DAMAGE CONTROL ORTHOPAEDICS
From the University of California, San Francisco, School of Medicine’s Orthopaedic Trauma Course, held May 18-
20, 2006
| DAMAGE CONTROL ORTHOPAEDICS —Alan L. Jones, MD, Director of Orthopaedic Trauma, Baylor University
Medical Center, Dallas, TX
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| Introductory remarks: in orthopaedic surgery, there has been evolution in approach to care of trauma patients; over
last 5 to 10 yr, developed better understanding of body’s immune response to trauma; in 1970s, multiply injured patient
with, eg, femur fracture, basically just placed in traction; in 1980s and early 1990s, practice of early femur fracture stabilization
arose, found to improve mortality and complication rates; led to concept of early total care, now evolved to concept
of “damage control” orthopaedics
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| Trauma patients: most patients easy to manage and do well, regardless of injuries or treatment they receive on first day;
smaller group of severely injured patients in extremis who clearly cannot undergo prolonged operation and require different
approach than early total care; third group are individuals actually very ill and at risk for doing poorly, but who resemble stable
trauma patients (hardest group to identify and to manage)
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| Comments: research at Hannover/Leeds demonstrated benefits of moving from early total care to damage control orthopaedics
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| Current spectrum of treatment: most stable trauma patients do well with early total care; unstable patients taken to
operating room (OR) for damage control; patients too sick to go to OR undergo external fixation in intensive care unit
(ICU) and damage control
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| Damage control in severely injured patients: debridement of open fractures; stabilization of pelvis and long bones
(usually with external fixation); delay of definitive care
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| Signs indicating borderline patient: pulmonary dysfunction; hypothermia; platelet count <95,000/µL; shock unresponsive
to therapy; lung contusions
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| When performing damage control: use simple external fixation frames (eg, 2 pins above and below fracture, anterograde
or retrograde nail; study has shown that, up to 6 wk out, can safely convert to intermedullary [IM] nail with low risk
for infection)
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| How long to delay definitive care/surgery: no good data; days 2 to 4 very risky time period (patient may look better,
but may be just as ill or as prone to inflammatory response as on day 1); waiting to days 5 to 7 recommended
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| LESSONS FROM HURRICANE KATRINA —Kyle F. Dickson, MD, Associate Professor and Director of Orthopaedic
Trauma, Tulane University Medical Center, New Orleans, LA
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| Introductory remarks: afternoon of day after Hurricane Katrina hit New Orleans, speaker drove around to see whether
people could reach his hospital; while most streets had debris, pathways still present allowing access; by following day, 6
ft of water outside hospital; 90% of city ended up under water
|
| Lessons learned: inadequacy of emergency management—despite statements from Federal Emergency Management
Agency (FEMA) that they could not have expected Hurricane Katrina, officials knew level 5 storm coming, just did terrible
job preparing for it; mayor botched evacuation of hospital patients; many New Orleans hospitals poorly designed, with generators
on first floor or in basement; fuel for generator at speaker’s hospital stored 2 blocks away; in triage, ran out of medicine
for ≈3 days; after 2 days, needed to transfer some young trauma patients to Tulane Medical Center; met resistance from armed
guards, who said Tulane no longer taking patients; ended up turning garage into “a little bit of an ICU”; while speaker feels he
did not do much in aftermath of Katrina, thinks orthopaedic surgeons need to be involved in these types of emergency situations;
when military come into emergency situation, they set up and control communications (staff at speaker’s institution had
no access or very limited access to hospitals in outside world)
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| Concluding comments: eventually, hospital staff and patients evacuated to airport, then driven by bus to Lafayette;
speaker returned early to check water level around his house; water extremely toxic (ended up contracting sepsis and cellulitis)
and remained for 4 wk
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| ISSUES CONFRONTING THE COMMUNITY SURGEON —Timothy J. Bray, MD, Clinical Professor of Orthopaedics,
University of California, Davis, School of Medicine
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| American Academy of Orthopaedic Surgeons (AAOS) position statement: “our trauma or emergency care
must be elevated to a level which ensures that each injured person has the greatest possible chance of survival and recovery”
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| General skills taught in residency: orthopaedic history and physical examination; orthopaedic diagnosis; basic
emergency department (ED) skills; care of hospitalized patient
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| Core competencies: taking care of patients and neighbors; getting up at night; working on-call schedules; practicing
general orthopaedics
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| Small towns: very dependent on their physicians and EDs; in small communities, tend to see hip fractures and slips, femoral
