What is Orthopaedic Trauma
Dr. Prokuski treats patients with acute fractures of the arms, legs, and pelvis. She also takes care of complications that arise from injuries including non-unions, mal-unions, infections, and amputations. Her elective specialty is post-traumatic elbow reconstruction with over a decade of expertise in making stiff elbows move again.
Treatment of nonunions and malunions
After a traumatic injury, bones don’t always heal correctly even after surgical intervention which can lead to 2 different types of bone healing complications known as nonunions and malunions.
A nonunion is when the bone tissue does not heal after an appropriate recovery period. Bones can take up to 9 months to fully heal. However, in some cases, especially after significant trauma, the body does not produce the necessary bone tissue required to heal the fracture. This may be due to poor surgical technique or it may be the result of the patient’s medical history or not following post-operative instructions. Smokers have a very high risk of developing nonunions as tobacco use inhibits bone (and all types of) healing.
When bones heal, but in an abnormal position, this is referred to as a malunion.
Both nonunions and malunions have similar symptoms:
- Pain or discomfort
- Reduced functioning
If you have continued pain in the area of a fracture long after the time of the injury, you may have a nonunion. Depending on the nature and severity of your nonunion, Dr. Prokuski may realign the bones, use plates for stability, and/or perform a bone graft to stimulate healing. If your nonunion includes damaged hardware from a previous surgery, our surgeons will need to remove that as well. In some instances, we may collaborate with other specialists and employ hyperbaric oxygen for healing in our treatment of nonunions. Unlike most orthopaedic practices, we enjoy the challenge of correcting these tricky complications.
Malunions are generally only corrected if they cause significant impaired functioning. Your orthopedic surgeon will perform an osteotomy, literally a “cutting of the bone.” The traumatized bones are carefully re-shapen to shorten, lengthen, or realign them in order to restore proper functionality.
Pelvis and acetabulum surgery
Pelvis and acetabular fractures are some of the most serious and complicated fractures treated by orthopaedic surgeons. Often these types of injuries occur due to trauma from motor vehicle collisions and other types of high impact accidents.
The pelvis is the bony ring that houses your lower abdominal organs. The acetabulum forms the socket on each side of the pelvis into which the top of the femur fits to form the hip joint. In a standard hip fracture, it is the ball portion of the joint that is damaged. A fracture of the acetabulum (socket) is more rare, and in most cases is due to significant trauma, where the ball joint is pushed through the acetabulum, causing the fracture.
Fractures of the pelvis and acetabulum often cause a lot of bleeding and serious damage to surrounding tissues, nerves and sometimes organs. These types of fractures put patients at high risk for future complications. Initially, the goal of the orthopaedic surgical team is to stabilize the area while the patient is treated for life-threatening bleeding or other injuries. Within ten days or up to several weeks later, an orthopaedic surgeon can begin the complex work of re-aligning and repairing the pelvic bones, which may require several surgeries.
The process of re-aligning the bones is known as a reduction. The orthopaedic team may first use an External Fixation technique, using pins and a frame outside the body to stabilize the bones. If the damage is extensive, surgeons may need to perform additionally surgeries to internally place plates and screws in the front and back of the pelvis.
With acetabular fractures, it is especially important to align the bones properly, since misalignment can lead to severe arthritis of the hip, eventually requiring a total hip replacement. Using an open reduction with internal fixation, the orthopaedic surgeon painstakingly re-aligns the bones and places screws and plates to hold them rigidly in place. This is very specialized bone work, and the importance of having a skilled surgeon cannot be overstated.
At Sonoran Orthopaedic Trauma Surgeons, we use the highly advanced MAKO robot-assisted platform to maximize precision and control during pelvic and acetabular reductions. As these types of patients are at extremely high risk of arterial or nerve damage, precision is key. Severe bleeding can also occur as major blood vessels are found in this area. Again, this is highly complex work that should only be done by someone with advanced surgical knowledge and experience.
If you or someone you care about has a pelvic or acetabular fracture, talk to their surgeon about transferring their care to our expert team.
Treatment for infected fractures and osteomyelitis
If you sustain a traumatic injury where the broken bone is exposed through the skin, you are at risk of developing a bone infection. Bone infections can also occur during surgery when bone is exposed, or when bacteria in other parts of the body travel to and infect the bone. An infection of the bone is called osteomyelitis.
Symptoms of bone infection include high fever, pain and tenderness over the site of the infection, a lump, skin reddening, and/or a general feeling of unwellness. Bone infection is often misdiagnosed and can remain dormant for years.
Antibiotics can clear up some infections, but others require surgery. If there is an abscess it will need to be drained. If the infection is affecting other organs and tissues (for example if an infection in the spine is pressing on the spinal cord), you’ll need surgery.
