Low-energy fractures can be painful and traumatic—but those that result from major trauma such as a motor vehicle accident or a fall from a significant height are of a different magnitude. Such accidents can cause serious injuries across the body, shattering or breaking multiple bones, sometimes in several places. Sometimes the broken bone fragments puncture the skin and are exposed. Treatment of these “complex” or “high-energy” fractures is complicated

According to Yale Medicine orthopaedic trauma surgeon Matthew D. Riedel, MD, fractures are labeled “complex” when the bone breaks into multiple pieces, when the soft tissue surrounding the bone is severely damaged or torn open, or when the patient has other illnesses or injuries that can complicate treatment and healing.

Helping patients with these severe injuries is not simply a matter of repairing broken bones, says Dr. Riedel. “All the doctors involved in the patient’s care have to work together to determine the timing and sequence of surgical procedures as well as how to safely move the patient forward through their entire treatment path.”

For example, an individual with a shattered knee fracture who also sustains head injuries in an accident cannot undergo knee surgery until their medical condition is stabilized. This is because surgery could result in low blood pressure, which can have potentially devastating effects on the head injuries. “The definitive surgery to fix the knee might need to wait days or weeks,” he says. “We may need to stabilize the patient with a less invasive surgery, such as the placement of an external fixator, which would buy time until we can safely do what needs to be done.”

Most patients with complex fractures are seen first in the emergency department, where doctors determine the extent and severity of the injuries. “We perform a very systematic evaluation on every trauma patient who comes in—in conjunction with the emergency, general surgery, plastic surgery, vascular surgery, and neurosurgery doctors,” says Dr. Riedel. “We find all the injuries and figure out which types of doctors (such as vascular surgeons, neurosurgeons, etc.) are needed to help with this person’s care. Then we work together to determine the timing and sequence of treatment.”

A clinical exam, blood tests, and imaging studies, including X-rays and computed tomography (CT) scans, are used to identify the problems. “We prioritize the injuries and make treatment decisions individually, based on the patient’s medical status and whether they are healthy enough to undergo a particular procedure at a certain time,” Dr. Riedel says.

Every trauma patient is different, so treatment must be modified to the specific case, with input from all the specialists involved in the patient’s care. If multiple surgeries are required, Dr. Riedel says, they may be done in several stages.

The initial goal is medical stabilization, life- and limb-saving procedures, and pain relief. Subsequent surgeries depend on the patient’s needs and ability to recover and face additional surgeries. Sometimes multiple procedures can be done at the same time. Considerations include not only the extent of a patient’s injuries, but also other medical conditions, such as obesity and smoking, both of which can slow down bone healing or affect wound healing—as well as pregnancy or heart disease. Among the many specialists involved are vascular surgeons and plastic surgeons, Dr. Riedel says.

Just one of two Level I trauma centers in Connecticut, Yale New Haven Hospital is where Yale Medicine's orthopaedic trauma surgeons provide life-saving treatment to many patients with serious traumatic injuries. Besides having five surgeons who specialize in orthopaedic trauma, Dr. Riedel says, Yale Medicine is unique in having “the depth and breadth of specialists not only in orthopaedics but also in vascular surgery, neurosurgery, plastic surgery, general surgery, and intensive care providers on staff and available 24/7 to provide the level of care patients like these need.”

Further, says Dr. Riedel, “Our department also features surgeons skilled in other types of orthopaedic surgery. Complex ligament reconstruction, bone regeneration and limb salvage, limb and digit replantation, and complex joint replacement are just a few of these other specialized orthopaedic services we are able to provide. It’s incredibly valuable for us to be able to reach out to our colleagues with that type of expertise and enlist their help." He adds, “We are all also actively involved in research that is changing how major orthopaedic trauma is treated around the world and remain on the cutting edge of new technologies and procedures to best treat our patients as well as teach others how to best care for severely injured patients.”