Aug 27, 2019
Some of the most unexpected injuries in medicine are due to orthopaedic trauma, which involves problems related to bones, joints, and soft tissues. Discover what some of the most common orthopaedic trauma injuries are and how we treat them.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: We’re speaking with Dr. Robert Golden, Chief of Orthopaedic Trauma Surgery at MedStar Washington Hospital Center. Thanks for joining us, Dr. Golden.
Dr. Golden: Thanks a lot for having me.
Host: Today we’re discussing common orthopaedic trauma injuries which commonly affect bones, joints, ligaments, tendons and muscles, and how we diagnose and treat them at MedStar Washington Hospital Center. Dr. Golden, could you begin by explaining why orthopaedic trauma injuries generally occur?
Dr. Golden: Sure. They can occur from multiple different kinds of mechanisms, the most common being falls and motor vehicle crashes. But we also see a large number of injuries from bicycle related injuries, scooter related injuries. We also, in this area, see a fair number of gunshot wounds.
Host: What are some of the most common orthopaedic injuries that you see?
Dr. Golden: A lot of them depend on how the person was injured. We do see a fair amount of injuries from pedestrians being struck by cars. They tend to get injuries to their legs and lower extremities. A lot of people who just fall, and they can hurt anything including ankles and lower extremities, but then they also tend to have a lot of wrist injuries and shoulder injuries from falling and putting their arms out to protect them.
Host: And could you explain, giving specifics, some of those injuries?
Dr. Golden: Sure. A very common mechanism when you fall and you put your arm out is that you break what’s called your distal radius, which is just the bone at the end of your arm right before your wrist. It’s a very common injury in older people as well as in younger people when they suffer a high energy fall. Some of the injuries from the pedestrians being hit by cars involve what’s called a tibial plateau, which is the top part of your tibia, right below your knee. You can imagine the bumper of the car striking you on the side and that bumper is right about the level of your knee, so a lot of people get injuries that way. Once it gets a little warmer and people go back to motorcycles or riding bicycles, then you start to see a little more high energy injuries, especially from the motorcycles and those can involve injuries to your femur or your thigh bone. And, the higher energy crashes with motorcycles, and with cars, then you can get some of the pelvis injuries that people see. The other thing we’ll see is we’ll get patients referred in who have had complications from fractures that they’ve had in the past. Sometimes the fractures just don’t heal and then that’s called a nonunion. Sometimes they heal but they heal in a crooked position. So, we’ll also treat those patients. And, if they haven’t healed, a lot of times you need to figure out why that is. Sometimes that’s because the bone simply doesn’t have enough blood supply to it. Sometimes it’s because the patient doesn’t have the components necessary to actually heal that, be it enough vitamin D in their system or other reasons that can prevent bone healing. So, oftentimes we’ll have to take them back to the operating room and do other procedures to try to get them to heal, including taking some bone from another part of their body and bringing it into the area where it hasn’t healed. If they’ve healed but it healed crookedly, called a malunion, sometimes we’ll even have to re-break the bone or cut it at the area where it’s crooked - sometimes that can be done as a single procedure. Sometimes we have to put on different kinds of apparatus that go on the outside of the bone and interface with a computer program so that we can control how the bone is manipulated over time and we’ll slowly restore them back to a straight position to get them to heal. The other thing we’ll often see as orthopaedic traumatologists is we also specialize in bone infections, so we’ll get patients referred in who have had bone infections for lots of different reasons, sometimes as a result of trauma but sometimes just as a result of getting an infection, so we’ll treat those as well. Oftentimes, that requires a surgery to open up the bone, get out as much of the infection as possible so that then antibiotics can be used to control the infection for long-term cure.
Host: Could you discuss common treatments for these injuries and how they work?
Dr. Golden: Sure. A lot of the injuries depend on where in the bone it’s broken. Injuries that occur close to the joints, which are called periarticular injuries, generally require plates and screws to fix them so that you can align the bone, make sure the joint is re-aligned back as perfectly as possible. And then that’s held in place with small metal plates that are held on to the bone with screws. That allows the bone to stay in the proper position and then it heals around it, so the plates are functioned like scaffolding and hold everything in the right spot and then it’s still up to the person to actually heal the bone. If you break some of the long bones, like your tibia or your femur, then sometimes we’ll put rods into them. Those go on the inside of the bone and, like the plates, they form a scaffolding, but these...the bone heals around them, so they’re totally contained within the bone itself.
Host: And what kind of recoveries can these patients expect?
