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Damage control orthopaedics. Evolving concepts

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THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG D A M A G E C O N T RO L
VO L U M E 87-A N U M B E R 2 F E B R U A R Y 2005 ORTHOPAEDICS

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 unsafe2.
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-
duced3. 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 elaborate3.
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
procedure3. 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 patients4. On November 6, 1958,
these pioneering surgeons established

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the Arbeitsgemeinschaft fr Osteosyn-
thesefragen (the Association for the
Study of Internal Fixation, or ASIF), or
AO, in Biel, Switzerland4. 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 injuries4. 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
fixation5. 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
fixation7. 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 trauma8. 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 institution9,10 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-
D A M A G E C O N T RO L
ORTHOPAEDICS
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 years1,9-12.
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
injuries13.
In the 1940s and 1950s, Arnold
Griswold, of Kentucky, used a damage
control approach to penetrating inju-
ries of the abdominal cavity14. In 1981,
Feliciano et al. reported that nine of ten
patients who had undergone hepatic
packing for the treatment of exsan-
guinating hemorrhage survived15. Stone
et al., in 1983, described a stepwise
approach involving intra-abdominal
packing and a laparotomy that was ter-
minated rapidly16. In 1992, Burch et al.
reported a 33% survival rate in a group
of 200 patients treated with abbreviated
laparotomy and a planned reopera-
tion17. Rotondo and Zonies, in 1993,
coined the term damage control and
reported a 58% rate of survival of pa-
tients treated with a standardized
protocol18. 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 exsanguination13. Phase one in-
volved an immediate laparotomy to
control hemorrhage and contamina-
tion18. 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 Israel18,19.
Physiology of Damage
Control Orthopaedics
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
interactions21. Reactive oxygen species,
eicosanoids, and microcirculatory dis-
turbances also play pivotal roles22. 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,

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gree of stimulation of the inflamma-

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.
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 syndrome23.
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 trauma24-27. This
response initially corresponds to the
first-hit phenomenon25. 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 points28.
An immediate increase in expression of
neutrophil L-selectin was reported in
patients with an injury severity score of
16 points29. Similarly, a significant (p <
0.05) increase in the expression of the
integrin CD11b was noted in more se-
verely injured patients29. 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-
tory markers8,30.
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 trauma31,32. 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 sepsis33. 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
trauma34.
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 trauma35. 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 phenomenon36. 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

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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

the response to the first hit and the re- development of posttraumatic compli- IL-10 inhibits the activity of TNF- and
sponse to the second (surgical) hit that cations such as multiple organ dysfunc- IL-1, and the levels detectable in the cir-
created the final fatal event. The above tion syndrome (Table I). Common culation correlate with the initial degree
studies suggest that the degree of the serum markers can be divided into of injury. Persistently high levels of IL-
initial injury is important in determin- markers of mediator activity such as C- 10 also correlate with sepsis. However,
ing a patients susceptibility to posttrau- reactive protein, tumor necrosis factor- its role in predicting outcome is still
matic complications. (TNF-), IL-1, IL-6, IL-8, IL-10, and debatable44.
The concept that a secondary sur- procalcitonin and markers of cellular Regarding the markers of cellular
gical procedure creates an additional in- activity such as CD11b surface receptor activity, mixed results have been re-
flammatory insult (a second hit) was on leukocytes, endothelial adhesion ported in the literature about the effi-
specifically addressed in a prospective molecules (intercellular adhesion mole- cacy of endothelial adhesion molecules
study of 106 patients with an average cule-1 [ICAM-1] and e-selectin), and (ICAM-1 and e-selectin) and the
injury severity score of 40.6 points37. HLA-DR class-II molecules on periph- CD11b receptor of leukocytes45. HLA-
Forty patients in whom respiratory, re- eral mononuclear cells. DR class-II molecules mediate the pro-
nal, or hepatic failure developed, alone C-reactive protein, procalcitonin, cessing of antigen to allow for cellular
or in combination, following a second- TNF-, IL-1, and IL-8 have not been immunity. They are considered to be re-
ary surgical procedure were compared shown to be reliable markers38-43. How- liable markers of immune reactivity and
with patients in whom no such compli- ever, IL-6 correlates well with the degree a predictor of outcome following
cations developed. There was a signifi- of injury, appears to be a reliable index trauma46,47.
cant (p < 0.05) elevation of the of the magnitude of systemic inflamma- Napolitano et al. reported that
neutrophil elastase and C-reactive pro- tion, and correlates with the outcome12. the severity of the systemic inflamma-
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
Fig. 2
and illustrate the impact of the opera-
Mean plasma elastase concentrations (and 95% confidence intervals) before and after intramed-
tive procedure on trauma patients at
risk for exhaustion of their biological ullary nailing of the femur from the time of admission to the emergency room (A&E) to 168 hours
reserve (Fig. 3). after surgery8. 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
Markers of Immune Reactivity MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and
Inflammatory markers may hold the unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br.
key to identifying patients at risk for the 1999;81:359.)

