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SKELETAL TRAUMA: BASIC SCIENCES, MANAGEMENT, ISBN: 978-0-323-63924-8 (vol 1)

AND RECONSTRUCTION, SIXTH EDITION 978-0-323-63925-5 (vol 2)
Copyright © 2020 by Elsevier Inc. All rights reserved. 978-0-323-61114-5 (set)

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 The Editors Dedicate the Sixth Edition to their
Families and to Fallen and Wounded Warriors

To my wife, Barbara Thea Browner; to my children:

Jeremy Todd Browner, Esq, Nina Mikhellasvili Browner,
MD, Nicole Browner Samuel, and Marc Aaron Samuel,
Esq, and to my grandchildren: Benjamin Noah Browner,
Zachary Myer Samuel, Dylan Jethro Samuel, Sophia
Alexandra Browner, and Emily Jordyn Samuel
In memory of my parents, Mona and Eric Browner
In appreciation for encouragement from my mother-in-
law, Betty Appleman Jacowsky
Bruce D. Browner

To my wife, Beryl Stephanie Abrams Jupiter, to my

daughter, Stacy Deborah Jupiter
In memory of my son, Benjamin Scott Jupiter
In memory of my parents, Miriam and Samuel Jupiter
Jesse B. Jupiter

To my wife, Ulrike Krettek, MD, to my children: Felicitas

Krettek and Florian Krettek
In memory of my parents, Felizitas & Heinz Krettek
In appreciation of their continuous support and
encouragement
Christian Krettek

To my wife, Veronica for the all help and support she

provides and her assistance in editing all the
manuscripts
Paul Anderson

We dedicate this text also to the brave men and women

in the military who have sacrificed their lives or
sustained serious injuries while fighting to preserve the
freedom and security of our nations
Contributors

Yves P. Acklin, MD, DMedSc Paul A. Anderson, MD, FAOA

Assistant Professor Department of Orthopaedics and Rehabilitation
Kantonsspital Baselland University of Wisconsin
Bruderholz, Switzerland Madison, Wisconsin
46: Fractures of the Humeral Shaft 33: Thoracolumbar Trauma
35: Osteoporotic Spinal Fractures
Julie E. Adams, MD
Professor, Orthopaedic Surgery Ajay Antony, MD
Mayo Clinic Health System Department of Anesthesiology
Rochester, Minnesota University of Florida College of Medicine
44: Trauma to the Adult Elbow Gainesville, Florida
15: Chronic Pain Management
Samuel B. Adams, MD
Department of Orthopaedic Surgery Paul M. Arnold, MD
Duke University Medical Center Department of Neurosurgery
Durham, North Carolina University of Kansas Medical Center
66: Malleolar Fractures and Soft Tissue Injuries of the Ankle Kansas City, Kansas
29: Pathophysiology and Early Management of Spinal Cord
Sulaiman Alazzawi, MBChB, MSc, MRCS, FRCS Injury
Trauma and Orthopaedics
The Royal London Hospital Courtney E. Baker, MD
London, United Kingdom Resident Physician
73: Articular Cartilage Reconstruction Using Osteochondral Department of Orthopaedic Surgery
Allografts Mayo Clinic
Rochester, Minnesota
Volker Alt, MD 4: Vascularity and Stability: The Pillars of Fracture Healing
Department of Trauma Surgery
University Hospital Giessen–Marburg GmbH Tessa Balach, MD
Campus Giessen, Germany Associate Professor
25: Understanding and Treating Chronic Osteomyelitis Residency Program Director
Division of Orthopaedic Oncology
Anthony M. Alvarado Department of Orthopaedic Surgery
Department of Neurosurgery University of Chicago
University of Kansas Medical Center Chicago, Illinois
Kansas City, Kansas 21: Pathologic Fractures
29: Pathophysiology and Early Management of Spinal Cord
Injury Justin Barr, MD, PhD
Department of Surgery
Louis F. Amorosa, MD Duke University
Assistant Professor of Orthopaedic Surgery Durham, North Carolina
Columbia University Medical Center and New York 1: The History of Trauma Care
Presbyterian Hospitals
New York, New York Craig S. Bartlett III, MD
32: Subaxial Cervical Spine Trauma Medical Director of Orthopaedic Trauma
Department of Orthopaedics and Rehabilitation
Jonas Andermahr, MD The University of Vermont
Professor of University Clinic of Cologne Burlington, Vermont
Director Center of Orthopaedic and Traumasurgery 65: Fractures of the Tibial Pilon
Kreiskrankenhaus, Mechernich, Germany
48: Fractures and Dislocations of the Clavicle

iv
 Contributors v

Michael R. Baumgaertner, MD Randy R. Bindra, MCh, FRCS

Professor Professor of Orthopaedic Surgery
Department of Orthopaedics and Rehabilitation Griffith University and Gold Coast University Hospital
Chief of Orthopaedic Trauma and Reconstruction Gold Coast, Australia
Yale School of Medicine 40: Fractures and Dislocations of the Hand
New Haven, Connecticut
53: Medical Management of the Patient With Hip Fracture Robert E. Blease, MD
55: Intertrochanteric Hip Fractures Orthopaedic Trauma Surgeon
MAJ U.S. Army (Ret)
Joan Elizabeth Bechtold, PhD Missoula, Montana
Gustilo Professor of Orthopaedic Research 20: Gunshot Wounds and Blast Injuries
Vice Chair Research
Department of Orthopaedic Surgery André P. Boezaart, MD, PhD
University of Minnesota; Professor of Anesthesiology and Orthopaedic Surgery
Graduate Professor Department of Anesthesiology
Biomedical Engineering University of Florida College of Medicine
University of Minnesota; Gainesville, Florida
Investigator 14: The Management of Acute and Perioperative Pain
Hennepin County Medical Center Associated With Trauma and Surgery
Hennepin Healthcare Research Institute and Excelen 15: Chronic Pain Management
Center for Bone & Joint Research and Education
Minneapolis, Minnesota Donald S. Bohannon, MD
6: Biomechanics of Fractures Associate Professor of Anesthesiology
Department of Anesthesiology
Christopher P. Bednarz, MD University of Florida College of Medicine
Virginia Commonwealth University School of Medicine Gainesville, Florida
Richmond, Virginia 14: The Management of Acute and Perioperative Pain
22: Osteoporotic Fragility Fractures Associated With Trauma and Surgery