Dr. Golden: Some of it depends on what’s injured. In general, bones take about 12 weeks or 3 months to heal. Some of the injuries, the hardware that we put in is strong enough to support their weight. If that’s the case, we’ll get them up as soon as possible right after the surgery and get them moving to minimize their stiffness that they might get, minimize the amount of muscle loss that they may have from not being able to move around. Some of the injuries, you just simply can’t do that. Some of the plates and screws that we put in have to get very close to the joints in order to get the joint perfect and those aren’t strong enough sometimes to support the person’s weight. If that’s the case, then they may have to have a period of not putting weight on that limb, using crutches or a walker or sometimes even a wheelchair, until that bone heals strongly enough that then they can start putting weight back on it. Oftentimes, if that’s the case, then we’ll have the physical therapists involved to try to minimize their stiffness and minimize any sort of muscle loss they may have from not using that limb. A lot of times we get other services involved, as well, to try to maximize their recovery, minimize the impact onto their life. Unfortunately, a lot of these people weren’t expecting anything to happen that morning and leave for a normal morning and then they have a huge life interruption from these traumas. So, it’s a little bit different that going in for an elective surgery when you know when it’s going to happen and you can plan for it. So, often we have to have a lot of social work involvement to help them in terms of planning for disability insurance and time off of work until they can be strong enough to get back to their occupations.
Host: Do you have any tips to help people prevent these injuries?
Dr. Golden: A lot of them, it’s just being careful with what you’re doing, especially with the motorcycles and bicycle crashes, and sort of knowing your limits. Unfortunately, sometimes it is just a random occurrence that happens. You can’t do anything about it if you’re driving down the street and somebody runs through a red light and hits you. You had nothing to do with that but, unfortunately, you still have to deal with the consequences of it.
Host: Are there certain patient populations you see the most with orthopaedic trauma injuries?
Dr. Golden: Orthopaedic trauma tends to be what’s called a bi-modal distribution most of the time, meaning that we see a lot of younger people in their late teens and twenties, then we see a lot of older people. Those injuries occur for different reasons. The young people tend to be doing the more high energy, risky sort of things - riding motorcycles, riding bicycles, doing things fast with high energy. The older people just lose their balance and have less stability in their bones. So, when they fall, they may break their hip, when, if you fell, you would just get right back up and be fine.
Host: Why is MedStar Washington Hospital Center the best place to seek care for orthopaedic trauma injuries?
Dr. Golden: Well, we have a full staff of orthopaedic traumatologists here. There’s two of us who specialize...orthopaedic trauma and that’s pretty much exclusively what we treat. But we also are supported by a full orthopaedic department that has specialists in all the other disciplines. So, sometimes if you have a injury to the bone and the ligaments, we’ll take care of some of the bony issues, and then some of the sports medicine people will take care of some of the ligament injuries or the hand people will take care of those specific injuries. We are also plugged in to the MedStar trauma service network here with the trauma team that can provide a multidisciplinary approach to make sure that any other injuries you may have that don’t relate to orthopaedics - injuries to internal organs or other body parts - can be managed, as well.
Host: Could you share a story in which a patient received optimal care for orthopaedic trauma injury at MedStar Washington Hospital Center?
Dr. Golden: Sure. We’ve had tons of patients come through since I’ve been here and a lot of them have multiple injuries. I just saw a guy who we treated seven years ago now was just coming back essentially to get a checkup. But he had injured both of his limbs, again this was a motorcycle crash, both of his lower legs, both of his feet, some of them were open fractures, meaning the bone had come out through the skin. He also had a bunch of injuries to internal organs. So, he came in, was treated by the general surgery trauma team to stabilize all his internal organ injuries. We then treated his bones. He needed several surgeries to try to minimize any risk of infection and prevent that from happening. We then stabilized his bones with the plates and screws and rods. And then the plastic surgery team provided flap coverage to get that covered as well. One of our more well-known instances of treating patients has been both with the Congressional baseball shooting, prior to that the Navy yard shooting. We had victims of those shootings here, as well, and that was truly an interdisciplinary exercise where there were the general surgery trauma team was involved, vascular surgery teams were involved, we were involved - and all that care came together at the specific times when it was appropriate to make sure that we first saved the lives, then, eventually, got everything fixed and back to function and, you know, getting back in to life.
Host: Do you have any advice for what patients can do before EMS arrives?
Dr. Golden: Well, a lot of it is just staying calm and keeping the limbs that you think are injured still. Sometimes that involves you just staying still and not moving around. If there’s other things available to help with that - and that can be as simple as finding some cardboard and rolling it up to form sort of a make-shift splint, or sometimes even newspapers are enough, just to help keep everything still - generally that’ll make it feel more comfortable because if the bones aren’t moving around where they're not supposed to, it will hurt less. That could also help prevent some of the associated injuries to the soft tissues around the bones that can be injured if the bone is moving abnormally. So, that may help the person who is hurt, in terms of just pain control, as well as trying to prevent some of the issues to the skin and the soft tissues. Sometimes, if it’s an open fracture and there’s actually bleeding from the wound, you can just put some pressure on the area where it’s bleeding and that will help minimize that as well, until an EMS professional arrives.
Host: Thanks for joining us today, Dr. Golden.
Dr. Golden: My pleasure. Thanks for having me.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.