Orthopedics focuses on the musculoskeletal system. Learn about the diagnosis, treatment, and rehabilitation of bone, joint, ligament, and muscle conditions.
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Orthopedic trauma encompasses a diverse array of injuries resulting from external forces applied to the body. Understanding the mechanism of injury is crucial for the traumatologist, as it predicts the pattern of the fracture and the associated soft tissue damage. Injuries range from simple mechanical failures of the bone to catastrophic disruptions of the skeletal framework.
The causes are categorized by the energy transfer involved. High velocity incidents create different pathologies than low velocity falls. Furthermore, the biological quality of the bone plays a significant role in susceptibility to injury.
Classification by mechanism of energy transfer
Pathological susceptibility of bone tissue
Correlation between impact and fracture pattern
Involvement of soft tissue structures
Fractures occur when the load applied to a bone exceeds its structural capacity. Compression forces cause crush fractures, tension forces cause avulsion fractures, and rotational forces cause spiral fractures. The direction and magnitude of the force leave a specific “signature” on the X ray.
Direct trauma, such as being struck by a bat, causes transverse fractures at the impact site. Indirect trauma, such as twisting the ankle, causes fractures distant from the point of impact. Understanding these mechanics aids in reduction and fixation.
Fractures are described using specific terminology that dictates treatment. A “simple” fracture has two fragments. A “comminuted” fracture has multiple pieces, indicating higher energy. “Transverse” fractures are perpendicular to the bone, while “oblique” fractures are angled.
“Intra articular” fractures extend into the joint surface, posing a high risk for arthritis. “Extra articular” fractures spare the joint. “Segmental” fractures involve a floating piece of bone between two breaks. Each type requires a unique mechanical strategy for repair.
A dislocation represents a complete loss of contact between two joint surfaces. This is a soft tissue emergency because the ligaments are torn, and the cartilage is under extreme pressure. Common sites include the shoulder, elbow, and hip.
A subluxation is a partial loss of contact. Both injuries compromise the stability of the joint. In high energy trauma, a joint can be both fractured and dislocated, a complex injury known as a fracture dislocation that is notoriously difficult to treat.
Compartment syndrome is a limb threatening condition caused by bleeding and swelling within a closed muscle compartment. The pressure rises to a point where blood flow is cut off to the muscles and nerves. It is most common in the leg and forearm following fractures.
The hallmark symptom is pain out of proportion to the injury and pain with passive stretching of the fingers or toes. This is a surgical emergency requiring immediate fasciotomy (slicing open the skin and fascia) to release the pressure.
Polytrauma is defined as significant injury to two or more body regions. Common causes are motor vehicle collisions, industrial accidents, and falls from height. These patients often have concurrent head injuries, chest trauma, and abdominal bleeding.
The orthopedic injuries in polytrauma are often severe, including femur fractures and pelvic disruptions. The “lethal triad” of hypothermia, acidosis, and coagulopathy must be managed before definitive orthopedic surgery can be performed.
Polytrauma is defined as significant injury to two or more body regions. Common causes are motor vehicle collisions, industrial accidents, and falls from height. These patients often have concurrent head injuries, chest trauma, and abdominal bleeding.
The orthopedic injuries in polytrauma are often severe, including femur fractures and pelvic disruptions. The “lethal triad” of hypothermia, acidosis, and coagulopathy must be managed before definitive orthopedic surgery can be performed.
A pathological fracture occurs when a bone breaks due to a minor force because it has been weakened by an underlying disease. The most common causes are osteoporosis, metastatic cancer, or bone cysts.
These fractures require a different approach. The surgeon must treat the underlying disease (e.g., stabilizing a tumor) in addition to fixing the bone. The healing potential is often compromised, necessitating augmentation with cement or specialized implants.
With the increasing number of joint replacements performed, periprosthetic fractures are becoming more common. These are fractures that occur around an existing metal implant, such as a hip or knee replacement.
These are complex injuries because the metal implant alters the blood supply and mechanics of the bone. Treatment often involves revision surgery to replace the loose implant with a larger one, in addition to fixing the broken bone.