Left untreated, osteomyelitis can lead to nonunions (when bones never properly heal and continue to cause pain years after the injury) or sepsis (a very serious complication where the infection gets into the bloodstream).
In severe cases, especially those that can occur in trauma patients, the infection causes so much bone damage that the result is debilitating. A surgeon must remove dead and infected bone tissue in order for the bone to be able to heal and the patient to regain use of the limb. Our surgeons employ a number of techniques to salvage diseased bone, including the utilization of hyperbaric oxygen to stimulate healing and collaboration with other specialists. Indeed, we specialize in this area, and we use every tool in our kit to help save limbs.
Regardless, amputation may be necessary. In cases of amputation, we use the Ertl technique to optimize the use of prosthetics after healing.
Sometimes injury, illness or congenital factors lead to a mismatch in the length of the arms or legs, with one being shorter than the other. After a traumatic injury, sometimes the bones heal in such a way that there is a discrepancy in length between the two extremities. This can happen in children, who are still growing, or in adults who have had a severe fracture, especially where the bone has been broken into several pieces or the fracture was an open fracture causing significant damage to the muscle and tissues surrounding the break. Bone infection can also lead to a limb length discrepancy.
Limb lengthening procedures are extremely complex surgical procedures. They are used when the discrepancy between limb lengths causes significant impairment of mobility, usually involving the femur (thigh bone) or the tibia (shin bone). Limb length discrepancy also puts additional stress on the rest of the musculoskeletal system.
An external lengthening procedure involves cutting the bone in the shorter leg into two pieces and affixing an external fixator, a kind of scaffolding outside the body that is connected to the bone with wires and/or pins. Five to ten days after surgery, the patient or a caregiver will turn the dial on the external fixator to gently separate the bone segments, allowing new bone tissue to form in between them. This is a slow process, with the bone growing about 1 inch per month, more slowly if the patient is a smoker or if the bone was severely damaged. The stabilizer must remain in place several months following the expansion until the new bone has developed sufficient strength.
With an internal lengthening procedure, the surgeon implants an expandable metal rod between the two segments of bone. Rather than being attached to an external scaffolding, the device gradually pulls the bone pieces apart on its own in response to the patient’s natural movements. The rod also keeps the bones aligned and provides stability during the lengthening process. There is less risk of infection and more convenience for the patient with internal lengthening; however, there is also less control over the speed of the lengthening process.
Dr. Laura Prokuski is an expert in the highly specialized field of elbow reconstruction. In fact, very few orthopaedic surgeons take on these types of cases, which involve complicated and delicate surgeries designed to give patients back mobility in the elbow and to repair disfigurement.
Dr. Prokuski can make stiff elbows move again, tighten loose ligaments, and repair previous elbow surgeries that left patients with limited mobility. This type of surgery may involve:
- Repairing damaged structures
- Replacing damaged structures with adjacent bone, ligaments, muscles, tendons, skin or nerves
- Bone fusion
- Joint replacement
- Bone spur removal
- Realignment of fractures
- Surgical decompression for nerve entrapment
Most patients who consult with us about elbow reconstruction cannot bend their elbows or have other issues which seriously limit their ability to participate in normal activities and enjoy their life.
Our goal with complex elbow reconstruction is to give them back the use of their arm.
Bone and joint transplantation
Advances in the field of orthopaedics now allow people to remain active and healthy well into their golden years. Where osteoarthritis of the knees, hips, shoulders and other joints used to cause significant pain and impairment of mobility, joint transplantation (often called joint replacement) has transformed lives.
Depending on your situation, your orthopaedic surgeon may recommend a partial replacement or total replacement of a joint or joints. During the surgery, the damaged parts of your joint are removed and replaced by an implant called a prosthesis. Today’s prostheses are so advanced that they can handle the stresses of everyday activities, so there are few limitations. The new artificial joints also last long enough that even younger people can have joint replacement surgery without the worry of the implant wearing out.
People who have experienced traumatic injury to their joints or who have had bone tumors removed may also need joint replacement or bone replacement.
Bone replacement is called grafting. The patient’s own transplanted bone material, donated bone material, or synthetic material can be used to replace damaged bone or to fill gaps. Bone grafting can also stimulate healing in nonunions (fractures that aren’t healing). The graft material provides a framework upon which new bone tissue can grow.
Our practice also performs minimally invasive bone grafting.
Minimally invasive bone grafting
Bone grafting involves transplanting the patient’s own bone material, donated bone material, or synthetic material, into an area of missing bone. Bone grafts may be needed when there is a gap due to injury, infection, or tumor removal. They can also stimulate bone regeneration in a nonunion (bone fracture that is not healing properly).
Traditionally, bone grafting involves an open surgery where the orthopaedic surgeon physically attaches graft material to the damaged area using pins, plates, screws, wires or cables.
In many cases, however, our orthopaedic surgeons can perform a minimally-invasive bone grafting technique which uses a syringe to deliver bone graft material, rather than making a surgical incision.
