Trauma is the “neglected disease.” It is the
leading cause of death for people age 1 to 34 years of all races
and socioeconomic levels and the third leading cause of death for
all age groups. Injuries create a substantial burden on society
in terms of medical resources used for treating and rehabilitating
injured persons, productivity losses caused by morbidity and premature
mortality, and pain and suffering of injured persons and their caregivers.
Each year in the United States, one in six residents requires medical
treatment for an injury, and one in 10 residents visits a hospital
emergency department (ED) for treatment of a nonfatal injury. Data
on injury prevalence and costs from the 2000 Medical Expenditure
Panel Survey (MEPS) and the National Health Accounts (NHA) reported
that injury-attributable medical expenditures cost as much as $117
billion in 2000, approximately 10% of total U.S. medical
expenditures. In 2001, there were 157,078 trauma-related deaths,
64% of which were due to unintentional trauma, half of
which were caused by motor vehicle crashes. An estimated 29.7 million
persons sustained nonfatal injuries during the same period. In 2001,
the death rates for motor vehicle-related injuries were 15.3 per
100,000 people, totalling 43,987. Crash injuries result in about
500,000 hospitalizations and four million emergency department visits
annually. The economic burden of motor vehicle-related deaths and injuries
is also enormous, costing the United States more than $150
billion each year. In 2001, approximately 140,000 Americans sustained
gunshot injuries. Twenty-nine thousand of these (21%) died
as a result. In the pediatric population, 10,000 deaths associated
with trauma are recorded annually in the United States. Trauma accounts
for 30% of pediatric emergency room visits and is the most
common cause of mortality in the noninfant child.
Musculoskeletal disorders generated 3.5 million admissions to
acute-care hospitals in the United States in 1988, more than 40% of
which were trauma-related. Musculoskeletal injuries have a tremendous
effect on the patient, the family, and the society in general because
1. physical and psychologic
effects of pain, limitation of daily activities, loss of independence,
and reduced quality of life;
2. direct expenditures for diagnosis
and treatment; and
3. indirect economic costs associated
with lost labor and diminished productivity.
Musculoskeletal injuries occur frequently, result in significant
disability, and consume a major portion of health care resources.
For example, the cost of hip fracture is estimated at $8.7
billion, or 43% of the total cost of all fractures. Direct
costs are about 80% of the total, of which inpatient hospital
care amounts to $3.1 billion and nursing home care $1.6
billion. More recent estimates show an increasing effect on the
U.S. economy, including over $150 billion per year in direct
and indirect cost from lost labor productivity due to trauma.
Mass casualty situations as a result of terrorism are the challenge
of the new millennium, requiring a highly organized and effective
trauma system. The capability to respond in an organized manner
has gained importance after terrorist attacks within United States.
In a mass casualty situation, limited resources must be allocated
for a great number of victims. The terrorist attacks in Oklahoma
City (1995) and at the World Trade Center (1993, 2001) showed the
inefficiencies of the civilian disaster response system. The Orthopaedic
Trauma Association has developed strategies to educate and optimize
the response to mass casualties.
Surveillance for fatal and nonfatal injuries-United
States, 2001. Vyrostek SB, Annest JL, Ryan GW. MMWR September 3,
2004/Vol. 53/No. SS-7. CDC.
Medical expenditures attributable to injuries-United States,
2000. MMWR January 16,2004. CDC.
Engelhardt S et al: The 15-year evolution of an urban trauma
center: What does the future hold for the trauma surgeon? J Trauma
Praemer A, Furner S, Rice DP: Musculoskeletal conditions in
the United States. Am Acad Orthop Surg, Park Ridge IL, 1992.
Soderstrom CA, Cole FJ, Porter JM: Injury in America: The role
of alcohol and other drugs—an EAST position paper prepared
by the injury control and violence prevention committee. J Trauma 2001;50:1.
Wynn A et al: Accuracy of administrative and trauma registry
database. J Trauma 2001;51:464.
Bone is a unique tissue because it heals by the formation of
normal bone, as opposed to scar tissue. In fact, it is considered
a nonunion when a bone heals by a fibroblastic response instead
of by bone formation. Whatever part of the skeleton it comes from,
bone has a fine fibroid structure. This is true for cortical and
cancellous bone from the diaphysis, epiphysis, or metaphysis. Bone will,
therefore, heal by the same mechanism wherever it breaks.
Fracture healing can be divided into primary and secondary healing.
In primary healing, the cortex attempts to reestablish itself without
the formation of callus (osteonal or haversian healing). This occurs
when the fracture is anatomically reduced, the blood supply is preserved,
and the fracture is rigidly stabilized by internal fixation. Secondary
fracture healing results in the formation of callus and involves
the participation of the periosteum and external soft tissues. This
fracture healing response is enhanced by motion and is inhibited
by rigid fixation.
Fracture healing can be conveniently divided, based on the biologic
events taking place, into the following four stages
1. Hematoma formation
(inflammation) and angiogenesis.
2. Cartilage formation with subsequent
3. Cartilage removal and bone formation
4. Bone remodeling
Hematoma Formation and Angiogenesis
Initially, there is an inflammatory phase characterized by an
accumulation of mesenchymal cells around the fracture site. The
formed hematoma is a source of growth factors. Transforming growth
factor beta (TGF-β) and platelet derived-growth
factor (PDGF) are released from platelets at the fracture site.
TGF-β induces mesenchymal cells and osteoblasts
to produce type II collagen ...