Fracture repair: successful advances, persistent problems, and the psychological burden of trauma

This article is intended to deliver three messages. First, minimally invasive methods of fracture repair are successful; when coupled with advances in implant design, these techniques yield higher union rates with fewer complications than prior methods of direct open fracture repair. Fracture repair has shifted away from direct, anatomic reconstruction of osseous surfaces and now emphasizes restoration of length, rotation, and alignment, with preservation of local soft tissues. The use of percutaneous plating and nailing techniques has expanded to many regions of fracture care. Although minimally invasive reduction techniques are more difficult to perform, there is little reason to expect a return to traditional open surgical methods. Second, open tibial fractures remain problematic despite recent advances in fracture care. Prospective evaluation of patients with open tibial fractures and/or mangled extremities in the Lower Extremity Assessment Project (LEAP) showed that at two years, most patients had poor outcomes, with only half of the patients returning to work. By seven years, half of the patients continued to report appreciable disability, and only one in three had outcome scores typical of a general population. More recent prospectively acquired data about open tibial fractures, gathered from a randomized trial of the effects of bone morphogenetic protein (BMP), showed that one year after injury, more than half of the patients who were managed with the current standard of care had treatment failure. Third, outcomes research has exposed evidence of widespread psychological distress following musculoskeletal trauma. Multiple studies have documented high rates of psychological distress among patients with musculoskeletal trauma. Psychological distress is strongly associated with patient outcome--including functional outcome--following trauma. Despite this strong association, no study evaluating the ability of clinicians to treat psychological distress after musculoskeletal trauma has been reported in the literature to my knowledge as of the time of this writing, nor do orthopaedic studies routinely control for psychological distress when evaluating outcome. Psychological distress after trauma, with its large impact on trauma outcomes, remains a substantial problem that is usually ignored and untreated.