Basics of Traumatology
Definition
Traumatology in orthopaedics is a subspecialty of medicine that focuses on the acute assessment, management, and treatment of injuries to the musculoskeletal system caused by external forces123. It encompasses the study of wounds and injuries to bones, joints, muscles, tendons, ligaments, and associated soft tissues resulting from accidents, violence, or other traumatic events3. Rationale: This definition establishes the scope and clinical significance of the specialty within the broader field of orthopaedics.
Epidemiology
Global Context
Injuries represent one of the leading causes of mortality and disability worldwide, with the Southeast Asia region accounting for the largest proportion of global injury-related deaths4. According to WHO data, 222 people die every hour from injuries in the South-East Asia Region, with road traffic injuries being the biggest killer among all unintentional injuries4.
Malaysian Context
In Malaysia, the current ratio of orthopaedic surgeons to the population is 1:50,0005. The prevalence of orthopaedic surgical site infections in Malaysian hospitals ranges from 1.243% in clean and clean-contaminated surgeries6. Among trauma admissions, major trauma (Injury Severity Score > 15) comprises 52.9% of cases, with young males aged 21-40 years forming 43.8% of all admissions7. Motorcycle crashes account for 73.4% of road traffic accident-related trauma cases7. Hip fractures show an incidence rate of 90 cases per 100,000 adults aged 50 and above8, with the incidence expected to rise by a factor of 3.5 by 20508.
The burden of musculoskeletal injuries extends beyond acute trauma, with 6.63% of Malaysian adults reporting bone fractures, predominantly affecting males (65.8%)9. Road injury remains the leading cause of mortality and morbidity, with Malaysia showing some of the highest age-standardised disability-adjusted life-year rates in the ASEAN region1011.
Pathophysiology
The pathophysiology of traumatic musculoskeletal injuries follows a predictable cascade:
Mechanism of Injury → Tissue Damage → Inflammatory Response → Healing Process
Trauma occurs through various mechanisms including high-energy impacts (motor vehicle accidents), low-energy impacts (falls), penetrating injuries, or overuse mechanisms12. The severity of tissue damage depends on the magnitude and direction of applied forces, with high-energy trauma often resulting in complex fracture patterns, soft tissue disruption, and associated injuries1314.
Classification
Injury Severity Classification
Musculoskeletal trauma is classified based on several parameters15:
By Onset:
Acute: Single traumatic event (24-48 hours)
Chronic: Prolonged exposure to repetitive stress (≥7 days)
By Tissue Involvement:
Bone injuries (fractures)
Soft tissue injuries (muscle, tendon, ligament)
Combined injuries (fracture-dislocations)
AO Classification System
The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification provides a standardized system for fracture classification based on bone location, fracture morphology, and severity161718. This alphanumeric system allows for consistent communication and treatment planning across the specialty18.
Damage Control Orthopedics Classification
Patients are stratified into categories based on physiological status1920:
Stable patients: Candidates for Early Total Care (ETC)
Borderline patients: Requires careful assessment
Unstable patients: Requires Damage Control Orthopedics (DCO)
Clinical Features
Primary Survey Assessment
All trauma patients require systematic evaluation using the ABCDE approach2122:
Airway control with cervical spine stabilization
Breathing assessment and respiratory support
Circulation with hemorrhage control
Disability/neurological assessment (Glasgow Coma Scale)
Exposure with hypothermia prevention
Red Flags Requiring Immediate Intervention
Hemorrhagic shock: Systolic blood pressure <90 mmHg, heart rate >130 bpm2223
Neurological compromise: Glasgow Coma Scale <92223
Open fractures: Direct communication between fracture site and external environment1224
Compartment syndrome: Increased pressure within fascial compartments25
Vascular injuries: Absent or diminished pulses, expanding hematoma26
Investigations
Bedside Assessment
Primary and secondary trauma survey
Focused Assessment with Sonography in Trauma (FAST)
Vital signs monitoring and neurological assessment
Rationale: Immediate life-threatening conditions require rapid identification and intervention2122
First-Line Imaging
Plain radiographs (anteroposterior and lateral views)
Computed tomography for complex fractures and polytrauma
Rationale: Plain radiographs provide initial fracture characterization, while CT offers detailed assessment of fracture patterns and associated injuries2728
Advanced Imaging
Magnetic resonance imaging for soft tissue evaluation
Angiography for suspected vascular injuries
Rationale: Advanced imaging guides definitive treatment planning and identifies occult injuries26
Management
Principles of Trauma Management
Initial Management (ABCDE approach): Life-threatening conditions take priority over limb-threatening injuries2122
Damage Control vs. Early Total Care: Decision based on patient physiological status and injury severity291920
Acute Management
For Stable Patients (Early Total Care):
Definitive fracture fixation within 24 hours
Internal fixation with plates, screws, or intramedullary nails
Rationale: Early definitive care in stable patients reduces complications and improves outcomes3031
For Unstable Patients (Damage Control Orthopedics):
External fixation for temporary stabilization
Delayed definitive fixation (4-15 days post-injury)
Rationale: DCO prevents "second hit" phenomenon and reduces risk of systemic complications321419
Definitive Management
Fracture Fixation Principles (AO Principles)3130:
Anatomical reduction to restore normal anatomy
Stable fixation (absolute or relative stability)
Preservation of blood supply to bone and soft tissues
Early mobilization to prevent complications
Specific Fixation Methods:
Compression plating: For simple fractures requiring rigid fixation
Bridging plates: For comminuted fractures
Intramedullary nailing: For long bone diaphyseal fractures
External fixation: For severe soft tissue injury or unstable patients
Long-term Management
Rehabilitation and physiotherapy
Management of complications (nonunion, malunion, infection)
Psychosocial support for PTSD and depression (43.3% prevalence in Malaysian trauma patients)3334
Rationale: Comprehensive care addresses both physical and psychological aspects of recovery33
Complications
Early Complications (0-2 weeks)
Hemorrhagic shock and coagulopathy
Fat embolism syndrome
Compartment syndrome
Infection and wound complications
Late Complications (>6 weeks)
Nonunion and malunion
Post-traumatic arthritis
Chronic pain syndromes
Psychological disorders (PTSD, depression)
Red Flag: The "triangle of death" - acidosis, hypothermia, and coagulopathy - represents irreversible physiological decompensation14
Prognosis
The overall mortality rate for trauma surgery admissions in Malaysia is 9.8%, increasing to 23.7% among ICU patients with major trauma (ISS >15)7. Key prognostic factors include:
Age: Elderly patients (>65 years) have increased morbidity and mortality
Injury Severity Score: ISS >15 indicates major trauma with higher complication rates
Time to definitive care: Delayed treatment increases risk of complications
Comorbidities: Diabetes, smoking, and malnutrition impair healing31
Long-term functional outcomes depend on injury location, severity, and quality of initial management. Hip fractures in the elderly carry significant morbidity, with mortality rates approaching 30% at one year8. However, modern trauma care principles and early rehabilitation have significantly improved outcomes, with 73.3% of patients achieving excellent functional outcomes following appropriate surgical management35.