neck fractures, and tibial fractures; will occasionally encounter more severely injured patient; in such case, need to employ
damage control orthopaedics (once fractures stable, can transfer patient to local traumatologist or proceed with internal fixation)
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| Reasons to maintain core general competency skills: lot of time spent learning basic fracture care; general surgeons
looking for business; further fragmentation of orthopaedic specialty not good idea
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| Ethics of orthopaedics: covenant between society and physicians changed; new and different generation of orthopaedic
surgeons (some have not taken Hippocratic oath); medicine is business; emergency care in “tug of war” (obligation
to care for patients vs business of orthopaedic surgery); orthopaedic surgeons need to take leadership position and
attempt to restore social contract
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| Ethics of call: ED demands—number of patients in EDs increased, while number of EDs decreased; orthopaedic surgeons
required to cover EDs in order to maintain hospital admitting privileges; AAOS statement on ED coverage; reasons
orthopaedic surgeons should take call
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| Solution: dropping off call in environment community probably unreasonable (especially when there are appropriate negotiable
solutions); well-designed rural emergency medical service (EMS) models associated with reduction in mortality
of 20%; AAOS endorsed efforts to establish statewide and regional trauma care systems
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| Typical community emergency models: private “on call” models; American College of Surgeons (ACS)-approved
programs (trauma panels; hospital-based or community-based traumatologists)
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| Reno model: trauma panel (21 community orthopaedic surgeons under directorship of traumatologist); phase 2/hybrid
system (orthopaedic traumatologists based at local trauma hospital hired as full associate in community private practice
offices); advantages of hybrid system for hospital and for orthopaedic surgeon; hospitals must “buy in” to system
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| MANAGING DIFFICULT INTERTROCHANTERIC FRACTURES —Michael R. Baumgaertner, MD, Professor, Department
of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT
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| Management of A1 fracture: “pretty hard to go wrong”; only real mistake one can make is to not open fracture; key
with any of these fractures is to get screw dead center and deep
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| Management of A2 fractures: depends on patient; in younger patient, goal to not just get him or her out of bed, but to
reconstruct proximal femur; in that case, do formal open reduction; in older patient, speaker would generally do IM fixation
(advantage of IM position is that it provides buttress to excessive collapse of implant and allows it to actually support
proximal femur as fracture heals)
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| Management of reverse oblique fractures: study by Haidukewych et al found compression hip screw not right device
for this fracture; generally, dynamic condylar screw (DCS) used; alternative approach is IM device; in study by Sadowski
et al, IM nail (proximal femoral nail [PFN]) outperformed 95° fixed-angle screw plate in every category (“from
complications to blood loss to reoperations”); thus, appears clear that at present time, IM nails are preferred treatment
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| Example of unstable fracture in elderly patient: percutaneous K wires or joy sticks used to get control of proximal
fragment (just enough to restore neck shaft axis); allows for fixing of fracture with acceptable mechanical alignment
in percutaneous fashion; goal in this case not radiographically perfect reduction, but reestablishment of axis in closed
technique to allow full weight bearing as fracture heals
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| Management of subtrochanteric-intertrochanteric fractures: some of most difficult fractures to manage;
younger patient treated differently than older patient; use lateral approach, which dramatically simplifies strategy for
achieving closed reduction, then simply split fascia and clamp it; in older patient, speaker hesitant to use lateral position;
exterior fixation pin percutaneously placed controls abduction; can then bring joystick in anterolaterally on base of femoral
neck and that will control flexion-extension; after that, can pin fragment to acetabulum in accessible position; put pin
out of way of ultimate entrance; essentially nailing reduced fracture
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| Tips for using IM devices in difficult fractures: entrance site—right place for placement of trochanteric nails is
at tip of trochanter or slightly medial; critically important to create channel in which to place implant; medial-directed
pressure on trochanteric block facilitates reaming; slight overreaming facilitates reestablishment of neck/shaft axis; implant
assembly—speaker discourages use of 125° device, recommends placement at least 130°; situation in which nail
at 130°, and know that leg in varus (key to abduct leg; critical to separate stage of nail entrance and neck/shaft axis, as
they occur at separate points; do not stop until screw dead center and deep)
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| DVT IN FRACTURE CARE: WHEN TO ANTICOAGULATE —Alan L. Jones, MD, Director of Orthopaedic Trauma,
Baylor University Medical Center, Dallas, TX
