The Diagnosis and Management of Musculoskeletal Trauma I.

Introduction and Philosophy

Epidemiology of orthopaedic trauma. Musculoskeletal trauma has gained significant and increased attention over the past 10 years for a number of reasons. Such reasons include the realization of its societal impact from health care costs and lost workdays in the labor force. These statistics are coupled with an increased realization that the orthopaedic surgeon and health care team can positively influence such statistics, both through excellent intervention as well as education on injury prevention. Leadership from key organizations [Orthopaedic Trauma Association (OTA), American Academy of Orthopaedic Surgeons (AAOS), American College of Surgeons (ACS), American Orthopaedic Association (AOA), and many others] has played a major role in lobbying for proactive trauma-related health care policy and implementation of public education programs for injury prevention. Whereas it is likely that certain of these educational measures such as seatbelt safety, aggressive standards for highway safety, and lower blood alcohol limits for drivers helps to lower accident related injury rates, other forces seem to counter such progress such as the pervasive trend toward faster cars, the burgeoning enthusiasm for extreme sports, and increased numbers of trauma survivors with significant musculoskeletal injuries due to airbags. An even greater awareness is emerging regarding the aging baby boomers who will account for massive demands on the health care system. The baby boomers will be hitting the 65-year-old age mark in approximately 10 years, and it is estimated that by the year 2040 there will be 35,000,000 more people over the age of 55 than there are now and that the number of hip fractures alone will increase from 250,000 to 500,000 on an annual basis (1). The estimated uptick in geriatric musculoskeletal trauma over the next 30 years is due to the vulnerability of the skeletal system from the natural process of relative bone mineral loss manifesting in the condition of osteoporosis. Compounding the number of injuries in this group is the increasingly active lifestyle of this aging population. To put it in perspective, it is estimated that one-third of all women reaching the age of 90 will sustain at least one hip fracture (2).

Definition of musculoskeletal trauma. Musculoskeletal trauma includes any injury to bone, joint (including ligaments), or muscle (including tendons). Nearly always, such injuries occur in combination, as the energy imparted to breaking a bone or tearing a ligament is also dissipated to impact structures nearby or even distant from the most obvious site. With greater experience, such combinations of injuries become more apparent to the diagnostician, which allows for swifter and more accurate detection of injury characterization. Multiple injuries. The energy it takes to render trauma to the musculoskeletal system can also dissipate to injure other organs. This is particularly common with the high energy mechanisms that are responsible for pelvic, spine, or long bone fractures. Due to the greater density and strength of bone in younger individuals, there is even greater energy required to create fractures in this population. Therefore, it is incumbent upon the trauma team to remain vigilant to the likelihood of injuries to other bones and other organ systems. Often, the dramatic and salient injuries during the initial patient evaluation will attract all the diagnostic and therapeutic attention, while occult and sometimes equally grave injuries remain initially undetected.

P.2

For example, it is estimated that only 7% of the patients who die from lifethreatening high-energy pelvic fractures actually die from arterial exsanguination related to the pelvic fracture itself (3), while the rest succumb due to injury involving other organ systems. Forty percent of patients with femur fractures have other associated fractures (4), and 90% of patients with scapula fractures have other associated injuries (5). These impressive associated injury statistics demand most heightened awareness when working up the trauma patient to keep the missed injury rate to a minimum.

Missed injury rate. The missed injury rate in the context of polytrauma has been reported to be 4% to 18% (6). These statistics may be lowered with appropriate protocols and underscore the importance of a most vigilant secondary survey, as well as a re-review of the patient's physical examination each ensuing day after injury. A secondary survey is a head-to-toe review by a physician that occurs after the initial primary survey, which is defined as the evaluation of three screening trauma films (lateral cervical spine, anteroposterior chest, and pelvic x-ray) and, most importantly, the patient's airway, breathing, and circulation (the ABCs). It is valuable to understand the main reasons cited for missing injuries: significant multisystem trauma with another more apparent orthopaedic injury, trauma victim too unstable for a full orthopaedic evaluation, altered sensorium, hastily applied initial splints obscuring other injuries, and poor radiographs (6).

Multiple patients. It is not uncommon, particularly at a Level I trauma center, to require simultaneous evaluation of multiple patients, such as with motor vehicle collisions in which multiple victims are involved. Doctors who have had some training on the fundamentals of trauma surgery and, in particular, Advanced Trauma Life Support (ATLS), which includes strategies for triaging patients and resources during a mass casualty situation, must be available in order to effectively captain the ship. ATLS courses have been developed, refined, and sponsored by the American College of Surgeons and have an excellent educational track record. Typically (but not exclusively), in the United States, it is a general surgery trauma surgeon who is running the trauma room. It is beyond the scope of this orthopaedic text to delve into the specifics of ATLS management, however; we will focus on certain of the fundamentals and cover the triage process of multiple orthopaedic injuries that may present during such circumstances. To further master the details of ATLS management, please refer to the ATLS Manual (7th edition) published in 2004 (7). It is imperative to understand what is an orthopaedic emergency and what is orthopaedically urgent. A review of the orthopaedic emergencies in a subsequent section of this chapter will help to understand how these injuries need to be prioritized for treatment. Furthermore, it is important to understand what measures can be taken to stage orthopaedic treatment. Not all broken bones need definitive treatment right away, and the practitioner must understand how to titrate the proposed

treatment to the physiologic presentation of the patient. For example, a patient with limited physiologic reserve, due to a great physiologic challenge from hemorrhagic shock and compromised ventilation from a hemothorax, should not spend 10 hours in the operating room getting several fractured bones fixed. In such a case, it may be wiser to place an external fixator across a broken femur rather than to immediately nail the femur and place a plaster splint on a displaced ankle fracture rather than to fix it right away. These measures save a lot of time, blood loss, anesthesia, and fluid challenge during a potentially critical stage in postinjury physiologic evolution. There are many ways to stage the treatment of injuries, which also gives the orthopaedist more time to solicit expertise, get to know the patient and family, plan the details of an operation, and understand the comorbidities and the likelihood of patient compliance. All these different factors may, in fact, impact the ultimate treatment that the orthopaedic surgeon chooses to render and will most certainly influence positive outcomes.