Damage Control Orthopedics in Trauma

Damage control orthopedics (DCO) is a staged management paradigm for severely injured polytrauma patients in extremis or borderline physiologic status, in whom early definitive fracture fixation would impose an excessive second hit on already compromised physiology, triggering systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS), and increased mortality. The strategy emphasizes life-saving control of bleeding, contamination, and hemodynamic instability through abbreviated procedures, followed by intensive care unit resuscitation, then delayed definitive reconstruction once physiology has normalized.

Indications for DCO include patients with persistent shock and metabolic acidosis (pH less than 7.25), hypothermia (less than 35 degrees Celsius), coagulopathy, severe traumatic brain injury, chest trauma with bilateral pulmonary contusions, ISS greater than 40, multiple long bone fractures, and difficult resuscitation. Borderline patients with ISS 25-40, head injury with AIS 3, hypothermia, lactate greater than 2.5 mmol/L, base deficit greater than 6, or platelet count less than 100,000 also benefit from staged approach. Stable patients with ISS less than 20 and adequate physiology are candidates for early total care with definitive fixation.

First-stage interventions include external fixation of long bone (femur, tibia, humerus) and pelvic ring fractures (pelvic binder, sheet, or anterior frame), debridement and irrigation of open fractures with antibiotic delivery, fasciotomy for compartment syndrome, hemorrhage control with arterial embolization or surgical packing, and washout of contaminated joints. Definitive fixation with intramedullary nailing, plating, or arthroplasty is performed once the patient is stable, typically 5-14 days after injury when SIRS markers, lactate, and oxygenation have normalized. Outcomes data support reduced ARDS, MODS, and mortality compared with early total care in selected severely injured patients. Multidisciplinary trauma team coordination, ICU monitoring with daily reassessment, and structured handoffs are central to successful damage control.