Stress fractures are overuse injuries caused by repetitive loading that exceeds the bone’s ability to repair itself. They are common in athletes and military recruits. Unlike acute fractures, they develop gradually over time.
They present as localized pain that worsens with activity. If not treated with rest, a stress fracture can propagate into a complete fracture. The tibia and metatarsals are the most frequent sites.
In severe trauma, the skin and subcutaneous tissue can be ripped away from the underlying fascia, known as a degloving injury. This disrupts the blood supply to the skin, leading to necrosis (tissue death).
These injuries are deceptive because the skin may look intact initially, but dies days later. They require serial debridement and often skin grafting or flap coverage by plastic surgeons.
Crush injuries occur when a body part is subjected to a high degree of force or pressure, typically from being trapped. This causes direct muscle cell death (rhabdomyolysis).
When the pressure is released, toxins from the dead muscle flood the bloodstream, which can cause kidney failure. Orthopedic management involves monitoring for compartment syndrome and managing the soft tissue viability.
Injuries occurring in industrial or farm settings are unique due to the high degree of contamination. Farm injuries often involve soil and manure, introducing dangerous bacteria like Clostridium (tetanus/gas gangrene) into the wound.
Industrial injuries may involve high pressure injection of grease or paint, or massive crush injuries from heavy machinery. These require aggressive antibiotic protocols and repeated surgical washouts.
When a pedestrian is struck by a car, they typically sustain a specific triad of injuries known as “Waddell’s Triad”: a femur or tibia fracture from the bumper, a chest or abdominal injury from the hood, and a head injury from striking the ground.
Understanding this pattern helps trauma teams look for associated injuries. The orthopedic surgeon focuses on the lower extremity fractures, which are often open and highly comminuted.
Gunshot fractures are classified by the velocity of the bullet. Low velocity handguns cause fractures with minimal soft tissue damage, which are treated similarly to closed fractures. High velocity rifles cause a cavitation effect, destroying a massive amount of soft tissue and shattering bone.
Treatment involves debridement of the missile track. The bullet itself is usually left in place unless it is in a joint or causing symptoms. The focus is on preventing infection and stabilizing the bone.
Blast injuries, seen in military or terror events, involve a primary wave (pressure), secondary wave (shrapnel), and tertiary wave (being thrown). This results in a complex mix of burns, fractures, and soft tissue loss.
Orthopedic management is part of a massive resuscitation effort. External fixation is commonly used to stabilize limbs quickly in a mass casualty scenario.
Falls produce axial loading injuries. The force travels up the skeleton, exploding the calcaneus (heel bone), crushing the tibial pilon (ankle), and compressing the lumbar spine vertebrae.
This mechanism is known as “Don Juan Syndrome.” Traumatologists know to check the spine and heels in anyone who has jumped or fallen from a height, as injuries are often multifocal.
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An avulsion fracture happens when a tendon or ligament pulls a piece of bone off. Instead of the ligament snapping, the bone gives way. These are common in the ankle and finger and often heal well without surgery, though they can be painful.
A displaced fracture means the bone ends have moved out of alignment. They might be shifted sideways, angled, or overlapping. Displaced fractures usually need to be “set” (reduced) and may require metal plates to hold them in the correct position for healing.
In toddlers, a spiral fracture of the tibia (Toddler’s Fracture) is common and usually accidental. However, in non walking infants or specific patterns, spiral fractures can sometimes be a sign of abuse, requiring the doctor to perform a careful social evaluation.
Road rash is a deep abrasion caused by sliding on pavement. If you have a broken bone underneath road rash, it is treated like an open fracture. The surgeon cannot cut through the infected abrasion, so surgery might be delayed until the skin heals.
Yes, repetitive physical stress can cause “stress fractures.” This is common in runners. However, emotional stress does not break bones. But stress hormones can slow down the healing process, so staying calm and rested helps recovery.
Nearly 50 million Americans have surgery each year. They wonder if they should rest or move to recover better. The choice greatly affects their healing
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