Review Question - QID 8192

The transition from early total care (ETC) to damage control orthopaedics has developed over the past 20 years in orthopaedic polytrauma situations. A vast number of studies over the past several years have investigated the timing and technique of orthopaedic intervention in the care of these patients and effects on outcomes. The goal is to avoid an iatrogenic second hit that can push a patient into adult respiratory distress syndrome (ARDS) or multiple organ failure (MOF). In a patient who is unstable, the algorithm shifts to damage control orthopaedics (DCO). In this patient, the minimum intervention to achieve orthopaedic stability is indicated; therefore, debridement and irrigation of open fractures, external fixation of lower extremity long bones, and splinting of upper extremity fractures is appropriate.

There are several parameters that can help classify a patient's condition and therefore guide the surgeon's initial management. Grade I is stable and the patient can be cleared for surgery for early total care. Grade II is borderline and these patients are found along a continuum. In general, the priority of each injury should be determined and the most important fixed first. The surgeon should continually check the patient's status and proceed as long as the patient is stable. Once the patient shows signs of deteriorating status, DCO should be implemented for the remaining injuries. Grade III is unstable and DCO should be the initial course of action. Grade IV is in extremis with life-threatening injuries and DCO should be implemented if possible.

In this scenario, answer choices 1 and 2 involve an ETC philosophy and would be inappropriate for this patient who is unstable with significant chest trauma. In answer choice 3, the humerus is not a higher priority than the femur fractures and should be one of the last fractures addressed surgically. Open reduction and internal fixation of the ankle fracture would not be indicated in an unstable patient.