auma Myths_Fig 1A.gif
Fig. 1 Using a long midline incision early on to treat a tibial plateau fracture doesn’t make sense, say the trauma mythbusters. A more effective treatment is to wait until soft tissues resolve and use two small incisions for double plating.
Courtesy of Robert F. Ostrum, MD

AAOS Now

Published 4/1/2011
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Terry Stanton

Trauma myths—BUSTED!

Surgeons look at evidence behind beliefs on trauma treatments

In trauma medicine, decisions are made quickly. Surgeons rely on their knowledge, training, and experience to choose the appropriate course of treatment. But in some situations, controversy surrounds the management of trauma patients. What a surgeon believes to be appropriate treatment—and what may have been successful treatment in his or her experience—may not be supported by the literature or the evidence.

At the 2011 AAOS Annual Meeting, a panel of trauma surgeons assumed the roles of “Mythbusters” and tackled the following commonly encountered notions:

  1. Severe intra-articular fractures should be treated in minimal fashion to leave bone stock for later surgery.
  2. Patients with severe intra-articular fractures will require a later reconstructive procedure regardless of treatment.
  3. Surgical intervention in comminuted intra-articular fractures has a high complication rate and may leave the patient with no good salvage plan or with infection.
  4. Nonsurgical treatment of calcaneus fractures equals surgical care.
  5. Proximal tibia fractures should not be nailed.
  6. Limb salvage is the preferred method for treating mangling injuries to the lower extremity.

Intra-articular fracture myths
In tibial plateau fractures, noted Robert F. Ostrum, MD, a common expectation is that the patient will ultimately need a total knee arthroplasty (TKA), so the injury is addressed with a midline incision and double plating (Fig. 1). “This is bad thinking that will lead to bad results,” he said.

In one series of almost 14,000 TKAs, just 0.0045 percent were performed subsequent to tibial plateau fractures. Arthritis resulting from these fractures is rather uncommon, for several reasons, including thick cartilage at the lateral plateau, protection of the joint by the meniscus, and stability at 10 degrees to 20 degrees of flexion.

“So maybe the articular reduction may not be as important as mechanical alignment and stability,” he continued. “Some of these patients, despite how well we do our job, are still going to get arthritis.” Research has shown that waiting for soft tissues to resolve and then making two small incisions for double plating is more effective than the previously used long midline incision early on.

In pilon fractures, he said, fracture grade and quality of reduction correlate with the final result, so that comminution is a significant factor. Posttraumatic arthritis in ankle fractures is much more common than in the knee, Dr. Ostrum noted. As with the knee, the two-stage technique of external fixation followed by open reduction and internal fixation (ORIF) seems preferred.

Dr. Ostrum discussed the bone stock question as it applies to calcaneus fracture. Wound problems with these fractures are much more common with a nonsurgical approach, and Maryland and AOFAS scores were considerably higher in ankles treated with surgery.

“So the question is, are you better off leaving them alone and doing a late fusion, or fixing them and doing a late fusion? You are much better off fixing them. Nonsurgical treatment just to have bone stock for the calcaneus is not a good idea.”

Although separating the variables of severity of injury and the quality of articular reduction is difficult, “these patients do deserve a legitimate attempt to try to get their injury reduced,” Dr. Ostrum concluded.

His verdicts?

  1. Severe intra-articular fractures should be treated in minimal fashion to leave bone stock for later surgery.
    BUSTED: “Minimal surgery to preserve bone stock is not helpful for later surgery; fixation is better, and most patients will not go on to have arthritis.”
  2. Patients with severe intra-articular fractures will require a later reconstructive procedure regardless of treatment.
    BUSTED: “As much as we think these patients with severe fractures are going to get bad arthritis, less than 7 percent actually do.”
  3. Surgical intervention in comminuted intra-articular fractures has a high complication rate and may leave the patient with no good salvage plan or with infection.
    BUSTED: “You are not going to make the patient worse by trying to put him or her back together again. With calcaneus fractures, do a decent job, wait, and follow-up with a late fusion.”

Treating fractures
Is nonsurgical treatment of calcaneus fractures equivalent to surgical care? Not exactly, according to Paul Tornetta III, MD. Potential advantages of surgery for calcaneus fractures include tuberosity alignment, subtalar congruence, and a restored width for shoe wear. Disadvantages include wound complications and scarring about the tendons. In addition, risk factors for complications—such as smoking, insulin-dependent diabetes, and open fractures—must be considered.

“These are significant risks with the extended lateral approach,” Dr. Tornetta said. Accurate evaluation of surgical outcomes is complicated by the absence or presence of workers compensation.

“Nonsurgical management can be reasonable for smokers older than 40 years, noncompliant patients, workers compensation patients, and sedentary older patients,” Dr. Tornetta said. The limited number of comparative studies shows no difference in pain or general health outcome measures between surgical and nonsurgical treatment. Surgery, however, results in fewer fusions, an earlier plateau period, an earlier return to work, and—for women in particular—restoration of height and width to facilitate shoe wear.

The ideal surgical candidate is a young female patient who is active, nonsmoking, nondiabetic, compliant, and willing to accept the risk of a poor result.

His verdict?

4. Nonsurgical treatment of calcaneus fractures equals surgical care.
BUSTED: “You are going to get your best and your worst results from surgical management,” he said, “and nonsurgical management is going to be some sort of a bell curve.”

Dr. Tornetta noted that nailing proximal tibia fractures has the advantage of decreased infection and of load sharing, while plating offers alignment (theoretically) and intra-articular extension.

“Proximal tibia fractures are hard to nail, even with experienced hands,” admitted Dr. Tornetta. Achieving good reduction requires good anteroposterior visualization, and he uses a semiextended technique for anterior angulation and blocking screws for posterior translation. On this myth, Dr. Tornetta concludes:

  1. Proximal tibia fractures should not be nailed.
    BUSTED. “If you get the perfect portal and the proper trajectory, nail in extension, and use blocking screws, this myth is clearly busted.”

Limb salvage or amputation?
Robert A. Probe, MD,
tackled the final “myth” on the preferred method for treating lower limb mangling injuries. Although salvage is an option in many cases, measures to avoid amputation may have become extreme or harmful to the long-term benefit of the patient, he noted.

In weighing decisions whether to amputate, physicians can turn to reported experience and outcomes and to decision-making tools. Sometimes the decision of whether to amputate is “very easy,” Dr. Probe said. “We’ve developed nice prostheses as a result of military conflicts, and we’ve all seen athletes who have returned to sport.”

On the other hand, not all patients have such favorable outcomes, and scoring systems have shown poor predictive ability. “As much as we would like to have objective data that help us make a comfortable decision on the night of injury, that’s proven not to be the case,” he said.

One long-held belief has been dismissed: If a patient has an insensate plantar foot, the patient probably does not need that limb.

Given current technologies and social strategies, said Dr. Probe, results for amputation and reconstruction are comparable. Current guidelines provide support for which limbs may be saved, but not for which limbs should be amputated. Given the poor outcomes for both treatment options, continued efforts should be made to improve treatment strategies and technologies. Nonmedical factors should be an integral part of future strategies to optimize functional outcomes.

His verdict?

  1. Limb salvage is the preferred method for treating mangling injuries to the lower extremity.
    BUSTED. “Whether it is tibia, calcaneus, or pilon, we can’t always restore great functional outcome and amputation may be preferred.”

Disclosures: Dr. Ostrum—AONA, Synthes; Dr. Tornetta—Smith & Nephew, Wolters Kluwer Health, Lippincott Williams & Wilkins; Dr. Probe—Stryker, Synthes.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org