Carlo Bellabarba, MD Christopher T. Born, MD, FACS, FAAOS

Professor and Vice Chair, Department of Orthopaedics Intrepid Heroes Professor of Orthopaedic Surgery
and Sports Medicine The Alpert Medical School at Brown University
Joint Professor, Department of Neurological Surgery Emeritus Chief, Division of Orthopaedic Trauma;
University of Washington School of Medicine Director, Weiss Center for Orthopaedic Trauma Research
Seattle, Washington; Rhode Island Hospital
Chief of Orthopaedics Providence, Rhode Island
Harborview Medical Center 13: Disaster Management
Seattle, Washington
30: Craniocervical Injuries: Atlas Fractures, Atlanto-Occipital Michael J. Bosse, MD
Injuries, and Atlantoaxial Injuries Department of Orthopaedic Surgery
38: Pelvic Ring Injuries Carolinas Medical Center—Atrium Health
Charlotte, North Carolina
Emanuel Benninger, MD 28: Psychological, Social, and Functional Manifestations of
Department of Surgery Orthopaedic Trauma and Traumatic Brain Injury
Clinic of Orthopaedics and Traumatology
Kantonsspital, Winterthur, Switzerland Richard Jackson Bransford, MD
47: Proximal Humeral Fractures and Glenohumeral Professor and Spine Fellowship Director
Dislocations Department of Orthopaedics and Sports Medicine
University of Washington
Michael A. Benvenuti, MD Harborview Medical Center
Department of Orthopaedic Surgery Seattle, Washington
Vanderbilt University Medical Center 30: Craniocervical Injuries: Atlas Fractures, Atlanto-Occipital
Nashville, Tennessee Injuries, and Atlantoaxial Injuries
4: Vascularity and Stability: The Pillars of Fracture Healing 38: Pelvic Ring Injuries

Kavi Bhalla, PhD

Assistant Professor of Epidemiology and Global Health
Department of Public Health Sciences
The University of Chicago Biological Sciences
Chicago, Illinois
2: Global Burden of Musculoskeletal Injuries
vi Contributors

Mark R. Brinker, MD Neal Chen, MD

Director of Acute and Reconstructive Trauma Interim Chief, Hand and Upper Extremity Service
Texas Orthopaedic Hospital Massachusetts General Hospital
Fondren Orthopaedic Group, LLP Assistant Professor
Houston, Texas; Harvard Medical School
Clinical Professor of Orthopaedic Surgery Boston, Massachusetts
University of Texas Medical School—Houston 45: Fractures of the Distal Humerus
Houston, Texas;
Clinical Professor of Orthopaedic Surgery Christina W. Cheng, MD
Tulane University School of Medicine Orthopaedic Spine Fellow
New Orleans, Louisiana; Department of Orthopaedics and Sports Medicine
Clinical Professor of Orthopaedic Surgery Harborview Medical Center
Baylor College of Medicine University Washington
Houston, Texas Seattle, Washington
26: Nonunions: Evaluation and Treatment 30: Craniocervical Injuries: Atlas Fractures, Atlanto-Occipital
Injuries, and Atlantoaxial Injuries
Nico Bruns, MD
Resident Trauma Department Jan-Dierk Clausen, MD
Hannover Medical School (MHH) Resident Trauma Department
Hannover, Germany Hannover Medical School (MHH)
73: Articular Cartilage Reconstruction Using Osteochondral Hannover, Germany
Allografts 73: Articular Cartilage Reconstruction Using Osteochondral
Allografts
Constantinus F. Buckens, MD, PhD
Department of Radiology Mark S. Cohen, BS, MD
University Medical Center Hand and Upper Extremity Division
Utrecht, The Netherlands Department of Orthopaedic Surgery
34: Fractures in the Ankylosed Spine Rush University Medical Center
Chicago, Illinois
Ryan P. Calfee, MD, MSc 42: Fractures of the Distal Radius
Associate Professor
Department of Orthopaedic Surgery Peter A. Cole, MD
Washington University School of Medicine Professor, Department of Orthopaedic Surgery
St. Louis, Missouri University of Minnesota
13: Disaster Management Minneapolis, Minnesota;
Chair, Department of Orthopaedic Surgery
Jon Carlson, MD Regions Hospital
Department of Orthopaedic Surgery St. Paul, Minnesota
University of Louisville School of Medicine 49: Scapula Fractures
Louisville, Kentucky 50: Chest Wall Trauma: Rib and Sternum Fractures
24: Diagnosis and Treatment of Complications 62: Tibial Plateau Fractures

Charles Cassidy, MD Leo M. Cooney, Jr., MD

Henry H. Banks Professor and Chairman Humana Foundation Professor of Geriatric Medicine
Department of Orthopaedics Yale University School of Medicine
Tufts Medical Center New Haven, Connecticut
Boston, Massachusetts 53: Medical Management of the Patient With Hip Fracture
41: Fractures and Dislocations of the Carpus
R. Richard Coughlin, MD, MSC
Renan C. Castillo, PhD Professor Emeritus of Orthopaedic Surgery
Associate Professor University of California, San Francisco;
Department of Health Policy and Management Institute for Global Orthopaedics and Traumatology
Johns Hopkins Bloomberg School of Public Health Orthopaedic Trauma Institute
Baltimore, Maryland Department of Orthopaedic Surgery
2: Global Burden of Musculoskeletal Injuries University of California, San Francisco
San Francisco, California
3: The Challenges of Orthopaedic Trauma Care in the
Developing World
 Contributors vii

Aaron Creek, MD Austin T. Fragomen, MD

Clinical Instructor of Orthopaedic Surgery Fellowship Director
University of Louisville Department of Orthopaedic Associate Professor of Clinical Orthopaedic Surgery
Surgery Hospital for Special Surgery
Norton Leatherman Spine Center Weill Cornell Medical College
Louisville, Kentucky Cornell University
33: Thoracolumbar Trauma New York, New York
27: Motorized Intramedullary Lengthening Nail for Limb
Pim A. de Jong, MD, PhD Reconstruction
Department of Radiology
University Medical Center Brett A. Freedman, MD
Utrecht, The Netherlands Associate Professor of Orthopaedics
34: Fractures in the Ankylosed Spine Mayo Clinic
Rochester, Minnesota
Sebastian Decker, MD 17: Compartment Syndromes
Specialist Surgeon in Trauma Surgery
Trauma Department Eli C. Garrard, MD
Hannover Medical School (MHH) Assistant Professor
Hannover, Germany Emory University School of Medicine
31: Craniocervical Injuries: C2 Fractures Atlanta, Georgia
38: Pelvic Ring Injuries 33: Thoracolumbar Trauma

