Orthopaedic Trauma

Orthopaedic trauma care covers the spectrum of simple isolated fractures to severe life threatening accidents with multiple broken bones. While many fractures can be treated very well by general orthopaedic surgeons, some can benefit from fracture specialists. More significant injuries with multiple broken bones, compound fractures and fractures near a joint, and fractures of the pelvis are more difficult to treat, and benefit the most from specialised care. Additionally, problems with healing including nonunions, infections (osteomyelitis) and healing with poor alignment (malunion) are often treated by fracture specialists. Dr Steyn have the unique expertise and training to treat these orthopaedic injuries. We can typically see patients within 24 hours and/or quickly arrange hospital-to-hospital transfers.

What is Orthopaedic Trauma?

Orthopaedic trauma is a branch of orthopaedic surgery specialising in problems related to the bones, joints, and soft tissues (muscles, tendons, ligaments) of the entire body following trauma. The main goal of this specialised area in orthopaedics is the healing of the fractured bones, as well as restoring the anatomic alignment of the joint surfaces to allow for recovery and return to maximum function of the injured body part.

Dr Steyn's comprehensive orthopaedic trauma capabilities include:
  • Minimally invasive surgery for fractures.
  • Treatment of nonunions and malunions.
  • Pelvis and acetabulum surgery.
  • Treatment for infected fractures and osteomyelitis.
  • Limb lengthening.
  • Bone and joint transplantation.
  • Minimally invasive bone grafting.
  • Complex soft tissue reconstruction.
  • Complex upper extremity reconstruction.

Dr Steyn has experience in extremity and pelvis fracture reconstruction, deformity correction, and bone transplantation. He utilises many leading-edge techniques including minimally invasive surgery and advanced external fixation. The latest in bone graft substitutes and bone-forming proteins are often used to assist in the reconstruction of bones that have not healed.

Treatment Options

Nonsurgical Treatment of Trauma Injuries

Some fractures and dislocations, particularly related to the clavicle, scapula, humerus, wrist, hand, and foot, can be treated non-operatively. Depending on the severity of the fracture, your physician may treat the injury non-surgically through an external fixation method. This method involves the use of splints, casts, braces, and other devices on the outside of the injury to stabilise the fracture.

Surgical Treatment of Trauma Injuries

An internal fixation method is when a physician performs minor surgery to place pins, wires, screws, and plates on the bone to stabilize it. Severe injuries may require more complex surgical procedures including bone grafting, limb lengthening, and complex reconstruction.

Recovery

The length of recovery for fractures depends on the type and severity of the injury. It can take 3 weeks up to several months for a bone to completely heal, and in the worst cases the bone may never heal completely. The good news is that often times the pain from the break will subside dramatically before the bone has completely healed.

Dr Steyn will prescribe a progressive plan to attempt to fully restore the fractured bone to pre-injury condition. You may experience stiffness and muscle fatigue as you start in on your new program. This is caused by atrophy of the muscles, joints, and ligaments from lack of activity. Carefully follow your Dr Steyn's recommendations to avoid re-injury.

Common Neck Injuries

Cervical Fracture

You have seven bones in your neck. These are the cervical vertebrae, which support your head and connect it to the shoulders and body. A fracture, or break, in one of the cervical vertebrae is commonly called a broken neck. Cervical fractures usually result from high-energy trauma, such as automobile crashes or falls. Athletes are also at risk. A cervical fracture can occur if:

  • A football player "spears" an opponent with his head.
  • An ice hockey player is struck from behind and rams into the boards.
  • A gymnast misses the high bar during a release move and falls.
  • A diver strikes the bottom of a shallow pool.

Any injury to the vertebrae can have serious consequences because the spinal cord, the central nervous connection between the brain and the body, runs through the center of the vertebrae. Damage to the spinal cord could result in paralysis or death. Injury to the spinal cord at the level of the cervical spine can lead to temporary or permanent quadriplegia, paralysing the entire body from the neck down.

Treatment will depend on which of the seven cervical vertebrae was damaged and the kind of fracture sustained. A minor compression fracture can be treated with a cervical brace worn for six to eight weeks until the bone heals. A more complex or extensive fracture may require traction, surgery and internal fixation, two to three months in a brace, or a combination of these treatments.

Common Shoulder Injuries

Broken Collarbone

A broken collarbone (fractured clavicle) is a common injury among two very different groups of people: children and athletes. Many babies are born with collarbones that broke during the passage down the birth canal. A child's collarbone can easily crack from a direct blow or fall because the collarbone doesn't completely harden until a person is about 20 years old. An athlete who falls may break the collarbone because the force of the fall is transmitted from the elbow and shoulder to the collarbone. The collarbone is considered part of the shoulder and helps connect the arm to the body. It lies above several important nerves and blood vessels. However, these vital structures are rarely injured when the collarbone breaks. The collarbone is a long bone, and most breaks occur in the middle section.

