- Patrick B. Leach, MD: Orthopedic Trauma Surgery
When you’ve suffered a traumatic musculoskeletal injury like a broken bone the consequences can seem overwhelming. It’s important to have the right medical team, the right treatment plan and the best possible care.
Traumatic injuries demand expert care; their treatment requires highly specialized training of the physician. The Orthopedic Trauma Center at Orthopedic Specialists of Southwest Florida provides this type of care. We have the experience needed to manage traumatic musculoskeletal injury and we understand the effects it can have on your life. At the Orthopedic Trauma Center, patients receive comprehensive fracture and traumatic musculoskeletal injury care, so that they can return to functional and productive lifestyles.
Please take a few minutes to familiarize yourself with the following terms. While some may seem scary at first, understanding these terms will help you understand the medical issues involved in recovering from your injury.
- FRACTURE: A break in the bone. Interchangeable with “broken bone.”
- IMMOBILIZATION: An important factor in the healing process in which a broken bone doesn’t move.
- STABILITY: The ability of a bone to hold up and bear weight.
- COMMINUTION: How many times a bone has broken. For instance, a bone with minimum comminution may only have one or two breaks in it.
- OPEN FRACTURE: A broken bone that penetrates the skin.
- CLOSED FRACTURE: A broken bone that doesn’t involve a break in the skin.
- FRACTURE LINE: The line identified on an x-ray that indicates where the bone is broken.
- INTRAMEDULLARY NAILS: A metal rod placed into the medullary cavity of a bone. IM nails are used to treat fractures of long bones of the body.
- METAL PLATES AND SCREWS: Another form of internal fixation, or devices placed inside the body to hold broken bones in place.
- EXTERNAL FIXATION: An external device that helps hold broken bones in place. It consists of an external frame connected to the bone by metal pins from outside the skin.
The basics of healing fractures
Treating a fracture: immobilization
When treating a fracture, the ultimate goal is maintaining as close to a perfect alignment as possible while the generation of the callus, the new bone formed to heal the fracture, occurs. In order to do that, we need to stabilize fractures. The methods we use when stabilizing broken bones include:
- External immobilization: splints or casts, and external Fixators
- Internal immobilization: implants which include metal rods, plates and screws.
Metal implants are used to stabilize fractures and are only meant to serve in the short term, until the healing process can occur. Once the fracture is healed, the implant is unnecessary but is often left in place because the patient would require another, unnecessary surgery to remove it. No metal implants last forever and biologic healing of the fracture must occur or the implant will fail or break.
Healing a fracture: stabilization
For a fracture to heal, there are two main requirements:
- Stability of the fracture while healing
- The body’s biologic ability to heal the fracture
Factors that affect achieving stability can include
- Fracture anatomy: The amount of possible stability associated with the fracture: If there is a large amount of fragmentation (comminution), it is harder to stabilize.
- Bone quality: Weak bones are harder to stabilize than strong ones. Disease processes such as osteoporosis can affect proper healing.
- Preexisting biological factors: Factors that can affect the body’s ability to heal a fracture include diabetes, peripheral vascular disease, immuno-compromisation and malnutrition. Smoking and obesity can also hinder the healing process.
- Local soft tissue injury: Is there a significant amount of muscle damage around the fracture.
- Evidence of healing: what the x-rays say
Evidence of healing can be identified on x-rays
- Primary fracture healing. This occurs in a broken bone with minimal fragmentation that has been stabilized using metal plates and screws. If there is a fracture line seen after implant surgery on the x-rays, it is checked until the fracture line slowly disappears, which indicates bone healing.
- Secondary fracture healing. This occurs when the fracture site itself is not directly open, but is stabilized by implants placed at remote destinations from the fractures, including intramedullary nails, external fixation, and even plates and screws (when they are performed in a “bridge-plating” fashion). In these instances, x-rays show a large amount of new bone indicated by cloudy white material appearing and filling in any associated gaps between fracture bones. The overall goal is obtaining adequate alignment and allowing natural physiologic processes to heal the fracture. (Note: The x-ray on the front of this brochure is an example of what secondary fracture healing looks like.)
Varying outcomes following a traumatic injury
Patient outcomes following a traumatic injury can vary. While the severity of a patient’s injury, as well as a number of other factors, significantly affect the final outcome for any patient, the most important element in recovery is the patient’s contribution and attitude towards healing. We frequently see patients that, while having severe injuries, have remarkable recoveries, which are largely due to the patient’s own determination and hard work.
