Management of fractures in the severely injured--influence of the principle of "damage control orthopaedic surgery"

Abstract

There have been substantial changes in the management of multiply injured patients over the last decades. In the 1950s and 60s, perioperative care was limited and the surgical techniques were not well developed. It was therefore discussed that a patient might be "too sick to operate" and the general recommendation was to postpone surgical care of the extremities,until a patient had stabilized. In addition this recommendation was maintained by fears of the "fat embolism syndrome", which was considered to be directly related to fat and intramedullary contents released from the fracture site leading many to believe that early manipulation of the fracture was unsafe. The use of simple splintage clearly demonstrated the importance of skeletal stabilisation by reducing the effect of any continuing injury and this positive effect of skeletal stabilistion became more obvious with the implementation of standardized techniques of osteosynthesis. In the 1970's, pioneer studies appeared in the literature reporting that immediate stabilisation of femur fractures drastically reduced problems of traumatic pulmonary failure and post-operative care when compared to traditional non-operative fracture management. Thereafter, immediate and complete definitive operative care of all fractures has been said to represent the optimal treatment for the patient with multiple orthopaedic injuries and the benefits of this approach have been demonstrated in numerous studies within the last two decades.However,exceptions have been discussed in the past few years, where the principle of early total care may not be beneficial (head and chest trauma, high ISS predisposing to posttraumatic complications, borderline patients). In high risk, borderline patients, the surgical burden was demonstrated to increase the risk of postoperative complications. For these patients, the concept of initial temporary fixation and secondary conversion to a definitive procedure has recently been advocated, and the term "damage control orthopaedic surgery" was coined. Within recent years, an increased consensus has occurred across the countries and the oceans in regards to the acceptance of the concept of damage control. This manuscript documents the pathogenetic back grounds and the clinical results leading to a change in the management of orthopaedic injuries towards damage control.