ModeratorDr Vijay Kumar

Co-ModeratorDr Venketish

PresenterDr Navin Singh

All India Institute of Medical Sciences

New Delhi

Objectives- Polytrauma

Historical perspetive

Introduction of DCO

Pathophysiology of DCO

Literature on DCO

Polytrauma As patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 times AIS score gt 2)

The Journal of Trauma and Acute Care Surgery [2014 77(4)620-623

Objectives- Polytrauma

Historical perspetive

Introduction of DCO

Pathophysiology of DCO

Literature on DCO

Polytrauma As patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 times AIS score gt 2)

The Journal of Trauma and Acute Care Surgery [2014 77(4)620-623

Polytrauma As patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 times AIS score gt 2)

The Journal of Trauma and Acute Care Surgery [2014 77(4)620-623

To describe the overall condition of the pt many trauma scoring systems have been developed like-

1 Abbrevieted injury scale(AIS)

2 Injury severity scale(ISS)

3 Revised trauma score

4 Anatomic profile

5 Glasgow coma scale

ABBREVIATED INJURY SCALE(AIS)

AIS is an anatomical scoring system first introduced in 1969

Injuries are ranked on a scale of 1 to 6

with 1 being minor 5 severe and 6 a nonsurvivable injury

Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall

score for patients with multiple injuries

Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)

Only the highest AIS score in each body region is used

The 3 most severely injured body regions have their score squared and added together to produce the ISS score

The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75

Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship

Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed

Before 1950s The multi trauma patient-too sick for an operation

The surgical stabilization of the fractures of the long bones was not routinely performed

Treatment preferred-cast and skeletal traction

1970- Studies shows that early stabilization of femoral

fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

ABBREVIATED INJURY SCALE(AIS)

AIS is an anatomical scoring system first introduced in 1969

Injuries are ranked on a scale of 1 to 6

with 1 being minor 5 severe and 6 a nonsurvivable injury

Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall

score for patients with multiple injuries

Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)

Only the highest AIS score in each body region is used

The 3 most severely injured body regions have their score squared and added together to produce the ISS score

The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75

Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship

Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed

Before 1950s The multi trauma patient-too sick for an operation

The surgical stabilization of the fractures of the long bones was not routinely performed

Treatment preferred-cast and skeletal traction

1970- Studies shows that early stabilization of femoral

fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Injury severity score(ISS)- ISS is an anatomical scoring system that provides an overall

score for patients with multiple injuries

Each injury is assigned an AIS and is allocated to one of six body regions (HeadFace Chest Abdomen Extremities (including Pelvis) External)

Only the highest AIS score in each body region is used

The 3 most severely injured body regions have their score squared and added together to produce the ISS score

The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75

Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship

Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed

Before 1950s The multi trauma patient-too sick for an operation

The surgical stabilization of the fractures of the long bones was not routinely performed

Treatment preferred-cast and skeletal traction

1970- Studies shows that early stabilization of femoral

fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

The ISS score takes values from 0 to 75 If an injury is assigned an AIS of 6 (unsurvivable injury) theISS score is automatically assigned to 75

Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship

Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed

Before 1950s The multi trauma patient-too sick for an operation

The surgical stabilization of the fractures of the long bones was not routinely performed

Treatment preferred-cast and skeletal traction

1970- Studies shows that early stabilization of femoral

fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Damage control is a new term first used by the United States Navy during World War II to describe emergency measures for control of flooding that threatens to sink a ship

Central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed

Before 1950s The multi trauma patient-too sick for an operation

The surgical stabilization of the fractures of the long bones was not routinely performed

Treatment preferred-cast and skeletal traction

1970- Studies shows that early stabilization of femoral

fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Before 1950s The multi trauma patient-too sick for an operation

The surgical stabilization of the fractures of the long bones was not routinely performed

Treatment preferred-cast and skeletal traction

1970- Studies shows that early stabilization of femoral

fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Treatment preferred-cast and skeletal traction

1970- Studies shows that early stabilization of femoral

fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

1970- Studies shows that early stabilization of femoral

fractures dramatically reduces fat embolism syndromepulmonary failure(ARDS) and postoperative complications

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Late 1980- There is a beneficial effect of early stabilization of

fractures on both morbiditymortality and hospital stay

Pt were able to mobilize early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

This new philosophy in the management of the pt with multiple injuries-best operation for the patient is one early and definitive procedure was named

EARLY TOTAL CARE(ETC)

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

ETC-Patients were able to mobilise early and were discharged from hospital sooner avoiding the complications associated with prolonged bed rest

J Trauma 198525375-84 J Trauma 199030792-8

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

When stabilization was delayed ndash the incidence of pulmonary complications was higher the hospital and ICU stay days were increased

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Early definitive stabilization of long bone fractures reduced the incidence of the fat embolism syndrome compared to traditional non surgical treatment

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Early 1990 Outcome after ETC-increased incidence of ARDS and

MOF

Operative procedure used to fix the bone-could provoke rather than protect from pulmonary complications

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

An unexpectedly high rate of pulmonary complications was reported in young patients after reamed femoral intramedullary nailing who had not suffered thoracic trauma

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

These complications developed mainly in pts with severe chest injuriessevere hemodynamic shock and in cases post reamed intramedullary nailing without thoracic trauma

J Trauma 199334540-8

J Bone Joint Surg [Br] 199981-B356-6120

This led to the conclusion that the method of stabilisationand the timing of surgery may have played a major role in the development of such complications