Recovering from a traumatic injury
The importance of physical therapy
Physical therapy plays an important role on the road to recovery from a traumatic injury. It can take many forms including home physical therapy, outpatient physical therapy and home exercise programs. Time with a physical therapist is designed to educate the patient about exercises and techniques to recover from their injury. Visits to physical therapy are very important. But, the most important form of physical therapy is daily exercise done on the patients’ own time to continuously rehabilitate. We encourage patients to work as hard as possible in their physical therapy to achieve the best outcome.
- Weightbearing: a common limitation A common limitation after a traumatic injury is restriction on the amount of weight the patient is allowed to bear onthe injured legs or arms. Weightbearing restrictions may last from six to 12 weeks during recovery.
- Weightbearing processes: Below is a protocol for gradually progressing from a state of complete non-weightbearing to full weightbearing:
Week by week progress starting at 25% going up to 100%: On the first week, a patient starts at 25% weightbearing, moves to 50% on the second week, 75% the third week and 100% on the final week. For a good way to judge the percentage of weightbearing is for the patient to weigh themselves and then divide their weight by four. Using this as 25% weightbearing, begin the first week putting that amount of weight on the patient’s leg. The next week double this for 50% weightbearing and the following week triple it for 75%. After the first 3 weeks, the patient may progress to full weightbearing.
Another guide to progressive weightbearing may be judged by the use of crutches or walker. If the patient has been using crutches, they can start by first walking with both crutches, gradually putting weight on the injured limb. Once a patient can bear weight on the affected limb without discomfort or difficulty, he or she can start using a single crutch or cane. Eventually, they won’t need an assistive device.
The importance of wound care
Wound care is a common element of recovery from musculoskeletal injury. This may involve management of a surgically closed wound or dressing changes for an open wound.
Types of wounds
Surgical wounds: Wounds that are created when an incision has been made and then closed. Closure methods can include absorbable sutures that are underneath the skin, non-absorbable sutures that are outside the skin and must be removed, and staples. Sutures or staples are commonly removed after 10 to 14 days. When swelling is present the time period can be extended to three weeks. In general, after 36 to 48 hours there has been enough healing of the surgical wounds that showering is allowed.
Open wounds: Wounds that are open and require dressing changes.
A wound is left open when closing the wound is either not possible due to skin tension or if closing a wound would leave a cavity underneath. Closing a wound over a cavity often leads to a collection of blood within the cavity. This is called a hematoma, and can become easily infected.
Dressings: The most common dressing changes for these wounds are wet-to-dry dressings. Gauze is soaked with sterile saline and the wound is gently packed, with dry gauze being placed over the packing. Another common management for open wounds is the use of Silvadene, an ointment whose antibacterial properties come from silver compound. This is often used over a wound that may be drying out.
Wounds and casts: Surgical open wounds may be covered and left beneath a cast. Patients sometimes have concerns that this might give rise to infection or cause trouble with healing the wound. But, this is a common method of keeping wounds clean and immobilizing soft tissues to encourage healing.
Wound VAC: A wound VAC (vacuum assisted closure) is a device that applies negative pressure to a wound. This has been shown to improve the blood supply to a healing wound while also preventing the wound from drying out. The device consists of a dressing fitted with a tube and attached to the wound VAC.
The wound VAC has revolutionized the treatment of open wounds. The wound VAC is primarily used while the patient is hospitalized, but there may be scenarios where the patient is using a wound VAC at home. In this case the wound VAC is usually changed by a home health caregiver or, the patient comes to the doctor’s office for regular changes. At times, patients and/or their families will change wound VACs on their own. .
Granulation tissue: a sign of healing
This is a red beefy tissue that can bleed somewhat easily, but represents a successful stage of healing for an open wound. Once a wound has significant granulation tissue, closure can be considered by use of a skin graft or by cauterization of the top layer of the granulation tissue. Cauterization can be performed in the office using silver nitrate. In this process, a light scab will form over the wound followed by formation of skin.
Our office will usually be responsible for prescription medications and the management for the acute pain of surgery and fracture care. This can involve the use of a number of different types of medications. In situations where a patient experiences chronic pain, a pain management specialist may be consulted to assume the management of pain medications.
Narcotic pain medications
Narcotic pain medications are frequently used for the management of acute pain. At the receptor level, narcotic pain pills don’t technically alleviate pain, but instead alleviate the feeling of discomfort from the pain. In other words, patients who are taking narcotic pain medications will often recognize that they still have pain, but they’re not bothered by that sensation.
