Citation

Cimbanassi S, OʼToole R, Maegele M, Henry S, Scalea TM, Bove F, Mezzadri U, Capitani D, Sala F, Kanakaris N, Coccolini F, Ansaloni L, Sgardello S, Bindi F, Renzi F, Sammartano F, Masse A, Rampoldi A, Puoti M, Berlusconi M, Moretti B, Rueger J, Arnez Z, Del Bene M, Chieregato A, Menarini M, Gordini G, De Blasio E, Cudoni S, Dionigi P, Fabbri A, Scandroglio I, Chiara O. J. Trauma Acute Care Surg. 2020; 88(2): e53-e76.

Affiliation

From the General Surgery-Trauma Team (S.C., S.S., F.B., F.R., F.S.), Niguarda Hospital, Milan, Italy; Department of Orthopedics (R.O.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Traumatology and Orthopedic Surgery Cologne-Merheim Medical Center (M.M.), Institute for Research in Operative Medicine, University Witten-herdecke, Koln, Germany; Trauma Surgery (S.H., T.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Orthopedic Surgery (F.B., U.M., D.C., F.S.), Niguarda Hospital, Milan, Italy; Major Trauma Centre (N.K.), LeedsTeaching Hospitals NHS Trust, Leeds, United Kingdom; General and Emergency Surgery (F.C., L.A.), Bufalini Hospital Cesena, Cesena; Orthopedic Surgery (A.M.), Traumatologic Center, University of Turin, Turin; Interventional Radiology (A.R.), Infectious Disease (M.P.), Niguarda Hospital; Orthopedic Surgery, Humanitas Clinical Institute (M.B.), Milan; Orthopedic Surgery (B.M.), Policlinic Hospital of Bari, University of Bari, Bari, Italy; Trauma and Reconstructive Surgery (J.R.), University Medical Center, Hamburg-Eppendorf, Germany; Plastic and Reconstructive Surgery (Z.A.), State University of Trieste, Trieste, Plastic Surgery (M.d.B.), S. Gerardo Hospital, Monza; Neuro Intensive Care (A.C.), Niguarda Hospital, Milan; Intensive Care (M.M., G.G.), Maggiore Hospital, Bologna; Intensive Care (E.D.B.), Rummo Hospital, Benevento; Orthopedic Surgery (S.C.), Tempo Pausania Hospital, Olbia; General Surgery (P.D.), IRCCS Policlinico S.Matteo, University of Pavia, Pavia; Emergency Medicine, Emergency Department (A.F.), Morgagni-Pierantoni Hospital, Italy; General Surgery (I.S.), Valle Olona Hospital, Busto Arsizio; and General Surgery and Trauma Team, Department of Trauma Network (O.C.), State University of Milan, Niguarda Hospital, Milan, Italy.

Copyright

(Copyright © 2020, Lippincott Williams and Wilkins)

DOI

10.1097/TA.0000000000002407

PMID

32150031

Abstract

BACKGROUND: In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.

METHODS: The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.

RESULTS: The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb.

CONCLUSION: Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE: Systematic review of predominantly level II studies, level II.

Language: en