Health & Fitness

Treating Orthopedic Trauma Patients

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Without notice, you can find yourself nursing a serious injury thanks to a fall, car crash, a workplace accident or a contact sport. The long road to recovery requires a team of dedicated healthcare professionals.

No matter how they’re caused, traumatic injuries are no fun for patients and can be challenging for doctors to treat.

No matter how they’re caused, traumatic injuries are no fun for patients and can be challenging for doctors to treat.

It can happen without warning … you find yourself with a critical injury resulting from a fall, a car crash, a workplace accident, or perhaps a contact sport. A trip to an immediate care clinic or ER may fix you up. But if your injuries are severe enough to land you in a hospital, the long road home again requires a team of dedicated professionals.

Peggy Johnson, DO, physician and medical director for the Monroe Clinic Urgent Care in Freeport, often sees patients with strains, sprains and simple, closed fractures.

“These can be the result of sports, yard work, hunting injuries or just missed steps,” Johnson says. “Frequently, the treatment involves support gear such as splints or ACE wraps. But, it can also include resting the area of concern, as in ankle or wrist injuries, as well as prescription anti-inflammatories and physical therapy.”

Sometimes patients don’t realize just how serious their injuries really are. With fractures, a referral to an orthopedics doctor may be necessary to ensure proper healing. In severe cases, patients are referred to a nearby emergency room.

“Criteria are based on the individual,” says Johnson. “For example, a toddler may not tolerate a fractured limb being maneuvered into a splint without medicinal support, or an adult may have chronic issues that create a situation which requires a higher level of care. Some general concerns would include open fractures with bone protruding through the skin or concerns of deep structure damage, including compressed nerves or damaged arteries, along with the development of complications such as compartment syndrome.”

Compartment syndrome occurs mostly in the lower legs, but can also happen in arms.

“When a traumatic injury occurs, swelling results that we can see anywhere on the body after trauma,” Johnson says. “However, the lower leg has fascial ‘compartments’ that limit the ability to stretch. In other words, swelling can be trapped within a compartment. When that happens, pressure builds and can cut off blood supply distally as well as cause nerve damage. This can cause symptoms like numbness and pallor of the skin. If not treated emergently, this can result in loss of the leg.”

Patients may be referred to an orthopedic specialist or to their primary physician.

“If it’s a fracture that will need management to ensure proper healing, the referral can be done at Monroe Clinic Urgent Care,” Johnson continues. “If the injury is a sprain and could heal with minimal intervention, the patient could be instructed to follow up with primary doctor and if concerns persist, then the primary may refer the patient to orthopedics.”

Obviously, patients injured in catastrophic vehicle or construction accidents would have been stabilized at the scene and sent directly to an emergency room. But occasionally a serious or critical patient will come to the Urgent Care.

“It is not recommended, but sometimes patients will downplay symptoms, usually to avoid worrying family, or they were recently in the hospital and are afraid to go back,” Johnson adds. “Once you explain the seriousness of the situation, they are agreeable.”

Every patient who walks into Monroe Clinic Urgent Care-Freeport is given a thorough evaluation which may include x-rays and other tests.

“Treatment options for injuries include various types of splinting, wraps, and medication for infection and pain,” she says. “Wounds can be sutured, stapled, steri-stripped, closed with tissue glue or just cleaned and bandaged. But again, certain injuries that create a concern for the arteries, nerves or other soft tissues may require other imaging than we have on site and would be acquired at the hospital.”

When walk-in patients have sustained more damage than can be easily remedied, they are referred or transferred by ambulance to the nearest emergency treatment center. Once there, they receive a more intensive level of triage to determine what must be done to address every injury.

When a critically injured patient arrives at the ER, the first priority is to assess for life threatening conditions, says Dr. Jonathan Ortman, medical director of the emergency department at KSB Hospital in Dixon, Ill.

“We immediately perform what is called a primary assessment. We evaluate the patient for injuries and compromise to their airway, breathing, circulation and neurological function,” Ortman explains. “Once these are evaluated and treated, we then move to a secondary examination, which evaluates for all other injuries including such orthopedic problems as fractures, dislocations, sprains and strains.”

It’s important to understand a patient’s history, both medical and the nature of the accident itself. It’s also important to know what underlying medical conditions the patient may have, such as diabetes, heart disease and other pre-existing health concerns.

“We also want to know what allergies they may have and the medications they’re on,” Ortman continues. “Understanding the mechanism of injury or how they were hurt is equally important. This gives us clues about what type of injuries to expect and look for. For example, if the patient was involved in a head on collision, we might expect to see injuries to the head, spine, chest and abdomen. A side impact injury may produce injuries to the head, neck and extremities. The presence and severity of these injuries may depend on such factors as vehicle speed, seat belt use and airbag deployment.”

From an orthopedic standpoint, some of the most severe injuries involve open fractures, as well as injuries to blood vessels and nerves. Open fractures occur when the broken bone is exposed to the outside environment by either an associated laceration or the bone itself cuts through the skin. These are serious injuries often requiring urgent surgery and antibiotics.

“Our assessment of orthopedic injuries includes obtaining a history from the patient and performing a physical exam,” he adds. “We assess for pain to the affected area, ability to use the injured part, any alteration in sensation or motor function, and vascular injury. Depending on what we find on exam, we may often obtain radiology studies such as x-rays or CT scans.”

