Early Definitive Care (EDC) VS Damage Control Orthopedics (DCO) in the Management of Femoral Shaft Fractures in Polytrauma Patients

In the case of diaphyseal fractures of long bone, the stabilization of the fracture site must be performed as early as possible as it reduces the risk of complications. However, the realization of a definitive osteosynthesis early, in particular the centromedullary nailing, will be responsible for an additional aggression for the patient, called second hit, which can create or aggravate respiratory or multi-visceral failure. Orthopedic damage control (DCO) is a simple surgical technique that has as a principle, the temporary stabilization of fracture sites by the use of external fixators. DOC reduces blood loss intraoperative, the operative times, and especially the intensity of the surgical aggression source of secondary complications. The broader clinical benefits of DOC compared to permanent early osteosynthesis, however, remain controversial. Most experts still recommend DOC for shocked or severely injured patients. For borderline patients, stable but with a risk of degradation due to surgery, its use remains highly debated. For the less severe patients, DOC is not recommended, except in cases of significant local tissue or bone decay. The initial DOC strategy is associated in most cases with a secondary reoperation to perform definitive osteosynthesis. The definitive osteosynthesis must ideally take place between the 4th and the 15th or 21st day to minimize the local risk or general complications. Thus, the choice of the initial strategy, as the optimal timing of secondary recovery should be discussed between the surgeon and the anesthesist.