Damage Control Trauma Care: Does It Save Lives or Make No Difference?

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Chapter 53 Damage Control Trauma Care: Does It Save Lives or Make No Difference?

RALF. SCHOENIGER, MD, PETER J. O’BRIEN, MD, FRCSC

Controversy still exists about the early definitive treatment of fractures in patients with multiple injuries. Several authors in the 1980s supported the benefit of early intramedullary nailing of femoral shaft fractures.¹^–⁶ However, because of experimental and retrospective studies in the 1990s, concerns were raised about primary intramedullary nailing of the femur, sometimes referred to as early total care (ETC), especially in patients with associated chest and head injuries.⁷^–⁹ The concept of “damage control orthopedics” (DCO) was then developed in the large trauma centers. This technique involves primary external skeletal fixation of the femoral fracture followed in a few days by definitive intramedullary nailing when the patient’s physiology has been completely corrected. Several authors have advocated delayed definitive treatment in the more recent literature.¹⁰^–¹³ Since the 1990s, there has been an ongoing debate about early versus delayed definitive fracture fixation in femoral shaft fractures in the setting of polytrauma and when treating femoral shaft fractures in patients with multiple injuries regarding whether the reamed or the unreamed technique should be used.

Since the late 1980s, the assessment and treatment of the patient with multiple injuries has markedly improved. The establishment of highly specialized trauma centers for early intervention of life-threatening injuries, such as intrathoracic, intraabdominal, and intracranial injuries, has led to greater survival rates in these patients.¹⁴^–¹⁷

In light of ongoing controversy since the 1990s with regard to timing and type of definitive treatment of long bone fractures in patients with multiple injuries, the purpose of this review is to provide guidance to clinicians based on the best available evidence on this topic.

EVIDENCE

Timing of Fracture Care in Patients with Multiple Trauma Injuries

Initial Clinical and Basic Science Research.

Several studies in the 1980s and 1990s found that early definitive care (less than 24 hours) leads to a decrease of morbidity and mortality.1–4,18–²¹ Most of the studies claimed that prevention of adult respiratory distress syndrome (ARDS), reduction of inflammatory mediators, and lower fat embolism rate were associated with early intramedullary nailing. In contrast, Pape and colleagues,⁷ in a retrospective review, found that although early intramedullary nailing of femoral shaft fractures in patients without chest injuries had a reduced risk for morbidity, the rates of ARDS and mortality were increased in patients with associated severe chest injuries treated with reamed intramedullary nailing within 24 hours of injury when compared with those who had delayed fracture fixation⁷ (Level of Evidence 3). Their suggestion was to consider alternate forms of femur fracture fixation or delayed definitive fixation in patients with severe chest injuries (Abbreviated Injury Scale [AIS] > 2). This then led to the development of the DCO concept. Other centers have advocated delayed definitive treatment in the more recent literature.¹⁰^–¹³

Experimental Animal Studies.

Parallel to the clinical studies, several experimental animal studies investigated the effect of reamed or unreamed nailing of the femur and the tibia on the intramedullary pressure and the rate of fat embolization.^8,^9,²²^–²⁸ In addition, Duwelius and researchers²² and Wolinsky and colleagues²⁸ examined the effect of intramedullary nailing on pulmonary function in normal and contused lungs.

Most of the studies showed that intramedullary nailing of the femur increases the intramedullary pressure.^8,^9,²²^–²⁴ No difference was found if a reamed or unreamed nailing procedure was used.^22,²³ Opening of the canal with an awl leads to the highest intramedullary pressure in studies by Heim and investigators²⁴ and Duwelius and researchers.²² Marrow element extravasation and fat emboli are clearly associated with reamed and unreamed nailing of the femur.^9,²²^–²⁴ ^,27 ^,28

Manning and coworkers ²⁵ showed greater rates of fat release in intact femurs compared with fractured femurs and concluded that the fracture is responsible for the low incidence of pulmonary dysfunction in the clinical field. Duwelius and researchers²² found minimal pulmonary dysfunction in normal and contused lung in their sheep model with reamed or unreamed nailing of the femur. However, the reamed technique had a greater rate of fat emboli in the histologic analysis. Wolinsky and his group²⁸ confirmed these results in 1998 in their sheep model with a reamed nailing procedure.