After determining the specific nature of the injury, the next step is to determine the necessary treatment. Minor injuries such as non-complex fractures, sprains and strains may require only splinting, ice, pain medication and referral to a primary physician for further care and follow up. More serious orthopedic injuries such as open fractures, severely broken bones, fractures involving joints and any compromising nerve or vascular function may require immediate orthopedic evaluation and perhaps surgery.

“Major traumas and critically injured patients may be sent to selected trauma centers for care,” Ortman concludes. “Most orthopedic injuries are less severe, and we’re able to care for such patients here at KSB.”

In major medical centers, patients undergo a team approach to treatment that takes into consideration every single aspect of their injuries. After a trauma patient is treated in the ER and admitted to the hospital, a general surgeon typically heads the treatment team, says Dr. Gregory Dammann, orthopedic specialist at FHN’s Freeport hospital.

“The general surgeon takes care of the patient as a whole, as opposed to a specialist or orthopedic surgeon,” Dammann explains. “How the patient is treated depends on the extent to which he or she has been stabilized. We establish the patient’s initial assessment through laboratory parameters and imagery including damage to the pulmonary system and head injuries.”

Surgery may be immediate or it may be delayed, depending on the patient’s overall condition.

“A traumatized patient may not be ready to tolerate extensive surgery. Our first order of business is damage control,” Dammann says. “Open fractures, in which we must treat skin and muscle damage, in addition to broken or shattered bones, are a priority.”

For patients who can’t tolerate surgery right away, external methods are used to stabilize breaks with splints, pins and bars to hold the limb in place. Another priority is to get the patient up, either sitting up or walking.

“This helps the patient heal because it prevents infection and blood clots as well as aids breathing,” Dammann says. “Open wounds are treated first in the ER, during which the wounds are cleaned, debrided and any debris from the accident is removed. In these cases, the risk of infection is between 10 and 20 percent. The larger the wound, the greater the risk of infection.”

When the patient is more stable, the general surgeon may perform multiple surgeries every couple of days to repair extensive damage. These surgeries can involve grafting skin and muscle as well as repairing bone internally.

Spinal injuries are treated differently, depending on where the damage occurred. Cervical (neck) injuries, middle back and lumbar (lower) back injuries require various kinds of attention, depending on the extent of the injury and whether or not it involves the spinal cord.

“We keep a close watch in case any neurological symptoms worsen,” Dammann adds. “Lumbar spine injuries can be treated operatively or non-operatively, depending on the stability of the fracture and any neurologic involvement. Non-operative treatment involves bracing and early mobilization. Again, it’s vital to get the patient up as soon as it’s feasible. Early mobilization helps the patient to recover. At one time, prolonged bed rest was the protocol, but no longer.”

Dammann emphasizes that treatment of critically injured patients is approached through a dedicated group effort.
“Everyone from the general surgeon to the nurses, therapists, hospitalists and others work together to further the patient’s healing,” Dammann says. “It plays a crucial role in the patient’s recovery.”

During the slow healing process, patients need help dealing not only with temporary incapacity but also with the pain that traumatic injuries can cause.

After a preliminary assessment and stabilization in the emergency room, patients who’ve suffered multiple severe injuries are usually admitted for further evaluation and treatment. Dr. Andrew N. Vo, who specializes in Physical Medicine & Rehabilitation and Pain Medicine at Mercyhealth’s Brain and Spine Center, says patients with serious orthopedic injuries may require surgery.

“Other treatments might include casting, bracing, splinting, local ice/heat and pain medications,” Vo adds. “Among other services, we help patients to manage pain by first assessing the underlying causes. This can be challenging, especially when the patient has traumatic brain injury that might make it difficult for him or her to communicate clearly. We concentrate on helping the patient to cope while we wait for them to heal, using medications and interventional procedures.”

Finding the appropriate combinations of pain management drugs depends on much more than what injuries the patient may have suffered. Age and pre-existing health conditions can adversely impact the patient’s ability to recover and also may inhibit the use of pain medications.

“For example, pain medications are metabolized by the liver and kidneys,” Vo explains. “If the patient has liver or kidney disease as a pre-existing condition, or those organs have been damaged because of the trauma the patient experienced, we must take that into consideration.”

Broken or shattered bones, with open or closed wounds, may be surgically repaired immediately or surgery may be delayed until the patient is stabilized enough to tolerate the stress this places on the body.

“Not all broken bones require surgery,” Vo says. “Many spinal injuries are not necessarily treated with surgery.”

Vo emphasizes that every patient is unique; how well he or she tolerates pain or the medications used to manage it is unique. Bone, muscle, organ and nerve injuries and damage can run the gamut from minor to catastrophic, and the variations are countless.

“Compound fractures may mean extended hospital stays,” Vo says. “We take every aspect of a patient’s condition into account, including their ability to function on their own at home.”

When patients are discharged, they’re usually prescribed a balanced, individually designed program of physical therapy and pain management medications that can include opioids and non-narcotic drugs.

“The goal is to maintain optimum pain control while the patient continues to recover and rehab,” Vo says.

Dammann, of FHN, says future field treatment of accident patients may involve the administration of antibiotics by paramedics before patients even arrive at the ER.

“We’re on the verge of a breakthrough in damage control for trauma victims,” he says. “The use of antibiotics prior to arrival at the hospital gives us a head start on preventing infection in critically injured patients. This in turn helps to ensure that these patients recover to the best extent possible, and makes future surgeries safer than they might otherwise be.”

It’s encouraging to know that, in the case of an unforeseen and catastrophic event, the region’s medical facilities, from immediate care to red-level trauma treatment, are standing ready to care for patients. With the advancement of technology, medications and highly trained professionals, end results are improving steadily.

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