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Orthopaedic Trauma

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					 74                           O R T H O P A E D I C

                              T R A U M A

 DANIEL ZINAR



                             M       usculoskeletal trauma can be divided into two
                             main groups. First is the patient with an isolated muscu-
                             loskeletal injury such as a fracture of the tibia. The second
                             type is the musculoskeletal injury that presents as part of
                             a polytraumatized patient, such as the patient who suf-
                             fers a pelvic fracture and femur fracture in a motor vehi-
                             cle accident. These two types of patients must be treated
                             differently. The rationale and explanation for the specific
                             treatment of each of these types of orthopaedic trauma are

often poorly understood. The aims of this chapter are to        diffuse swelling of the leg, with a circumferential measure-
elucidate (1) the correct method of evaluating the patient      ment of the leg demonstrating 3 cm of increased size as
with a musculoskeletal injury, either monotrauma or poly-       compared to the opposite leg. A moderate amount of ec-
trauma, (2) the difference between initial and definitive        chymosis was present about the anteromedial aspect of the
management of the orthopaedic trauma patient, (3) the           tibia. There was an obvious deformity of the leg, with the
complications associated with both types of patients with       lower portion externally rotated. The injured leg was about
orthopaedic injuries, (4) available treatment options for       1 cm shorter than the uninjured leg. The pulses and motor
patients with orthopaedic trauma, and (5) the basic princi-     and sensory neurologic evaluation were normal.
ples in the management of open fractures.                            Radiographs of the lower leg revealed a comminuted
                                                                fracture of the tibia and fibula at the middle one-third of
                                                                the bones. Significant displacement was noted at the frac-
CASE 1                                                          ture site, with about 1 cm of shortening. Radiographs of
LOWER LEG PAIN, SWELLING,                                       the knee and ankle revealed no other injuries.
AND DEFORMITY                                                        The patient was counseled regarding options, and a
                                                                treatment plan was discussed. Initially, after intravenous
A 22-year-old Hispanic female presented to the emer-            sedation as well as a local anesthetic block, a closed ma-
gency room with complaints of left leg pain, swelling, and      nipulation and reduction was performed. A long leg cast
deformity following a twisting injury during a collision in a   was applied, and repeat radiographs demonstrated satis-
soccer game. The injury occurred 2 hours before her ar-         factory angular alignment, correction of prior rotational
rival in the emergency room. She was brought to the hos-        deformity, and only 5 mm of limb shortening. The patient
pital by her friends, who had placed her leg in a home-         was admitted to the hospital for observation because of
made cardboard splint. She denied any other injuries            the significant swelling that had been present. After 24
suffered in this accident. There was no history of prior        hours, she was discharged home with crutches, having
trauma to this leg. Physical examination was significant for     maintained a normal neurovascular examination. The pa-

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5 4 0      O R T H O P A E D I C          S U R G E R Y




