Trauma: More Than “Broke – Fix it”

Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

“If it’s broke then fix it.” When I was a resident I heard this phrase often, as it was a favorite comment of one of my co-residents. He argued that trauma surgery was just a matter of putting the pieces of humpy dumpty back together again and letting them heal. Simple, right? Since residency, I’ve heard this common statement uttered by those who like to downplay the complexity of trauma surgery. This rather reductionist argument has an understandable origin. Those of us who’ve trained in modern surgery are steeped in the concepts espoused by those such as Gissane and the Swiss AO/ASIF group, who taught us about rigid internal fixation, anatomical reduction, etc. For many years, the focus has been entirely on bone healing, with little regard to the inconvenient “stuff” you need to get through to fix the bone, and the trauma caused by that inconvenience. As such, many foot and ankle trauma surgeons have followed in these orthopedic footsteps, the end result of which is "putting two bones back together" as the primary goal of trauma repair.

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It is only recently that the pendulum is starting to swing toward the other side. For example, surgeons are now discussing the “soft tissue envelope.” Consider calcaneal fracture repair, in which the most difficult complications occur as a result of compromised soft tissue. Sural neuritis, peroneal tendon problems, and dehiscence which may lead to calcaneal osteomyelitis are challenges often encountered after these procedures. It’s understandable, considering these significant complications, that some are advocating minimally invasive repair with external fixation. Think about compartment syndrome, which doesn’t even need a fracture to occur. This is a dreaded complication that, if missed initially, can completely disable a patient and perhaps lead to litigation. Never a pretty picture! Or what about the poster child for soft tissue complications, the open pilon fracture? The amputation risk for failed open pilon fracture repair is so significant that an entire sea change has occurred, transitioning from immediate ORIF, to temporary stabilization with external fixation and delayed repair. These examples demonstrate a paradigm shift toward a more holistic patient approach when dealing with traumatically induced injuries.

However, are we holistic enough? Whether it is bone or soft tissue, shouldn’t trauma be more than “broke — fix it?

I’ve always found those trauma patients whom I’ve been tasked to treat to be complex, multifaceted cases that were always more than putting two bones back together. Considerations that complicated their care included such issues as general medical health (or lack thereof), arterial disease, bone and soft tissue healing concerns, postoperative support, weightbearing vs. nonweightbearing (more commonly patients’ weightbearing when they weren’t supposed to), insurance issues, legal issues (luckily of the disability sort rather than suing me), rehabilitation, and chronic pain, among others.

We need to expand our approach to go beyond the local injury and remember there is a patient attached to that traumatized body part. Just as the treatment of diabetic wound patients has moved toward a multidisciplinary approach, the same needs to be done for our trauma patients. How many patients have adverse psychological responses to their injury and rehabilitation? How many will have to deal with permanent disability and pain? In the future, we should consider changing our paradigm to “If the part’s broke - fix the patient.”

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

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Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]