REVIEW

CURRENT
OPINION Damage control orthopedics: current evidence
Philipp Lichte a, Philipp Kobbe a, Derek Dombroski b, and Hans C. Pape a

Purpose of review
There is still an ongoing debate whether damage control orthopedics (DCO) or other treatment strategies
should be favored in the treatment of multiply injured patients. This review gives an overview of the current
literature concerning this important question in the treatment of severely injured patients.
Recent findings
Several studies could show that DCO can reduce the inflammatory burden due to surgery (second hit).
The only randomized study showed a benefit for borderline patients treated by DCO in comparison to
early total care. Other studies showed advantages for early care treatment in similar patients.
Summary
In severely injured patients, DCO should be considered. On the other hand, there is still a lack of
randomized studies for a more precise characterization of the patients who benefit from DCO treatment.
Keywords
borderline patients, DCO, ETC, inflammatory response, second hit

INTRODUCTION hit’ mainly depends on the timing of surgical

Polytrauma is still a major cause of death in young
persons. Survival rates could be improved during
the last decades because of improved intensive
care medicine and new surgical approaches. Never-
theless, there is an ongoing debate on whether
fractures in severely injured patients should be
managed by early definitive operative care or
whether a staged management is favorable.
TRAUMA AND THE IMMUNE SYSTEM
Trauma causes a sustained response of the immune
system. The extent of the reaction depends on
the degree of the trauma and the basic state of the
patient. Typically, an early hyperinflammatory
stage is followed by a hypoinflammatory stage.
Surgical treatment can induce an inflammatory
response as well. In the setting of a singly injured
healthy patient, these additional inflammatory
changes are of no further consequence for the
patient. However, in multiply injured patients
prolonged surgery with relevant blood loss, hypo-
thermia, and surgical trauma can cause an excessive
inflammatory reaction (second hit). Therefore in
these patients, extensive surgical procedures can
trigger systemic inflammatory response syndrome,
acute respiratory distress syndrome (ARDS), and
multiple organ failure (MOF) by this secondary
inflammatory reaction. The triggering of a ‘second
interventions, whereby choosing a time point a
few days after trauma minimizes the risk of this
detrimental immunologic response.
DISADVANTAGES OF DELAYED
FRACTURE CARE
Delayed fixation of major fractures can forward
local and systemic complications. It can be associ-
ated with negative consequences for short-term
results as well as for long-term results.
Patients without adequate fixation, especially
of long bone, pelvic, and spine fractures cannot
be mobilized at an early stage. They are often
forced to remain in a recumbent position for a long
period and therefore are at high risk for pulmonary
complications like pneumonia but also decubitus
ulcers and gastrointestinal stasis. The consequence
of delayed fracture fixation leads to a prolonged
a
Department of Orthopaedic Trauma Surgery, Medical School of the
RWTH Aachen University, Aachen, Germany and bDepartment of Ortho-
paedic Surgery, Parkland Memorial Hospital, Dallas, Texas, USA
Correspondence to Hans C. Pape, FACS, Chair of the Department of
Orthopaedic Trauma Surgery, Medical School of the RWTH Aachen
University, Pauwelsstrasse 30, 52066 Aachen, Germany. Tel: +49
2418089350; fax: +49 2418082415; e-mail: hpape@ukaachen.de
Curr Opin Crit Care 2012, 18:647–650
DOI:10.1097/MCC.0b013e328359fd57

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 Trauma
KEY POINTS
 DCO can reduce the inflammatory response in the
initial stage after trauma.
 DCO should be considered in the treatment of critically
ill patients after trauma.
 Further randomized studies are necessary to define
patients who will benefit from DCO treatment.
ICU treatment with more infection-related compli-
cations.
From the musculoskeletal perspective, delayed
fixation of major fractures interferes with compre-
hensive physiotherapy. Prolonged immobilization
of major joints can lead to stiffness impairing func-
tional outcomes. Disuse muscle atrophy impairs the
long-term outcome.
DAMAGE CONTROL ORTHOPEDICS
Damage control philosophy in trauma means
only immediate lifesaving procedures directed at
stopping bleeding are performed in the initial phase.
Afterwards, stabilization of the patient follows in the
ICU. Definitive reconstruction interventions will
follow after the patients’ physiological parameters
have improved. This philosophy was adapted to
orthopedic interventions.
The damage control orthopedics (DCO) concept
of surgical treatment uses minimally invasive
surgical techniques for the primary stabilization of
all major fractures to control hemorrhage and stop
the cycle of ongoing immunological impact of
unstable long bone fractures. The primary tool in
DCO is the external fixator which can be used for
temporary stabilization of most long bone fractures
and selected pelvic fractures. External fixation
provides sufficient stability for wound care and early
mobilization, and thereby facilitates nursing care.