                                                                 M
tient returned for a follow-up visit 3 days and again 1 week                  GENERAL CONSIDERATIONS
after her injury. Repeat radiographs at each visit revealed
preservation of her alignment. She was seen at weekly in-                     usculoskeletal trauma is the number one cause of
tervals during the next month until the 4-week mark,             lost work time in the United States. It is also the leading
when she was placed into a below knee tibial fracture            cause of death in the 20–40 year age range. Most muscu-
brace. Radiographs were taken every 3–4 weeks as an out-         loskeletal injuries are isolated and do not involve polytrau-
patient. The patient began partial weight bearing at the 6-      matized patients. The wide spectrum of possible ortho-
week mark, and progressed to full weight bearing over the        paedic injuries can involve any age range from infant to
next 2–3 months. Radiographs demonstrated healing of             geriatric patient. The mechanism of injury is vital to the as-
the fracture with bridging callus after 4 months. Clinical       sessment of the patient. Injuries are often separated into
examination revealed no tenderness of motion at the frac-        low energy versus high energy injuries. Athletic injuries are
ture site.                                                       for the most part considered to be of the low energy variety,
                                                                 but still may be quite severe. High speed motor vehicle,
                                                                 motorcycle, or pedestrian-versus-auto accidents make up
CASE 2                                                           most high energy orthopaedic injuries. Equally important is
MULTIPLE ORTHOPAEDIC INJURIES                                    that over 70% of orthopaedic trauma patients in the emer-
                                                                 gency room have either alcohol or drugs as a contributing
A 59-year-old white male was driving under the influence          etiologic factor to their accident (Case 2). Despite advances
of alcohol when he lost control of his car and was thrown        in preventative measures such as motorcycle helmets, more
over an embankment. He was brought into the hospital             attention is still given to methods of treating orthopaedic in-
by paramedics, who found him conscious at the scene              juries after they occur than to preventative measures. Use
with stable vital signs. On arrival in the emergency room,       of protective athletic equipment, seatbelts, and airbags are
he complained of pain in the right leg, lower abdomen,           examples of some progress that has been made.
and left wrist. He had no other complaints, other than                Long bone fractures (i.e., femur, tibia, and humerus)
slight numbness in the left index finger and thumb. After         usually occur as a result of direct trauma. A bending, twist-
evaluation by the trauma service, he was cleared of any          ing, or axial loading force is usually responsible for creating
other systemic injuries. Physical examination showed ten-        the fracture. The amount of energy imparted to the trauma-
derness and swelling over the suprapubic area; pain,             tized area is responsible for the magnitude of the injury. A
swelling, and deformity of the right thigh; and obvious          highly comminuted (>2 fracture fragments) fracture or
deformity with localized tenderness at the left wrist. The       open fracture usually implies a higher level of energy re-
neurovascular examination was normal except for de-              sponsible for the trauma. A fracture is just part of a severe
creased sensation to pinprick in the region of the median        soft tissue injury that involves the bone. The significant
nerve of the left hand.                                          swelling and ecchymosis in the limb of both cases presented
     Laboratory studies revealed an Hct of 39.5%, which,         is just as significant as is the bony injury. The amount of de-
when repeated 1 hour later, was 35.0%. Radiographs re-           formity present after a fracture is directly related to the
vealed a pelvic fracture with diastasis of 5 cm at the pubic     amount of soft tissue injury (i.e., muscle and ligamentous
symphysis. In addition, a midshaft femur fracture was seen       damage, periosteal stripping, neurovascular injury). The de-
with about 3 cm of shortening, and a displaced fracture of       gree of soft tissue injury may be significant, leading to the
the distal radius was identified. A cystourethrogram was          development of a compartment syndrome. The higher the
performed and no urologic injury was noted. A CT scan of         energy of injury, the higher the likelihood of significant
the pelvis showed no evidence of posterior pelvic instability.   bleeding that can lead to a compartment syndrome.
     The patient had placement of a sugar tong splint on              The amount of soft tissue damage present in an ortho-
the left upper extremity fracture and was counseled re-          paedic injury greatly influences the type of treatment and
garding treatment options. He was brought to the operat-         management. Low energy injuries such as the tibial fracture
ing room within 24 hours and underwent uneventful in-            (Case 1) with less soft tissue damage are more likely to be
tramedullary rodding of the right femur fracture, open           treated nonoperatively, with a splint or casts. Higher en-
reduction/internal fixation of the pubic symphysis diasta-        ergy injuries such as the motor vehicle accident (Case 2)
sis, and closed reduction and percutaneous pinning of the        with more severe soft tissue damage are more often unsta-
left distal radial fracture. The patient remained hemody-        ble and require operative stabilization with either internal
namically stable both intraoperatively and postoperatively.      or external fixation.
The patient was sitting upright in bed on postoperative               The presence of fractures in the multiply injured patient
day 1 and was seen by physical therapy for gait training         requires a more aggressive approach in the management of
with crutches on postoperative day 3. Resolution of his          pelvic, spine, and femur fractures. All of these injuries, if not
paresthesias in the left hand had occurred by the time of        stabilized early, can result in mandatory bed rest for the pa-
his discharge home on day 7.                                     tient, with a concomitant increase in mortality and morbidity
                                                                        O R T H O P A E D I C           T R A U M A           5 4 1


