) of 7 points was associated with
a 100% rate of amputation. Georgiadis
et al.
114
reported that, of forty-five patients
with a severe open tibial fracture requir-
ing free tissue transfer for soft-tissue
coverage, twenty-seven were treated
with limb salvage and eighteen were
treated with early amputation. The pa-
tients in the limb salvage group had an
average of three complications, whereas
there was a total of seventeen complica-
tions in the early amputation group.
Renewed interest in treatment of
the mangled lower extremity has been
generated by the dissemination of the
results from the LEAP study, a prospec-
tive, longitudinal, observational, out-
comes study at eight Level-I American
trauma centers
107-109
. In this study, the
attending surgeons directed all eval-
uations, decisions, and extremity treat-
ment. There were 656 eligible patients
ranging in age from sixteen to sixty-nine
years. Fifty-five patients were excluded
from the study: thirty-six refused to par-
ticipate, thirteen died in the hospital,
and six were not enrolled because of ad-
ministrative failure, which left a study
group of 601 patients. In that group,
thirty-two patients had bilateral injuries,
which were analyzed separately, and 569
had a unilateral injury.
The main hypothesis of the study
was that, after the investigators con-
trolled for the severity of the limb in-
jury, the presence and severity of other
injuries, and patient characteristics,
amputation would prove to have a
better functional outcome than
reconstruction for the treatment of
traumatic amputations, Type-IIIB and
IIIC open tibial fractures, selected
Type-IIIA open tibial fractures, vascu-
lar injuries, major soft-tissue injuries,
and severe foot injuries.
The LEAP study patients differed
from the general population with re-
gard to many characteristics. They were
more likely to be male; they were less
educated; they were more often blue
collar workers; they were less insured
(38% had no insurance); they were
more likely to be healthy, heavy drink-
ers, smokers, neurotic, and extroverted;
they were less agreeable; and they had a
lower income.
Patients with a severe injury of
the lower extremity and absent plantar
sensation at the time of admission had
substantial impairment at twenty and
twenty-four months. Patients treated
with limb salvage did not have poorer
outcomes than those treated with am-
putation. Absent plantar sensation did
not even predict the state of plantar
sensation at twenty-four months. Nei-
ther the injury characteristics nor the
presence and severity of ipsilateral or
contralateral limb injuries significantly
correlated with the outcomes as as-
sessed with the Sickness Impact Profile
(SIP). Patients with a through-the-knee
amputation had worse regression-
Staged intramedullary nailing was
performed on post-injury day 2.
Fig. 4-E

DAMAGE CONTROL
ORTHOPAEDI CS
adjusted SIP scores (p = 0.05) and
slower self-selected walking speeds (p =
0.004) than did patients with either a
below-the-knee or an above-the-knee
amputation
109
. Patients who had been
rehospitalized for a major complica-
tion also had poorer outcomes. Signifi-
cant (p 0.05) predictors of a poor
outcome were a high-school education
or less, a household income below the
federal poverty line, being nonwhite, a
lack of insurance, receiving Medicaid
benefits, a poor social support net-
work, low self-efficacy, smoking, and
involvement in the legal system for in-
jury compensation. A proportion of the
patients who had undergone limb re-
construction had not fully recovered
by two years; 10.8% of those patients
had nonunion, 4.7% did not have soft-
tissue healing, and 15% were judged to
need additional surgery.
The SIP scores in the LEAP study
were significantly higher (p < 0.01)
than published population scores
115
.
Significant (p < 0.05) improvement was
observed over time for all dimensions
of the SIP except for psychosocial func-
tioning. The percentage of patients with
a slower walking speed was higher in
the amputation group than in the re-
construction group (p < 0.05). There
was no difference between the two
groups in terms of SIP scores for dis-
ability or the percentage who returned
to work. The patients who had under-
gone reconstruction took longer to
achieve full weight-bearing, and they
had more rehospitalizations and hospi-
tal days (p < 0.01). Contrary to the
studys hypothesis, the two-year out-
comes following the reconstructions
were not significantly worse (or better)
than those following the amputations.
