Early fixation of fractures has been found to significantly reduce the incidence of pulmonary complications and organ failure and to improve survival [10, 11]. The principles of fracture management in polytrauma patients continue to be of crucial importance. Over the last 5 decades various strategies of fracture treatment in the multiply injured have been evolved. The various new methodologies remain controversial .
The concept of total care (ETC) developed in the 80s with O' Brien et al stating that in a majority of cases of femoral shaft fracture, interlocking, intramedullary nailing can be done.
Oztuna et al found in their experimental study that early internal fixation of long bones results in decreased bilateral translocation from the gut . Complications of fractures have been noted for many decades. When treated non operatively in traction, approximately 20% of young people with femur fractures would develop some manifestations of fat embolism. Riska et al also observed that early fixation of femoral fractures resulted in a drop in the fat embolism syndrome . Several studies have documented the reduction in pulmonary complications and organ failure in early fracture fixation [10, 11, 14, 15].
Recently however application of early total care has been reported as not being beneficial to all the patients, with adverse outcome being encountered in poly trauma patients  The application of early total care in cases with co existing chest injuries, head trauma and those with mangles extremities may be potentially harmful . There is also evidence that an increased complication rate may be encountered in such cases [6, 16].
Pape et al in their study of 35 patients found a sustained inflammatory response after intramedullary instrumentation. Reinforcing the clinical importance of this, they named it as the phenomenon of the second hit . Additional operative trauma may cause an inflammatory body reaction similar to the systemic reaction after mild to moderate accidental injury. [ISS < 25] Accordingly initial operative surgery exceeding 6 hours is critical for the outcome .
Border stated that the realization that problems that cause death later on, or produce major problems in ICU care, begin with resuscitation and are present only in those with severe injuries. He also attributed the difficulty of doing the femoral fractures the night of the admission with severe chest injuries, not with the intramedullary nail, but with the reaming . The correct treatment of an injured extremity involves understanding the entire reconstruction process, post operative management and rehabilitation. It is therefore important that the initial stabilization includes the vision of definitive fracture care . Performance of limited surgical interventions subsequently reduces blood loss and transfusion requirements. This can only be beneficial in these critically ill patients, reducing the risk of developing systemic complications and early mortality . The principle of Damage Control orthopaedics (DCO) was used for the first time by Orthopaedic Surgeons from R. Adams Cowley Shock Trauma Center . The intent of this principle is not to postpone fracture stabilization but to allow immediate fracture fixation in patients who are not cleared for definitive fracture care.
Orthopedic Management of a large number of polytrauma cases in a setting of mass disaster with its inherent challenges has never been studied. The fracture care in polytrauma cases in mass disasters is complicated further by the occurrence of crush syndrome, renal failure, contamination and neurovascular compromise .
Covey documented the difficulties encountered in managing mass casualties. The challenges require the patients to be triaged and treated in an austere and dangerous environment, undergo staged resuscitation and definitive surgery and endure prolonged evacuation, often involving air and ground transport .
In situations of polytrauma with delayed referral being the norm rather than the exception, the cases are at a higher risk from the second hit. Damage control orthopedics in such situations may provide additional advantage that might manifest in terms of better overall care of patients. This includes lower requirement of blood transfusions and reduced operating time.
External fixations as a prime modality for the application of damage control Orthopedics provide the following advantages:
The soft tissue injuries and associated wound contamination is so severe that in these cases the pin sites do not represent a significant additional source for infection. The small bacterial inoculum inherent to the pin sites is often not sufficient to overcome host defenses to cause deep septic complications, even in the presence of physiologic complications which are accentuated by delayed referral. In all our cases which were converted to intramedullary nails, excision of pin tracts with wash out was done. The fixators provided more than adequate stabilization to facilitate nursing and eliminated fracture movement. The fixators also allowed good wound care and physiotherapy.
Our series was complicated by the coexistence of three problems in combination i.e. injuries sustained in a mass disaster, polytrauma and delayed referral. In such a situation application of damage control orthopaedics is not only a reasonable alternative but perhaps the most judicious one as well.
Delayed referral complicates management of polytrauma cases. Hirschberg et al mentioned high observed rates of multiple organ failure in patients surviving the initial 24 hours after their injuries . These processes seem to be initiated by cascading events resulting from blood loss and inflammatory release leading to a 'vicious circle' of shock, hypothermia, acidosis and coagulopathy resulting in end organ failure . Delayed referral from the contaminated and austere surroundings of a mass disaster means that the patient has already sustained a 'second hit' in terms of the delay. It is difficult for any of the injury scoring systems to justifiably grade the patients, and hence the criteria for application of damage control might vary. An early definitive surgery in such situations might equal a 'third hit'.
Mass disasters tend to overwhelm the capacity of the hospitals to cope with the massive and relatively unexpected load of patients. This situation often overwhelms the surge capacity of the hospitals as well. In such situations, to facilitate the care of polytrauma patients as well as the patients with lesser injuries, the management of operating time takes prime importance. The average time taken to attain the preliminary fixation in our patients was 38.5 minutes. In the absence of any comparable study we found this time to be 37% of the time taken to fix a similar series of fractures dealt with a total care methodology in our hospital. This represents a significant saving in the operating time and a judicious use of stretched theatre resources.
Even though predictive factors for the individual trauma patient that would allow identification of patients who are too ill to undergo early total care are still lacking, the injury severity systems constitute reasonable predictors of potential complications .
Our study is unique in several respects. It reports a one year followup of polytrauma cases referred after a delay from the site of trauma. The damage control method was applied in the absence of a composite trauma center and all cases required referral to nearby hospitals for specialized management of other coexisting injuries. We applied the interlocking intramedullary nailing in cases where infection was absent and ring fixators in all cases with indicators of infection. We carried out conversion osteosynthesis by intramedullary nailing in cases which took up to 33 days for return referral. Only one case of deep infection was encountered which was dealt by early removal of hardware. Out of the 11 intraarticular fractures 4 developed stiffness after completion of treatment. We feel this group which necessitates trans articular fixation in the damage control mode might not benefit from this modality in the broad sense. Two of these were however managed by manipulation. 18 of our cases developed pin tract infections due to the external fixators applied before the final conversion. All of these were managed by debridement, excision and antibiotics.
This study is limited by the lack of a comparative study conducted elsewhere in similar circumstances.