Indications of Trauma Damage Control Orthopaedics (TDCO)

The concept of TDCO, stemming from a better understanding of the physiopathology of the serious traumatized, opposes to early total care of the fractures of the limbs. In the initial phase, the objective is to limit the surgical aggression by giving up the ideal osteosynthesis for a temporary stabilization of fractures, in a simple and quick technique, mostly by external fixation. To shorten the operating time decreases the importance of the "surgical shock" and allows an intensive care corrects local metabolic disturbances, corrects local hypothermia, and reverses coagulopathy.The TDCO so contains three systematic stages:- As a matter of urgency, control of the haemorrhage and the infection by débridement and wound care of the open damage then the stabilization of fractures by temporary external fixation ;- Resuscitation in intensive care unit and optimisation of patient’s conditions ;- Intervention for definitive surgical treatment when the patient is physiologically stabilized (complement to the external fixation or conversion in definitive internal fixation).All the patients and all the contexts do not justify a treatment by a TDCO. Certain indications are now identified well:- Multiply injured patients with associated vital damage. It is the original indication of the TDCO. Four groups (stable, borderline, unstable, and in extremis) are described from three main clinical indicators (shock, hypothermia, coagulopathy). The stable patients owe and the limit patients can benefit from a definitive osteosynthesis at once while the latter is not recommended in patients unstable or in extremis ;- Segmental limb injury that combines and addresses complex soft tissue and bony injuries. Three situations correspond to this TDCO of regional indication: the multiple long-bone injuries without vital lesion with damage staged and fracture of the femur, the open fractures with severe open wounds and the extensive closed soft tissue contusion ;- The limitation in technical means and/or human beings. The TDCO is applicable in precarious situation. The "TDCO of war" is the prime example. A forward surgical unit, in a context of insecurity or a massive afflux of wounded persons, can provide TDCO emergent care, before transfer to a high level trauma center were additional resources are available. It is also a temporary solution, in a civilian structure where all the skills are not available before transfer towards a more specialized structure.