However, reconstruction involves a
higher complication risk, additional
surgical procedures, and more hospital
readmissions. Also, the risk of late am-
putation was 6.4%. As a result of this
study, we cannot assume that either an
amputation or a successful reconstruc-
tion will provide a superior result.
Webb et al. reported that patients
with a limb-threatening Type-III open
tibial shaft fracture managed with limb
salvage had outcomes that were similar
to those of patients who had under-
gone an amputation
116
. The authors
noted several surgeon-controlled vari-
ables that appeared to influence the
course of the fracture and the patient
outcome. Wound coverage with sim-
ple methods provided better results
than flap coverage, external fixation
and flap coverage provided worse
results than amputations, and bone-
Fig. 5-A
Antibiotic bead pouch for treatment of an open proximal tibial fracture (Fig. 5-A), with a
close-up view (Fig. 5-B). Adjacent to the bead pouch are traumatic arthrotomy and fasciot-
omy wounds that have been closed. Spanning external fixation across the knee for man-
agement of the tibial fracture and a femoral traction pin for management of an ipsilateral
acetabular fracture were also utilized in this patient.
Fig. 5-B
,
DAMAGE CONTROL
ORTHOPAEDI CS
grafting performed within three
months after the injury had a trend
for a better outcome than did bone-
grafting that was accomplished later. In
addition, Webb et al. found that the
timing of dbridement and of soft-
tissue coverage did not influence the
outcome, and the most common com-
plications warranting readmission
were nonunion and infection.
Smith et al. reported that pa-
tients treated with late amputation af-
ter a complex lower-extremity injury
reported significantly (p < 0.05) higher
levels of disability than did those who
had had an amputation either during
the first hospitalization or within the
first three months after the injury
117
.
These investigators noted a high num-
ber of hospitalizations for complica-
tions (p < 0.0001), a high number of
infections (p < 0.001), and a high
number of surgical procedures in the
late-amputation group (p < 0.0001).
They stated that when severe lower
limb trauma places an individual at
risk of amputation there is value in
making that difficult decision in a
timely fashion.
The LEAP data suggest an in-
creasing trend toward limb salvage
rather than immediate amputation for
complex open lower-extremity injuries.
A damage control orthopaedics ap-
proach to saving the limb may make it
possible to improve surgeon-controlled
variables that appear to be related to
better outcomes. The use of spanning
external fixation, antibiotic bead
pouches
118-120
(Figs. 5-A and 5-B), and
the vacuum-assisted wound closure
technique may provide a bridge to
staged osseous reconstruction and soft-
tissue coverage procedures
121
. Vacuum-
assisted wound closure subjects the
wound bed to negative pressure by way
of a closed system and thereby removes
edema from the extravascular space
121
.
Isolated Complex
Lower-Extremity Trauma
An isolated complex extremity injury
(other than a mangled limb) is a possi-
ble indication for a limited form of
damage control orthopaedics that we
have termed limb damage control or-
thopaedics. Specific injuries that are
amenable to this approach include
complex proximal tibial articular and
metaphyseal fractures and distal tibial
pilon fractures. These clinical situa-
tions usually combine a complex frac-
ture pattern, either open or closed,
with a substantial soft-tissue injury.
Limb damage control orthopaedics is
useful for preventing soft-tissue com-
plications by spanning the articular
segment with an external fixator and
avoiding areas of future incisions. Then
TABLE IV Prevalence of Adult Respiratory Distress Syndrome, According to Type of Femoral Fixation, Associated with Three
Different Approaches to Treatment of a Multiply Injured Patient in Hannover, Germany
Patients with Adult Respiratory Distress Syndrome*
P Value
Early Total
Care Period
Intermediate
Period
Damage Control
Orthopaedics Period
Primary intramedullary nailing 77 (32.7) 20 (22.7) 29 (15.1) 0.003
Primary external fixation, secondary intramedullary nailing 38 (16.2) 10 (11.4) 15 (7.8) 0.002
Primary plate fixation 45 (19.1) 14 (15.9) 42 (21.9) 0.001
*The values are given as the number of patients with the percentage in parentheses. P values indicate significant differences between
early total care and damage control orthopaedics. The prevalence of adult respiratory distress syndrome was significantly lower with the
damage control orthopaedics approach. Indicates a significant difference (p < 0.05) between primary intramedullary nailing and primary ex-
ternal fixation with secondary intramedullary nailing.
