Peer-review started: September 29, 2018
First decision: November 14, 2018
Revised: December 11, 2018
Accepted: December 12, 2018
Article in press: December 13, 2018
Published online: January 18, 2019
Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the “second hit” effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.
Core tip: Damage control orthopaedics (DCO) is the treatment of lesions that provoke major bleeding and pathological inflammatory response, whilst avoiding the traumatic effects of major surgery in a patient who is already traumatised (the “second hit” effect). The concept of DCO has not previously been validated and much controversy remains as to whether the indiscriminate application of DCO might be clinically and economically harmful. In addition, parameters associated with the acid-base system have been published with the idea that the existence of normalised parameters will enable patients to receive major surgical procedures, under a concept termed early appropriate care. This paper discusses the above concepts.