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tory response syndrome at admission

may be an accurate predictor of mortal-
ity and the length of stay in the hospital
by trauma patients48. 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 trauma49.
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 risk50.
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 others51. 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 phagocytosis52. 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 injury46.
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 unit53-55. This association depends
on the presence of the TNF2 allele. Ho-
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.
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 TNFB256. Homozy-
gous patients also have higher circulat-
ing TNF- concentrations and higher
multiple organ dysfunction syndrome
scores compared with heterozygotes57.
IL-6 polymorphisms have been
reported and were detected in both the
3 and the 5 flanking regions and exon
558,59. The SfaNI polymorphism is lo-
cated at position 174. A homozygotic
constellation of this polymorphism
coincided with decreased IL-6 serum
levels during inflammation60,61. Poly-
morphisms in the IL-10 gene have also
been demonstrated62. Eskdale et al.
reported that stimulation of human
blood cultures with bacterial li-
popolysaccharide showed large inter-
individual variation in IL-10 secretion63.
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
characterized64,65. 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
infection66. 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

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(e.g., the abbreviated injury scale67, in-
jury severity score68,69, revised trauma
score70, anatomic profile71, and Glasgow
coma scale72) 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 extremis74. 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 score75 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
deterioration74. 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
D A M A G E C O N T RO L
ORTHOPAEDICS
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 score75 >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
indicating borderline status (Table II) that the increase in mortality may be
and factors associated with a high risk more closely related to associated inju-
of adverse outcomes (Table III), should ries and physiologic parameters than to
determine how the patient is treated. In the bilateral femoral fracture itself 77. Wu
Louisville, some of the additional clini- and Shih78 noted that bilateral femoral
cal criteria that we have used as a basis fracture indicates severe systemic and
for shifting to damage control ortho- local injuries. Thus, such injuries are
paedics include a pH of <7.24, a tem- ideal for damage control orthopaedics.
perature of <35C, operative times of
more than ninety minutes, coagulopa- Pelvic Ring Injuries
thy, and transfusion of more than ten Exsanguinating hemorrhage associated
units of packed red blood cells. Further- with pelvic fracture is another injury
more, certain specific orthopaedic in- complex suitable for damage control
jury complexes appear to be more orthopaedics. Hemorrhage can result
amenable to damage control ortho- from a combination of osseous, venous,
paedics; these include, for example, and arterial bleeding. Although the
femoral fractures in a multiply injured most common arterial injuries involve
patient, pelvic ring injuries with exsan- the internal iliac artery or its branches
guinating hemorrhage, and poly- (e.g., the superior gluteal artery), inju-
trauma in a geriatric patient. ries to the common and external iliac
arteries have been reported and are as-
Femoral Fractures sociated with a poor outcome79. The
Femoral fractures in a multiply injured specific radiographic pattern of the pel-
patient are not automatically treated vic ring injury and the mechanism of
with intramedullary nailing because of the injury can help one to anticipate the
concerns about the second hit of such a amount of bleeding, but there is no pre-
procedure. In addition to the second cise injury pattern that predicts hemor-
hit, which results in an additional sys- rhage consistently. An additional
temic inflammatory response, embolic complicating factor can be the presence
fat from use of instrumentation in the of a pelvic binder put in place by emer-
medullary canal will worsen the pulmo- gency medical responders, as it may de-
nary status. Patients with a chest injury crease the pelvic volume, realign the
(an abbreviated injury score of >2 pelvic ring, and contribute to a benign-
points) are most prone to deterioration looking pelvic radiograph.
after an intramedullary nailing There are nonetheless some con-
procedure76. sistent findings associated with a higher
Bilateral femoral fracture is a likelihood of hemorrhage. Posterior
unique scenario in polytrauma that is pelvic ring injuries are associated with a
associated with a higher mortality rate two to threefold increase in blood re-
and incidence of adult respiratory dis- placement requirements compared with
tress syndrome than is a unilateral fem- anterior injuries80,81. Anterior-posterior
oral fracture77. Copeland et al. noted compression type-III injuries and lat-

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survived), greater transfusion require-