Fig. 6
The current treatment algorithm from Hannover, Germany, for the use of damage control ortho-
paedics is based on a prompt and accurate determination of whether the patient is stable, bor-
derline, unstable, or in extremis. 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, ETC = early total care, OR = operating room, DCO = damage con-
trol orthopaedics, and ICU = intensive care unit.
o
DAMAGE CONTROL
ORTHOPAEDI CS
minimally invasive plate osteosynthe-
sis can be performed at a stage when
the condition of the soft tissue enve-
lope is optimized.
When Can Secondary Orthopaedic
Procedures Be Performed?
One of the most important issues in
damage control orthopaedics is the tim-
ing of the secondary surgical procedures
(definitive osteosynthesis). Days 2, 3,
and 4 are not safe for performing defini-
tive surgery. During this period, marked
immune reactions are ongoing and in-
creased generalized edema is observed. A
recent prospective study demonstrated
that multiply injured patients subjected
to secondary definitive surgery between
days 2 and 4 had a significantly (p <
0.0001) increased inflammatory re-
sponse compared with that in patients
operated on between days 6 and 8
12,122
. It
was concluded that, in different post-
traumatic periods, variable inflamma-
tory responses to comparable stimuli are
observed. This variation may contribute
to the differences in clinical outcome
(e.g., a higher incidence of multiple or-
gan failure) that have been reported
12
.
In Hannover, Germany, all high-
risk patients have been managed with a
treatment plan that involves a re-evalu-
ation of clinical and laboratory parame-
ters in the emergency department after
the primary diagnostic workup
1
. On the
basis of this re-evaluation, specific rec-
ommendations can be made for specific
groups of patients in the form of an al-
gorithm (Fig. 6).
Clinical Outcomes of Damage
In the early 1990s, the approach in
Hannover changed from performing
definitive surgery in all patients to using
an external fixator as a temporary
measure to stabilize the fracture and
subsequently carrying out secondary
definitive internal fixation
1
. In a retro-
spective evaluation, three different
time-periods were identified. In the
early total care period, between January
1, 1981, and December 31, 1989, the
protocol for the treatment of a femoral
shaft fracture was early definitive stabi-
lization (within less than twenty-four
hours). In the intermediate period, be-
tween January 1, 1990, and December
31, 1992, the usual protocol for treating
a femoral shaft fracture in a multiply
injured patient at risk for posttraumatic
complications changed from early de-
finitive stabilization to early temporary
fixation. In the damage control ortho-
paedics period, beginning in 1993, the
protocol for such an injury in such a pa-
tient was early temporary stabilization
(within twenty-four hours) followed by
secondary conversion to intramedullary
nailing. The rates of multisystem organ
failure and adult respiratory distress
syndrome were found to be signifi-
cantly higher (p < 0.05) in the earlier
time-periods (Table IV). In addition,
during the latest time-period, patients
who were treated with damage control
orthopaedics demonstrated a lower risk
of adult respiratory distress syndrome
than those treated with initial in-
tramedullary nailing.
Risk of Local Infection with
The use of spanning external fixation
carries the risk of pin-track infection. In
the series in Hannover, the risk of infec-
tion following definitive intramedul-
lary nailing (Table V) was not greater
than that in other studies of patients
who had undergone intramedullary sta-
bilization after external fixation
123-125
.
Contemporary rates of pin-track infec-
tion are still substantial, but they are
minimized when the duration of exter-
nal fixation is brief
126
.
Practical Considerations for
Practical considerations for spanning
external fixation include the use of an
external fixation system that is user-
friendly and can be applied rapidly.
Self-drilling pins, which can be manu-
ally inserted, can be applied quickly
with a limited need for fluoroscopy.