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

The findings indicated that ETC was not appropriate for all multiply-injured patients and that there was a particular subgroup in whom management by this approach was detrimental

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

They concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients(ISSgt25)

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

(ISS)gt25 Higher infammatory burden acute lung

injury and increased mortality rate

Some patients who are so severely injured that they

cannot tolerate long operations blood loss and

especially medullary canal manipulation without a

signifcant life threatening deterioration of pulmonary

function and overall homeostasis

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

ldquoDAMAGE CONTROL ERArdquo

Clinical Course-Three factors

1Trauma load(First hit)

2Biological response

3Treatment(Surgical LoadSecond hit)

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Damage Control Orthopaedics

-Damage control orthopaedics(DCO)is a strategy that

focuses on managing and stabilising major orthopae

dic injuries in selected polytrauma patients who are

in an unstable or extremis physiological state(1)

Its priorities are ndash

- control of haemorrhage

- provisional stabilisation of major skeletal fractures

-management of soft-tissue injuries

-minimising the degree of surgical insult to the patient

1 Injury Int J Care Injured (2009) 40S4 S47ndashS52

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Staged Treatment

Stage 1 early temporary external

fixation stabilization

Stage2

resuscitation of the patient in ICU and optimization of his

condition

Stage 3 delayed definitive

management of the fracture

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Physiology-

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

The cytokine response evidenced by fever leukocytosis

hyperventilation tachycardia commonly seen in injury is referred

to as systemic inflammatory response syndrome (SIRS)

This inflammatory reaction has been implicated in the

development of ARDS and MOF

Jbone jt surg199981(Br)256-61

J Trauma 2003557-13

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

First and second hit phenomenon

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Damage control philosophy in polytruma

Surg Cdr us Dadhwar Maj N Pathak

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Patients who have sustained orthopaedic trauma have been divided into four groups

-stable- Borderline- unstable and - in extremis

Pape HC Hildebrand F Pertschy S Zelle B Ga-rapati R Grimme K Krettek C Reed RL 2nd

Changes in the management of femoral shaft fractures in polytrauma patients from early total care to damage control orthopedic surgery

J Trauma 200253452-62

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Stable patients-ETC

Unstable and in extremis-DCO

Borderline-

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Basic strategies of DCO- Immediate and rapid stabilization of long bone

fractures typically with external fxation

Release of tight soft tissue compartments (compartment syndrome)

Reductions of dislocations

Surgical debridement of open wounds

Amputation in cases of unsalvageable extremities

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Treatment goals

Stop the ongoing injury

Facilitate patient care

Restore function

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Stop the ongoing injury

Remote organ injury occurs as a consequence

of musculoskeletal injury

Mediators

bull activated neutrophils

bull chemical mediators

bull fat emboli

bull marrow contents

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Remote organ injury

- long bone fractures

- Soft tissue injury

- Compartment syndrome

- Infection

- Ischemiareperfusion

Primay target lungs

Secondary targets gut kidney brain etc

Resultant injury is progressive ARDSMODS

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Stop the ongoing injury

Release compartments

Reduce dislocations

Debride open wounds

Stabilize long

bones

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Stabilize long bones

Splints amp traction

Ex-fix

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Splints amp traction

Best reserved for

Essentially stable

fractures

Isolated extremity fractures

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

ldquoExternal Fixator is a device uses for

stabilization and immobilization of long bone

open fracturesrdquo

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Minimally invasive operations

External fixation of femur ndash 35 minutes 90 ml blood loss

Intramedully nailing of femur -130 minutes 400 ml blood loss

Scales et al ldquo external fixation as a bridge to intramedullary for patients with multiple injuries and with femur fractures damage control orthopaedicsrdquo

JTrauma 200048 613-23

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

47

Biomechanics of External Fixator

Intrinsic stability of frame (S)

EX I

S = -----------

L

E=modulus of elasticity =constant

I= moment of intertia= constant

L= distance of frame from axis

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

48

Thus Stiffness is inversely proportional to the distance of the assembly from the bone

(closer the frame to bone -more stable assembly)

Biomechanics

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

49

Mechanics of Bone Pin Interface

To increase stability of bone ndashpin interface

1 Adequate no of pins in each fragments

( 2 for most bone amp 3 for femur)

2 Increase pin pitch

3 Increase size of pin

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Indications for Rapid Ex Fix

Patient in extremis

Massive open injury (degloving injury)

Vascular damagerepair

Mass casualities

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Patient in Extremis

Multiple other severe injuries

Extreme hypotension

Coagulopathy

Massive head injury

Aortic transection

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Early skeletal stabilization

Reduce blood loss

Minimize mediator release

Improve pulmonary

function

Decrease sepsis and

pain

Improved treatment

of head injured

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Issues while applying DCO-1 Safety

2 Timing of definitive fixation

3 Is DCO associated with high rate of infection

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

They concluded that immediate external fixation followed by early closed

intramedullary nailing is a safe treatment method for fractures of the shaft the femur in

selected multiply injured patients

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

In patients with multiple injuries-EF is viable alternative to attain temporary stabilization-rapid and causes minimal blood losscan be followed by IMN when pt is stabilized

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

An aggressive and early damage control approach to treat femuur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality bu TRISS

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

When is the right time to perform secondary definitive surgery

In a study by Pape et al-compared two group having same ISS and GCS

group 1- early definitive surgery between 2- 4 days(46 MOD)-higher level of IL-6

group 2-late definitive surgery 5-8 days (157)

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days

Infection rate after DCO is comparable to those after primary IMNPin site contamination was more common where the fixator was in place for gt14 days