John R. Dimar, II, MD Joshua L. Gary, MD

Clinical Professor of Orthopaedic Surgery Associate Professor
University of Louisville Department of Orthopaedic McGovern Medical School at UTHealth Houston
Surgery Houston, Texas
Norton Leatherman Spine Center Staff 39: Surgical Treatment of Acetabular Fractures
Chief of Pediatric Orthopaedics
Norton Children’s Hospital Ralph Gaulke, MD, PhD
Louisville, Kentucky Professor
33: Thoracolumbar Trauma Deputy Head of the Trauma Department
Hannover Medical School (MHH)
Shah-Nawaz M. Dodwad, MD Hannover, Germany
Orthopaedic Spine Surgeon 43: Diaphyseal Fractures of the Forearm
Department of Orthopaedic Surgery
University of Texas Health Sciences Center at Houston Tad Gerlinger, MD, COL (ret)
Houston, Texas Director, Adult Reconstruction Fellowship
33: Thoracolumbar Trauma Assistant Professor, Rush University Medical Center
Associate Professor, USUHS
John C. Dunn, MD Midwest Orthopaedics at Rush
William Beaumont Army Medical Center Chicago, Illinois
El Paso, Texas 13: Disaster Management
19: Soft Tissue Reconstruction
George M. Ghobrial, MD
Elton R. Edwards, MB, BS, FRACS Department of Neurosurgery
Department of Orthopaedic Surgery Thomas Jefferson University
Alfred Hospital Philadelphia, Pennsylvania
Melbourne, Australia 36: Avoiding Complications in Spine Trauma Patients
57: Subtrochanteric Fractures of the Femur
Peter V. Giannoudis, MD, FACS, FRCS
Garth A. Elias, MD Professor and Chairman
Clinical Associate Professor of Surgery Academic Department of Trauma and Orthopaedic
University of Pittsburgh School of Medicine Surgery
Pittsburgh, Pennsylvania School of Medicine
10: Evaluation and Treatment of the Multi-Injured Trauma University of Leeds
Patient Leeds, United Kingdom
58: Femoral Shaft Fractures
James Ficke, MD, FACS 69: Periprosthetic Fractures of the Lower Extremity
Robert A. Robinson Professor and Chairman
Department of Orthopaedic Surgery
Johns Hopkins Medicine
Baltimore, Maryland
71: Limb Salvage and Reconstruction
viii Contributors

Peter Ginaitt, RN, EMT Daniel Guenther, MD

Senior Environmental Health and Safety Officer Consultant, Outside Lecturer
Emergency Manager Department of Orthopaedic Surgery, Trauma Surgery, and
Rhode Island Public Transit Authority Sports Medicine
Member, FEMA National Advisory Council Cologne Merheim Medical Center
Providence, Rhode Island Written/Herdecke University
13: Disaster Management Cologne, Germany
60: Patella Fractures and Extensor Mechanism Injuries
I. Leah Gitajn, MD 61: Dislocations and Soft Tissue Injuries of the Knee
Assistant Professor
Department of Orthopaedics George J. Haidukewych, MD
Dartmouth Geisel School of Medicine Department of Orthopaedic Surgery
Dartmouth Hitchcock Medical Center Orlando Medical Center
Lebanon, New Hampshire Orlando, Florida
67: Foot Injuries 56: Posttraumatic Reconstruction of the Hip Joint

Wade Gordon, MD Shannon Hann, MD

Southern Oregon Orthopaedics; Department of Neurosurgery
Rogue Regional Medical Center Thomas Jefferson University
Medford, Oregon Philadelphia, Pennsylvania
8: Principles and Complications of External Skeletal Fixation 36: Avoiding Complications in Spine Trauma Patients

Thomas Gösling, MD Sigvard T. Hansen, Jr., MD

Professor of Trauma and Orthopaedic Surgery Harborview Medical School
General Hospital Braunschweig Seattle, Washington
Braunschweig, Germany 68: Posttraumatic Reconstruction of the Foot and Ankle
58: Femoral Shaft Fractures
Mitchel B. Harris, MD
Richard A. Gosselin, MD, MPH, MSC, FRCS(C) Department of Orthopaedic Surgery
Associate Clinical Professor, Department of Orthopaedic Massachusetts General Hospital
Surgery Harvard Medical School
Co-Director, Institute for Global Orthopaedics and Boston, Massachusetts
Traumatology 11: Initial Evaluation of the Spine in Trauma Patients
University of California, San Francisco
San Francisco, California James S. Harrop, MD
3: The Challenges of Orthopaedic Trauma Care in the Department of Neurosurgery
Developing World Thomas Jefferson University
Philadelphia, Pennsylvania
James A. Goulet, MD 36: Avoiding Complications in Spine Trauma Patients
Professor and Chief of Orthopaedic Trauma
Department of Orthopaedic Surgery Brandi Hartley, MD
University of Michigan Department of Orthopaedic Surgery
Ann Arbor, Michigan University of Louisville School of Medicine
52: Hip Dislocations Louisville, Kentucky
24: Diagnosis and Treatment of Complications
Matt L. Graves, MD
Hansjörg Wyss AO Medical Foundation Chair of Nael Hawi, MD, MBA
Orthopaedic Trauma Consultant, Outside Lecturer
Professor and Residency Program Director Trauma Department
Department of Orthopaedic Surgery, Division of Trauma Hannover Medical School (MHH)
University of Mississippi Medical Center Hannover, Germany
Jackson, Mississippi 59: Fractures of the Distal Femur
8: Principles and Complications of External Skeletal Fixation
Roman Hayda, MD, COL (ret)
Stuart A. Green, MD Associate Professor Orthopaedic Surgery
Clinical Professor Brown University Warren Alpert School of Medicine
Orthopaedic Surgery Director Orthopaedic Trauma
University of California, Irvine Rhode Island Hospital
Irvine, California Providence, Rhode Island
8: Principles and Complications of External Skeletal Fixation 13: Disaster Management
 Contributors ix

Austin Heare, MD Joey P. Johnson, MD

Assistant Professor Orthopaedic Surgery Assistant Professor
University of Miami Miller School of Medicine Department of Orthopaedic Surgery
Department of Orthopaedics Loma Linda University
Miami, Florida Loma Linda, California
49: Scapula Fractures 2: Global Burden of Musculoskeletal Injuries

