The American Journal of Surgery 183 (2002) 622 629

Review

The timing of fracture treatment in polytrauma patients: relevance of

damage control orthopedic surgery*
Hans-Christoph Pape, M.D.a,, Peter Giannoudis, M.D.b, Christian Krettek, M.D.a
a

Department of Trauma Surgery, Hannover Medical School, Carl-Neubergstr. 1, 30625 Hannover, Germany
b
Department of Trauma and Orthopaedics, St Jamess University Hospital, Leeds, United Kingdom
Manuscript received July 16, 2001; revised manuscript December 21, 2001

Abstract
Information illustrating the benefits of fracture stabilization after multiple trauma has been gathering for almost a century. At the turn
of the last century, the introduction of the Thomas splint clearly demonstrated the importance of skeletal stabilization in the management
of these patients. The introduction of standardized surgical treatment for fractures in the early 1950s is considered today as the turning point
in the care of the polytraumatized patient. With the knowledge acquired, the application of early operative fixation of fractures in severely
injured patients in the 1980s has yielded to the concept of early total care of all fractures. Yet, in distinct patient subgroups with severe
thoracic injuries and very high injury severity scores, this concept has been associated with adverse outcomes. Therefore, in a further era
that began in the 1990s, a different approach has been favored for these subgroups. It recommends early (initial) temporary stabilization
followed by secondary definitive osteosynthesis of major fractures in patients at high risk of developing systemic complications. In the last
decade, attempts have been made to determine which patients benefit from early total care and which ones should undergo a secondary
definitive approach. This manuscript provides a historical overview on the changing treatment of fractures and summarizes the evolution
of damage control orthopedic surgery. 2002 Excerpta Medica, Inc. All rights reserved.
Keywords: Fracture treatment; Polytrauma; Orthopedic surgery; Damage control

During the 1950s and 1960s, surgical stabilization of long

bone fractures after multiple trauma was not routinely advocated as it was thought that the patient was not stable
enough to withstand prolonged operations. Fears of the fat
embolism syndrome also dominated the philosophy in
managing polytrauma patients. Fat embolism was considered to be directly related to fat and intramedullary contents
released from the fracture site leading many to believe that
early manipulation of the fracture was unsafe [1,2].
The use of simple splintage (Thomas splint) clearly demonstrated the importance of skeletal stabilization by reducing the effect of any continuing injury and thus clinically
contributing to improved outcome. This positive effect of
skeletal stabilization became more obvious with the implementation of standardized techniques of osteosynthesis [3].
These two events are today considered as the turning points
in the care of the polytraumatized patient. However, the

implication of these developments were not appreciated

widely at first and, for years, the philosophy prevailed that
the the patient is too sick to operate on and the patient was
kept in the enforced bedrest position of skeletal traction.
Initial surgical stabilization was allowed only if the patient
was in a clinically excellent condition. Moreover, it was
noted that fracture healing would occur more rapidly, if the
operation was performed nonacutely. Therefore, most authors recommended to delay surgery until 10 to 14 days
after the injury [4,5]. In the early 1970s the first pioneer
studies appeared in the literature reporting that immediate
stabilization of femur fractures drastically reduced problems
of traumatic pulmonary failure and postoperative care when
compared with traditional nonoperative fracture management The definition of early operative treatment implied
stabilization within 24 hours [6,7].

The era of early total care

* This manuscript is dedicated to Harald Tscherne, who has influenced
the discussion and the standards of fracture treatement substantially.
Corresponding author. Tel.: 0049-511-532-2279; fax: 0049-511-5328279.
E-mail address: Pape.hans-christoph@mh-hannover.de

Several reports in the early 1980s provided further evidence for the beneficial effects of operative fracture stabilization [8,9]. The more severe the injury, the greater the

