Introduction
It has been convincingly demonstrated that the damage control strategy minimizes the second trauma of orthopedic surgery. This concept was developed by general surgeons about a decade ago for the management of abdominal injuries after blunt trauma. Since then, many authors have advocated limiting the extent of the initial surgery for blunt trauma and performing intensive care treatment after hemorrhage control has been achieved. Likewise, clinical studies have demonstrated an increased incidence of multiple organ failure (MOF) after an initial surgery of long duration. Meanwhile, the damage control strategy has been adopted by traumatologists to treat extremity fractures.
The aim of the study is to evaluate the concept of damage control by immediate external fracture fixation (DCO) and consecutive conversion osteosynthesis. Is it time savings and safe?
Methods
Thirty-nine patients (30 males and 9 females), aged 3–82 years, (with a mean of 38.1±19.9 years) with orthopaedic-type severe poly-trauma were managed by damage control orthopedics from January 2008 to October 2009 at KFSK and BCH. Thirty one out of the 39 patients were sent to the intensive care unit (ICU). The ISS7 ranged from 17 to 57, with an average of 31.9. The control group consisted of 54 patients (47 males and 7 females) with multiple injuries with a mean age of 42.9 ± 16.9 years and an ISS of 30.2 ± 6.3). Damage control orthopedic surgery included: a) Immediate life-saving surgery,, which was required in 17 cases; b) Surgery for controlling heavy bleeding, which was required in 11 cases; c) Wound bleeding control, infection control, washing, dressing, and temporally closing the wound; and d) Provisional minimally-invasive external fixation, which was performed in 39 patients.
Results
The treatment group from patients with multiple injuries with additional orthopedic injuries consisted of 39 patients with a mean age of 38.1±19.9 years and an ISS of 31.9 ±9.2). All these latter patients were exclusively treated according to DCO. None of the patients underwent ETC. Major accompanying injuries (Abbreviated Injury Scale Score 3) were thoracic trauma, brain injury, and abdominal trauma in 79.5%, 51.3%, and 25.6%, respectively. The control group consisted of 54 patients with multiple injuries with a mean age of 42.9 ± 16.9 years and an ISS of 30.2 ± 6.3. The overall (ISS) showed a comparable level between both groups if one considers the Abbreviated Injury Scale score for extremity trauma to be responsible for the difference between 31.9 in DCO and 30.2 in control group patients. DCO patients had an even higher incidence of severe trauma to the trunk. Immediate fracture fixation was required in 60 fractures. Fractures concerned the femur in 25 and the tibia in 20 cases. Unstable pelvic fractures were found in 13 and complex fractures of the upper extremities in 2 cases. Of all fractures, 72.9% were closed and 27.1% were open. DCO required a mean of 38.7±20.5 minutes (SEM, 3.3) per patient including the time needed for soft-tissue management in the 27.1% that were open fractures. Operation time differed for closed fractures (average, 29.2 minutes; range, 15–55 minutes) and open fractures (average, 48.7 minutes; range, 25–125 minutes) because of soft-tissue management. Accordingly, blood loss averaged 232.1 mL (SEM, 16.7) for external fixation with soft-tissue management, whereas virtually no blood loss was observed for external fixation alone. Transfixation of neighboring joints was necessary in 40% of all fractures, comprising 13 unstable pelvic and 20 metaphyseal fractures. Three patients developed five complications caused by external fixation. Two of the patients developed pin track infection requiring local debridement. Five patients died before definitive treatment as a result of severe traumatic brain injury (n =2), multiple organ failure (n =1), pulmonary embolism (n =1), and myocardial infarction (n =1). The mortality rate was 12.8%.
Male patient 33 yrs old presenting Type B1 fracture (Left); and postop radiograph showing anatomic reduction (Right).
Open fracture femur Type IIIB treated by external fixator (Left); Open fracture tibia Type IIIA treated with external fixation and after fracture union (Right).
Discussion
Damage control aims to eliminate three death-threats (metabolic acidosis, low body temperature and coagulation disorder) resulting from hemorrhagic shock, in which the traditional complicated resuscitation procedures are simplified and, thus are possibly performed timely before the patient falls into irreversible shock. It recommends that patients should stay in the ICU till their physiological states are able to withstand the definitive surgery. Most common complications associated with external fracture fixation are pin-track infections, deep infections, and non-unions. A low mortality rate of 12.8% indirectly hints an improved survival of the DCO patients versus controls. The study clearly demonstrates the enormous time savings and reduction of blood loss during initial treatment if patients with multiple injuries are treated according to DCO. We feel that DCO is a safe strategy in severely injured patients with multiple injuries who are too critically ill for ETC and for those patients who cannot be safely assigned to the clinical pathway of early total care.