In a retrospective study [Level of Evidence III
(low)], blood loss and operation time in patients
with femur fractures either managed with early total
care (ETC; n ¼ 284) or DCO (n ¼ 43) were compared.
The median operating room time for patients
managed with DCO was 35 min with an estimated
blood loss of 90 ml compared to patients managed
with ETC in which the median operating room time
was 135 min with an estimated blood loss of 400 ml.
Similar results have been reported by Tuttle et al. [1]
who found a significantly reduced operation time
(22 vs. 125 min) and blood loss (37 vs. 330 ml)
comparing patients with femoral shaft fractures
managed with DCO (n ¼ 55) or ETC (n ¼ 42) [Level
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of Evidence III (low)]. These findings have been
confirmed with a Level of Evidence II (moderate)
by Taeger et al. [2] who managed 75 patients
with DCO. In the course, 57 of these were converted
to definitive fracture care (hypothetical ETC). Oper-
ation time for DCO maneuvers was 62
30 min
as compared to a significantly higher mean oper-
ation time for conversion (hypothetical ETC) of
233
19 min. Blood loss was also significantly
lower for DCO (<50 ml) than for hypothetical
ETC (472 ml) [2].
DCO treatment with external fixation is useful
in critical patients to perform fracture stabilization
faster and with less blood loss than definitive
internal stabilization.
DAMAGE CONTROL ORTHOPEDICS
EFFECTS ON THE IMMUNE SYSTEM
There is evidence that DCO surgery minimizes the
‘second hit’ phenomena because of a reduction of
the surgical influence on the first phase.
In a prospective, randomized, multicenter
study, 35 polytrauma patients [Injury Severity Score
(ISS) >16] with long bone shaft fractures were either
managed with ETC (n ¼ 17) or with DCO (n ¼ 18),
and serum inflammatory markers were measured
preoperatively, perioperatively, and postoperatively
[3]. In contrast to the sustained increase in the
inflammatory burden in the patients managed with
ETC, this burden was not observed in the DCO
patients after initial external fixation and secondary
conversion to an intramedullary implant [3] [Level
of Evidence I (high)]. This finding was confirmed
by a retrospective comparison of 174 patients
with femoral shaft fractures and a New Injury
Severity Score (NISS) of at least 20. In this cohort
of patients managed with ETC, a significantly
higher systemic inflammatory response was found,
although patients in the DCO group (n ¼ 97) had a
significantly higher NISS than those in the ETC
group (n ¼ 77) [Level of Evidence III (low)].
These findings may become clinically relevant
in the treatment of patients who are at high risk of
developing systemic complications.
WHICH PATIENT BENEFITS FROM
DAMAGE CONTROL ORTHOPEDICS?
Stubig et al. [4] reported a tendency toward a higher
incidence of ARDS in patients with an ISS of
25–39 treated with ETC than in the DCO group,
whereas in less severely injured patients ETC shows
benefits [Level of Evidence III (low)]. The benefit of
DCO becomes obvious once the entire trauma popu-
lation is divided into subgroups (stable, borderline,
Volume 18  Number 6  December 2012

unstable, and in extremis). This benefit is sup-
ported by Morshed et al. [5] with their retrospective
study including 3069 patients [Level of Evidence III
(low)] and by the only available prospective
study investigating the incidence of acute lung
injury (ALI), showing that ETC is reasonable in
stable patients but has a higher risk of mortality
and ALI in more severely injured patients (border-
line patients) than DCO [6] [Level of Evidence I
(high)]. Criteria for borderline condition are as
follows:
(1) ISS greater than 40;
(2) Multiple injuries (ISS >20) in combination with
thorax trauma;
(3) Multiple injuries in combination with severe
abdominal or pelvic injury and hemorrhagic
shock at the moment of administration;
(4) Patients with moderate or severe head trauma;
(5) Radiographic evidence of pulmonary contu-
sion;
(6) Patients with bilateral femur fractures;
(7) Body temperature below 358C.
&
Nicholas et al. [7 ] compared in 2011 their bor-
derline femur fracture patients with the results of
the prospective study [Level of Evidence III (low)].
They found shorter ICU and ventilator days, fewer
septic complications and a potentially lower inci-
dence of organ failure despite the fact that 86% of
&
their borderline patients were treated by ETC [7 ].
