DAMAGE CONTROL ORTHOPAEDICS
A 28-year-old man is brought to the emergency department after a road traffic accident in which the car he was driving collided with a truck at high speed.
Following his initial treatment in the emergency department he has been intubated because of his reduced level of consciousness and his initial assessment has identified pulmonary contusions, a left sided pneumothorax, some frontal cerebral contusions, bilateral femoral fractures and an open left tibial fracture.
- How would you proceed with his resuscitation?
This patient is severely injured and will require the attention of a skilled trauma team. He should be treated along ATLS principles with attention to life-threatening injuries and while the system is sequential, the use of a team allows concurrent activity. Active haemorrhage should be controlled and blood products replaced. He should have intravenous access established and a chest drain sited for the pneumothorax. The limbs should be assessed for evidence of haemorrhage, extremity injury and vascular status. The open wound at the tibia should be inspected, gross contamination should be removed, a photograph taken and saline soaked gauze applied. Intravenous antibiotics, usually a cephalosporin, should be administered as well as tetanus toxoid. Spinal precautions should be maintained until the spine can be reliably clinically and radiographically cleared in order to prevent future disability. A trauma CT should be performed examining the head, cervical spine, chest, abdomen and pelvis. If there is any question over the vascular supply to the limbs then a CT angiogram can be performed additionally to identify any vascular injury to the lower limb. The limbs can be splinted temporarily in box splints or plaster to allow transfer.
The initial resuscitation aims to address life-threatening injuries, stabilise the patient and to normalise abnormal physiology, in particular the lethal triad of hypothermia, coagulopathy and acidosis so that definitive treatment can be undertaken. A decision would be made by the trauma team leader and the neurosurgeons as to whether clinical assessment would suffice or whether an intracranial pressure monitoring device should be placed. Additional monitoring and treatment lines can be placed as required and ventilatory support provided. Resuscitation can be continued in the operating theatre or intensive care unit as appropriate.
- Can you tell me about the concepts that would guide your treatment for this patient?
The care of the polytraumatised patient has been based on the concepts of early total care where the patient receives early definitive care for all injuries or damage control surgery where temporising initial life and limb saving treatments are undertaken, using external fixators, plaster of Paris, splints and traction for fracture care followed by later definitive treatments. These concepts relate to the pathophysiology of major trauma where the patient undergoes an initial systemic response at the time of injury followed by a further systemic inflammatory response between days 2 and 4 following the initial injury. This is a period where they are at particular risk of pulmonary and systemic complications. Prolonged surgery or major surgery in this period may exacerbate this inflammatory response with poor outcomes and so, for selected patients, there is evidence that a temporising damage control approach is the best treatment strategy.
Early total care is appropriate for patients who are stable as well as unstable patients who respond to initial resuscitation. Patients who are in extremis should be treated with damage control principles. Patients in an intermediate clinical group are referred to as ‘borderline’. Serum lactate and the trend in this measurement have been shown to be a good marker of suitability for early total care for these borderline patients. A serum lactate of less than 2 mmol/litre is ideal and a serum level greater than 2.5 mmol/litre has been associated with a poorer response to resuscitation, reduced perfusion and worse outcomes with early total care.
There has been some more recent evidence to suggest that most polytrauma patients actually benefit from early definitive fracture fixation and a new concept of early appropriate care is developing from the two original ideas of damage control and early total care. Early appropriate care is based on the philosophy that early care has been shown to be beneficial for most patients and that patient selection should be based on an individual patient assessment of the presenting patient state and their response to resuscitation.
- How would you prioritise his orthopaedic injuries for treatment?
Once the patient is optimised for surgery I would ideally plan to treat all limb injuries in one sitting but this would be dependent on the condition of the patient and any change in his condition perioperatively.
I would position the patient on a radiolucent fracture table and proceed to debride and stabilise the tibia fracture first. Depending on the condition of the wound, soft tissues, fracture after debridement and the patient overall, I would consider siting an intrameduallary nail but if there was any concern I would apply an external fixtator to the tibia.
If the patient condition permitted continued surgery then I would proceed to perform bilateral retrograde femoral nail fixation. This has the advantage for the polytraumatised patient that repeated patient re-positioning is not required. If the patient condition does not permit intramedullary nailing then I would apply monolateral external fixators to both femoral fractures deferring definitive fixation until the patient was stable enough to tolerate this.