0002-9610/02/$ see front matter 2002 Excerpta Medica, Inc. All rights reserved.
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H.-C. Pape et al. / The American Journal of Surgery 183 (2002) 622 629

effect of early stabilization appeared to be [10]. The supporting

randomized trial from Bone et al [11] considered 178 patients
with femoral fractures randomized to an early stabilization
(within 24 hours) or a late stabilization group (after 48 hours)
group. Although mortality data was weakened by only three
deaths overall, patients with delayed fracture stabilization had
a higher incidence of pulmonary complications (pneumonia,
adult respiratory distress syndrome [ARDS]), and stayed
longer in critical care and in a hospital overall. This study
received widespread support. With confirmation from others,
the philosophy of early fracture stabilization in seriously injured patients was firmly established.
Early stabilization of major skeletal injuries (early total
care [ETC]) became the golden rule in trauma surgery. The
studies supporting this approach were based on the fact that
the problems of fat embolism syndrome had been realized to
derive from unstabilized fractures. By introducing routine
operative stabilization, this complication could be reduced
dramatically [12,13]. Furthermore, the improvements in intensive care medicine that allowed better cardiorespiratory
monitoring. Also, those improvements were associated with
an ability to perform prolonged artificial ventilation without
setting the patient at risk of developing respiratory complications and supported a more aggressive surgical approach.
Even though these studies were generally accepted, there
was still much controversy. In 1995, Reynolds et al [21]
retrospectively summarized 105 patients with femoral shaft
fractures treated by reamed intramedullary nailing (IMN)
during an 11-year period. Patients were separated according
to immediate nailing (IMN 24 hours), early treatment
(IMN 24 to 48 hours), and late treatment (IMN 48 hours).
In patients with low injury severity (Injury Severity Scale
[ISS] score 18) there was a tendency toward fewer pulmonary complications in the immediate operation group. In
multiple trauma patients (ISS 18) no relationship between
timing and outcome was seen. The authors criticize all
previous reports and state that none of these studies have
proven that the improvements in outcome were an isolated
effect of improved treatment of the femur fracture [21].
Some authors even described a stepwise approach that included stabilization of major fractures within 24 hours. Several
time intervals were differentiated: the first operative period
includes emergency life-saving procedures, which have to be
performed within 1 to 2 hours (acute period). This is followed
by the primary period (day 1 surgery) for limb-preserving
procedures, open fractures, open joints, closed limb fractures,
and compartment syndromes. The secondary period, defined
as 48 to 72 hours after trauma serves for reconstructive procedures requiring prolonged operation such as severe intraarticular fractures. During the tertiary period, defined as
more than 72 hours after injury, further prolonged joint reconstructions such as acetabular fractures or secondary wound
closure and bone grafting may be performed [14].
In general terms, ETC represented a great achievement
for many patients in terms of rapid mobilization, rapid
reduction of pain, and a reduction in the complications

623

associated with prolonged bed rest. The advantages for

countless patients who were able to ambulate early have
been well described [1517].

The borderline era

The dogma of the benefits of early total care (fracture
stabilization) was increasingly questioned. Ecke et al [18]
performed a multicenter study that included 1,127 patients
with femur fractures. An unexpectedly high rate of pulmonary complications was found after primary (24 hours)
stabilization, which was mainly performed by reamed nailing. These problems were particularly noticeable in the
young age group, 20 to 30 years old, with no risk of
pulmonary complications due to preexisting disease. Almost no patient had suffered thoracic trauma. Therefore the
timing and the type of surgical stabilization were believed to
play the major role [18].
Studies that previously advocated primary stabilization
in all trauma patients were criticized for their study design
(inclusion of patients who died from hemorrhagic shock and
head trauma, inclusion of patients receiving no fracture
reduction in the late operation group, ARDS definition, and
so forth). More specifically, several studies supported
Eckes observation that the adverse outcome (eg, ARDS)
appeared to occur in the presence of severe chest injuries,
after severe shock states, or in patients in an uncertain
clinical condition [19 22].
From animal studies and from the clinical viewpoint, it
became evident that the severity of injury apparently set
these patients up for a high risk to deteriorate after early
orthopedic operations. While the degree of hemorrhagic
shock can be reliably monitored, it is rather difficult to
quantify the degree of thoracic trauma initially. It is of note
that the parenchymal injury (pulmonary contusion) is more
important for the functional disturbances than the osseous
injury. The following summary indicates the available
methods for early evaluation of the degree of chest trauma.
Chest radiograph
Some authors made the diagnosis of pulmonary contusion on the basis of the admission plain chest radiograph
alone [23,24]. However, the dynamic nature of this parenchymal injury is well known and the admission chest plain
film x-rays have been found to underestimate the severity of
pulmonary contusion [25]. Recently, it was shown that the
use of the combination of osseous findings, parenchymal
injury, and physiologic parameters improved the ability to
judge the risk of pulmonary complications [26].
Computed tomography
It has been argued that chest computed tomography (CT)
offers additional diagnostic properties, eg, in regard to the