These results are in line with another retrospective
study [Level of Evidence III (low)] from the USA
which concluded that reamed intramedullary nail-
ing of femoral fractures is safe even in severely
injured patients [8]. They reported very low rates
of ARDS and death. This study concluded that DCO
might play a lifesaving role for only certain very ill
patients, but is rarely needed. They also reasoned
that delayed fracture care (more than 8 h after
trauma) might be better than early stabilization
&&
[8]. In 2011, Morshed et al. [9 ] published a retro-
spective analysis which shows that intramedullary
nailing of femoral shaft fracture in the setting of
serum bicarbonate-defined hypoperfusion is associ-
ated with increased morbidity [Level of Evidence III
(low)]. They conclude that DCO measures and
aggressive resuscitation prior to definitive fracture
care seems to have a benefit in patients in shock
&&
[9 ]. Another retrospective investigation also
showed that ETC (defined as definitive care within
the first 24 h) shows acceptable complication rates
even in multiply injured patients with severe
&
abdominal, head, and chest injuries [10 ] [Level of
Evidence III (low)]. They favor ETC within the first
hours in comparison to delayed fracture care and
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Damage control orthopedics: current evidence Lichte et al.
emphasize the importance of sufficient resuscita-
&
tion before fracture care [10 ].
A retrospective review which compared skeletal
traction vs. DCO treatment showed no advantage
for external fixation [Level of Evidence III (low)]
[11]. The authors concluded that patients who
do not need a general anesthesia for lifesaving
operations can be treated safely by skeletal traction
as a temporization method [11].
Though most studies about the timing of
definitive fracture care in multiply injured patients
focus on long bone fractures, especially femoral
fractures, in 2010, Enninghorst et al. [12] reported
that early definitive care (<6 h) of unstable pelvic
ring fractures in severely shocked multiply injured
patients seems to be beneficial to delayed treatment
[Level of Evidence III (low)]. Vallier et al. [13] inves-
tigated the role of ETC in pelvic ring and acetabular
fractures [Level of Evidence III (low)]. They com-
pared definitive fixation within 24 h with definitive
care more than 24 h. They found a lower morbidity
and a shortened ICU stay in the group treated
within the first 24 h [13]. Because of the lack of
DCO comparison group in both studies, a statement
about the role of DCO in these fractures is not
possible.
The classification of a patient’s physiological
status is often made in concert with all treating
physicians. While the ISS or NISS may not
get calculated on admission, the status of the
patient needs to be assessed early. In the USA, the
orthopedic surgeon, the general surgery trauma
surgeon, the intensivist, and the anesthesio-
logist make this assessment. The European system
has a greater role for the orthopedic trauma
surgeon in this decision-making process. Regardless
who classifies the patient as stable or not, an
accurate assessment needs to be made as it deter-
mines the treatment and ultimately affects the
outcomes.
In conclusion, stable patients should be treated
by ETC. Data for borderline patients are contro-
versial, but the only prospective study showed
an advantage for DCO. Therefore, we recommend
DCO treatment for borderline and unstable
patients. More prospective data are necessary to
define the patients who benefit from DCO more
precisely.
LONG-TERM RESULTS AND
COMPLICATIONS AFTER DAMAGE
CONTROL ORTHOPEDICS TREATMENT
After DCO, no higher rate of complications is
reported in comparison to ETC. Harwood et al.
[14] showed that the risk of infection following
www.co-criticalcare.com 649
 Trauma
DCO was equivalent as compared to primary
definitive care (4.5%) [Level of Evidence III
(low)]. Although no increased risk of infection
following external fixation could be shown,
contamination of pin sites was significantly more
likely when conversion to intramedullary nailing
occurred later than 14 days [14]. Van den Bossche
et al. [15] showed that external fixation for femoral
shaft fractures in severely injured patients is a
safe option in terms of infectious complications
(neither superficial nor deep infections) [Level
of Evidence III (low)]. Also Scalea et al. [16] and
Nowotarski et al. [17] found no significant differ-
ences in infectious complications comparing DCO
with ETC [Level of Evidence III (low)]. A report
about battlefield injuries confirmed these results
[Level of Evidence IV (low)]. They reported no
case of septic complications after early conversion
to internal fixation. There was only one post-
conversion infection after 3 months of external
fixation [18].
In conclusion, DCO is a safe method regarding
infectious complications. In light of the inflam-
matory burden, the conversion to a definitive,
biomechanically superior implant should not be
performed before days 5–7 after trauma. However,
because of an increased risk of local pin site con-
tamination the conversion should be performed
before day 14.
CONCLUSION
DCO reduces the operative burden in the initial
phase by reducing blood loss and operation
time. Therefore, surgery-related inflammation
can be reduced and systemic complications caused
by the ‘second hit’ may be reduced. In stable
patients, this is of minor importance and there-
fore ETC is preferable. In critically ill patients,
DCO treatment should be considered and exter-
nal fixation of the major fractures should be
performed. Conversion to definitive fracture treat-
ment should be performed within 14 days after
trauma. Further randomized studies are needed
for a more precise characterization of indications
and results.
Acknowledgements
None.
