Review Question - QID 215826

This patient is under resuscitated given her pH <7.25 and base excess <-5.5, thus would best be treated with damage control orthopedics (DCO).

Damage control orthopedics (DCO) is a treatment strategy that emerged in 2000 and focuses on approaching polytrauma patients with a goal of minimizing the impact of the "second-hit" through delayed definitive treatment. Management consists of splinting and using external fixators to stabilize the patient until a more appropriate physiologic environment exists for definitive fixation. Patients are at an increased risk of ARDS and multisystem failure during the inflammatory window which occurs between days 2-5 following injury. The "second-hit" of definitive surgical fixation should not be performed during this time.

Pape et al review the changes in the management of femoral shaft fractures in polytrauma patients between early total care and damage control orthopedic surgery. They report that the incidence of multiple organ failure decreased significantly when early total care was abandoned for damage control orthopedics regardless of how femoral shaft fractures were treated. They conclude that DCO resulted in less complications despite higher injury severity in this study.

Pape et al review the impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters. They report elevated levels of IL6 and IL8 occurred postoperatively in patients undergoing intramedullary instrumentation. They conclude that damage control orthopedic surgery appears to minimize the additional surgical impact induced by acute stabilization of the femur.

Figure A demonstrates a left transverse femoral shaft fracture. Figure B demonstrates a ipsilateral humeral shaft fracture. Figure C shows a right tibial plateau fracture.

Incorrect Answers:
Answer 1: Early Total Care is the concept that all fractures should be fixed in one trip to the operating room. This is found to exacerbate the second hit phenomenon and should not be performed in under resuscitated patients.
Answer 2: Early appropriate care is utilized when patients meet one of the following criteria: lactate of < 4.0 mmol/L, pH ≥ 7.25, or a base excess ≥ -5.5 mmol/L. The patient does not meet these criteria and thus, EAC is not indicated.
Answer 4 and 5: These are not treatment strategies utilized in the care of orthopedic trauma patients.