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H.-C. Pape et al. / The American Journal of Surgery 183 (2002) 622 629

Table 1
Injury severity and complications in patients undergoing definitive orthopedic surgery at several various time points within the last decades
Author

Year

Inclusion
criteria

Mean ISS
(range in
subgroups)

Mean
ISS
primary
definitive
surgery

Mean
ISS
secondary
definitive
surgery

ARDS
incidence
(range, %)

Mortality
(range, %)

Johnson
Bone
Pape
van Os
Charash
Bone
Bosse
Carlsson

1985
1989
1993
1994
1994
1995
1997
1998

ISS18

ISS18
?
ISS18
ISS18
ISS17
?

38
3132
3455
2938
2529
2629
2330
1834

38.2
31.8
52.2

27

38.0
31.3
55.2

29

739
0.63.3
733
2026
010
033
13
2172

4.5
1.2
221
5.3
860
8.2
2.7
06

ISS Injurity Severity Scale score; ARDS adult respiratary distress syndrome.

detection of ventral pneumothorax [27]. However, the differentiation between pulmonary contusion (PC) and aspiration may be difficult. Also, the time delay induced by this
protocol is controversial for patients with multiple severe
injuries. Similar thoughts according to the cost benefit analysis are important.
Arterial blood gas analysis
The admission blood gas analysis does not reflect the
overall degree of pulmonary injury. If taken as the only
parameter, difficulties in discriminating patients who later
do or do not survive have been described. Also, the nonsurvivors could not be separated out on the basis of the
PaO2/FiO2 ratio until 1 day after trauma [28,29].
Bronchoscopy
Admission bronchoscopy has been advocated and has
been said to represent both a valuable diagnostic and therapeutic tool. Some authors have described changes of the
bronchial epithelium associated with pulmonary contusion,
before it could be diagnosed on chest roentgenography [30].
Also, microvascular changes have been shown to be present
in bronchoalveolar lavage fluid on admission of patients
with blunt multiple injuries [31]. Despite all the benefits of
bronchoscopy, it is understood that it is not feasible as a
routine procedure in the polytrauma patient.
Extravascular lung water
The determination of pulmonary extravascular lung water is able to quantify the degree of interstitial edema and
represents a reliable bedside measurement [32,33]. However, pulmonary edema does not develop until days after
trauma and therefore it is not an adequate parameter to
predict the development of pulmonary complications [34].
In summary, the dynamic nature of the thoracic injury and
the difficulty in determining the true severity of injury on

