Damage Control Orthopedics: Indications and Principles in Missile Extremity Injuries

Seance of wednesday 14 september 2016 (Blessés par armes de guerre et par explosions. Principes de chirurgie de guerre applicable à des blessés lors d’attentat. Recommandations de l’École du Val-de-Grâce SÉANCE ANNUELLE COMMUNE AVEC LE SERVICE DE SANTÉ DES ARMÉES)

DOI number : 10.2699/3bk3-1g23/emem.2017.3.003

Abstract

Evolution of the damage control surgery concept, Damage Control Orthopedics (DCO) was first developed to limit additional trauma in unstable polytraumatized patients with femoral shaft or pelvic fractures. The purpose was to avoid the lethal triad (acidosis, hypothermia, coagulopathy) using fast and temporary fracture stabilization by external fixation, secondarily converted to definitive internal fixation. Later, temporary external fixation was extended to the management of complicated isolated limb traumas for which the ideal treatment cannot be provided at the initial phase: fractures with arterial injury requiring vascular repair, epiphyseal fractures with skin complications (mostly at the knee and ankle level) or multifocal limb trauma (especially those involving the femur). Other indications are related to austere environments due to limited surgical means or massive casualties requiring collective damage control procedures. For these reasons DCO procedures are often required to manage missile extremity injuries, and are nearly mandatory in the military practice. Temporary external fixation is a part of a global strategy raised to save the life by hemorrhage control, to save the limb by vascular repair, and to preserve the function by prevention of infection and treatment of compartment syndrome. Definitive bone fixation, either internal or external, will be performed secondarily according to fracture location, soft-tissue injury severity and potential infectious complications.