1. Damage Control Orthopedics
Case for small group discussion: General principles
Keywords: Damage control orthopedics
AOTrauma External Fixation

2. Learning objectives
Describe the indications for damage control orthopedics
Describe the advantages of using modular external fixators to save life and limb
Describe the techniques to reduce pin complications
Realize how to prevent potential complications of the procedures

3. 50-year-old man, motorcycle accident, sent to emergency department
Initial vital signs: blood pressure (BP) 90/60; heart rate (HR) 120; respiratory rate (RR) 30/min; body temperature (BT) 36.5°C
Dyspnea, semi-consciousness
Moderate pale conjunctiva
Chest: crepitation both lungs
Abdomen soft, not distend
Right wrist: swelling, deformity, tenderness
Left ring finger: swelling and deformity
Right knee: ballottement, swelling around knee, tenderness, neurovascularly intact
Left leg: swelling, deformity, crepitus, tenderness, neurovascularly intact

4. After resuscitation, chest x-ray was done
Diagnosis: multiple fracture ribs on both sides with hemopneumothorax of right side
Treatment: implantable cardioverter defibrillator (ICD) was inserted
Vital signs: BP 110/60; HR 100; BT 36.8°C
Difficulties in spontaneous breathing: on respirator
For faculty:
Do not discuss too much about resuscitation.
Just show the previous slides and this slide, then let participants think about investigations for all fractures.
Spend time discussing management of multiple fractures after the patient is resuscitated and vital signs are controlled.

5. What are the next investigations concerning fractures?
Rx: resuscitation, ICD was inserted
Vital signs: BP 110/60; HR 100; BT 36.8°C
Difficulties in spontaneous breathing: on respirator
50-year-old man
Right wrist: swelling, deformity, tenderness
Left ring finger: swelling and deformity
Right knee: ballottement, swelling, tenderness around the knee
Neurovascularly intact
Left leg: swelling, deformity, crepitus, tenderness, neurovascularly intact
For faculty:
Let participants request all x-rays needed according to the information provided on the slides.
What are the next investigations concerning fractures?

6. Right Left Anything needed? For faculty :
You can notice that there is fracture line which extends into the shaft of right tibia, but due to multiple injuries the surgeons might miss it and could not see the whole injury on the right side. The miss diagnosis in multiple-fracture patient occurs often.
X-rays should be done in every suspected area.
Two views at each area.
Including joint above and below to rule out missing diagnosis.
Left

7. x-rays including joint above and below
Do not forget to have
x-rays including joint above and below
For faculty:
You can show that the fracture was not only located at tibial plateau but also extended into the shaft. So the principle of seeing joint above and below is important.

8. Is
Is there any role of this total body scan in multiple-trauma patient if this facility is available?

9. What will you do for fracture?
Right
For faculty:
Now let participants discuss what they are going to do with all fractures at this stage.
What is their choice?
What will be first: traction and splint, especially for the fracture subluxation of tibial plateau
Neurovascular is also of concern.
Now, what will be further than splint
Keep in external splint
Skeletal traction
Open reduction and internal fixation of fracture (early total care)
DCO with modular tube external fixation
Left

10. Right Left Traction and splint! What next? For faculty :
You can ask participants about the technique, such as :
Pins position for femur
Number of pins for each fracture fragment
How to reduce pin-tract complications, such as pin position which will be safe and no soft-tissue motion
How to reduce heat (NSS cooling)
How to deal with very short segment of proximal tibia
Left

11. For faculty :
You can ask participants about the technique, such as :
Pins position for femur
Number of pins for each fracture fragment
How to reduce pin-tract complications, such as pin position which will be safe and no soft-tissue motion
How to reduce heat (NSS cooling)
How to deal with very short segment of proximal tibia

12. Right
For faculty
When using “self-tap” pin, how to avoid complication of too much penetration into the soft tissue of opposite cortex
How is the feeling of far cortex before it is penetrated
Sharp drill is important
When using “ self-drill, self-tapping“
The far cortex should not be penetrated, the tip of the pin should be stopped just at perching at far cortex
What will happen if it penetrates through the far cortex
Appropriate traction will facilitate definitive fracture reduction and fixation (not keep fracture shorten or contracted)

13. For faculty:
When is the proper time to fix definitively?

14. Take-home messages
After resuscitation in multiple-fracture patients, secondary survey is important to have complete diagnosis
Screening x-rays in every suspicious area
X-ray should include the joint above and below the injured area
Monolateral external fixation with modular technique is an effective and fast method to stabilize the fracture of long bones especially lower extremity
Simple splint for upper extremity is acceptable in acute management in damage control orthopedics

15. Take-home messages
Drilling and application of Schanz pins are vital to reduce pin complication
Knowledge of safe zone and anatomy is crucial