Damage Control Orthopaedics (DCO)

Definition

• A staged surgical strategy in polytrauma patients

• Aims to minimise physiological insult by:

  • Performing temporary stabilisation first

  • Delaying definitive surgery until patient stabilisation

Rationale

Major trauma → systemic inflammatory response

Early extensive surgery (“second hit”) may lead to:

• ARDS

• Multi-organ failure

• Death

DCO reduces this risk by limiting early surgical stress

Core Concept

• First hit = initial trauma

• Second hit = major surgery

Goal:

• Avoid second hit in unstable patients

Indications

Physiologically Unstable Patient

• Hypotension

• Coagulopathy

• Acidosis

• Hypothermia

“Lethal Triad”

• Acidosis

• Hypothermia

• Coagulopathy

Other Indicators

• Severe chest trauma

• Head injury

• Multiple long bone fractures

• Massive blood loss

Patient Categories (Simplified)

Stable

• Proceed with early total care (ETC)

Borderline

• Individualised decision

Unstable

• DCO preferred

In extremis

• Life-saving procedures only

DCO Strategy

Stage 1: Initial Surgery

• Rapid (<60–90 min)

• Goals:

  • Control bleeding

  • Temporary stabilisation

Methods:

• External fixation

• Pelvic binder / fixation

• Damage control laparotomy

Stage 2: ICU Resuscitation

• Correct:

  • Acidosis

  • Coagulopathy

  • Hypothermia

Monitor:

• Lactate

• Base deficit

Stage 3: Definitive Surgery

• Performed after physiological recovery

• Timing:

  • Usually day 2–5

Orthopaedic Applications

Long Bone Fractures

• Temporary external fixation

Pelvic Fractures

• Binder → external fixation → C-clamp

Spine Injuries

• Delay definitive surgery unless neurological emergency

DCO vs Early Total Care (ETC)

Monitoring Parameters

• Lactate

• Base deficit

• Hemodynamics

• Temperature

Improvement indicates readiness for definitive surgery

Complications

• Infection (external fixators)

• Delayed union

• Multiple surgeries

Prognosis

• Improved survival in unstable patients

• Reduced systemic complications

Pits & Pearls

• Physiology > fracture pattern

• External fixation saves lives in unstable patients

• Timing of conversion is critical

• Borderline patients require careful judgment

Pitfalls

• Performing definitive surgery in unstable patient

• Delaying stabilisation too long

• Ignoring physiological parameters

• Poor ICU coordination

Mini Decision Algorithm