Operating time can be decreased by
multiple operating teams working on
opposite ends of the same limb or on
different extremities. External fixation
systems that employ snap-and-click
clamps can be assembled rapidly. In ad-
dition, a system that allows flexibility in
pin placement is preferable so that areas
of future incisions can be avoided.
Overview and Future Directions
Damage control orthopaedics is ideal for
an unstable patient or a patient in extre-
mis, and it has some utility for the bor-
derline patient as well. Specific injury
complexes for which damage control
orthopaedics should be considered are
femoral fractures (especially bilateral
fractures), pelvic ring injuries with pro-
found hemorrhage, and multiple injuries
in elderly patients. Specific subgroups of
multiply injured orthopaedic patients
who may benefit from damage control
orthopaedics are those with a head injury,
chest trauma, or a mangled limb. A lim-
ited form of damage control orthopaedics
(limb damage control orthopaedics) is a
rational alternative for the treatment of
isolated, complex limb injuries.
Clinical data and emerging discov-
eries in molecular medicine may con-
tinue to provide answers to the question
of when orthopaedic surgeons should
use a damage control orthopaedics ap-
proach. Prospective, multicenter studies
similar to the Lower Extremity Assess-
ment Project may ultimately be neces-
TABLE V Comparative Data on Postoperative Local Complications During the
Three Periods of Fracture Care in Hannover, Germany
Patients with Complication*
P Value
Early Total
Care Period
Intermediate
Period
Damage Control
Orthopaedics Period
Pin track infection 2/39 3/21 4/68 NS
Wound infection 5/235 2/88 3/191 NS
Osteomyelitis 2/235 0/88 1/191 NS
*Number of patients with a complication/total number of patients. NS = not significant.
,
DAMAGE CONTROL
ORTHOPAEDI CS
sary to better understand the role of
damage control orthopaedics in the
treatment of patients who have sustained
orthopaedic trauma, especially those
with concomitant injuries to the chest
and head. Despite the lack of prospec-
tive clinical studies, many trauma centers
have already modified their approach to
the treatment of orthopaedic patients
with multiple injuries by incorporating
the principles of damage control
orthopaedics
1
.
NOTE: The authors thank Paul Tornetta III, MD, for his encour-
agement and enthusiasm, which contributed greatly to this
instructional course lecture. They also express their appreci-
ation to Timothy E. Hewett, PhD, for his thoughtful review of
this manuscript.
Craig S. Roberts, MD
Arthur L. Malkani, MD
Jorge L. Rodriguez, MD
Departments of Orthopaedic Surgery (C.S.R
and A.L.M.) and Surgery (J.L.R.), University of
Louisville, 210 East Gray Street, Suite 1003,
Louisville, KY 40202. E-mail address for C.S.
Roberts: craig.roberts@louisville.edu
Hans-Christoph Pape, MD
Department of Trauma Surgery, Hannover
Medical School, Carl-Neuberg-Strasse 1,
Hannover 30625, Germany
Alan L. Jones, MD
Department of Orthopaedic Surgery, Univer-
sity of Texas Southwestern Medical Center at
Dallas, 5323 Harry Hines Boulevard, Dallas,
TX 75390-8883
Peter V. Giannoudis, MD
Department of Trauma Orthopaedic Surgery,
University of Leeds, Beckett Street, Leeds LS9
7TF, United Kingdom
The authors did not receive grants or outside
funding in support of their research or prepa-
ration of this manuscript. They did not receive
payments or other benefits or a commitment
or agreement to provide such benefits from
a commercial entity. No commercial entity
paid or directed, or agreed to pay or direct, any
benefits to any research fund, foundation, edu-
cational institution, or other charitable or
nonprofit organization with which the authors
are affiliated or associated.
Printed with permission of the American
Academy of Orthopaedic Surgeons. This arti-
cle, as well as other lectures presented at the
Academys Annual Meeting, will be available
in February 2005 in Instructional Course Lec-
tures, Volume 54. The complete volume can
be ordered online at www.aaos.org, or by call-
ing 800-626-6726 (8 A.M.-5 P.M., Central
time).
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