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J Am Acad Orthop Surg, Vol 17, No 9, September 2009, 541-549.
© 2009 the American Academy of Orthopaedic Surgeons
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Timing of Fracture Fixation in Multitrauma Patients: The Role of Early Total Care and Damage Control Surgery

Hans-Christoph Pape, MD, Paul Tornetta, III, MD, Ivan Tarkin, MD, Christopher Tzioupis, MD, Vani Sabeson, MD and Steven A. Olson, MD

Dr. Pape is W. Pauwels Professor and Chairman of Orthopaedic/Trauma Surgery, University of Aachen, Aachen, Germany, and Adjunct Professor, Division of Orthopaedic Traumatology, University of Pittsburgh Medical Center, Pittsburgh, PA. Dr. Tornetta is Chief, Trauma Surgery, Boston Medical Center, Boston, MA. Dr. Tarkin is Chief, Trauma Service, and Assistant Professor, University of Pittsburgh Medical Center. Dr. Tzioupis is Research Fellow, University of Pittsburgh Medical Center. Dr. Sabeson is Resident, Division of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC. Dr. Olson is Chief, Division of Orthopaedic Surgery, Duke University School of Medicine.

Dr. Tornetta or a member of his immediate family has received royalties from, has received research or institutional support from, and serves as a paid consultant to or is an employee of Smith & Nephew, and has stock or stock options held in ExploraMed. Dr. Olson or a member of his immediate family serves as a board member, owner, officer, or committee member of the Southeastern Fracture Consortium Foundation, serves as a paid consultant to or is an employee of Synthes, and has received research or institutional support from Synthes. None of the following authors or a member of their immediate families has received anything of value from or holds stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Pape, Dr. Tarkin, Dr. Tzioupis, and Dr. Sabeson.

Reprint requests: Dr. Pape, Department of Orthopaedic Surgery, University of Aachen Medical Center, 30 Pauwels Street, 52074 Aachen, Germany.

The optimal timing of surgical stabilization of fractures in the multitrauma patient is controversial. There are advantages to early definitive surgery for most patients. Early temporary fixation using external fixators, followed by definitive fixation (ie, the damage control approach), may increase the chance for survival in a subset of patients with severe multisystem injuries. Improved understanding of the pathophysiology of trauma has led to a greater ability to identify patients who would benefit from damage control surgery. A patient is classified as physiologically stable, unstable, borderline, or in extremis. The stable patient can undergo fracture surgery as necessary. An unstable patient should be resuscitated and adequately stabilized before receiving definitive orthopaedic care. The decision whether to perform initial temporary or definitive fixation in the borderline patient is individualized based on the clinical condition. In patients presenting in extremis, life-saving measures are pivotal, followed by a damage control approach to their injuries.






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Copyright © 2009 by the American Academy of Orthopaedic Surgeons.