TABLE III Clinical Parameters Associated with Adverse Outcomes in Multiply ments (10.9 units for the patients who
Injured Patients as Reported in Hannover, Germany
died compared with 2.9 units for those
Unstable condition or resuscitation difficult (borderline patient) who survived), and greater fluid infu-
Coagulopathy (platelet count <90,000)
sion (12.4 L for the patients who died
compared with 4.9 L for those who sur-
Hypothermia (<32C)
vived)87. These differences highlight the
Shock and >25 units of blood needed importance of considering damage
Bilateral lung contusion on first plain radiograph control orthopaedics for elderly pa-
Multiple long-bone injuries and truncal injury; abbreviated injury score of 2 points tients. In addition, treatment should be
directed toward measures that enhance
Presumed operation time >6 hr
immediate mobilization and the avoid-
Arterial injury and hemodynamic instability (blood pressure <90 mm Hg) ance of prolonged bed rest in this pa-
Exaggerated inflammatory response (e.g., IL-6 >800 pg/mL) tient population.

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
angiography83.
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 Europe85.
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 age86. This value is
essentially half of the LD 50 injury se-
verity score for individuals between
twenty-four and forty-four years of
age85. 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 requirements83. 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
Special Situations in
Damage Control Orthopaedics
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
beneficial6,88-91 and others believing that
early fracture stabilization is not safe
and may be harmful76. 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 States6. 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 trauma92.
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

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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 injury93. 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
function94. Furthermore, unstabilized
fractures may cause physiologic deteri-
oration in these patients as a result of
increased soft-tissue damage, fat embo-
lism, and respiratory insufficiency95-99.
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 fixation100,101. 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 fixation102. Mc-

Fig. 4-A

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-B

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Fig. 4-C Fig. 4-D

Figs. 4-C and 4-D Initial external fixation was performed at the time of the diaphragmatic repair.

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 fixation103.
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 fixation104. 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 discharge105. 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 significance106.
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

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Fig. 4-E
full neurological recovery will occur.
Mangled Extremities
Prior to the Lower Extremity Assess-
ment Project (LEAP) study107-109, there
were limited data on the contemporary
treatment of severely injured or man-
gled lower extremities. Lange110 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
D A M A G E C O N T RO L
ORTHOPAEDICS
Staged intramedullary nailing was
performed on post-injury day 2.
Stern111 reported that seven of nine
Type-III open tibial fractures required
secondary amputation.
Hansen112 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 centers107-109. 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-

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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
Fig. 5-A
tibial shaft fracture managed with limb
Antibiotic bead pouch for treatment of an open proximal tibial fracture (Fig. 5-A), with a
salvage had outcomes that were similar
close-up view (Fig. 5-B). Adjacent to the bead pouch are traumatic arthrotomy and fasciot-
to those of patients who had under-
omy wounds that have been closed. Spanning external fixation across the knee for man-
gone an amputation116. The authors
agement of the tibial fracture and a femoral traction pin for management of an ipsilateral
noted several surgeon-controlled vari-
acetabular fracture were also utilized in this patient.
ables that appeared to influence the
course of the fracture and the patient
adjusted SIP scores (p = 0.05) and tioning. The percentage of patients with outcome. Wound coverage with sim-
slower self-selected walking speeds (p = a slower walking speed was higher in ple methods provided better results
0.004) than did patients with either a the amputation group than in the re- than flap coverage, external fixation
below-the-knee or an above-the-knee construction group (p < 0.05). There and flap coverage provided worse
amputation109. Patients who had been was no difference between the two results than amputations, and bone-
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 scores115.
Significant (p < 0.05) improvement was
observed over time for all dimensions
of the SIP except for psychosocial func- Fig. 5-B

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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*

Early Total Intermediate Damage Control
Care Period Period Orthopaedics Period P Value
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.

