Definition
- Temporary stabilisation of fractures in a physiologically compromised polytrauma patient
- Definitive fixation is delayed until resuscitation is complete
Rationale
- Trauma is the first hit and prolonged surgery or reamed nailing is a second hit
- Marrow contents enter the circulation and add to the inflammatory response, with a risk of ARDS and multiple organ failure
- Early total care, with fixation within 24 hours, reduced pulmonary complications in stable patients
- Damage control applies to the borderline, unstable and in extremis patient
Patient Selection
- Borderline features include ISS over 40, ISS over 20 with chest trauma, bilateral femoral fractures, pulmonary contusion, hypothermia and head injury
- Resuscitation markers guide timing, and early appropriate care uses lactate under 4.0 mmol/L, pH of at least 7.25 or base excess of at least minus 5.5
- Prolonged operative time predicts deterioration
Management
- Phase 1 controls haemorrhage with a pelvic binder, external fixation, traction, vascular shunting and fasciotomy
- Phase 2 is ICU resuscitation to correct acidosis, coagulopathy and hypothermia
- Phase 3 is definitive fixation once stable, usually from day 5 to 10
- Avoid major fixation on days 2 to 4 when the immune response peaks
- Convert external fixation to a nail within about 2 weeks to limit pin tract infection
- Phase 4 is reconstruction and rehabilitation
Evidence
- Evidence is mostly observational, with limited randomised data
- Pape and colleagues reported lower organ failure with damage control in borderline patients
- Early appropriate care allows safe definitive fixation within 36 hours when markers normalise
Written by Western Health Orthopaedic Department
Last updated October 2026
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 15 October 2026.