Bone marrow is harvested from the iliac crest (the uppermost bones of the pelvis). This material is then injected into the nonunion or other area requiring bone regeneration. The surgeon uses imaging to ensure the correct placement of the graft material.
Minimally-invasive bone grafting avoids the need for an incision and shortens patient recovery times.
Complex soft tissue reconstruction
After a traumatic accident involving fractures, it’s not just the bones that must be fixed. The soft tissues around those bones (muscles, ligaments, veins, arteries, skin) also must be carefully repaired in order to restore functionality to a traumatized body.
These are not easy surgeries, especially since the moment the patient arrives in the emergency room, doctors must quickly make decisions in order to stop bleeding and keep the patient alive. This means that conditions aren’t always favorable for the orthopaedic surgeon who comes in later to perform reconstructive surgery.
Complex soft tissue reconstruction is as much an art as it is a science. Expert reconstructive surgeons have a vast amount of experience in this area, and can assess how to best approach the reconstruction of a traumatic injury. There are many moving parts, and no two injuries are the same.
Some techniques used by our orthopaedic trauma surgeons include:
- Microsurgery (highly precise surgery done with the use of a microscope)
- Tissue expansion (balloon placed under the skin or other tissues and inflated slowly to stimulate additional tissue growth)
- Skin grafts (transplant of skin from another area of the body)
- Wound closure techniques (special stitches that improve healing outcomes)
- Relaxing skin incisions (tiny incisions made near the wound to provide more “play” in the skin around the wound)
- Negative pressure wound therapy and vacuum-assisted closure (uses reduced air pressure to improve healing)
- Fasciocutaneous and muscle flaps (tissue or muscle transplants with an intact blood supply from other areas of the body)
- Bone shortening
- Ertl technique
Orthopaedic surgeons work with plastic surgeons and other specialists to determine and carry out the best treatment plan for complex soft tissue reconstruction.
Complex upper extremity reconstruction
Complex upper extremity reconstruction is an extremely specialized facet of orthopaedic surgery. Devastating injuries to the upper extremities often involve bone fractures as well as severe damage to tendons, ligaments, nerves and soft tissue. Blood flow can also be hindered.
Arthritis or congenital abnormalities affecting the arm or hand may also indicate surgery.
Techniques used in upper extremity reconstruction may include:
- Microsurgery (highly precise surgery done with the use of a microscope)
- Bone grafts (transplanted bone material)
- Tissue grafts (transplanted skin, muscle or other soft tissue)
- Tendon transfer (for hand surgery)
- Nerve transfer (to restore muscle function or sensation)
- Flaps (tissue or muscle transplants with an intact blood supply)
With upper extremity reconstruction, our orthopaedic surgeons understand that purposeful reconstruction involves many pieces of a puzzle being able to fit together to restore meaningful functionality. Our goal will always be to give our patients the best result that current surgical techniques and technology allow.
Revision surgeries for trauma patients
If you have suffered a traumatic injury in the past and have not recovered as well as you expected, consider seeing one of our orthopaedic surgeons about revision surgery.
Trauma injuries can be extremely complicated, and your initial amputation or reconstruction surgery may not have employed all of the latest techniques available to restore optimal functionality. Also, complications such as bone infections or nonunions (bones not healing properly) can occur through no fault of the surgeon. Your medical history can also affect how you heal. If you are a smoker, your risk goes up even further.
Our expert orthopaedic trauma surgeons offer surgical revisions to address post-trauma problems such as:
- malunions (healed fractures that are misaligned)
- bone infections
- lack of mobility
- impaired functionality
- pain associated with the use of prosthetics
We also specialize in areas of orthopaedics that most practices won’t touch, such as elbow reconstruction (making stiff elbows move again, tightening loose ligaments, and restoring mobility). We employ the Ertl technique for amputation revisions so our patients can use their prosthetics more easily without pain or discomfort. We also use state-of-the-art techniques such as minimally-invasive bone grafting for bone regeneration and the MAKO robot-assisted surgical platform for hip replacement and pelvis surgery.
Our orthopaedic surgeons are experts in their field, having received the most intensive training in orthopaedic trauma treatment and staying abreast of the latest technological advancements.
If you are a trauma patient who is unhappy with your recovery, come see us for a consultation. With our help your injuries can become a part of your journey, but not your final destination.
A behind the scenes chat with Laura about her love for orthopaedic surgery.
Orthopaedic Trauma Surgeon
Dr. Prokuski treats patients with acute fractures of the arms, legs, and pelvis. She also takes care of complications that arise from injuries including non-unions, mal-unions, infections, and amputations.
Dr. Prokuski was born and educated in the great state of Iowa. This Midwestern upbringing instilled the values of hard work, personal sacrifice, and the importance of community.
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