No evidence has been provided from this basic physiology research that reamed intramedullary nailing of the femur leads to greater pulmonary dysfunction than unreamed nailing. However, manipulation of the medullary canal does have a negative effect on pulmonary physiology.

Immunologic Response Studies.

Another field of interest is the systemic inflammatory response syndrome (SIRS) score of patients with multiple injuries related to the time of treatment. Several studies since the early 1990s have shown that the inflammatory response correlates with the severity of the injury, patient outcome, and mortality.²⁹^–³⁶ However, only two studies have focused on the comparison of early versus delayed fixation.^32,³⁵ Pape and colleagues³⁵ show in their prospective, randomized, multicenter study with 35 patients from 2003 that certain interleukin levels (IL-6 and IL-8) are significantly increased in the primary intramedullary fixation group. Both groups were similar regarding age, injury severity score (ISS), AIS, and Glasgow Coma Scale (GCS). However, no difference was found in the IL-1 level and in the incidence of ARDS, sepsis, and multiorgan failure (Level of Evidence 2).

The second study that is from the same group, reported by Harwood and colleagues ³² in 2005, looked retrospectively at 174 patients and found a greater SIRS score in the early fixation group despite having significantly lower ISSs, and fewer head and chest injuries. They also had longer intensive care unit (ICU) stays, higher ARDS rates, and more multiorgan failures. Although the authors’ conclusion that DCO does not add additional detrimental inflammatory response to the patient seems clear, the study did not demonstrate that the greater SIRS score in the early definitive fixation group will lead to more complications (Level of Evidence III).

No clinical evidence exists from these results that high levels of interleukin or high SIRS scores lead to a significantly greater rate of complications when timing of the fracture care is within 24 hours.

Chest Injuries and Femur Fractures.

The benefits of early definitive fracture fixation in patients with associated chest injuries have been demonstrated repeatedly.^1,^4,^{18–21,37–43} In contrast, Pape and colleagues⁷ were the first to demonstrate in their study from 1993 that early reamed intramedullary nailing in patients with severe chest injuries (AIS > 2) increased the risk for ARDS and death. In the same study, early fixation without chest injury was associated with decreased morbidity.

Comparison between studies is difficult. One main difficulty is the definition of the severity of chest trauma. In most studies, an AIS score of greater than 2 is considered to be a severe chest injury. In several studies, however, the AIS is either not mentioned or is indicated as 2 or lower.^1,^{19, 38, 44} Another difficulty is the great variety of the ISSs in the studies. Most studies use an ISS of greater than 18 as a criterion for inclusion.^1,^{3, 7, 20, 37, 40} However, often the ISS was significantly different across studies and across the two treatment groups.³⁹

As mentioned previously and as shown in Table 53-1, most studies showed either no difference or better outcome in the early definitive fixation group.

TABLE 53-1 Chest Injuries

Bone and coauthors ¹ showed in their prospective, randomized clinical study from 1989 that the incidence of pulmonary complications such as ARDS, pneumonia, and fat embolism is greater when the fracture fixation is delayed (Level of Evidence 2). This study was a prospective, randomized, clinical trial, but there were some limitations regarding the definition of the severity of the chest injury. In a retrospective review, similar results were presented from this group³⁷ in 1995 with a chest AIS greater than 3 (Level of Evidence 3).

Interestingly, regarding Pape and colleagues’⁷ study, Charash and colleagues⁴⁰ arrived at an opposite conclusion using the same study design in their study with 138 patients. A complication rate of 56% was observed in the patient group with delayed definitive fracture fixation, and associated severe chest injuries were compared with a rate of only 16% in the early fixation group (Level of Evidence 3).

In the more recent literature, Handolin and researchers ⁴¹ and Weninger and colleagues⁴³

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