Matthew Herring, MD Clifford B. Jones, MD, FAOA, FACS

Orthopaedic Trauma Institute National Chief of Orthopaedic Trauma, Center for
Department of Orthopaedic Surgery Orthopaedic Research and Education (CORE
University of California, San Francisco Institute®)
Zuckerberg San Francisco General Hospital and Trauma Professor, Orthopaedic Surgery, University of Arizona
Center Medical School–Phoenix
San Francisco, California Center Chiefs for Orthopaedic Trauma, University Medical
50: Chest Wall Trauma: Rib and Sternum Fractures Center, Banner Orthopaedic & Spine Institute
Phoenix, Arizona
Jennifer Hoffman, MD 18: Open Fractures
Associate Professor
Department of Orthopaedics Bernhard Jost, MA, MD, FAOA
Tufts Medical Center Department of Orthopaedic Surgery and Traumatology
Boston, Massachusetts Kantonsspital, St. Gallen, Switzerland
41: Fractures and Dislocations of the Carpus 47: Proximal Humeral Fractures and Glenohumeral
Dislocations
Jacob Hoffmann, MD
Resident Jesse B. Jupiter, MD
Orthopaedics Director of Orthopaedic Hand Service
McGovern Medical School at The University of Texas Massachusetts General Hospital
Health Science Center at Houston Harvard Medical School
Houston, Texas Boston, Massachusetts
33: Thoracolumbar Trauma 48: Fractures and Dislocations of the Clavicle
51: Replantation
Langston T. Holly, MD
Professor and Vice Chair Warren Kadrmas, MD, COL (s)
Department of Neurosurgery and Orthopaedics Deceased
David Geffen School of Medicine at UCLA 13: Disaster Management
Los Angeles, California
37: Principles of Orthotic Management Steven P. Kalandiak, MD
Assistant Professor
Joseph R. Hsu, MD Orthopaedics
Orthopaedic Trauma Surgeon University of Miami
Professor, Department of Orthopaedic Surgery Miami, Florida
Carolinas Medical Center 20: Gunshot Wounds and Blast Injuries
Charlotte, North Carolina
71: Limb Salvage and Reconstruction Stephen L. Kates, MD
Professor and Chairman
Robert Jacobs, MD Department of Orthopaedic Surgery
University of Minnesota Virginia Commonwealth University
Minneapolis, Minnesota Richmond, Virginia
65: Fractures of the Tibial Pilon 22: Osteoporotic Fragility Fractures

Michael Jagodzinski, PhD Stuart D. Kinsella, MD

Department of Orthopaedic Trauma Department of Orthopaedic Surgery
Schaumburg Hospital Massachusetts General Hospital
Obernkirchen, Germany Harvard Medical School
60: Patella Fractures and Extensor Mechanism Injuries Boston, Massachusetts
61: Dislocations and Soft Tissue Injuries of the Knee 11: Initial Evaluation of the Spine in Trauma Patients

Sameer Jain, MBChB, MSc, FRCS Melissa Klausmeyer, MD

Senior Arthroplasty Fellow Department of Surgery
Wrightington Hospital Kaiser Permanente
Wigan, United Kingdom West Los Angeles Medical Center
69: Periprosthetic Fractures of the Lower Extremity Los Angeles, California
51: Replantation
x Contributors

Brian S. Knipp, MD Richard F. Kyle, MD

Department of Surgical Services Professor of Orthopaedic Surgery
Naval Medical Center, Portsmouth University of Minnesota
Portsmouth, Virginia Faculty, Orthopaedic Department
16: Evaluation and Treatment of Vascular Injuries Hennepin Healthcare
38: Pelvic Ring Injuries Minneapolis, Minnesota
6: Biomechanics of Fractures
Dominic Konadu-Yeboah, MBChB, MPH, FGCS,
FWACS Paul M. Lafferty, MD
Adjunct Lecturer Director of Orthopaedic Trauma
Department of Surgery, Trauma and Orthopaedics Twin Cities Orthopaedics
Kwame Nkrumah University of Science and Technology, Golden Valley, Minnesota
Kumasi 62: Tibial Plateau Fractures
Part-Time Lecturer
Department of Surgery Loren Latta, PE, PhD
University of Health and Allied Sciences, Ho Professor Emeritus, Director of Biomechanics Research
Senior Specialist Orthopaedics
Komfo Anokye Teaching Hospital University of Miami, Miller School of Medicine
Kumasi, Ghana Miami, Florida
3: The Challenges of Orthopaedic Trauma Care in the 7: Closed Fracture Management
Developing World
William F. Lavelle, MD
Christian Krettek, PhD, FRACS, FRCSEd Department of Orthopaedic Surgery
University Professor SUNY Upstate Medical University
Director of the Trauma Department Syracuse, New York
Hannover Medical School (MHH) 33: Thoracolumbar Trauma
Hannover, Germany
31: Craniocervical Injuries: C2 Fractures Alexander Lerner, MD, PhD
59: Fractures of the Distal Femur Head of Department, Orthopaedic Surgery
63: Nonunions and Malunions about the Knee Ziv Medical Center
73: Articular Cartilage Reconstruction Using Osteochondral Professor, Faculty of Medicine in Galilee
Allografts Bar-Ilan University
Zefat, Israel
Ashesh Kumar, MD, MSc, FRCSC 71: Limb Salvage and Reconstruction
Orthopaedic Surgeon
St. Michael’s Hospital Michael P. Leslie, DO, FAOA
Toronto, Canada Department of Orthopaedics and Rehabilitation
7: Closed Fracture Management Yale School of Medicine
New Haven, Connecticut
Sanjeev Kumar, MD 55: Intertrochanteric Hip Fractures
Department of Anesthesiology
University of Florida College of Medicine Paul E. Levin, MD
Gainesville, Florida Professor of Orthopaedic Surgery and Vice-chairman
15: Chronic Pain Management Albert Einstein College of Medicine/Montefiore Medical
Center
Jonneke S. Kuperus, MD, PhD Bronx, New York
Department of Orthopaedic Surgery 28: Psychological, Social, and Functional Manifestations of
University Medical Center Orthopaedic Trauma and Traumatic Brain Injury
Utrecht, The Netherlands
34: Fractures in the Ankylosed Spine Geoffrey S.F. Ling, MD, PhD
COL (ret.), Medical Corps, U.S. Army
Swamy Kurra, MBBS Professor of Neurology, USUHS
Department of Orthopaedic Surgery The Johns Hopkins University
SUNY Upstate Medical University Baltimore, Maryland
Syracuse, New York 28: Psychological, Social, and Functional Manifestations of
33: Thoracolumbar Trauma Orthopaedic Trauma and Traumatic Brain Injury