secondary to pulmonary complications. Extremity injuries,            with a low energy mechanism of injury, the comminution
such as a distal radius fracture in a polytrauma patient, do         and significant displacement of the fracture, along with
not require the same level of aggressiveness because a delay         the clinical findings of ecchymosis and swelling, should be
in stabilization does not affect the patient systemically. The       viewed with a high level of suspicion for development of a
patient can still be mobilized in a splint or cast with any frac-    compartment syndrome. This is a clinical diagnosis that is
ture other than the spine, pelvis, or femur.                         made in the presence of unremitting pain and tense
                                                                     swelling, despite adequate fracture immobilization. Since
                                                                     a compartment syndrome is an easily treated entity by


T         DIAGNOSIS                                                  means of a fasciotomy, its presence or absence should al-
                                                                     ways be in the differential diagnosis of major extremity
       he diagnosis of most musculoskeletal trauma requires          trauma. Compartment syndromes can exist even in the
a careful history with regards to the mechanism of injury, a         presence of open fractures, because not all fascial spaces
detailed physical examination focusing on the injured area,          are decompressed with open fractures.
and appropriate radiographs. The history will alert the                   The presence of a fracture must alert the examiner to
physician as to the seriousness of the injury, as well as to the     ensure that the fracture is closed as opposed to open. Open
need to focus or generalize the musculoskeletal examina-             fractures require immediate attention because of the signifi-
tion. The diagnoses of the orthopaedic injuries in both cases        cant risk of infection. The treatment protocol for open frac-
is fairly apparent. As a general rule in any extremity injury,       tures includes (1) intravenous antibiotics, (2) operative de-
the physician must rule out the presence of an injury to the         bridement of devitalized bone and soft tissue, with irrigation
joint above as well as the joint below the injury by both clin-      to reduce contamination, (3) skeletal stabilization with inter-
ical and radiographic examination. When the diagnosis of             nal or external fixation, (4) aggressive soft tissue coverage,
tibia fracture (Case 1) is made, radiographs and clinical ex-        and (5) early limb rehabilitation. Open fractures are classi-
amination must include the knee and ankle joint.                     fied according to the system of Gustilo. Grade I is consid-
     The diagnosis of the spectrum of injuries suffered in a         ered a lower energy injury with a soft tissue wound usually
multiply traumatized patient presents a more complex prob-           less than 1 cm; grade II involves a higher energy with either
lem. After a routine musculoskeletal examination is done,            further fracture comminution or a wound greater than 1 cm;
the patient should be carefully re-examined 24–48 hours              grade III injuries are subdivided into IIIA, IIIB, and IIIC.
after the initial injury, to rule out the presence of a more         All grade III injuries are high energy injuries, with type A in-
subtle or minor injury. More trivial but ultimately function-        volving large soft tissue flaps with periosteal stripping; type
ally significant injuries may be overlooked initially, especially     B requiring soft tissue coverage with a local or free muscle
closed upper extremity injuries of the hand, forearm, and            flap; and type C requiring arterial vascular reconstruction.
shoulder, as well as ligamentous injuries to the knee.                    Abdominal, urologic, and neurologic sequelae of dis-
     The diagnosis of a displaced, partially unstable pelvic         placed pelvic fractures should always be included in the
fracture should alert the physician to perform other diag-           differential diagnosis. In the hemodynamically unstable
nostic tests, including a computed tomography (CT) scan to           patient, a supraumbilical diagnostic peritoneal lavage
examine the posterior integrity of the pelvis as well as inlet       should be performed to rule out significant intra-abdomi-
and outlet oblique radiographs. Diastasis of the public sym-         nal bleeding. Careful neurologic examination must be
physis greater than 5 cm is often associated with disruption         done to document any lumbosacral plexus injury that may
of posterior pelvic anatomy. With significant anterior pelvic         occur with displaced posterior pelvic structures. A multi-
disruption, routine urologic evaluation with a cystourethro-         disciplinary approach is necessary in these patients. In ad-
gram is recommended before Foley catheter insertion.                 dition, complete examination of the perineal area must be
                                                                     done to evaluate for the possibility of an open pelvic frac-
 K E Y       P O I N T S                                             ture. Rectal and vaginal examination is mandatory in order
 • As a general rule in any extremity injury, the physician must     to exclude a tear or perforation.
 rule out the presence of an injury to the joint above, as well as
 the joint below the injury, by both clinical and radiographic ex-


