Chapter 28 Damage Control Orthopaedics: Fracture Management

This chapter will present the key concepts of damage control orthopaedics (DCO), with a focus on the principles of external fixation and open fracture debridement.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Identify the following critical orthopaedic injuries:
   • Long bone fractures
   • Pelvic fractures
   • Open fractures
   • Dislocations and fracture dislocations of large joints
   • Compartment syndrome
2. Understand the goals of damage control orthopaedic procedures:
   • Control hemorrhage
   • Decrease contamination
   • Prevent or treat compartment syndrome
   • Prevent further soft tissue damage
   • Facilitate transfer
3. Understand and/or demonstrate damage control skills associated with critical orthopaedic injuries, including the following:
   • Stabilization of a pelvic fracture with a binder or sheet
   • Fracture reduction
   • Limb immobilization with splinting
   • External fixation of fractures of the lower extremity and pelvis

General Considerations — Initial Management

• Control of compressible external hemorrhage
  • Direct pressure
  • Wound packing
  • Tourniquet
• Control of bleeding from pelvic fractures
  • Pelvic binder
  • External fixation
  • Angioembolization
  • Preperitoneal pelvic packing
  • REBOA
• Assessment of neurovascular status
  • Hard and soft signs of vascular injury
  • Ankle-brachial index
  • Peripheral nerve examination
• Assess for evidence of open fracture (broken skin communicating with the fracture).
• Reduction and stabilization
  • Grossly deformed extremities should undergo gentle closed reduction and splinting prior to imaging.
  • Fracture instability can lead to soft tissue and vascular compromise.
• Principles of reduction
  • Reduction involves restoring the anatomical alignment of a fracture or dislocation of a deformed limb. Reduction allows for the following:
    • Tamponade of bleeding at the fracture site
    • Reduction of traction on surrounding soft tissue with reduced swelling
    • Decreased pressure on the skin, helping prevent skin necrosis
    • Reduced risk of secondary nerve injury
    • Restoration of any affected blood supply
  • Once fracture reduction is achieved, it must be stabilized by a splint or external fixation:
    • Choice of immobilization depends on local resources and level of experience.
    • The basic rule of splinting is that the bone above and below a joint fracture should be immobilized following reduction.
    • In general, external fixation is preferable to splinting in the setting of extensive soft tissue or vascular injury.
    • Larger bones, especially the femur, are better stabilized by external fixation.
• Monitor for compartment syndrome.

Management of Open Fractures

• Open fractures are most often classified using the system described by Gustilo et al., defined as follows:
  • Type I—wound < 1 cm, minimal contamination
  • Type II—wound > 1 cm, without extensive soft tissue injury
  • Type III—high-energy open fractures
    • IIIA—adequate soft tissue coverage of fractured bone is possible with remaining tissue
    • IIIB—extensive soft tissue injury with periosteal stripping and bony exposure; needs tissue reconstruction
    • IIIC—arterial injury requiring repair
• The greatest factor in reducing infection is the length of time to antibiotics. The goal is less than two hours from the time of injury.
• All open fractures require gram-positive antibiotic coverage and tetanus toxoid as soon as possible. Broad-spectrum antibiotics should be considered for all type III and/or grossly contaminated fractures.

Operative Principles

• Open fractures require formal (operative) debridement and irrigation.
• The timing of surgery will depend on the anatomic extent of injury and the patient’s physiologic status:
  • Surgery should be performed after the patient has been adequately resuscitated.
  • Complex open fractures, mangled limbs, and heavily contaminated wounds will be prioritized, because their physiologic impact is significant.
  • Simple open fractures are ideally treated within six to eight hours.
• Surgical debridement should consist of a deliberate exploration of the entire zone of injury with the goals of removal, retention, and preservation:
• Remove:
  • Gross contamination and foreign bodies
  • Necrotic muscle and skin
  • Nonarticular bone fragments devoid of significant soft tissue attachments
• Retain:
  • Major articular fragments
  • Marginal muscle
  • All viable tissue should be preserved in order to permit the greatest number of definitive care options.
• Preserve:
  • Peripheral nerves (tag to facilitate identification)
  • Blood vessels
  • Bone fragments with significant soft tissue attachments (i.e., bone fragments with a reasonable vascular supply)
• Irrigation: The preferred technique is to use a large volume of normal saline delivered by a low-pressure system (such as cystoscopy tubing). High-pressure pulsatile lavage is not recommended.
• Remember that wounds can evolve over time. In blast or high-energy wounds, it is uncommon for muscle and skin to progress to necrosis in spite of initially appearing viable. In such cases, the wound should be left open and reexplored.