admission continue to represent important drawbacks in regards to the decision making for the timing of orthopedic
operations. The unexpected complications after early total care
became evident when the principle was followed in patients
whose degree of trauma was underestimated initially.
Another issue that clouded the debate as to what is the
best management of selected multiple injured patients was
the strict application of the ETC rule for all patients, ie, even
those with very severe injuries [10]. Table 1 presents the
mean ISS scores and the outcome in patients submitted to
ETC during the last 3 decades. Over the years, there appears
to be a trend towards less severe mean injury severity in
patients who were submitted to primary definitive stabilization. This may reflect a more cautious approach in regard to
the operative management. Moreover, in some studies (Table 1, line 4) that favor primary definitive stabilization in
their discussion, the data suggest that ETC had only been
performed in patient groups that demonstrated lower injury
severity scores (35,36).
These reasons explain why unexpected deteriorations
were found in selected subgroups of multiple injured patients. The clinical difficulty to judge preoperatively which
of these patients could safely undergo ETC stimulated the
creation of a specific subgroup of patients being at special
risk to deteriorate, the so-called borderline patient.
It was then tried to describe the borderline patient on the
basis of clinical and laboratory findings [37,38]. Table 2
documents the clinical description of the borderline patient.
The clinical relevance of the description of this patient
subgroup becomes evident if a certain surgical load adds to
the load induced by the initial trauma. The creation of this
subgroup illustrates the difficulties of clinical judgement
even within the last decade. Although some of the criteria
were derived from clinical experience only, others were the
result of clinical studies undertaken to evaluate the impact
of initial surgery on outcome. In a series of prospectively
documented patients from the German Trauma Registry, it
was clearly shown that initial surgery exceeding 6 hours is
associated with adverse outcome. These clinical parameters

H.-C. Pape et al. / The American Journal of Surgery 183 (2002) 622 629
Table 2
Patient description used for the diagnosis of the borderline patient*
Polytrauma ISS 20 and additional thoracic trauma (AIS 2)
Polytrauma with abdominal/pelvic trauma ( Moore 3) and
hemodynamic shock (initial BP 90 mm Hg)
ISS 40 or above in the absence of additional thoracic injury
Radiographic findings of bilateral lung contusion
Initial mean pulmonary arterial pressure 24 mm Hg
Pulmonary artery pressure increase during intramodullary nailing 6
mm Hg
* Modified from Pape et al [37].
ISS Injury Severity Scale score; AIS abbreviated injury scale; BP
blood pressure.

and the ones to describe the borderline patient were based

on physiologic parameters that can be obtained by routine
laboratory and physiologic monitoring. The quantification
of the load of trauma by other means such as cascade
reactions of the immunologic, inflammatory, and hemostatic
response have not become available until recently. In addition, the importance of these parameters was not well described. Table 3 lists further criteria to increase the treating
physicians awareness in diagnosing this patient subgroup.
In summary, the effectiveness of initial temporary stabilization of orthopedic operations in preventing unexpected
patient deterioration resulted in the development of a new
approach in the management of musculoskeletal injuries in
the polytraumatized patient.
The damage control era
In general, the clinical course after severe blunt trauma is
determined by three principal factors, the initial degree of
injury (first hit, trauma load), the individual biological
response, and the type of treatment (second hit, surgical
load). Obviously, only one of these three factors can be
modulated by medical treatment, which implies that the
impact of inadequate clinical decisions can be overwhelming. The more severely the patient is at risk for adverse
outcome, the more careful one has to be in regard to the
management plan.
At first glance, operative treatment may be regarded as
only a small piece of the entire management plan, ranging
from rescue systems, prehospital care, perioperative cardiorespiratory support, and intensive care treatment. However,
following the concept of early total care, clinical observations revealed that some action within our treatment must
have been wrong to set some of the patients up for unexpected deterioration. As shown in Fig. 1, the three factors
trauma load, individual response, and treatmentwere
thought to cause additive effects until the biological reserve
of a patient was overwhelmed, thus leading to an adverse
outcome. This metaphor was chosen owing to its similarity
toward the uncontrolled microvascular injury and the associated systemic interstitial edema. The latter is known to be
related to an overactive inflammatory response and may

