Damage control in orthopaedics

damage control in orthopaedics

1. Damage control in orthopaedics Dr.sunil

2. Damage control orthopaedics(DCO)is a strategy that focuses on managing and stabilising major orthopaedic injuries in selected polytrauma patients who are in an unstable or extremis physiological state. Its priorities are – - control of haemorrhage , - provisional stabilisation of major skeletal fractures, -management of soft-tissue injuries - minimising the degree of surgical insult to the patient

3. TWO-HITS THEORY .First Hit ( Trauma ) – Hypoxia – Hypotension – organ & soft tissue injury – fractures  Second Hit (operation) – ischemia/reperfusion injury – compartment syndrome – operative intervention – infection

4. Stage 1: early temporary External Fixation Stabilization of unstable fractures and the control of hemorrhage and, if indicated, decompression of intracranial lesion. Stage 2: resuscitation of the patient in ICU optimization of his condition. Stage 3: delayed definitive management of the fracture

5. Physiological response to injury Inflammatory immune response Innate immune response Adaptive immune response Systemic Inflammatory Response Syndrome (SIRS) Compensatory Anti-inflammatory Response Syndrome (CARS) Multi Organ Dysfunction Syndrome (MODS) pathophysiology

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7. SIRS DEFINITION  Heart rate: > 90 bpm  WBC: <4000/mm3 or >12000/mm3 or >10 %  Respiratory rate: >20/min with PaCO2<32mmHg  Core temperature: <360C or >380C 2 of 4 parameters = SIRS

8. • IL-6 reliable index of the magnitude of systemic inflammation and correlates with the outcome(n=3.2 pg/ml) • IL-10 correlate with the initial degree of injury and persistently high levels of IL-10 correlate with sepsis .(n =< 18 pg/ml)

9. Patient Selection for Damage Control Orthopaedics Patients who have sustained orthopaedic trauma are divided into : a)Stable - local preferred method b)Borderline - damage control orthopaedics often preferred c ) Unstable - damage control orthopaedics d)In extremis - damage control orthopaedics

10. Stable hemodynamics No need for inotropic stimulation No hypoxemia,no hypercapnia Lactate < 2mmol/l Normal coagulation Normothermia Urinary output>1 ml/kg/h Indications for early total care

11. 1)Blunt trauma: - hypothermia,coagulopathy , shock/blood loss,soft tissue injury 2)Penetrating trauma:-hypothermia , coagulapathy,acidosis 3)Complex pattern of severe injuries-expecting major blood loss and a prolonged reconstructive procedure in physiologically unstable patient Indications for damage control in orthopaedics

12. Injury complexes suitable for damage control orthopaedics

13. Femoral Fracture Femoral fractures in a multiply injured patient are not automatically treated with intramedullary nailing because ‘second hit ’ fat emboli Patients with a chest injury are most prone to deterioration after an intramedullary nailing procedure because of fat emboli syndrome Bilateral femoral fracture is associated with a higher mortality rate and incidence of adult respiratory distress syndrome than is a unilateral femoral fracture

14.  Cerebral - Cerebral edema CVS - Hypotension and shock Respiratory - Acute lung injury, ARDS  Liver - hepatocytes dysfunction Renal - Renal tubular necrosis, acute renal failure Hematologic - DIC MODS

15. Pelvic Ring Injuries Excessive haemorrhage associated with pelvic fracture Conditions where haemorrhage can be expected, when there is pelvic injury : -Posterior pelvic ring injuries -Anterior-posterior compression type III injuries, lateral compression injuries -Pelvic fracture in patients over 55 years old

16. What is done ? Minimally invasive pelvic stabilisation - Pelvic binder - External fixator - Pelvic c-clamp • Angiography and embolisation Indications : 1.Initial treatment of pelvic fractures associated with hypotension that have not responded to the placement of a pelvic binder, external fixator , pelvic cclamp , and transfusion of four units or more of blood

17. 2. expanding retroperitoneal hematoma, 3 . a massive retroperitoneal hematoma observed on Embolisation later than 3 hours after injury increased risk of mortality -Average procedure time is 90 minutes Pelvic Packing Indication :- . Patient with severe hypotension and a pelvic fracture that is unresponsive to other initial treatment measures , associated with imminent risk of death

18. Chest Injuries Treatment of multiply injured patients with long bone fractures and a chest injury: early fracture stabilisation (within 48 hours)is safe and may be beneficial

19. Head Injuries • Early stabilisation doesn’t enhance or worsen the outcome in patients with head injury management • Based on the individual clinical assessment and treatment requirements Damage control orthopaedics can provide temporary osseous stability to an injured extremity, functioning as a temporary bridge to staged definitive osteosynthesis , without worsening the patient's head injury or overall condition. • Aggressive management of intracranial pressure • Maintenance of cerebral perfusion pressure at >70 mmHg and intracranial pressure at <20 mm Hg

20. Isolated Complex Lower-Extremity Trauma Proximal tibial articular and metaphyseal fractures , metaphyseal fractures, distal tibial pilon fractures Useful for preventing soft-tissue complications by spanning the articular segment with an external fixator and avoiding areas of future incisions . Then minimally invasive plate osteosynthesis can be performed at a stage when the condition of the soft tissue envelope is optimized.

21. When can secondary orthopaedic procedures be performed? Days 2, 3 and 4 are not safe ( marked immune reactions and increased generalised oedema ) Days 6 to 8 less risk

22. Thank you