John Y. Kwon, MD Travis Loidolt, DO

Chief, Orthopaedic Foot & Ankle Service The Orthopaedic Specialty Center of Northern California
Orthopaedic Surgery Roseville, California
Beth Israel Deaconess Medical Center 33: Thoracolumbar Trauma
Boston, Massachusetts
67: Foot Injuries
 Contributors xi

David W. Lowenberg, MD Gareth Medlock, FRCSGlasg

Clinical Professor Consultant, Trauma and Orthopaedics
Department of Orthopaedic Surgery Aberdeen University
Stanford University School of Medicine Aberdeen Royal Infirmary
Redwood City, California Aberdeen, Scotland, United Kingdom
25: Understanding and Treating Chronic Osteomyelitis 7: Closed Fracture Management

Thuan V. Ly, MD Umesh S. Metkar, MD

Associate Professor Department of Orthopaedic Surgery
Department of Orthopaedics Beth Israel Deaconess Medical Center
The Ohio State University Wexner Medical Center Boston, Massachusetts
Columbus, Ohio 33: Thoracolumbar Trauma
54: Intracapsular Hip Fractures
Phillip M. Mitchell, MD
Ellen J. MacKenzie, PhD Orthopaedic Surgery Resident
Bloomberg Distinguished Professor Department of Orthopaedic Surgery
Dean, Bloomberg School of Public Health Vanderbilt School of Medicine
The Johns Hopkins University Nashville, Tennessee
Baltimore, Maryland 4: Vascularity and Stability: The Pillars of Fracture Healing
28: Psychological, Social, and Functional Manifestations of
Orthopaedic Trauma and Traumatic Brain Injury Charles N. Mock, MD, PhD, FACS
Professor of Surgery
Christiaan N. Mamczak, DO, FAOAO University of Washington
Beacon Orthopaedics and Sports Specialists Seattle, Washington
Volunteer Clinical Faculty, Assistant Professor of 3: The Challenges of Orthopaedic Trauma Care in the
Orthopaedic Surgery Developing World
Indiana University School of Medicine–South Bend
South Bend, Indiana Philipp Mommsen, MD, PhD
12: Damage Control Orthopaedic Surgery: A Strategy for the Consultant, Outside Lecturer
Orthopaedic Care of the Critically Injured Patient Trauma Department
Hannover Medical School (MHH)
Meir T. Marmor, MD Hannover, Germany
University of California, San Francisco Orthopaedic 69: Periprosthetic Fractures of the Lower Extremity
Trauma Institute
Department of Orthopaedic Surgery Jensa C. Morris, MD, FACP
San Francisco General Hospital Assistant Clinical Professor of Medicine
San Francisco, California Yale University School of Medicine
64: Tibial Shaft Fractures Medical Director
Center for Musculoskeletal Care at Yale University School
Amir M. Matityahu, MD of Medicine and Yale New Haven Hospital
University of California, San Francisco Orthopaedic New Haven, Connecticut
Trauma Institute 53: Medical Management of the Patient With Hip Fracture
Department of Orthopaedic Surgery
San Francisco General Hospital Victor A. Morris, MD
San Francisco, California Assistant Professor of Medicine
64: Tibial Shaft Fractures Yale School of Medicine
New Haven, Connecticut
Tyler C. McDonald, MD 53: Medical Management of the Patient With Hip Fracture
House Officer
Department of Orthopaedic Surgery Yusef I. Mosley, MD
University of Mississippi Medical Center Marion Bloch Neuroscience Institute
Jackson, Mississippi Saint Luke’s Hospital
9: Principles of Internal Fixation Kansas City, Missouri
36: Avoiding Complications in Spine Trauma Patients
Tristan E. McMillan, MBChB, MRCS, PgC
Department of Orthopaedic Surgery Calin S. Moucha, MD
Aberdeen Royal Infirmary Associate Professor of Orthopaedic Surgery
Aberdeen, Scotland, United Kingdom Department of Orthopaedic Surgery
7: Closed Fracture Management Icahn School of Medicine at Mount Sinai
New York, New York
23: Surgical Site Infection Prevention
xii Contributors

Christian W. Müller, MD F. Cumhur Oner, MD, PhD

Trauma Department Department of Orthopaedic Surgery
Hannover Medical School (MHH) University Medical Center
Hannover, Germany; Utrecht, The Netherlands
Department for Orthopaedics and Trauma 34: Fractures of the Ankylosed Spine
Asklepios Klinik Wandsbek
Hamburg, Germany Brett D. Owens, MD
31: Craniocervical Injuries: C2 Fractures Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Alan D. Murdock, MD, FACS Warren Alpert Medical School, Brown University
Chief of Emergency Surgery Providence, Rhode Island
Division of Trauma 2: Global Burden of Musculoskeletal Injuries
Allegheny General Hospital
Pittsburgh, Pennsylvania Patrick W. Owens, MD
10: Evaluation and Treatment of the Multi-Injured Trauma Associate Professor
Patient Orthopaedic Surgery
University of Miami
George P. Nanos, III, MD Miami, Florida
Department of Surgery 20: Gunshot Wounds and Blast Injuries
Uniformed Services University
Department of Orthopaedics Eric Pagenkopf, MD
Walter Reed National Military Medical Center Envision Physician Services
Bethesda, Maryland Dallas, Texas
19: Soft Tissue Reconstruction 12: Damage Control Orthopaedic Surgery: A Strategy for the
72: Amputations in Trauma Orthopaedic Care of the Critically Injured Patient

