Algorithms for the treatment of multiply-injured patients with concomitant orthopaedic injuries have continued to evolve over the past several decades. Advances in surgical techniques and implants have revolutionised the treatment of specific musculoskeletal injuries. Improved understanding of the implications of applying these techniques to patients with compromised physiology has led to critical reevaluation of the issues surrounding definitive orthopaedic care. A discussion of these issues as they apply to the multiply-injured patient with associated femoral shaft fracture provides insight into how Damage Control Orthopaedics has evolved. As well as what questions remain unanswered in our ongoing efforts to decrease mortality and improve long-term functional recovery in this difficult and challenging patient population.

While femur fracture patients in the 1950s and 1960s were often deemed ‘too sick’ for surgical treatment, the high morbidity and mortality associated with long-term traction as a primary treatment modality led to recognition of the benefits of early fracture care in the 1980s. Multiple studies demonstrating the benefit of early fixation of femur fractures in multiply-injured patients led to a dramatic shift in treatment protocols towards urgent, if not emergent, definitive stabilisation of the femur. However, weaknesses of these early studies exist and their results were often over-interpreted. In the late 1980s and early 1990s, evidence began to accumulate that early definitive treatment consisting of reamed intramedullary nailing of the femur might actually be detrimental in an at risk subgroup of patients. Early interpretation of these results led to a move toward ‘unreamed’ nails in multiply-injured patients in an effort to minimise the pulmonary impact of reaming. Our current level of understanding appears to indicate that there exists a much more complex interaction between multiple factors including patient characteristics, associated injuries, timing and mode of orthopaedic stabilisation employed. As the relative importance and influence of these multiple factors becomes clearer, our ability to appropriately select patients for early total care versus damage control orthopaedics should improve the potential for damaging physiological effects of treatment. In the meantime, application of the principles of damage control to those patients for whom it is clearly indicated, as well as to those for whom it may not be clear cut, appears to have minimal, if any, deleterious effect.

Operative approaches to the acetabulum are generally classified into anterior, posterior, extensile or combined approaches. The choice of approach depends upon the fracture pattern and the amount of relative displacement affecting the anterior and posterior bony structures. Occasionally, extensile or combined surgical approaches are indicated for the treatment of complex fracture patterns with extensive involvement of both the anterior and posterior acetabular anatomy. However, it is believed that these approaches may be associated with higher complication rates than more limited surgical approaches.

The ilioinguinal approach described by Letournel is routinely employed in the treatment of anterior column, anterior wall, anterior column/posterior hemi- transverse and certain associated both-columns, transverse and T-type fractures. The utility of this approach is sometimes limited by difficulty in visualising, reducing and applying instrumentation to the quadrilateral plate and posterior column components of these fractures.

A surgical approach described by Stoppa in 1989—and later extended to acetabular indications by Cole and Bolhofner—can be used, often in combination with the lateral window of the standard ilioinguinal approach, to effectively treat the same range of fractures as an ilioinguinal approach. Access to the quadrilateral plate and certain displaced posterior column fracture lines is enhanced by this approach—possibly eliminating the need for combined or extensile approaches in certain cases. A retrospective study undertaken at our institution demonstrated that anatomic articular reduction was achieved in 14 of 17 complex acetabular fractures treated via a Stoppa approach. All fractures in the study had at least 5 mm of posterior column displacement preoperatively.