Traumatic injury is the nation's leading cause of death of people age one to 44, fifth leading cause of death overall, and a leading cause of long-term disability.

Many such injuries involve serious damage to bones and joints. Offering a comprehensive approach to the repair of these such conditions, Duke's orthopaedic trauma program is a key component of Duke's Level I trauma care services.

Duke's multidisciplinary trauma team uses the latest techniques to repair shattered bones, including vascularized bone transplants and minimally invasive approaches. Diagnosis of more subtle but potentially serious injuries is another distinctive capability. When trauma patients receive expert, highly coordinated care, lives can be saved and long-term quality of life greatly improved.

Trauma: Its Impact on Society

"Sorry to meet you." That's the way Bob Zura, MD, often greets new patients. Zura is not being rude -- he's wryly acknowledging the fact that anyone who needs his services could also use some sympathy.

A Duke orthopaedic trauma surgeon, Zura spends his days caring for people who, in a moment of carelessness or bad luck, have sustained severe injuries to their bones and limbs.

Through the doors of Duke's emergency department they come, dozens every week. Children with elbows broken in an accidental flip off schoolyard monkey bars or a backyard trampoline. Suburban high-schoolers tooling around in off-road vehicles that took a tumble; inner-city teens shot during gang scuffles. Drunk, distracted, or sleepy drivers pulled from wrecked cars -- as well as their passengers and the more prudent drivers in their path.

Their misfortunes are borne out on the national level. According to the National Safety Council, the National Center for Injury Prevention and Control, and other sources, accidental injuries are the fifth leading cause of death in the nation and among the leading causes for missed work. The statistics are devastating.

Motor vehicle crashes are the leading cause of death in the United States for children and young adults ages one to 24; falls are the leading cause of injury death in persons over 65. More than 200,000 children are injured each year on playgrounds.

The results of these mishaps are broken arms and legs, shattered pelvises, crushed and severed limbs, and every other kind of insult the body's skeletal system can sustain. While some of these injuries can easily be repaired, many are potentially debilitating or disabling; others can be fatal.

Comprehensive Care Meets Complex Challenges

The more than 2,000 trauma patients who are brought to Duke each year have had at least one stroke of luck: They have access to the very latest approaches to the repair of shattered bones.

"Trauma is a huge problem that exacts all sorts of costs on society, from lost lives to lost work," says James Nunley, MD, chair of orthopaedic surgery at Duke. "But the good news about traumatic injuries is that, with excellent care, the injuries can often be cured, and the patient restored to a high level of function.”

Duke's orthopaedic trauma program is a key component of Duke's trauma care services, which are rated Level I (providing the most comprehensive trauma care available) by both the State of North Carolina and the American College of Surgeons. Out of 500 hospitals statewide, Duke is one of just five to achieve this designation.

“Trauma care is a team sport,” says Steve Olson, MD, who has significantly expanded and enhanced orthopaedic trauma surgical services at Duke since he assumed leadership of the program four years ago.

“While traumatologists [surgeons who specialize in the treatment of wounds and injuries] provide the structure, all of our surgeons contribute to care of trauma patients, often in extraordinary ways."

In addition to highly trained general surgeons, neurosurgeons, and orthopaedic surgeons, Duke's trauma team includes neurologists, trauma nurses, respiratory therapists, and pharmacists.

Also readily available are experts in other specialties, such as plastic surgeons with expertise in the coverage of open wounds and the salvage of mangled extremities. Since trauma patients often have other health problems -- such as an elderly patient who's been injured in a fall, yet also has serious heart disease -- Duke's multidisciplinary approach can be a literal lifesaver.

Innovative Approaches for Urgent Needs

Duke’s orthopaedic trauma team uses a range of cutting-edge techniques during the reattachment or repair of severed or mangled extremities -- extremely challenging procedures that call for expertise in mending not only the limb itself, but the many delicate blood vessels that nourish it.

Minimally invasive techniques similar to those used in elective orthopaedic surgery represent another major advance in trauma care. Performed through smaller incisions, such procedures offer special advantages in the trauma setting.

"Bone is a living tissue and needs blood to heal," Zura says. "So the less we can disrupt the tissues that nourish the bone, the more rapid the recovery -- and the more successful the procedure."

When a whole section of bone has been crushed or shot away, Duke surgeons can often replace them with vascularized transplants taken from the fibula, one of the bones of the lower leg. Duke orthopaedic surgeon James Urbaniak, MD, helped to pioneer this technique, which relies on the insight that the tibia -- the lower leg's heavier bone -- can bear most of the weight of the body if a segment of the fibula has been removed.

The technique is an example of what Olson considers the key to successful orthopaedic trauma procedures: Finding the perfect balance between boldness and caution. "We surgeons are driven to innovate and keep pushing the envelope to help people get better," he says. "But we also know we can get burned if we think we're smarter than one who designed us."

While many of the injuries treated by the orthopaedic trauma team are dramatic, some are more subtle. Compartment syndrome, for example, is a condition in which damage to a limb causes swelling which is contained by the fascia -- the tissues that house muscles -- and can, in extreme cases, be fatal.

Because the condition can be caused by minor injuries as well as major ones, diagnosis can be tricky, says Olson: "Most doctors don't deal with compartment syndromes often enough to recognize them, but we know what to look for -- we're able to identify and treat them promptly, before irreversible damage is done."

Careful Sequencing of Repairs is Crucial

Whatever surgical interventions will be required for a trauma patient's long-term quality of life, the first order of business is working with the general surgeons and other trauma caregivers to get the patient out of danger.

Rather than immediately repair everything that's broken -- an approach that was once standard -- the orthopaedic trauma team usually opts to externally stabilize injured limbs with intricate networks of metal splints known as "traveling traction," with an eye toward more complete repairs later.

"People with traumatic injuries are in a state of shock," Olson says. "As soon as they're aware of what's happened to them, they become very concerned about their quality of life -- but before that can be addressed, the entire surgical and medical team needs to make sure that their life itself isn't in danger."

Every time a trauma patient comes in, says Zura, "Every team member springs into action, playing their part like members of a symphony orchestra." When patients receive that level of coordinated expertise -- enhanced with perhaps just a bit of celestial luck -- near-miraculous recoveries can occur.

Olson recalls one young couple who was in a serious accident while the husband was driving his wife and new baby home from the hospital. "The mother had brain injuries and multiple bone fractures, and we didn't think she'd make it," says Olson. "She needed several surgeries -- and for the first few months, her husband had to parent their new baby alone. But she pulled through and now she's doing fine. Seeing a positive outcome like that is the best part of our job."

Level I Care and the Ounce of Prevention

According to Olson, getting to an expert facility when injury occurs offers a patient's best shot at a happy ending.

"Regional hospitals that have gone through the procedures to be certified as trauma centers have systems and resources to provide trauma care,” says Olson. “Those patients who require truly comprehensive trauma care, however, are typically transferred to a Level I trauma center such as Duke.

"The important thing with trauma is that the physicians don't miss things that could cause long-term disability," Olson adds. "So people should make sure they're taken to a place that has complete trauma care systems in place." He points out that even when Duke's trauma care unit is too busy to accept patients from more remote areas, residents of Durham and Orange counties are always ensured access.

Of course, if you really want a long, disability-free life, do your level best to avoid traumatic injury in the first place. "Most people think of trauma as a random occurrence," Olson says. "But at least half of all serious injuries could be avoided if people were more careful."