External Fixation — Equipment

• A vital component of DCO is reduction of fractures followed by stabilization with splints and/or external fixators.
• Modern external fixation sets include a variety of types of hardware allowing frames to be individualized to each injury.
• The basic components (Figure 1) required for external fixation are as follows:
• A drill: Battery-powered drills are the most common, but a hand brace can be used in an austere environment to insert the pins.
• A drill guide/tissue protector is inserted into the incision down onto the bone to protect soft tissue from the pin and facilitate placement into the bone.
• Half pins (Schanz screws): Fracture pattern and location will dictate the choice of pins, which come in a variety of lengths and diameters. Generally, 5–6 mm pins are used for the femur and tibia. Self-drilling, self-tapping pins are preferable for DCO, as they do not require predrilling, thus saving time. The pin is the critical link between the bone and the frame.
• Clamps: Coming in a variety of shapes and sizes, clamps provide a secure connection between the pins and the rod(s).
• Rods (or bars): Rods were originally made of stainless steel and aluminum alloy but are now more commonly carbon fiber due to increased strength and facilitation of subsequent imaging.

External Fixation — Technique

• Knowledge of anatomy is critical for the proper placement of external fixation pins and to prevent complications.
• Major nerves, vessels, and organs (in the case of pin placement for pelvic fractures) must be avoided.
• Intraarticular pin placement should be avoided.
• Tendon impalement should be avoided.
• The “safe zones” for external fixation pin placement in the femur (Figure 2) and tibia (Figure 3) are seen below.

• The basic steps of pin placement are as follows:
  • Provisionally reduce and align the fracture.
  • Identify the fracture site (with imaging if possible).
  • Make a 1 cm skin incision at the desired site of insertion (within a safe zone).
  • Spread soft tissues down to the bone and insert the drill guide/tissue protector onto the bone cortex.
  • Insert the self-drilling, self-tapping pin through the drill guide/tissue protector and then through both cortices of the bone using the drill.
  • The pin should be positioned to go through the center of the cross-section of the bone (Figure 4).
  • Once the first cortex is penetrated, there will be a detectable drop in resistance, which will return once the second cortex is entered. Care must be taken to avoid plunging beyond the far cortex, as this may result in injury to major vessels or nerves (Figure 4).
  • The ideal construct for stability consists of placing one pin as close to the fracture as possible (greater than two fingerbreadths) and another pin as far away as possible within the same bone, with two pins (four total) on either side of the fracture.
  • As pins are placed, the pin clamp(s) and rod can be used as a guide to determine the insertion sites of subsequent pins.
  • Using additional clamp(s) and rod(s), the pins are connected. With the limb aligned, the final frame can be secured.
  • Pin clamps should be placed 1.5–2 cm from the skin to maximize stability.
  • Additional rods can be added to improve stability.
  • A number of frame types can be constructed, depending on the fracture site and the desired alignment.
  • External fixator pin sites can become the sites of infections. Daily cleaning with chlorhexidine solution and dressing with iodine-soaked gauze is essential to minimize infection.

External Fixation — Femoral Shaft Fractures

• Femoral shaft fractures are stabilized using pins (5 or 6 mm) placed laterally or anterolaterally in the safe zones (Figure 2) both proximal and distal to the fracture (Figures 5–10).
• The advantage of lateral pin placement is that it will not interfere with future prone positioning to treat other injuries.
• Two external fixation methods can be used to obtain final reduction and alignment of a femoral shaft fracture:
  1. Place the most proximal and distal pins first and attach a long rod. The leg is then positioned into the desired alignment, and the clamps are tightened. The pins closest to the fracture are then placed, using the rod and attached pin clamps as a guide. Desired alignment is confirmed, and the whole construct is tightened for final configuration (Figures 5–10).
  2. Connect the two proximal pins and the two distal pins with short rods. The rods serve as handles that will assist with fracture reduction and alignment, with an additional rod attached to and spanning the previously placed ones (Figures 11 and 12).

