Damage Control Orthopaedics (DCO)

1. Historical Background and Concept

• 1970s: Literature began to challenge non-operative management of multiple injuries, as prolonged bed rest worsened outcomes.
• Early total care (ETC): Emerged in the 1980s - fix all fractures within 24 hours. Became the gold standard for most polytrauma patients.
• 1993: The term "damage control" was first introduced for abbreviated abdominal surgery in penetrating trauma, aimed at avoiding the lethal triad.
• Late 1990s: ETC found to cause ARDS in 33% and mortality in 21% of patients with severe chest trauma who underwent early femoral nailing (Pape et al.). This led to the "second hit model" and the birth of DCO.

Rosen's Emergency Medicine: "The overall approach to all major fractures gradually shifted to early temporary fracture stabilization, resuscitation of the patient to a stable physiologic state, and definitive fixation at a later time once the patient is hemodynamically stable."

2. The Lethal Triad - Core Rationale for DCO

• Acidosis impairs enzymatic clotting factor function
• Hypothermia worsens coagulopathy and cellular metabolism
• Coagulopathy leads to ongoing hemorrhage and worsening acidosis

3. ATLS 11th Edition (2025) Updates Relevant to DCO

4. Phases / Stages of DCO

1. Resuscitation - correct the lethal triad; DCR with 1:1:1 blood products
2. Haemorrhage control - pelvic binder, external fixator, REBOA if available, angioembolisation
3. Decompression - fasciotomy for compartment syndrome
4. Decontamination - wound washout, debridement of open fractures
5. Fracture splintage - temporary external fixation of long bones and pelvis

• Normalise physiology: correct hypothermia, acidosis, coagulopathy
• Monitor: lactate, base excess, pH, core temperature, urine output
• Avoid further surgical insults until stable

• Convert external fixators to intramedullary nailing (femur)
• Definitive pelvic plating
• ORIF of other fractures

Bailey & Love's: "Definitive fixation of the fractures (conversion of the external fixators to intramedullary nailing for the femur and plating of the pelvis) would usually take place 4 days later, when the physiological state of the patient has been normalised, or even later if necessary."

5. Indications for DCO vs. Early Total Care (ETC)

• pH ≥ 7.25
• Base excess ≥ -5.5 mmol/L
• Lactate < 4.0 mmol/L
• No severe head injury or cardiac ischaemia

Rockwood & Green's: "The type and timing of surgical intervention will depend on the magnitude and duration of acidosis, associated coagulopathy, and the response to resuscitation."

6. Techniques of DCO

Femoral Fractures

• Provisional external fixation: 2 Schantz pins on each side of fracture in unipolar configuration
• Distal femoral skeletal traction is an acceptable alternative
• Unreamed retrograde intramedullary nail: occasionally used as an alternative to external fixation in damage control
• Convert external fixation to definitive IMN within 2 weeks to minimise infection risk

Pelvic Ring Injuries

• External fixation with iliac crest pins (easier) or supra-acetabular pins (greater rotational control) for anterior ring injuries
• Circumferential pelvic sheet reduction for complete posterior ring disruption
• Skeletal traction for vertical shear (VS) pelvic ring injuries
• Acetabulum fractures: not amenable to external fixation; skeletal traction is provisional

Thoracolumbar Spine

• "Spine damage control": posterior reduction and instrumentation within 24 hours, followed by anterior fusion ≥3 days later if needed
• Reduces complications and length of stay compared with delayed fixation

Open Fractures

• Emergency washout and debridement
• External fixation for temporary stabilisation
• Definitive management after wound is clean and patient is stable

Compartment Syndrome

• Fasciotomy is an urgent/emergent DCO procedure that can be performed in the emergency department or resuscitation area

7. Physiologic Monitoring During DCO

• Prolonged R time → FFP/clotting factor concentrates
• Delayed K time → cryoprecipitate (fibrinogen)
• Reduced maximum amplitude → platelets

• 30% amplitude reduction at 30 min post-maximum → tranexamic acid

8. Role of Rosen's Emergency Medicine (EM Perspective)

• Setting: DCO measures can begin in the ED, resuscitation bay, or OR
• EM role: Facilitate stabilisation, coordinate OR/angiography suite transfer, and pre-operative preparation
• Key principle: Do NOT proceed to operative fixation if:
  • Haemodynamic stabilisation has not been achieved
  • Potentially life-threatening conditions remain unresolved
  • Adequate lab/imaging workup is incomplete
• Temporary stabilisation: External fixation or splinting to aid haemorrhage control and tissue oxygenation
• Complications of immobilisation to watch for: DVT/PE, pneumonia, pressure sores, catheter UTI, delirium (especially in elderly)

9. DCO vs. ETC: Modern Nuances and Newer Concepts

• Early Appropriate Care (EAC): Definitive stabilisation of pelvis, spine, acetabulum, and femur within 36 hours in adequately resuscitated patients (pH ≥7.25, BE ≥-5.5, lactate <4)
• Safe Definitive Surgery (SDS)
• PRISM (Prompt Individualised Safe Management): Patient-centred, personalised approach recognising that each patient has a different genetic/physiologic response to the same trauma - the team makes real-time decisions based on evolving physiology rather than rigid protocols

Bailey & Love's: "The PRISM concept accepts that the decision-making process should be based on the principles of doing no 'further harm to the patient', intervening promptly and utilising the idea of individualised/personalised medicine."

10. Missed Injuries - A DCO Pitfall

• Altered level of consciousness
• Haemodynamic instability precluding thorough examination
• A more apparent injury in the same extremity distracting from a second injury
• Inadequate initial radiographs

11. Recent Evidence (2025 Systematic Review)

• No statistically significant difference in overall mortality between early (<24h) and late fracture stabilisation
• Femoral nailing reduced ICU length of stay and duration of mechanical ventilation compared with external fixation
• Conclusion: Immediate nailing is superior to staged approaches in stable polytrauma patients; DCO (external fixation) remains appropriate for unstable patients, but high-quality evidence remains limited

Summary: DCO Decision Framework

POLYTRAUMA PATIENT
        ↓
Is patient physiologically stable?
(pH >7.25 | lactate <4 | normothermic | normal coag)
        ↓
    YES → Early Total Care / EAC:
           Definitive fixation within 24-36h

    NO → DAMAGE CONTROL ORTHOPAEDICS:
           1. xABCDE resuscitation (ATLS 11)
           2. Temporary external fixation
           3. ICU resuscitation (correct lethal triad)
           4. Reassess at 24-72h
           5. Definitive fixation when physiologically normalised (≥4 days)

• Rockwood and Green's Fractures in Adults, 10th ed (2025), pp. 564-580
• Campbell's Operative Orthopaedics, 15th ed (2026), Damage Control Orthopaedics section
• Bailey & Love's Short Practice of Surgery, 28th ed, Chapter 26, Table 26.2
• Rosen's Emergency Medicine, 9th ed, Chapter 41: Damage Control Orthopaedic Surgery section
• ATLS 11th Edition (ACS, 2025) - xABCDE and damage control resuscitation