Treating musculoskeletal trauma is one of the most interesting, exciting, but also challenging branches of medicine. Let me share why.
Bone healing is miraculous. Unique among all tissues except liver, bone can heal with tissue regeneration, not scar. Still, this miraculous regeneration takes place only if the bone is immobilized at first and then gradually loaded. On the other hand, humans are designed to move. Too much immobility is not only unhealthy, it can also be lethal. Immobility is thus at once the essence and the enemy of complete fracture healing. We must hold fractures in place, but in a manner that allows the earliest restoration of movement and loading.
Too often underappreciated is the role of soft tissues in fractures. Wound breakdown and infection – even if the bone ultimately unites – are common causes of poor outcomes. Atrophy and stiffness, likewise, can compromise the result. To avoid these problems, a fracture should be considered not only as an injury to bone, but rather as an extension of a soft tissue injury.
The concepts of mobilization and the importance of the soft tissue overlap. Dr Robert B Salter, a pioneering Canadian orthopaedic surgeon, presented work that is forever imprinted in my memory: images from experiments showing healing cartilage in an animal model, contrasting joints immobilized or allowed to move after injury. The mobilized joints were almost normal whilst the immobilized joints had disintegrated!
Advances in imaging technology, surgical technique, and implant design have facilitated soft-tissue-friendly treatment solutions. Better surgical devices, particularly for brittle bones, have allowed for that needed mixture of rigidity and mobilization. These advances in isolation, however, improve only the potential for improved outcomes. Realizing this potential and translating it into optimal patient outcomes demands more than technology. Successful outcomes remain dependent on a clear understanding and correct application of long-known principles of treatment. Physicians must know when to intervene and when to stand down. All must work collaboratively, to provide integrated care. A perfect x-ray is only a small part of the equation. Any treatment plan that does not completely consider the whole picture – the medical, rehabilitative, and psychosocial aspects, among others – is a plan designed to fail.
Moreover, a good plan is not enough. Too often patients are uninformed or misinformed. We must empower patients and their families with the necessary knowledge and confidence to co-manage rehabilitation and ongoing wellness.
To help ensure that the necessary knowledge is shared, in this fracture volume we have tried to convey key concepts and principles of integrated and person-centered management of patients with fractures. Just as a fracture can be immobilized too much or too little, the level of detail provided here can be criticized for being simplistic or excessive. We aimed to provide the information medical students, junior doctors, and other trainees can use to form a solid foundation for further learning. Your experience – the ultimate outcome – will let us know if we succeed.
Enjoy the journey.