Dealing with and responding to orthopedic trauma is an important part of an orthopedic practice. Usually as a clinic becomes more established in practice they decrease the level of trauma that they care for, or they simply stop taking trauma cases all altogether. I have become a contrarian and have actually increased the level and complexity of trauma that I care for. The type of trauma that I see can occur from a fall at home, an injury during a sporting event, a motor vehicle accident, or in the case I recently saw from violent activity.
To the left is an x-ray of a recent case that occurred while I was on-call. This was a teenager who was shot with a .25 caliber handgun in the right arm. The patient sustained an open fracture of the humerus. A fracture is considered open when there is any exposure to the environment. They are graded I, II and III depending on the complexity of the wound and tissue damage. This type of fracture requires early operative intervention since there is an open wound and a comminuted fracture that is not stable. As I saw the patient in the emergency trauma room, I decided to take the patient to the operating room right away. With an open fracture the options are to clean the wound out and temporarily stabilize with an external fixation device. Then at a later date the surgeon can do the definitive procedure. The other choice is to do the definitive procedure at the first operation. Since the wound was just an entry hole from the bullet and it had not exited I elected the latter.
Surgery Process for Orthopedic Trauma
The patient was brought to the operating room within a couple of hours after arriving in the ER. I cleaned out the entry wound then did an open reduction and internal fixation with a plate and screws. This requires making a large incision to expose the fracture. During the surgery I found that the initial x-rays did not show the extent of the fracture. There were over a dozen pieces, and it involves putting the pieces back together like a puzzle. The important point is to get the largest fragments together first and then work your way to stabilize the smaller pieces with screws using the lag technique. This case took about two hours to complete, but the patient ended up with a stable fracture that should go onto healing with care.
One question that I anticipate is why I didn’t take the bullet out. As you can see from the x-rays, the plate is on the lateral or outer side of the arm. This is where the incision was made. The bullet is on the medial side. It would have required more extensive surgery and the risk of nerve damage as well as infection, add these factors together and it was wisest to leave the bullet alone. The patient also has a second bullet in the chest that went subcutaneously from the right to left side. The trauma surgeon who was following that injury elected to leave that bullet alone as well.