                                                                     T
 amination                                                                     TREATMENT

                                                                           he goal of fracture treatment is restoration of func-
                                                                     tion. Having diagnosed a fracture of the midshaft of the


S       DIFFERENTIAL DIAGNOSIS                                       tibia and fibula (Case 1), what information is needed to
                                                                     make a decision regarding management? The initial dis-
      evere swelling due to bleeding within an enclosed              placement of the fracture, the condition of the soft tissue,
fascial space may occur after any significant trauma to an            and the functional demands of the patient should all be
extremity. Although the tibia fracture (Case 1) occurred             considered in treating any long bone fracture. The deci-
5 4 2      O R T H O P A E D I C         S U R G E R Y


sion to use cast treatment rather than internal or external     patients should have the majority of their musculoskeletal
fixation operative treatment in Case 1 was made based on         injuries stabilized within the first 24 hours. A well-resusci-
the results of the closed reduction. Acceptable alignment       tated trauma patient is usually in the best state of health at
of a fractured long bone is individualized depending on         the time of admission. Isolated musculoskeletal injuries do
the particular fracture being treated. For the tibia, less      not require the same degree of aggressiveness.
than 1 cm of shortening, less than 5 degrees of angulation,         The distal radius fracture (Case 2) differs from the other
and less than 10 degrees of malrotation is acceptable. If       injuries in that it represents an intra-articular fracture.
the fracture had not maintained alignment within these          These fractures require exact alignment of the articular por-
limits, surgical stabilization with an internal plate or rod    tion of the fracture within 1–2 mm. The same treatment op-
versus external fixation would have been necessary. Many         tions exist: casting, external fixation, and internal fixation.
patients are unable to tolerate cast treatment because of       This decision depends on the fracture stability, the condition
the length of time needed for limb immobilization. Joint        of the soft tissue of the limb, and individual surgeon experi-
stiffness can occur in any area after prolonged immobiliza-     ence. The particular fracture in Case 2 was treated with
tion. The decision of what type of definitive treatment to       closed reduction and percutaneous internal fixation.
be used should be made within the first 7–10 days after
the injury in order to expedite return to full function. Op-     K E Y        P O I N T S
erative treatment has the advantage of earlier restoration
                                                                 • Initial displacement of the fracture, condition of the soft tis-
of function with the added (minimal) risk of infection. All      sue, and functional demands of the patient should all be consid-
risks and benefits of each treatment should be discussed          ered in treating any long bone fracture
with the patient before deciding the management course.
                                                                 • Concern with most unstable pelvic fractures is risk of hemor-
     Femoral fracture treatment in the adult is noncontro-       rhage due to venous injury in the posterior pelvis; surgical
versial. Intramedullary nailing is the preferred method in       skeletal stabilization can be done emergently to assist in the re-
both the isolated and polytrauma patient (Case 2). This is       suscitation of the patient by closing the pelvic volume and re-
a low risk, safe, and effective procedure that allows the pa-    ducing the hemorrhage
tient to be mobilized early and return to normal function.       • Polytrauma patients should have the majority of their muscu-
Traction treatment or cast immobilization are not recom-         loskeletal injuries stabilized within the first 24 hours; a well-re-
mended for adult femoral fractures because of the long           suscitated trauma patient is usually in the best state of health at
healing time of 3–4 months, and the limitation of the pa-        the time of admission
tient’s return to normal function. Prompt treatment of all
fractures whenever possible is preferred, especially in the
multiply injured patient whose fractures of the spine,
pelvis, or femur would otherwise confine them to bed rest.