  • Sagging shoulder (down and forward).
  • Inability to lift the arm because of pain.
  • A grinding sensation if an attempt is made to raise the arm.
  • Although a fragment of bone rarely breaks through the skin, it may push the skin into a "tent" formation.

Diagnoses

Although a broken collarbone is usually obvious, your orthopaedist will do a careful examination to make sure that no nerves or blood vessels were damaged. An X-ray is often recommended to pinpoint the location and severity of the break.

Treatment

Most broken collarbones heal well with conservative treatment and surgery is rarely necessary.

  • A simple arm sling can usually be used to immobilize the arm. A child may have to wear the sling for 3 to 4 weeks; an adult may have to wear it for 6 to 8 weeks.
  • Depending on the location of the break, your physician may apply a figure-of-eight strap to help maintain shoulder position.
  • Analgesics such as acetaminophen or nonsteroidal anti-inflammatory medications such as aspirin or ibuprofen will help reduce pain.
  • A large bump will develop as part of the healing process. This usually disappears over time, but a small bump may remain.
  • Range of motion and strengthening exercises can begin as soon as the pain subsides. However, you should not return to sports activities until full shoulder strength returns.
  • In rare cases, depending on the location of the break and the involvement of shoulder ligaments, surgery is needed. Surgery usually gives good results.


Fracture of the Scapula

Triangular, mobile and protected by a complex of surrounding muscles, the shoulder blade (scapula) is rarely broken. Scapula fractures represent less than 1 percent of all broken bones. High-energy, blunt trauma such as a motorcycle or car crash or falling from significant height can fracture the scapula and cause other major injuries such as broken ribs or damage to the head, lungs or spinal cord. Symptoms include:

  • Extreme pain when you move the arm.
  • Swelling around the back of the shoulder.
  • Skin abrasions.
Without treatment, a fractured scapula can result in chronic shoulder pain and disability.

To give you appropriate treatment, your doctor will probably need to take X-rays of your shoulder and chest to describe and classify the location(s) of fracture to the scapula. In some cases, your doctor may also need to use other diagnostic imaging tools such as CT scan (computerized tomography). One or more parts of the scapula may be fractured:

  • Scapular body (50-60 percent of cases).
  • Scapular neck (25 percent).
  • Glenoid.
  • Acromion.
  • Coracoid.
Your doctor will evaluate the position and posture of the shoulder and treat any soft tissue damage (i.e., abrasions, open wounds, and muscular trauma). Your doctor may want a detailed neurovascular examination, which may not be possible if you have other severe injuries.

Nonsurgical treatment with a simple sling works for most fractures of the scapula. The immobilisation devices hold your shoulder in place while the bone heals. In many cases, your doctor may want you to start early range of motion exercises within the first week after the injury. Other fractures may need 2 to 4 weeks of immobilisation. Your shoulder may feel stiff when the doctor removes the sling. Begin limited active use of your shoulder immediately. Continue passive stretching exercises until complete shoulder motion returns. This may take 6 months to a year. If you have an isolated scapular body fracture, your doctor may want you to stay in the hospital. Certain types of scapular fractures may need further evaluation:

  • Fractures of the glenoid articular surface (shoulder joint) in which bone has moved out of place (displaced) significantly.
  • Fractures of the neck of the scapula with severe angular deformity.
  • Fractures of the acromion process with impingement syndrome.
In these cases, you may need surgery in which the doctor uses plates and screws to hold together the bone.

Common Hip Injuries

Fracture of the Pelvis

The pelvis is a ring-like structure of bones at the lower end of the trunk. The two sides of the pelvis are actually three bones (ilium, ischium, and pubis) that grow together as people age. Strong connective tissues (ligaments) join the pelvis to the large triangular bone (sacrum) at the base of the spine. This creates a bowl-like cavity below the rib cage. On each side, there is a hollow cup (acetabulum) that serves as the socket for the hip joint.

Many digestive and reproductive organs are located within the pelvic ring. Large nerves and blood vessels to the legs pass through it. The pelvis serves as an attachment point for muscles that reach down into the legs and up into the trunk of the body. A pelvic fracture is often associated with substantial bleeding, sensory and motor dysfunction, and other injuries.

How it happens

Growing teens, especially those involved in sports, are one group of people at risk for a particular type of pelvic fracture. Many "pulled muscles" may actually be undetected avulsion fractures of the pelvis. These fractures usually occur with sudden muscle contractions. A small piece of bone from the top of the hipbone is torn away by the muscle. This is a very stable type of fracture. It does not involve the entire pelvic ring or injure internal organs.

Another group at risk for pelvic fractures is elderly people with osteoporosis. An individual may fracture the pelvis during a fall, such as when getting out of the bathtub or descending stairs. These injuries usually do not damage the structural integrity of the pelvic ring, but may fracture an individual bone.