Claudia Neunaber, MD Dror Paley, MD, FRCSC

Outside Lecturer Director
Head of the Experimental Trauma Research Laboratory Paley Orthopaedic and Spine Institute
Trauma Department West Palm Beach, Florida
Hannover Medical School 63: Malunions and Nonunions About the Knee
Hannover, Germany 70: Principles of Deformity Correction
73: Articular Cartilage Reconstruction Using Osteochondral
Allografts Hari K. Parvataneni, MD
Associate Professor of Orthopaedic Surgery
Olga C. Nin, MD Orthopaedics and Rehabilitation
Assistant Professor of Anesthesiology University of Florida College of Medicine
Department of Anesthesiology Gainesville, Florida
University of Florida College of Medicine 14: The Management of Acute and Perioperative Pain
Gainesville, Florida Associated With Trauma and Surgery
14: The Management of Acute and Perioperative Pain
Associated With Trauma and Surgery Alpesh A. Patel, MD, FACS
Department of Orthopaedic Surgery
Tianyi Niu, MD Department of Neurosurgery
Department of Neurosurgery Northwestern University
David Geffen UCLA School of Medicine Feinberg School of Medicine
Los Angeles, California Chicago, Illinois
37: Principles of Orthotic Management 33: Thoracolumbar Trauma

Sean E. Nork, MD Andrew B. Peitzman, MD, FACS

Department of Orthopaedic Surgery Distinguished Professor of Surgery
Harborview Medical Center Mark M. Ravitch Professor and Vice-Chairman,
Seattle, Washington Department of Surgery
57: Subtrochanteric Fractures of the Femur UPMC Vice-President for Trauma and Surgical Services
University of Pittsburgh School of Medicine
Daniel P. O’Connor, PhD Pittsburgh, Pennsylvania
Professor, Department of Health and Human 10: Evaluation and Treatment of the Multi-Injured Trauma
Performance Patient
University of Houston
Houston, Texas
26: Nonunions: Evaluation and Treatment
 Contributors xiii

Elizabeth M. Polfer, MD Craig S. Roberts, MD

Department of Orthopaedics Department of Orthopaedic Surgery
William Beaumont Army Medical Center University of Louisville School of Medicine
El Paso, Texas; Louisville, Kentucky
Department of Surgery 24: Diagnosis and Treatment of Complications
Uniformed Services University
Bethesda, Maryland Mellisa Roskosky, PhD
72: Amputations in Trauma Department of International Health
Johns Hopkins Bloomberg School of Public Health
Benjamin K. Potter, MD Baltimore, Maryland
Department of Surgery 17: Compartment Syndromes
Uniformed Services University
Department of Orthopaedics Milton Lee (Chip) Routt, Jr., MD
Walter Reed National Military Medical Center Professor
Bethesda, Maryland Andrew R. Burgess Endowed Chair
72: Amputations in Trauma McGovern Medical School at UTHealth Houston
Houston, Texas
Daniel E. Prince, MD 39: Surgical Treatment of Acetabular Fractures
Memorial Sloan Kettering Cancer Center
New York, New York Michael J. Roy, MD, MPH
63: Malunions and Nonunions About the Knee COL (ret), U.S. Army
Professor of Medicine
Rene Przkora, MD, PhD Uniformed Services University
Department of Anesthesiology Bethesda, Maryland
University of Florida College of Medicine 28: Psychological, Social, and Functional Manifestations of
Gainesville, Florida Orthopaedic Trauma and Traumatic Brain Injury
15: Chronic Pain Management
S. Robert Rozbruch, MD
Stefan Rammelt, MD, PhD Service Chief
University Hospital Carl Gustav Carus Professor of Clinical Orthopaedic Surgery
Dresden, Germany New York, New York
68: Posttraumatic Reconstruction of the Foot and Ankle 27: Motorized Intramedullary Lengthening Nail for Limb
Reconstruction
Mark C. Reilly, MD
Department of Orthopaedic Surgery David E. Ruchelsman, MD, FAAOS
Rutgers–The State University of New Jersey Chief, Hand and Upper Extremity Surgery
Newark, New Jersey Director, Hand Surgery Research & Education Foundation
57: Subtrochanteric Fractures of the Femur Clinical Associate Professor of Orthopaedic Surgery
Tufts University School of Medicine
Noam Reshef, MD Consultant, Massachusetts General Hospital/Harvard
Orthopaedic Surgeon Medical School
Orthopaedic Sports Services and Shoulder Surgery Newton, Massachusetts
Ziv Medical Center 40: Fractures and Dislocations of the Hand
Zefat, Israel
71: Limb Salvage and Reconstruction Markus Rupp, MD
Department of Trauma Surgery
Martinus Richter, MD, PhD University Hospital Giessen–Marburg GmbH
Department for Foot and Ankle Surgery Campus Giessen, Germany
Rummelsberg Hospital 25: Understanding and Treating Chronic Osteomyelitis
Schwarzenbruck, Germany
67: Foot Injuries Glenn S. Russo, MD, MS
Connecticut Orthopaedic Specialists
David Ring, MD, PhD Clinical Assistant Professor
Associate Dean for Comprehensive Care Department of Surgery
Department of Surgery and Perioperative Care Frank H. Netter School of Medicine at Quinnipiac
Dell Medical School—The University of Texas at Austin University
Austin, Texas Hamden, Connecticut
48: Fractures and Dislocations of the Clavicle 33: Thoracolumbar Trauma
xiv Contributors

