Introduction

Fractures are common injuries in abused children, second only to cutaneous bruising (1). Although fundamental to the documentation of abuse, the fractures are rarely life-threatening and few result in long-term deformity. Specific types of fractures are known to be associated with abuse, and their recognition is important for their accurate identification and in understanding their significance.

Many reports of unexplained subdural hematomas (SDHs) in infants had appeared before Caffey’s historic 1946 article, but it was only after he associated these lesions with certain patterns of skeletal injury that the modern medical entity of child abuse was formulated (2). In a sense, recognition of the role of skeletal injuries in child abuse became the catalyst for the surge of interest in child maltreatment after Caffey’s original description.

In the years that followed, most reports of child abuse focused mainly on the radiologic alterations associated with the skeletal trauma (3–14). The confident documentation of skeletal injury, facilitated by characteristic radiologic alterations, provided investigators the opportunity to study the multiple facets of child abuse. Eventually, the blend of the clinical and the radiologic findings led Kempe, Silverman, and others to bring these associations to the status of the “battered child syndrome” (15).

Objectives

1. List the advantages of early fracture fixation.

2. Discuss risk factors and complications of orthopedic trauma including advanced age, obesity, intoxication, compartmental syndrome, positioning injuries, and fat embolism.

3. Evaluate anesthetic concerns for patients with hip fracture, pelvic injury, and traumatic spinal cord injuries.

4. Review the options for postoperative pain control after orthopedic trauma including patient-controlled analgesia (PCA), epidural analgesia, and peripheral nerve blocks.

INTRODUCTION

Almost 60 million people are injured in the United States annually, accounting for roughly one in six hospital admissions. There are as many as 148,000 deaths related to trauma each year in the United States [1]. Unintentional injuries were the fifth leading cause of death in 2004 [2]. The fund of knowledge gained from experiences and research work has given victims of trauma significant potential for survival. This is particularly so when considering orthopedic trauma and the anesthetic management of its victims.

This chapter breaks the surface of the choppy waters of orthopedic trauma anesthesia. By exploring the patients that present, and the scenarios by which they may be married to trauma, as well as concepts related to their care, the anesthesia practitioner may gain a new perspective on the management of patients who have suffered acute orthopedic injuries.

EARLY FRACTURE FIXATION

When assessing a multiple-injury patient, attention to all systems is in high order. Although acute cardiopulmonary, visceral, and neurologic trauma take precedence, it is of extreme importance that orthopedic injuries are fully evaluated (see Chapters 13 and 15).