625

cause a true overload of the pulmonary drainage capacity of

the lymph. This manifests itself as interstitial edema, which
is an indicator of postoperative worsening and organ dysfunction [39,40].
When the clinical observations resulted in a change of
treatment, ie, reduction of the degree of initial surgery, it
was the clinical impression that the number of unexpected
deteriorations following the initial operative period were in
fact reduced. We were, however, unable to explain the
phenomenon by means of medical terms. It was not until
recently that the increased knowledge about posttraumatic
immunologic changes helped us understand the physiological background better. The initial degree of injury has been
named the first hit. Many studies are now available demonstrating this issue [41 43]. This first hit phenomenon can be
modified by the type of treatment, ie, the second hit [42]. It
can be induced by a variety of factors such as blood loss,
bacteremia, and infections [43]. This second insult may take
many forms, among them sepsis and surgical procedures.
Even in the presence of a moderate first hit, a second hit can
amplify the degree of damage, thus leading to increased
morbidity and mortality. These models of biological response to different stimuli have now become the basis of
our treatment plans. The damage control principle therefore
is based on the foundation of minimizing the degree of the
second hit impact, ie, surgery. The inflammatory reaction
induced by the operative procedure has now been quantified.
Quantification of the first hit in addition to parameters of
the coagulation cascade, the determination of parameters of
the inflammatory cascade have been proven to be reliable.
Among these, proinflammatory cytokines appear to provide
the most reliable results. The comparison made by Roumen
et al [44,45] between several inflammatory mediators highlighted that interleukin-6 (IL-6) is most specific for trauma
patients, while tumor necrosis factor- (TNF-) and IL 1-
demonstrated a greater accuracy in patients with hemorrhage and in nonsurvivors after ARDS and multiple organ
failure (MOF) [44,45].
Likewise, previous results from our group have discounted the value of the measurement of systemic TNF-
Table 3
Parameters associated with adverse outcome in multiply injured patients
Criteria

Reference

Unstable condition or resuscitation difficult

(borderline patient)
Coagulopathy (platelet count 90,000)
Hypothermia (32C)
Shock and 25 units of blood
Bilateral lung contusion on first plain film
Multiple long bones plus truncal injury AIS 2 or more
Presumed operation time 6 hours
Arterial injury and hemodynamic instability (RR 90)
Exaggerated inflammatory response (eg, Il-6 800 pg/mL)

[26,38]
[21]
[67]
[67]
[26]
[43a]
[38]
[29]
[43a,44
47,51]

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H.-C. Pape et al. / The American Journal of Surgery 183 (2002) 622 629

Table 4
Recommendations for staged treatment of femoral shaft fractures*

Stable patient
Borderline patient

Unstable patient

Patient in extremis

Injury severity and distribution

Recommendation for treatment

Isolated femoral shaft fractures and

polytrauma without thoracic trauma
Polytrauma with thoracic trauma
(AISTh 24 points) borderline
patient (Table 2)
Polytrauma with thoracic trauma
(AISTh 4 points) or in critical
condition
Cardiorespiratory dysfunction
resistant to therapy

ETC
BA

DC

DC

Treatment according to locally preferred method

(RFN/UFN/plate)
UFN intraoperative PA catheter (intraoperative
PA pressure increase 6 mm Hg: modification of
ventilatory support)
No intramedullary instrumentation: temporary
external fixator or distractor in operation theater
or ICU
Temporary external fixator in ICU

* Modified from Charash et al [36].

ETC early total care; BA approach for borderline patients; DC Damage control; PA pulmonary artery; RFN reamed femoral nail; UFN
unreamed femoral nail; ICU intensive care unit.

concentrations as an acute marker of trauma and surgery.

The serum levels of TNF- have also not been shown to
correlate with the development of MOF and septic shock in
trauma patients [46]. Although the role of TNF- as an
inflammatory mediator has been recognized in many patient
groups, it was argued that in trauma patients binding of
serum TNF- to its shed soluble receptors [47] may interfere with measurement of its serum levels [48], which
would explain these negative findings. It was ruled out that
this effect was caused by the timing of blood collection [49].
In contrast, increased IL-6 levels remained elevated for
more than 5 days after trauma in patients with a high injury
severity score, and early elevated IL-6 levels were able to
discriminate trauma patients who later develop organ failure
[50]. In addition, previous results from our group have
shown that systemic IL-6 concentrations exceeding 800
pg/mL on admission are predictive of later organ failure
[51]. IL-6 has also been proven to represent an adequate
marker to quantify the burden of a surgical procedure.
Cruickshank et al reported that elective surgical procedures
cause an acute rise in venous levels of IL-6 in proportion to
the magnitude and duration of the surgery. That study was
criticized because it compared various types of surgical
procedures and did not focus on a comparable insult. However, when the impact of reamed intramedullary nailing of
the femur was measured as a standardized operation, the
results were confirmed. The measurements from separate
laboratories revealed a similar increase in venous levels of
IL-6 during reamed intramedullary nailing of the femur
[41,52]. A further well-described phenomenon after trauma
is the priming of leukocytes. Clinical studies demonstrated
that this activation is associated with an increase in the IL-6
concentrations [43]. One other study also investigated antiinflammatory cytokine releases. An immune suppressive
effect after femoral nailing (reamed and unreamed), determined by an increased IL-10 release, was demonstrated
[53].
Quantification of the second hit: in patients undergoing
various operations, IL-6 serum levels have been demon-