                                                                E         FOLLOW-UP
The combination of the supine, bedridden patient whose
chest is horizontal has been shown to lead to an increase               ffective postoperative follow-up requires an under-
in pulmonary complications in the polytrauma setting, in-       standing of the average healing time of most fractures. Al-
cluding pulmonary emboli.                                       though most fractures may be healed in 3–5 months, it may
     Pelvic fracture treatment is based on stability. Frac-     take up to 1 year for full functional recovery. Intra-articular
tures that are stable to both vertical and rotation forces      fractures require at least 2 years’ minimum follow-up to see
(type A) can be treated without surgery. Partially stable       whether any post-traumatic arthritis will develop. Patients
fractures (type B) (Case 2) may do better after surgical        can expect functional improvement for up to 2 years follow-
stabilization because they decrease pain by limiting frac-      ing most fractures. Radiographs should be taken at monthly
ture motion, decrease bleeding, and restore the normal          intervals for the first 3 months and then every 6–12 months
anatomy. Completely unstable fractures (type C) (i.e., with     for 2 years. At each visit an assessment of functional recov-
both rotation and vertical instability) require stabilization   ery should be measured by recording the range of motion
in order to restore fracture stability and normal function.     of adjacent joints, muscle strength, and the level of func-
The timing of surgery depends on the condition of the pa-       tion—both work and recreational. Despite appropriate
tient. The concern with most unstable pelvic fractures is       management of fractures, some patients may never regain
the risk of hemorrhage due to venous injury in the poste-       full function because of irreversible damage to soft tissues
rior pelvis. Surgical skeletal stabilization can be done        (muscle, tendon, ligament, and cartilage).
emergently to assist in the resuscitation of the patient by
closing the pelvic volume and reducing the hemorrhage.           K E Y        P O I N T S
In the hypotensive trauma patient this is best done with         • Intra-articular fractures require at least 2 years’ minimum
external fixation. The patient in Case 2 was hemodynami-          follow-up to see whether any post-traumatic arthritis will
cally stable at the time of arrival so internal fixation could    develop
be performed as definitive pelvic stabilization. Polytrauma
                                                                        O R T H O P A E D I C          T R A U M A          5 4 3


                                                                    Gustilo RB, Anderson JT: Prevention of infection in the treat-
 • At each visit an assessment of functional recovery should
                                                                        ment of 1,025 open fractures of long bones: retrospective
 be measured by recording range of motion of adjacent joints,
                                                                        and prospective analysis. J Bone Joint Surg Am 58:453, 1976
 muscle strength, and level of function—both work and recre-
 ational; despite appropriate management of fractures, some              Outlines the classification system of open fractures, and a
 patients may never regain full function because of irre-                protocol of management to reduce complications.
 versible damage to soft tissues (muscle, tendon, ligament,
 and cartilage)
                                                                    QUESTIONS

                                                                    1. Early repair of fractures may?
SUGGESTED READINGS
                                                                        A. Improve pulmonary function.
Bone L, Johnson K, Weigelt J et al: Early versus delayed femoral        B. Be dictated by the patients’ hemodynamic status.
    fracture stabilization: a prospective randomized study. J           C. Allow improved functional outcome.
    Bone Joint Surg Am 71:336, 1989                                     D. Be performed by external or internal fixation.
    Multiply injured patients with femoral shaft fractures have         E. All of the above.
    a lower mortality and morbidity if their fractures are stabi-   2. Pelvic fractures?
    lized within the first 24 hours of injury.
                                                                        A. Usually require urgent operation.
Ghanayem A, Wilber J, Lieberman J, Matta A: The effect of la-           B. Require body casting and prolonged bed rest.
   paratomy and external fixation stabilization on pelvic vol-           C. May be associated with significant hemorrhage.
   ume in an unstable pelvic injury. J Trauma 38:3, 1995                D. Make evaluation of the abdomen with open peri-
    Demonstrates the effect of reducing the pelvic volume by                toneal lavage mandatory.
    placement of an external fixation device, which in turn can          E. All of the above.
    reduce hemorrhage.                                              (See p. 604 for answers.)