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| Risk factors for deep venous thrombosis (DVT) in fracture patients: highest risk associated with hip or pelvic
fractures; joint replacement surgery; spinal cord injury; multiple trauma; stroke; other risk factors—age; patient history or
family history of thromboembolism; inherited coagulation disorders; heparin-induced thrombocytopenia (HIT); arthroscopic
surgery; surgery lasting >45 min; malignancy; confinement; lower extremity immobilization; central lines; minor
surgery; varicose veins; inflammatory bowel disease; swelling; obesity; history of acute myocardial infarction (MI) or heart
failure; sepsis; chronic obstructive pulmonary disease (COPD); women-specific risk factors (eg, oral contraceptives, hormone
replacement, pregnancy); important to have check list that includes all these risk factors and to obtain information on
these for every patient
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| Comments: DVT in trauma “incredibly common”; pulmonary embolism (PE) occurs in 1% of cases; patients with DVT
more likely to have PE; keep in mind that every treatment has own risk factors; not known whether DVT prophylaxis has
any effect on rates of PE and death from PE; reality almost all adult orthopaedic patients at moderate to high risk for
DVT; thus, every patient either needs prophylaxis or good reason not to do prophylaxis
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| Chemical prophylaxis: heparin—use of unfractionated heparin can result in heparin resistance and HIT (occurs in
1%-2% of patients), so need to monitor patient’s platelets every few days; study comparing unfractionated heparin and
fractionated heparin (enoxaparin [Lovenox]) found enoxaparin patients had fewer DVTs and proximal DVTs, but greater
risk for bleeding; important to note that, even with prophylaxis, 33% of enoxaparin patients and almost 50% of heparin patients
still had DVT; contraindications include ongoing bleeding, solid organ injury, traumatic brain injury, and regional
anesthesia; warfarin (Coumadin)—because of slow onset and long half-life, difficult to use in early phase of trauma, but
has some usefulness when duration prolonged; in study comparing warfarin to enoxaparin, warfarin not as effective in preventing
DVT but much better at preventing bleeding; aspirin—multiple studies shown aspirin ineffective as single agent;
however, has some additive effect to warfarin, enoxaparin, or other regimens; long half-life; inexpensive; positive effects
in preventing acute MI and stroke; easy to use, especially at time of discharge
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| Mechanical prophylaxis: include graduated compression stockings; intermittent compression (foot pumps or sequential
compression devices [SCDs]); placement of filter in vena cava (temporary or permanent); efficacy—if on patient
constantly, intermittent foot pumps and SCDs shown to reduce rate of DVT; in speaker’s opinion, biggest problem with
mechanical devices is lack of patient compliance; biggest risk associated with pneumatic device (eg, SCD) in patient with
DVT is of squeezing DVT out of leg and into lungs; caval filters—reduce risk for PE; however, increase risk for DVT;
mechanical problems can develop; ultimately, may not have impact on patient mortality; currently, speaker feels filters
have no role in prophylaxis (best reserved for patients with known DVT or PE who cannot undergo anticoagulation;
speaker feels filters, for most part, overused)
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| Key point: most patients who die of PE received prophylaxis
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| Current approach: run down check list of risk factors and determine presence or absence in every patient; unless risks
assessed, cannot choose appropriate therapy; in patient with high risk for DVT but low risk for bleeding—can give
enoxaparin safely; consider use of mechanical device; in patient with tibial fracture and moderate risk of bleeding
from traumatic brain injury—consider using unfractionated heparin, with or without mechanical device; in multiple-
trauma patient with high risk for bleeding—use mechanical device; consider surveillance studies; every day, must determine
whether patient can receive anticoagulation therapy
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| Screening: in review of 1000 patients, 50% underwent screening for DVT; most patients got mechanical prophylaxis, chemical,
or both; total hospital costs for screening $500,000; screening did not reduce incidence of mortality from PE
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| Mobilization: no data to support that mobilization will reduce rate of PE or DVT
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| Duration of anticoagulation: most regimens discontinued at hospital discharge; however, some evidence to support
continuation in high-risk patients (particularly hip fracture)
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Educational Objectives
| The goal of this program is to provide listeners with a better understanding of some of the challenges of practicing damage
control orthopaedics. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Explain the advantages of damage control orthopaedics over early total care in the management of the severely ill
polytrauma patient.
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| 2. Recognize the signs indicating that a seemingly stable trauma patient might in fact be borderline and would do
poorly with early total care.
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| 3. Discuss some of the issues confronting the community orthopaedic surgeon, including the need to maintain core
competency skills and the pressures and reasons to cover the hospital emergency department.
