BY CATHY BREITENBUCHER | PHOTOGRAPHY BY DAN BISHOP
More than half of all trauma patients have orthopedic injuries — many times, multiple fractures.
Statewide, fewer than 10 surgeons specialize in orthopedic trauma, working in Madison and at Froedtert Hospital and Children’s Hospital of Wisconsin. Froedtert Hospital is the only Level I trauma center in the state. It’s also the busiest, with some 1,500 cases in 2011; patients come from as far away as the upper peninsula of Michigan.
Brandyce Tolbert of Milwaukee was one of those patients after she was taken to Froedtert last summer following a minivan accident — the leading cause of traumatic orthopedic injuries. She was thrown from the passenger’s seat and sustained a complicated hip socket fracture; the joint was in multiple pieces. Adding to the case’s difficulty: Tolbert was seven months pregnant.
“When the paramedics tried to extract me from the van, that’s when I knew it was more than a dislocation. The pain was just excruciating,” recalls Tolbert, now 29.
“The baby was fine. It was just my body wasn’t OK at all.”
Tolbert spent 12 days in the hospital and needed to use a wheelchair at home for a month. The last two weeks of her pregnancy, Tolbert used crutches. She carried her baby to term, and her son was born healthy via a planned C-section.
Up to half of pregnant women who sustain a pelvic fracture end up miscarrying, says Dr. Jason Roberts, the orthopedic trauma surgeon who treated Tolbert.
It took about three hours of surgery to set Tolbert’s broken hip, about as long as it would have if she had not been pregnant, Roberts says. To keep tabs on the baby’s health, a nurse from the obstetrics unit and high-risk anesthesiologists were brought into the operating room. A fetal monitor was used to detect any fetal distress. The team was prepared to do an emergency Caesarean section, if necessary.
“Her hip socket was repaired and now she has a nice, smooth hip joint,” says Roberts. “We wanted to optimize her long-term function and try to prevent arthritis in the hip as much as possible, for as long as possible.”
Roberts and Dr. Gregory Schmeling head the orthopedic trauma service at Froedtert & the Medical College of Wisconsin, with a dedicated operating room and specially trained technicians and nurses available around the clock.
To become an orthopedic trauma surgeon, Roberts first completed medical school and a five-year residency in orthopedic surgery. Then, he had an additional year of orthopedic trauma training that focused on the care of pelvic fractures, severe joint injuries and patients with multiple injuries.
Orthopedic trauma surgeons also work on non-emergency cases, treating patients whose fractures didn’t heal fully or healed out of position.
Nearly every case is unique because of the variety of injuries — some severe, some less so. And, patients can be any age, and come in all shapes and sizes, with differing underlying medical conditions.
Upon arrival at a trauma center, patients first are evaluated by general trauma and critical care surgeons. The bulk of care may be directed by the orthopedic trauma team because its expertise is in both fractures and trauma. Later, they may be seen by microvascular, plastic or reconstructive surgeons, and eventually by rehabilitation specialists.
Medical teams must prioritize the injuries and carefully schedule surgeries. “Sometimes fixing that broken leg at the right time can help the ICU doctors get the patient stabilized more quickly and better,” says Roberts.
In less-severe injuries, trauma orthopedic specialists need to weigh the pros and cons of surgery; at times, the patient’s age is a major factor in the decision.
“Sometimes we advise against surgery because we think it won’t necessarily help them recover, or they may heal just as well without it,” Roberts explains.
Last year, the Froedtert & MCW team treated approximately 100 patients who needed surgery to repair pelvic fractures. Most broken hips involve the ball at the top of the thighbone. Less common — and more difficult to treat — is a fracture of the socket.
Other complex injuries can include fractures of the heel bone, knee or ankle. And, any fracture near a joint can disturb the bone surface and lead to arthritis. All it takes is an imperfection as small as one millimeter, according to Roberts.
“In the most severe injuries we treat, even with what we consider a great outcome and with optimal treatment, oftentimes these can be life-changing injuries,” says Roberts.
Some patients sustain organ injuries or other trauma as well. If they develop an infection in the bone, “it requires an aggressive, multidisciplinary approach,” according to Roberts.
Doctors encounter another challenge outside the operating room: helping each patient understand his or her injuries and what kind of recovery is possible.
“We try to be encouraging, but at the same time realistic,” says Roberts. “We definitely have patients who beat the odds — frequently. We tell them what the expected outcome is for most patients, but we can’t really guarantee that’s going to be their outcome.
“We try to give our best educated guess what their function will be.”
As for Tolbert, she is back working full-time at a bank and caring for her family — “business as usual.” She continues to do home exercises in hopes of eliminating a slight limp. Her hip has healed well, according to Roberts.
“Nobody wants to get in a car accident, but the whole process made it a learning experience,” says Tolbert. “You appreciate things more. It tested my strength. I’m grateful.”