strated to be closely related with the magnitude of the injury

(burden of trauma) and with the operative procedure (second hit) [40]. The degree of surgery was determined by
T-cell production of interferon- (IFN-), TNF-, and IL-2,
which was reduced after open surgery but not after laparoscopic abdominal surgery [54]. Moreover, patients who
develop postoperative complications after major abdominal
surgery reveal a decrease in IL-1 production [55], and a
biphasic pattern of other T-cell cytokines [56]. These and
other studies reveal that the immunomodulatory mechanisms after elective surgery and after primary surgery in
trauma patients are well described [57]. Our recent clinical
findings support these results in that IL-6 concentrations
varied according to the type of orthopedic surgery. Specifically, the inflammatory response induced by femoral nailing was biochemically comparable with that induced by
uncemented total hip arthroplasty. Moreover, in polytrauma
patients, an additional impact due to primary surgery could

Fig. 1. Impact of the initial trauma and of the treatment on the clinical
status of the polytraumatized patient.

H.-C. Pape et al. / The American Journal of Surgery 183 (2002) 622 629

be determined that occurs in addition to the one induced by

the initial trauma [52]. To further quantify the impact of the
second hit, the authors assessed the role of femoral nailing.
The immune suppressive effect of femoral nailing (reamed
and unreamed) was measured by looking at the IL-10 release and the expression of class II human leukocyte antigen
(HLA) expression on peripheral blood mononuclear cells.
Reamed femoral nailing was associated with greater impairment of immune reactivity than was the unreamed nailing
technique [53].

Clinical evidence for the usefulness of DCO

These results provided the evidence that the subclinical
effects of surgical procedures can induce clinically relevant
changes. This approach has been proven effective in patients with severe abdominal injuries [58,59]. The stepwise
approach foresees initial blood control and planned secondary definitive measures. Orthopedists meanwhile relied on
the positive experiences made in patients with abdominal
trauma and performed a similar strategy for fracture treatment. The term damage control coined by general surgeons was therefore implemented as damage control orthopedics, or DCO, for the patient with orthopedic injuries
[61,62].
Most of the discussions in regard to this strategy deal
with the stabilization of long bone fractures. Less discussion
has occurred in regard to the management of pelvic instabilities, but similar mechanisms appear to be relevant. The
development of the pelvic clamps has provided a useful tool
for emergent hemorrhage control and temporary fixation of
the unstable pelvic ring injury. Likewise, an external fixator
can be applied in the emergency room or even in the
intensive care unit if the patient is in extremis. Initial open
reduction and internal fixation in patients with a critical
condition does not appear to be appropriate any more. The
protocol currently used in both departments (Leeds and
Hannover) foresees packing of the pelvis as an emergency
procedure for hemorrhage control, followed by temporary
stabilization using external fixators [60].
The effectiveness of DCO for major orthopedic fractures
was recently described in two published clinical studies.
Both Scalea et al [61] and Nowotarski et al [62] reported
favorable results in patients with very high risk of organ
failure. It is of note that one of these preliminary studies was
performed in a center that had previously favored the early
total care approach and reported no complications in a select
group of polytraumatized patients [63]. Our group has begun to use damage control orthopaedic surgery in 1990. The
results confirm these two studies [64]. It appears that the
favored orthopedic tool for DCO is the application of external fixators. They are easy to use to provide adequate
stability and are not time consuming. There is, however, the
risk of infection. This has not been borne out in clinical
practice and numerous authors have shown the feasibility of

