Definition of Damage Control Orthopaedics

Damage control orthopaedics is an approach that contains and stabilizes

orthopaedic injuries so that the patient's overall physiology can improve. Its
purpose is to avoid worsening of the patient's condition by the second hit of a
major orthopaedic procedure and to delay definitive fracture repair until a time
when the overall condition of the patient is optimized. Minimally invasive surgical
techniques such as external fixation are used initially. Damage control focuses on
control of hemorrhage, management of soft-tissue injury, and achievement of
provisional fracture stability, while avoiding additional insults to the patient.
History of Fracture Surgery and Birth of Damage Control Orthopaedics
We previously stated that: Information illustrating the benefits of fracture
stabilization after multiple trauma has been gathering for almost a century.1 We
also noted that during this time fears of the `fat embolism syndrome' also
dominated the philosophy in managing polytrauma patients. Early manipulation of
long-bone fractures was considered unsafe2.
External fixation, an essential component of damage control orthopaedics,
developed slowly and was outpaced by the development of internal fixation. In
Switzerland in 1938, Roul Hoffmann produced an external fixator frame that
allowed the fracture to be mechanically manipulated and reduced3. In 1942, Roger
Anderson advocated castless ambulatory treatment of fractures with use of a
versatile linkage system, but the device was banned in World War II for being too
elaborate3. In 1950, a survey by the Committee on Fractures and Traumatic Surgery
of the American Academy of Orthopaedic Surgeons (AAOS) concluded that the
complications of external fixation frequently exceed any advantages of the
procedure3. Also in 1950, Gavril Abramovich Ilizarov developed the ring system for
fractures and deformities, but his device did not reach the West until the late 1970s.
On March 15, 1958, Maurice Mller, Hans Willenegger, and Martin Allgwer
convened a group of interested Swiss general and orthopaedic surgeons, including
Robert Schneider and Walter Bandi at the Kantonsspital, Chur, Switzerland, to
discuss the status of fracture treatment, which usually included traction and
prolonged bed rest and led to poor functional results in a high percentage of
patients4. On November 6, 1958, these pioneering surgeons established the
Arbeitsgemeinschaft fr Osteosynthesefragen (the Association for the Study of
Internal Fixation, or ASIF), or AO, in Biel, Switzerland4. The key objective of the AO
was the early restoration of function, whether a patient was being treated for an
isolated fracture or for multiple injuries4. Matter noted that this strategy led to
aggressive traumatology involving early total care of the trauma victim,
culminating in the statement: This patient is too sick not to be treated surgically.4
By the 1980s, the accepted care of a major fracture was early or immediate
fixation5. Substantiating this approach were eleven studies (ten retrospective and

one prospective), with the one by Bone et al.6 being most frequently cited. Bone et
al. reported that the incidence of pulmonary complications (adult respiratory
distress syndrome, pneumonia, and fat embolism) was higher and the stays in the
hospital and the intensive care unit were increased when femoral fixation was
delayed.
In 1990, Border reported on a comprehensive study of patients with blunt trauma
that challenged the accepted practice of immediate definitive fixation7. This
changed practice in the early 1990s, and a more selective approach to fracture
fixation was used; however, early fixation was still performed in most cases. During
the 1990s, more was learned about the parameters associated with adverse
outcomes in multiply injured patients and about the systemic inflammatory
response to trauma8. It became clear that fracture surgery, especially
intramedullary nailing, has systemic physiologic effects. These effects became
known as the second hit phenomenon.
The era of damage control orthopaedics started around 1993. Two reports from one
institution9,10described temporary external fixation of femoral shaft fractures in
severely injured patients. From 1989 to 1990, the frequency of using temporary
external fixation increased from <5% to >10%. The mean duration of external
fixation until intramedullary nailing was less than one week. Compared with patients
treated with immediate definitive fixation, those treated initially with external
fixation had more severe injuries, with higher injury severity scores and transfusion
requirements in the initial twenty-four hours. The term damage control began to
be used in the orthopaedic literature over the last six to seven years1,9-12.