External Fixation — Tibial Shaft Fractures

• Fractures of the tibial shaft are stabilized using pins (5 or 6 mm) placed in the safe zones on the medial aspect of the tibia (Figure 3).
• The steps for placing an external fixation device for a tibial shaft fracture are depicted in Figures 13–18 below.

External Fixation — Distal Femur and Proximal Tibia Fractures

• Fractures of the distal femur or proximal tibia/ tibial plateau will require a knee-spanning external fixation for stabilization.
• A fracture dislocation of the knee may also require knee-spanning external fixation.
• Pins in the femur can be placed in the lateral position, as described above in the section on femoral shaft fractures. More commonly, the pins will be placed in the anterior thigh, taking care to avoid the suprapatellar pouch by placing the pins at least a handbreadth above the superior pole of the patella (Figure 19).
• A “bump” should be placed under the knee to create a small amount of flexion to relieve stretch on the neurovascular bundle.
• Two pins are placed in the anterior portion of the femur and two pins in the medial portion of the tibia (Figure 19).
• Rods are attached to the pin clamps and are used to create a construct that spans the knee (Figure 20). Additional rods and clamps can be added to improve stabilization.

External Fixation — Distal Tibia Fracture and Ankle Instability

• When a fracture is too distal on the tibia to allow pin placement above the metaphysis, or if the ankle joint is unstable, an ankle-bridging external fixator will be required.
• The proximal portion of an ankle-bridging construct is anchored with pins placed in the tibia above the fracture (Figure 21).
• The distal portion of the ankle-bridging construct requires a calcaneal pin:
  • An incision is made over the medial aspect of the center of the calcaneus (a fingerbreadth below and behind the medial malleolus) (Figure 21). The posterior tibial artery and posterior tibial nerve should be avoided by placing the pin in the posterior part of the calcaneal tuberosity.
  • A centrally threaded pin (Figure 22) is drilled, from medial to lateral, completely through the calcaneus and through the skin of the lateral foot (Figure 23).
  • The pin is advanced until bicortical purchase with the threads is obtained.
• Pin clamps and stabilizing rods are added to complete the construct (Figure 24).

Pelvic Fractures — General Considerations and Management

• The physiological consequences and initial management of hemodynamically unstable pelvic fractures is well described in chapter 21.
• The optimal approach to the management of complex and/or unstable pelvic fractures requires a multidisciplinary effort to control the hemorrhage and to provide temporary and ultimately definitive fixation.
• Unstable fractures include anterior-posterior compression (open book), lateral compression, and vertical shear injuries (Figure 25).
• The pelvic ring should be promptly closed with a pelvic binder while the patient undergoes resuscitation and adjunctive control of hemorrhage (pelvic packing, REBOA, and/or angioembolization), as described in chapter 21.
• Consideration should also be given to external fixation of the pelvis.

External Fixation of the Pelvis

• External fixation of the pelvis is indicated for temporary (or in some cases, definitive) stabilization of unstable pelvic ring fractures.
• It is important to remember that external fixation controls and stabilizes the anterior pelvic ring, and in most cases definitive fixation will be required (in a delayed fashion) for associated posterior ring injuries.
• Pins are placed in either an iliac crest or a supraacetabular arrangement (Figure 26).
• Though either technique can be done without x-ray guidance, supraacetabular pins are much more difficult to place. As such, the iliac crest technique is preferred in the hands of nonspecialists practicing DCO and will be described below.

Pelvic External Fixation Using Iliac Crest Technique

• Prep the bilateral pelvic brim/hip regions utilizing a chlorhexidine or Betadine solution. It is also prudent to include the abdomen in the prep area in case hemorrhage control via laparotomy is required.
• Internal rotation of the feet and traction on the leg(s) may help with reduction of the pelvic fracture.
• The anatomic landmark for pin placement in the pelvis is the anterior superior iliac spine (ASIS) bilaterally. This should be marked and the skin incised longitudinally, approximately 2 cm posterior to the ASIS, for pin placement (Figure 27).
• Pins are placed in each hemipelvis, with a trajectory toward the ipsilateral greater trochanter (Figure 28). Additional pins can be placed to increase stability.
• Once the pins are placed, pin clamps and rods are used to create an A-shaped frame across the pelvis (Figures 29 and 30).
• The pelvis is then reduced to the desired alignment, and the frame is tightened. The bars can be angled down toward the feet should abdominal surgery be required.
• Additional pins and bars can be added to the construct to increase stability if needed.