Augusto Sarmiento, MD David W. Shearer, MD, MPH

Chairman Emeritus Chief Resident
Orthopaedics Department of Orthopaedic Surgery
University of Miami University of California San Francisco
Miami, Florida San Francisco, California
7: Closed Fracture Management 3: The Challenges of Orthopaedic Trauma Care in the
Developing World
Adam A. Sassoon, MD
Department of Orthopaedic Surgery Yushane Celestine Shih, MD
UCLA David Geffen School of Medicine Department of Orthopaedic Surgery
Los Angeles, California University of Minnesota
56: Posttraumatic Reconstruction of the Hip Joint Minneapolis, Minnesota
6: Biomechanics of Fractures
Jason W. Savage, MD
Center for Spine Health Michael S. Shuler, MD
Cleveland Clinic Hand and Upper Extremity
Cleveland, Ohio Athens Orthopaedic Clinic
35: Osteoporotic Spinal Fractures Athens, Georgia
17: Compartment Syndromes
Jonathan G. Schoenecker, MD, PhD
Associate Professor Cameron Smith, MD, PhD
Jeffrey W. Mast Chair in Orthopaedics, Trauma and Hip Assistant Professor of Anesthesiology
Surgery Department of Anesthesiology
Department of Orthopaedic, Pediatrics, Pathology and University of Florida College of Medicine
Pharmacology Gainesville, Florida
Vanderbilt University Medical Center 14: The Management of Acute and Perioperative Pain
Nashville, Tennessee Associated With Trauma and Surgery
4: Vascularity and Stability: The Pillars of Fracture Healing
Dale C. Smith, PhD
Patrick Schottel, MD Professor of Military Medicine and History
Assistant Professor Uniformed Services University of the Health Sciences
Orthopaedics and Rehabilitation Bethesda, Maryland
University of Vermont College of Medicine 1: The History of Trauma Care
Burlington, Vermont
65: Fractures of the Tibial Pilon Christoph Sommer, MD
Kantonsspital Graübunden
Lisa K. Schroder, BSME, MBA Graubünden, Switzerland
Director, Geriatric and Orthopaedic Trauma Academic 46: Fractures of the Humeral Shaft
Programs
Department of Orthopaedic Surgery David A. Spiegel, MD
University of Minnesota & Regions Hospital Pediatric Orthopaedic Surgeon
Minneapolis, Minnesota The Children’s Hospital of Philadelphia
49: Scapula Fractures Associate Professor of Orthopaedic Surgery
The University of Pennsylvania School of Medicine
Gregory D. Schroeder, MD Philadelphia, Pennsylvania;
Assistant Professor of Orthopaedic Surgery Consultant in Orthopaedics
Department of Orthopaedic Surgery Hospital and Rehabilitation Centre for Disabled Children
Rothman Institute at Thomas Jefferson University Banepa, Nepal
Philadelphia, Pennsylvania 3: The Challenges of Orthopaedic Trauma Care in the
33: Thoracolumbar Trauma Developing World

David Seligson, MD Andre R. Spiguel, MD

Department of Orthopaedic Surgery Assistant Professor, Division of Orthopaedic Oncology
University of Louisville School of Medicine Department of Orthopaedic Surgery
Louisville, Kentucky University of Florida
24: Diagnosis and Treatment of Complications Gainesville, Florida
21: Pathologic Fractures
 Contributors xv

Christian Spross, MD Daniel G. Tobert, MD

Department of Orthopaedic Surgery and Traumatology Department of Orthopaedic Surgery
Kantonsspital Massachusetts General Hospital
St. Gallen, Switzerland Harvard Medical School
47: Proximal Humeral Fractures and Glenohumeral Boston, Massachusetts
Dislocations 11: Initial Evaluation of the Spine in Trauma Patients

Ryan D. Stancil, MD Marko Tomov, MD

Department of Orthopaedics and Sports Medicine Orthopaedic Surgery
University of Washington Mayo Clinic
Seattle, Washington Rochester, Minnesota
56: Posttraumatic Reconstruction of the Hip Joint 17: Compartment Syndromes

Robert J. Steffner, MD Alexander R. Vaccaro, MD, PhD, MBA

Assistant Clinical Professor Richard H. Rothman Professor and Chairman,
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Stanford University Professor of Neurosurgery
Palo Alto, California Co-Director, Delaware Valley Spinal Cord Injury Center
21: Pathologic Fractures Co-Chief of Spine Surgery
Sidney Kimmel Medical Center at Thomas Jefferson
Scott P. Steinmann, MD University
Professor, Orthopaedic Surgery President, Rothman Institute
Mayo Clinic Health System Philadelphia, Pennsylvania
Rochester, Minnesota 32: Subaxial Cervical Spine Trauma
44: Trauma to the Adult Elbow
Jorrit-Jan Verlaan, MD, PhD
Iain M. Stevenson, MBChB, FRCS Department of Orthopaedic Surgery
Department of Orthopaedic and Trauma Surgery University Medical Center
Aberdeen Royal Infirmary Utrecht, The Netherlands
Aberdeen, Scotland, United Kingdom 34: Fractures in the Ankylosed Spine
7: Closed Fracture Management
James P. Waddell, CM, MD, FRCSC
Daniel Stinner, MD, FACS Professor, Division of Orthopaedic Surgery
Orthopaedic Trauma Surgeon University of Toronto
Assistant Professor Toronto, Ontario, Canada
Vanderbilt University Medical Center 7: Closed Fracture Management
Nashville, Tennessee
71: Limb Salvage and Reconstruction Richa Wardhan, MD
Associate Professor of Anesthesiology
Marc F. Swiontkowski, MD Department of Anesthesiology
Professor, Department of Orthopaedic Surgery University of Florida College of Medicine
University of Minnesota Medical School Gainesville, Florida
Minneapolis, Minnesota 14: The Management of Acute and Perioperative Pain
54: Intracapsular Hip Fractures Associated With Trauma and Surgery

David M. Tainter, MD Douglas Wardlaw, MBChB, ChM, FRCSEd

Department of Orthopaedic Surgery Professor
Duke University Medical Center Robert Gordon University
Durham, North Carolina Aberdeen, United Kingdom
66: Malleolar Fractures and Soft Tissue Injuries of the Ankle 7: Closed Fracture Management

Michel A. Taylor, MD, MSc, FRCSC Gregory A. Watson, MD, FACS

Department of Orthopaedic Surgery Assistant Professor of Surgery and Critical Care
Duke University Medical Center University of Pittsburgh School of Medicine
Durham, North Carolina Pittsburgh, Pennsylvania
66: Malleolar Fractures and Soft Tissue Injuries of the Ankle 10: Evaluation and Treatment of the Multi-Injured Trauma
Patient
Scott M. Tintle, MD
Associate Professor
Walter Reed National Military Medical Center
Bethesda, Maryland
19: Soft Tissue Reconstruction
xvi Contributors

J. Tracy Watson, MD Brad J. Yoo, MD, FACS

Professor of Orthopaedic Surgery Associate Professor
The CORE Institute Department of Orthopaedics and Rehabilitation
University of Arizona College of Medicine Yale School of Medicine
Banner University Medical Center New Haven, Connecticut
Phoenix, Arizona 55: Intertrochanteric Hip Fractures
5: Biology and Enhancement of Skeletal Repair
Yury Zasimovich, MD
Thomas Sanjay Weber-Spickschen, MD Assistant Professor of Anesthesiology
Consultant Department of Anesthesiology
Trauma Department University of Florida College of Medicine
Hannover Medical School (MHH) Gainesville, Florida
Hannover, Germany 14: The Management of Acute and Perioperative Pain
61: Dislocations and Soft Tissue Injuries of the Knee Associated With Trauma and Surgery