Unfortunately, abuse of narcotic pain medications is common. Due to the high potential for abuse, and strict federal regulation of narcotic pain medications, we are very cautious prescribing narcotic pain medications. We recognize that pain is an individual phenomenon and that patients may require differing levels of narcotic pain medications. However, there are limits to which we can safely prescribe narcotic pain medications due to concerns of over-sedation and overdosing. Most patients do not require narcotic pain medications for longer than two to four weeks after their injury.
Other pain medications
Non-steroidal anti-inflammatory medications (NSAIDs) include those such as ibuprofen (Advil), naproxen (Aleve), and Celebrex. These medications do an excellent job of relieving pain without the addictive potential of narcotic pain medications.
Sleep disturbance is a common result of a traumatic injury. Reasons for disturbing sleep include pain, deviation from a patient’s usual daily activity pattern, depression, and anxiety associated with the recovery from traumatic injury.
We try to avoid prescribing sleep aids because, often, they are being mixed with narcotic pain medications and can have significant side effects.
Muscle relaxers like sleep aids are extremely habitforming. We may use Valium for a very short duration following the patient’s injury if muscle spasm is significant. However, due to tolerance and addiction to these medications, we try to limit their use.
These medications are used when pain seems to be caused by irritated or hypersensitive nerve endings and can greatly reduce patients’ post-injury pain. Patients don’t develop tolerance to these medications and they can be used on a long-term basis without significant side effects. We often use these medications to reduce the amount of narcotic pain medication used during recovery.
Returning to work and driving
We do our best to work with every patient, providing them with realistic expectations as to when they’ll be able to return to work and providing proper documentation for the patient’s employer. There’s frequently a significant amount of paperwork associated with this and we strive for an efficient turnaround.
Driving after a musculoskeletal injury can be a complex issue. Recommendations have been made that after any serious musculoskeletal injury, patients should be retested by the Department of Motor Vehicles for their driver’s license. We haven’t made this a formal recommendation but patients can be restricted in their driving after certain injuries. It is important to note that you should never drive if you are still taking narcotic pain medications.
Despite the best efforts of physician and patient, complications can occur. Below is a list of some of the more common post treatment complications.
The rate of infection following traumatic musculoskeletal injury can be quite high as compared to an elective procedure. Patient factors that can contribute to infection include: preexisting diseases such as diabetes, tobacco use, alcohol or drug abuse, obesity, malnutrition, and chronic kidney or liver disease. We use prophylactic antibiotics judiciously to try to prevent infection.
Regarding prophylactic antibiotics, patients frequently ask why they are not put on an antibiotic, “just in case.” This has been a common, ill-advised practice that can contribute to development of bacteria resistant to common antibiotics. This area has been heavily studied. What has been found is that a short, usually 24 hour, course of intravenous antibiotics at the time of a patient’s procedure provides the best prevention of postoperative infection without contributing to resistance. Continuing either intravenous or oral antibiotics longer than this initial course has not been shown to improve postoperative infection rates.
If an infection develops, patients are often treated with intravenous antibiotics for 6 or more weeks. In this situation, we generally have the results of a culture to help determine the proper antibiotic to use. Because the antibiotic is specifically matched to the bacteria, longer term treatment usually does not contribute to the development of resistance.
Blood clots are extremely common following musculoskeletal injury. Wherever possible, we will use either oral or injectable medications to limit blood clots. Unexplained swelling, calf pain, and shortness of breath are some symptoms of blood clots. If you experience these symptoms, call our office immediately!
There’s no orthopedic implant that will securely hold a bone forever if the fracture doesn’t heal. For this reason, we can sometimes see broken screws, plates or rods that occur as a result of a fracture not healing.
Not all fractures will heal. If a fracture doesn’t heal, it will mean further surgery. Further surgery can involve the placement of bone graft and/or new surgical implants.
Swelling is often the last symptom to improve following an injury. It can often take months and, at times, some swelling can be permanent following an injury.
Insurance and disability paperwork
We strive to complete all requested insurance and disability paperwork in a timely manner, however this paperwork will usually not be available on the day we receive it. We can fax the paperwork once it has been completed.
Billing and payment options
We recognize that a traumatic musculoskeletal injury is a major unplanned financial burden that can affect a patient’s income. Our billing office will work diligently with you to find resources for assistance if necessary. As long as patients are open to discussions with the billing staff and work with the billing staff on creating a scheduled payment plan, we can work with most financial situations.