However, most pelvic fractures involve high-energy forces, such as those generated in a motor vehicle accident, crush accident or fall. Depending on the direction and degree of the force, these injuries can be life-threatening.

Diagnoses

A broken pelvis is painful, often swollen and bruised. The individual may try to keep the hip or knee bent in a specific position to avoid aggravating the pain. If the fracture is due to trauma, there may also be injuries to the head, chest or legs. There is usually considerable bleeding, which can lead to shock. Summon emergency assistance. The injuries must be stabilized and the individual taken to a trauma center for definitive care. All pelvic fractures require X-rays, usually from different angles, to show the degree of displacement to the bones. A computed tomography (CT) scan may be ordered to define the extent of other injuries. The physician will also examine the blood vessels and nerves to the legs to see if they have been injured.

Treatment

Stable fractures such as the avulsion fracture experienced by an athlete will normally heal without surgery. The physician may prescribe a painkiller (analgesic). The patient will have to use crutches or a walker, and will have to avoid putting weight on the hip until the bones heal. Because mobility may be limited for several months, the physician may also prescribe a blood thinner to reduce the risk of blood clots forming in the veins of the legs.

Pelvic fractures that result from high-energy trauma are often life-threatening injuries because of the extensive bleeding. In these cases, doctors may use an external fixator to stabilize the pelvic area. This device has long screws that are inserted into the bones on each side and connected to a frame outside the body. The external fixator allows surgeons to address the internal injuries to organs, blood vessels, and nerves. What happens next depends on the type of fracture and the patient's condition. Each case must be assessed individually, particularly with unstable fractures. Some pelvic fractures may require traction; for others, the external fixator may be sufficient. Unstable fractures may require surgical insertion of plates or screws of a biocompatible metal.


Hip Fractures

Hip fractures are a serious health problem common among elderly men and women who fall in their own homes. In 2003 there were about 345,000 hospitalizations for hip fractures (Source: National Center for Health Statistics; Centers for Disease Control and Prevention; 2003 National Hospital Discharge Survey). Only one in four patients recover completely.

A hip fracture is a break near the top of your thighbone (femur) where it angles into your hip socket. When you break your hip, it usually hurts too much to stand and your leg may turn outward or shorten. In most cases, you need hospitalization and surgery. Get to your doctor or emergency room right away.

Diagnosis

Your doctor will X-ray both of your hips to determine exactly where the bone broke and how far out of place the pieces have moved. If the fracture does not show up on X-rays, you might also get an MRI (magnetic resonance imaging) scan. Most hip fractures are one of two types:

  • Femoral neck fractures are 1-2 inches from the joint.
  • Intertrochanteric fractures are 3-4 inches from the joint.

Surgery and early mobilization

Modern treatment for a hip fracture aims to get you back on your feet again as soon as possible while your broken bone heals. (Treatment may vary for certain elderly people who were already bedridden, have other complicated medical conditions and are not in much pain.) Your doctor will reposition the fracture and hold it in place with an internal device.

  • Femoral neck fracture: Pins (surgical screws) are used if you are younger and more active, or if your broken bone has not moved much out of place. If you are older and less active, you may need a high strength metal device that fits into your hip socket, replacing the head of your femur (hemiarthroplasty). In some patients, a total hip replacement is the best option.
  • Intertrochanteric fracture: A metallic device (compression screw and side plate or hip nail) holds the broken bone in place while it lets the head of your femur move normally in your hip socket.

Your doctor will tell you when you should start standing and walking again after surgery. You will probably need crutches, a walker or other help. You may need to do physical therapy or rehabilitation exercises to get back to your normal level of activity.

Common Knee Injuries

Fracture of the Knee

A knee fracture can be a break of any of the bones around the knee—Femur (thigh bone), Patella (kneecap), Tibia (shin bone).

The femur, patella, and tibia are the main bones around the knee. The femur is connected to the patella by the quadriceps tendon and the patella is connected to the tibia by the patellar tendon. Either of these important tendons can also be injured when a bone is broken.

There are many causes of a fracture around the knee. A very common cause is a car accident. A blow to the knee during almost any contact sport can also result in a fracture. Falls from heights or even sudden indirect forces, such as stumbling down stairs, can cause a fracture.

Diagnosis

The diagnosis of a knee fracture is made initially by a history of an acute injury to the area. On physical examination, there will be moderate to severe swelling and usually an inability to bear weight on the affected leg. X-rays will usually confirm the fracture but sometimes an MRI (Magnetic Resonance Image) or CT (Computed Tomography) scan may be needed to further assess the damage.

Treatment

Treatment for knee fractures is based on the severity of the fracture and the bone involved. Usually, fractures of the femur require some form of surgical stabilisation. Mild fractures of the patella can sometimes be treated with immobilisation. Displaced patellar fractures, however, require surgery. Finally, tibia fractures are highly variable and need individual assessment prior to developing a treatment plan. Most surgery involves the placement of screws, plates, wires or rods.