Mitchell C. Weiser, MD, MEng Vilijam Zdravkovic, MD, MSc

Instructor of Orthopaedic Surgery Department of Orthopaedic Surgery and Traumatology
Department of Orthopaedic Surgery Kantonsspital
Montefiore Medical Center and Albert Einstein College of St. Gallen, Switzerland
Medicine 47: Proximal Humeral Fractures and Glenohumeral
Bronx, New York Dislocations
23: Surgical Site Infection Prevention
Lewis G. Zirkle, MD
Seth K. Williams, MD Founder and President
Associate Professor SIGN Fracture Care International
Spine and Trauma Divisions Clinical Professor
Department of Orthopaedics and Rehabilitation University of Washington
University of Wisconsin School of Medicine and Public Richland, Washington
Health 3: The Challenges of Orthopaedic Trauma Care in the
Madison, Wisconsin Developing World
33: Thoracolumbar Trauma
Hans Zwipp, MD
Marcel Winkelmann, MD Chairman (ret)
Specialist Surgeon in Trauma Surgery University Center of Orthopaedics and Trauma
Trauma Department University Hospital Carl Gustav Carus
Hannover Medical School (MHH) Dresden, Saxony, Germany
Hannover, Germany 68: Posttraumatic Reconstruction of the Foot and Ankle
38: Pelvic Ring Injuries
Gregory A. Zych, DO, FAOA
Jennifer Wozniczka, MD Christine E. Lynn Distinguished Chair in Orthopaedic
TRIA Orthopaedics Trauma
Minneapolis, Minnesota Professor, Orthopaedic Trauma
6: Biomechanics of Fractures Department of Orthopaedics
Miller School of Medicine
Robert Wysocki, MD University of Miami
Hand and Upper Extremity Division Miami, Florida
Department of Orthopaedic Surgery 20: Gunshot Wounds and Blast Injuries
Rush University Medical Center
Chicago, Illinois
42: Fractures of the Distal Radius
 Foreword

I am honored and humbled to have been asked to write the Now in its tenth year, and thanks to the generous support
foreword to the sixth edition of Skeletal Trauma. I have person- of the Department of Defense, METRC has helped foster
ally relied on this formative text throughout my career, and collaborations in support of the research needed to address
I look forward to placing this new edition on my bookshelf the many unanswered questions raised throughout this
alongside the many other volumes I frequent in the course volume. Continued investment in collaborative research will
of my research. advance the care of injured service members in future conflicts
The significance of asking a health services researcher, and contribute to the medical readiness of current forces
not a surgeon, to write the foreword to this text is not lost by optimizing recovery and return to duty following common
on me. It signals an appreciation of orthopaedic trauma as in-garrison musculoskeletal injuries.
a major public health problem—both here in the United I am particularly pleased to see increased attention paid in
States and globally. So, allow me to bring a public health this sixth edition to the management of both perioperative
perspective to some of the topics covered in this text and pain and chronic pain. We know that postoperative pain is
on trauma orthopaedics more broadly. a major determinant of long-term outcome and disability
It is appropriate that any comprehensive text on skeletal following orthopaedic trauma. We also know that recent efforts
trauma begin with a discussion of the global burden of to address pain have led to an unprecedented increase in
musculoskeletal injuries. As outlined in Chapter 2, injuries opioid prescriptions and a monumental public health crisis.
remain a leading cause of death and disability in the United Opioid overdose deaths now exceed the number of deaths
States and around the world, claiming nearly 5 million lives from car crashes, guns, HIV, and even the Vietnam War.
annually. For every injury death, there are an estimated 10 to Today, more than 2 million Americans are afflicted with
50 survivors who sustain temporary or permanent disabilities. opioid use disorder. Orthopaedic surgeons are the third-
Although data on the long-term consequences of injury are highest prescribers of opioid pain medication, accounting
fragmented, it is generally acknowledged that much of this for nearly 8% of all prescriptions. In response to this growing
disability is attributed to musculoskeletal trauma. Fractures epidemic, new prescribing guidelines have taken shape,
alone account for 40% of the health burden of nonfatal and states have passed laws making it harder to prescribe
injuries. Low- and middle-income countries (LMICs) suffer high doses to first-time patients. Opioid prescriptions have
a disproportionate share of the global injury burden. In declined by one-third since their peak; however, there have
LMICs, injuries result in more than 220 million disability- been unintended consequences. Patients with uncontrolled
adjusted life years lost each year—more than heart disease, pain who are unable to obtain adequate relief are turning
cancer, tuberculosis, malaria, and HIV combined. Chapter to cheaper and more available street drugs as an alternative.
3 does a superb job of addressing the challenges in man- Today, the majority of opioid deaths are caused by heroin,
aging this burden in LMICs with appropriate attention fentanyl, and other street drugs. Reducing opioid-related
paid to improving systemwide approaches to trauma care deaths requires a comprehensive, community-based approach,
within the context of the Global Alliance for Care of the including broad access to medications such as methadone
Injured. and buprenorphine. Meanwhile, the orthopaedic community
I applaud the editors for continuing to leverage the col- must stay vigilant in following best practices in prescribing
laborations between the military and civilian orthopaedic opioids and continue to investigate new ways to manage
communities. Throughout history, lessons learned from battle pain’s debilitating effects. Chapters 14 and 15 provide
have been fundamental to advancing injury care in civilian a wide-ranging and forward-looking discussion on this
life. Equally important, however, has been the need to further important topic.
develop and refine these advances in civilian practice during I will end with a plea for paying more attention to the
peacetime so they are available during future conflicts. This psychosocial comorbidities that often accompany both military
is particularly important today as US combat activity de- and civilian musculoskeletal trauma. Depression and post-
escalates. Developing military–civilian partnerships and traumatic stress are common. Even subclinical symptoms of
establishing a national trauma system that can ensure the emotional distress and anxiety can affect recovery if not
delivery of optimal care from point of injury to hospitalization, addressed. Significant improvements in long-term patient
rehabilitation, and reintegration back into society were key outcomes will not be possible without addressing the psy-
recommendations of a recent report from the National chological sequelae of the physical injury and traumatic event,
Academies of Sciences, Engineering, and Medicine. The as Chapter 28 makes clear. The orthopaedic trauma care
commitment to these partnerships was embodied in the Major team plays an important role in recognizing early signs of
Extremity Trauma Research Consortium (METRC), a network psychological distress through effective screening mechanisms
of military and civilian trauma centers established to build and initiating strategies that can treat these symptoms within
the evidence for best practices in orthopaedic trauma care. a patient- and family-centered environment.

xvii