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| 4. Select the most effective approach and tools for managing difficult intertrochanteric fractures.
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| 5. Assess the risks for deep venous thrombosis, pulmonary embolism, and for bleeding in adult orthopaedic trauma patients,
and with that information, choose the appropriate therapy.
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Discussed on This Program
Aspirin (acetylsalicylic acid; ASA) [several trade names and preparations]
Clopidogrel bisulfate [Plavix]
Enoxaparin sodium [Lovenox]
Heparin sodium injection
Indomethacin [Indocin, Indocin SR, Indomethacin SR, Indomethacin Extended-Release]
Phytonadione (vitamin K) [AquaMEPHYTON, Mephyton]
Warfarin sodium [Coumadin]
Suggested Reading
Barquet A et al: Intertrochanteric-subtrochanteric fractures: treatment with the long Gamma nail. J Orthop Trauma
14:324, 2000; Baumgaertner MR: The pertrochanteric external fixator reduced pain, hospital stay, and mechanical
complications in comparison with the sliding hip screw. J Bone Joint Surg Am 84-A:1488, 2002; Baumgaertner MR,
Solberg BD: Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint
Surg Br 79:969, 1997; Bhattacharyya T et al: The value of the dedicated orthopaedic trauma operating room. J
Trauma 60:1336, 2006; Bong MR et al: Comparison of a sliding hip screw with a trochanteric lateral support plate to an
intramedullary hip screw for fixation of unstable intertrochanteric hip fractures: a cadaver study. J Trauma 56:791, 2004;
Borer DS et al: The effect of screening for deep vein thrombosis on the prevalence of pulmonary embolism in patients
with fractures of the pelvis or acetabulum: a review of 973 patients. J Orthop Trauma 19:92, 2005; Bray TJ: Design of
the Northern Nevada Orthopaedic Trauma Panel: a model, level-II community-hospital system. J Bone Joint Surg Am 83-
A:283, 2001; Ferdinand KC: Public health and Hurricane Katrina: lessons learned and what we can do now. J Natl
Med Assoc 98:271, 2006; Franco C et al: Systemic collapse: medical care in the aftermath of hurricane katrina. Biosecur
Bioterror 4:135, 2006; Giannoudis PV, Pape HC: Damage control orthopaedics in unstable pelvic ring injuries.
Injury 35:671, 2004; Haidukewych GJ et al: Reverse obliquity fractures of the intertrochanteric region of the femur. J
Bone Joint Surg Am 83-A:643, 2001; Handoll HH et al: Heparin, low molecular weight heparin and physical methods
for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database
Syst Rev (4):CD000305, 2002; Hildebrand F et al: Damage control: extremities. Injury 35:678, 2004; Kelsey LJ et
al: Thrombosis risk in the trauma patient. Prevention and treatment. Hematol Oncol Clin North Am 14:417, 2000; Kurtoglu
M et al: Intermittent pneumatic compression in the prevention of venous thromboembolism in high-risk trauma
and surgical ICU patients. Ulus Travma Acil Cerrahi Derg 11:38, 2005; Lindskog DM, Baumgaertner MR: Unstable
intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg 12:179, 2004; Pape HC et al: Changes in
the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery.
J Trauma 53:452, 2002; Roberts CS et al: Damage control orthopaedics: evolving concepts in the treatment of
patients who have sustained orthopaedic trauma. Instr Course Lect 54:447, 2005; Sadowski C et al: Treatment of reverse
oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a
prospective, randomized study. J Bone Joint Surg Am 84-A:372, 2002; Schiff RL et al: Identifying orthopedic patients
at high risk for venous thromboembolism despite thromboprophylaxis. Chest 128:3364, 2005; Steele N et al: Thromboprophylaxis
in pelvic and acetabular trauma surgery. The role of early treatment with low-molecular-weight heparin. J
Bone Joint Surg Br 87:209, 2005; Sullivan SD et al: Cost-effectiveness of fondaparinux compared with enoxaparin as
prophylaxis against venous thromboembolism in patients undergoing hip fracture surgery. Value Health 9:68, 2006; Templeman
D et al: Reducing complications in the surgical treatment of intertrochanteric fractures. Instr Course Lect
54:409, 2005.
Faculty Disclosure
In adherence with ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Jones, Dickson, Bray, and Baumgaertner were recorded at the Orthopaedic Trauma Course, held May 18-20,
2006, in San Francisco, CA, and sponsored by the University of California, San Francisco, School of Medicine. The
Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.
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