grafting performed within three technique may provide a bridge to have termed limb damage control or-
months after the injury had a trend staged osseous reconstruction and soft- thopaedics. Specific injuries that are
for a better outcome than did bone- tissue coverage procedures121. Vacuum- amenable to this approach include
grafting that was accomplished later. In assisted wound closure subjects the complex proximal tibial articular and
addition, Webb et al. found that the wound bed to negative pressure by way metaphyseal fractures and distal tibial
timing of dbridement and of soft- of a closed system and thereby removes pilon fractures. These clinical situa-
tissue coverage did not influence the edema from the extravascular space121. tions usually combine a complex frac-
outcome, and the most common com- ture pattern, either open or closed,
plications warranting readmission Isolated Complex with a substantial soft-tissue injury.
were nonunion and infection. Lower-Extremity Trauma Limb damage control orthopaedics is
Smith et al. reported that pa- An isolated complex extremity injury useful for preventing soft-tissue com-
tients treated with late amputation af- (other than a mangled limb) is a possi- plications by spanning the articular
ter a complex lower-extremity injury ble indication for a limited form of segment with an external fixator and
reported significantly (p < 0.05) higher damage control orthopaedics that we avoiding areas of future incisions. Then
levels of disability than did those who
had had an amputation either during
the first hospitalization or within the
first three months after the injury117.
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 Fig. 6
possible to improve surgeon-controlled The current treatment algorithm from Hannover, Germany, for the use of damage control ortho-
variables that appear to be related to paedics is based on a prompt and accurate determination of whether the patient is stable, bor-
better outcomes. The use of spanning derline, unstable, or in extremis. ER = emergency room, ABG = arterial blood gases, FAST =
external fixation, antibiotic bead focused assessment sonography for trauma, I/O ratio = intake/output ratio, ABP = arterial blood
pouches118-120 (Figs. 5-A and 5-B), and pressure, IL-6 = interleukin-6, ETC = early total care, OR = operating room, DCO = damage con-
the vacuum-assisted wound closure trol orthopaedics, and ICU = intensive care unit.

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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 812,122. 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 reported12.
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 workup1. 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
Control Orthopaedics
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 fixation1. 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
D A M A G E C O N T RO L
ORTHOPAEDICS
TABLE V Comparative Data on Postoperative Local Complications During the
Three Periods of Fracture Care in Hannover, Germany
Patients with Complication*
Early Total
Care Period
Pin track infection 2/39
Wound infection 5/235
Osteomyelitis 2/235
*Number of patients with a complication/total number of patients. NS = not significant.
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
Damage Control Orthopaedics
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 fixation123-125.
Contemporary rates of pin-track infec-
tion are still substantial, but they are
minimized when the duration of exter-
nal fixation is brief126.
Practical Considerations for
Damage Control Orthopaedics
Practical considerations for spanning
Intermediate Damage Control
Period Orthopaedics Period P Value
3/21 4/68 NS
2/88 3/191 NS
0/88 1/191 NS
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-

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VO L U M E 87-A N U M B E R 2 F E B R U A R Y 2005
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
orthopaedics1.
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
1. Pape HC, Giannoudis P, Krettek C. The timing of
fracture treatment in polytrauma patients: rele-
vance of damage control orthopedic surgery. Am J
Surg. 2002;183:622-9.
2. Bradford DS, Foster RR, Nossel HL. Coagulation
alterations, hypoxemia, and fat embolism in fracture
patients. J Trauma. 1970;10:307-21.
3. Rang M. The story of orthopaedics. Philadelphia:
WB Saunders; 2000.
4. Matter P. History of the AO and its global effect on
operative fracture treatment. Clin Orthop.
1998;347:11-8.
5. Pape HC, Schmidt RE, Rice J, van Griensven M,
das Gupta R, Krettek C, Tscherne H. Biochemical
changes after trauma and skeletal surgery of the
lower extremity: quantification of the operative bur-
den. Crit Care Med. 2000;28:3441-8.
6. Bone LB, Johnson KD, Weigelt J, Scheinberg R.
Early versus delayed stabilization of femoral frac-
tures. A prospective randomized study. J Bone Joint
Surg Am. 1989;71:336-40.
7. Border JR. Blunt multiple trauma: comprehensive
pathophysiology and care. New York: Marcel Dekker;
1990.
8. Giannoudis PV, Smith RM, Bellamy MC, Morrison
JF, Dickson RA, Guillou PJ. Stimulation of the inflam-
matory system by reamed and unreamed nailing of
femoral fractures. An analysis of the second hit. J
Bone Joint Surg Br. 1999;81:356-61.
9. Nowotarski PJ, Turen CH, Brumback RJ, Scarboro
JM. Conversion of external fixation to intramedul-
lary nailing for fractures of the shaft of the femur in
multiply injured patients. J Bone Joint Surg Am.
2000;82:781-8.
10. Scalea TM, Boswell SA, Scott JD, Mitchell KA,
Kramer ME, Pollak AN. External fixation as a bridge
to intramedullary nailing for patients with multiple
injuries and with femur fractures: damage control or-
thopedics. J Trauma. 2000;48:613-23.
11. Townsend RN, Lheureau T, Protech J, Riemer B,
Simon D. Timing fracture repair in patients with se-
vere brain injury (Glasgow Coma Scale score <9). J
Trauma. 1998;44:977-83.
12. Pape HC, van Griensven M, Rice J, Gansslen A,
D A M A G E C O N T RO L
ORTHOPAEDICS
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
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The authors did not receive grants or outside
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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
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