Conflicts of interest
All authors declare that they have no conflict of interests.
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REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 724).
1. Tuttle MS, Smith WR, Williams AE, et al. Safety and efficacy of damage
control external fixation versus early definitive stabilization for femoral shaft
fractures in the multiple-injured patient. J Trauma 2009; 67:602–605.
2. Taeger G, Ruchholtz S, Waydhas C, et al. Damage control orthopedics in
patients with multiple injuries is effective, time saving, and safe. J Trauma
2005; 59:409–416.
3. Pape HC, Grimme K, van Griensven M, et al. Impact of intramedullary
instrumentation versus damage control for femoral fractures on immunoin-
flammatory parameters: prospective randomized analysis by the EPOFF
Study Group. J Trauma 2003; 55:7–13.
4. Stubig T, Mommsen P, Krettek C, et al. Comparison of early total care (ETC) and
damage control orthopedics (DCO) in the treatment of multiple trauma with
femoral shaft fractures: benefit and costs. Unfallchirurg 2010; 113:923–930.
5. Morshed S, Miclau T III, Bembom O, et al. Delayed internal fixation of femoral
shaft fracture reduces mortality among patients with multisystem trauma.
J Bone Joint Surg Am 2009; 91:3–13.
6. Pape HC, Rixen D, Morley J, et al. Impact of the method of initial stabilization
for femoral shaft fractures in patients with multiple injuries at risk for complica-
tions (borderline patients). Ann Surg 2007; 246:491–499.
7. Nicholas B, Toth L, van Wessem K, et al. Borderline femur fracture patients: early
total care or damage control orthopaedics? ANZ J Surg 2011; 81:148–153.
&
The authors retrospectively compared the rates of systemical complications after
femoral early total care in borderline patients with the results of the randomized trial
of Pape et al. and saw a distinct lower complication rate. This study carves out that
maybe the different organizational form in the treatment of trauma patients can
influence the discussion of DCO vs. ETC. Even this is a reason for the need of more
randomized trials concerning this question.
8. O’Toole RV, O’Brien M, Scalea TM, et al. Resuscitation before stabilization of
femoral fractures limits acute respiratory distress syndrome in patients with
multiple traumatic injuries despite low use of damage control orthopedics.
J Trauma 2009; 67:1013–1021.
9. Morshed S, Corrales LA, Lin K, Miclau T. Femoral nailing during serum
bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction
&&
in multisystem trauma patients. Injury 2011; 42:643–649.
This retrospective cohort study analyzes the serum bicarbonate as a marker for the
timing of femoral nailing. The authors conclude that appropriate damage-control
measures and aggressive resuscitation prior to definitive fracture care are advised,
and serum bicarbonate might be able to guide clinical decision-making.
10. Nahm NJ, Como JJ, Wilber JH, Vallier HA. Early appropriate care: definitive
& stabilization of femoral fractures within 24 h of injury is safe in most patients
with multiple injuries. J Trauma 2011; 71:175–185.
This retrospective study of 750 patients which compared early definitive care with
damage control treatment in femoral fractures shows that definitive treatment
might be saved even in severely injured patients. The authors emphasized the
importance of appropriate resuscitation before operative treatment.
11. Scannell BP, Waldrop NE, Sasser HC, et al. Skeletal traction versus external
fixation in the initial temporization of femoral shaft fractures in severely injured
patients. J Trauma 2010; 68:633–640.
12. Enninghorst N, Toth L, King KL, et al. Acute definitive internal fixation of pelvic
ring fractures in polytrauma patients: a feasible option. J Trauma 2010;
68:935–941.
13. Vallier HA, Cureton BA, Ekstein C, et al. Early definitive stabilization of unstable
pelvis and acetabulum fractures reduces morbidity. J Trauma 2010; 69:677–
684.
14. Harwood PJ, Giannoudis PV, Probst C, et al. The risk of local infective
complications after damage control procedures for femoral shaft fracture.
J Orthop Trauma 2006; 20:181–189.
15. Van den Bossche MR, Broos PL, Rommens PM. Open fractures of the femoral
shaft, treated with osteosynthesis or temporary external fixation. Injury 1995;
26:323–325.
16. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to
intramedullary nailing for patients with multiple injuries and with femur frac-
tures: damage control orthopedics. J Trauma 2000; 48:613–621.
17. Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external
fixation to intramedullary nailing for fractures of the shaft of the femur in
multiply injured patients. J Bone Joint Surg Am 2000; 82:781–788.
18. Mathieu L, Bazile F, Barthelemy R, et al. Damage control orthopaedics in the
context of battlefield injuries: the use of temporary external fixation on combat
trauma soldiers. Orthop Traumatol Surg Res 2011; 97:852–859.
Volume 18  Number 6  December 2012