627

primary external fixation, followed by definitive stabilization of orthopedic surgery [64 68].
As with every principle, there are opponent meanings to
the DCO strategy. Most of the manuscripts dealing with the
issue of early definitive treatment were published between
1985 and 1995. They relied mainly on the studies by Johnson et al [10] and Bone et al [11]. When their results were
questioned based on the results from other studies [18,22],
numerous other reports were undertaken to support the
concept of early total care in all fractures regardless of the
severity of injury and the type of investigation performed
[15,35,36]. However, all these studies varied widely in their
inclusion criteria, the mean injury severity, and other parameters. One criticism, addressed by a highly esteemed
orthopedist, may be cited as an example at this point: Court
Brown [69] comments on the retrospective report by Boulanger et al as follows . . . the groups were as well
matched as possible . . . but table I clearly indicates considerable differences among the groups. In addition, . . . the
other important point is that although we know the average
ISS, we do not know how many patients presented with very
high scores. . . . To our knowledge, there is currently no
prospective randomized study available that investigates the
issue of damage control orthopedic surgery. However, it is
of note that recently large trauma centers apparently have
begun to modify their management strategies even in the
absence of such a study especially in the United States.
Please note that the study published by Bosse et al [63] in
1997 was in favor of early aggressive management, whereas
Scalea et al [61] reported 3 years later about the feasibility
of damage control. Both papers are from the Shock Trauma
Center in Baltimore.
When the principle of DCO is followed, the next question then has to address the issue of the optimal timing of
secondary procedures. In this regard, it appears that the
posttrauma days 2 to 4 are not ideal to perform secondary
definitive operations. At this time, sustained immunologic
changes are ongoing [70] and fluid shifts (increased generalized tissue edema) have not yet normalized [71]. In a large
survey of 4,314 patients it was investigated, that the timing
of a secondary operation of more than 3 hours duration
may be related to the development of organ dysfunction.
Patients were separated according to the presence or absence of multiple organ failure. Secondary surgery in patients who later developed organ failure was performed
between day 2 and 4, whereas patients without organ failure
were operated on between days 6 and 8 (P 0.0001) [72].
Moreover, it was recently shown that patients who are
submitted to secondary definitive orthopedic surgery at days
2 to 4 after trauma demonstrated worse inflammatory
changes compared with those operated on at days 6 to 8.
Therefore, it appears that in patients after damage control
orthopedic surgery, a certain waiting period of several days
may be required [73].

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H.-C. Pape et al. / The American Journal of Surgery 183 (2002) 622 629

Fig. 2. Flow diagram highlighting the algorithms for treatment of major

fractures in consideration of the current knowledge of the impact of surgery
after severe trauma. OR operating room; ICU intensive care unit;
ETC early total care; DCO damage control orthopedic; Ex.Fix.
external fixation.

Conclusion
Damage control orthopedics currently appears to be the
treatment of choice for patients with severe polytrauma who
are at high risk to develop systemic complications, such as
multiple organ failure. Animal and clinical studies have
revealed that this approach reduced the impact of the second
hit. Clinical studies investigating the type and the timing of
surgery clearly demonstrated that improvements in the clinical status coincided with a less sustained inflammatory
response, if this principle is followed. The authors feel that
the following principles are relevant: the procedure can be
conceived as part of the resuscitation effort by maintaining
blood volume and tissue oxygenation, thus minimizing the
damage induced by the procedure while utilizing the surgical treatment options to maintain the benefits of fracture
stabilization.
Based on the evolution of the above concepts regarding
the management of polytrauma patients, the following recommendations can be made for specific group of patients
(Fig. 2). It is anticipated that, with the rapid advances in the
field of molecular medicine and genetics, the discovery of
suitable inflammatory markers will guide us better in appropriately selecting patients at risk for posttraumatic complications and, therefore, choosing the most appropriate
treatment protocol.

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