Small fractures can be painful and traumatic – but those that result from a motor vehicle accident or a fall from a high place are of a different magnitude. Such accidents can cause serious injuries all over the body, shattering and/or breaking multiple bones, often in several places. Treatment of these "complex” or “high energy” fractures is complicated.

Yale Medicine has one of two Level I trauma centers in Connecticut, four surgeons who specialize in orthopaedic trauma, and specialists to provide care for trauma patients. It also has an international reputation for groundbreaking work and innovations in treating orthopaedic trauma.

According to Natalie Casemyr, MD, assistant professor of Orthopaedics & Rehabilitation at Yale Medicine, fractures are labeled “complex” when the bone breaks into bits and pieces, when the soft tissue surrounding the bone is severely damaged, or when the patient has other illnesses or injuries that complicate treatment and healing.

Helping these patients is not just a simple matter of repairing a broken bone, says Dr. Casemyr. “All the doctors involved have to work together to figure out the timing of surgical procedures and how to safely move the patient forward in treatment.”

For example, a patient with a shattered shoulder who also sustained head injuries in an accident can’t undergo surgery until his or her medical condition is stabilized. This is because surgery could result in low blood pressure with potentially devastating effects. “The definitive surgery to fix the shoulder might need to wait weeks,” she says. “We may need to stabilize the patient with 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,” says Dr. Casemyr. “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 figure out the timing and sequence of treatment.”

A clinical exam, blood tests, and imaging studies, including X-ray and computerized tomography (CT) scan, are used to identify the problems. “We prioritize the injuries and make treatment decisions individually, based on the patient’s medical status and if he or she is strong enough to undergo a particular procedure,” Dr. Casemyr says.

Every trauma 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. Casemyr says,they may be done in several stages.

The initial goal is medical stabilization 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 one time. Considerations include not only the extent of a patient’s injuries, but also other medical conditions, such as obesity or smoking (which slow down bone healing), or pregnancy or heart disease. Among the many specialists involved are vascular surgeons and plastic surgeons, Dr. Casemyr says.

Just one of two hospitals with the equipment and skills to treat life-threatening injuries in Connecticut, Yale New Haven Hospital is where Yale Medicine's orthopaedic surgeons provide life-saving treatment to many patients with serious traumatic injuries. Besides having four surgeons who specialize in orthopaedic trauma, Dr. Casemyr says, Yale Medicine is unique in having “the depth and breadth of specialists on staff to provide the kind of care patients like this need.”

Further, says Dr. Casemyr, “our department also includes people skilled in other types of orthopaedic surgery.” For example, a person whose shoulder is splintered may benefit from a shoulder replacement. “It’s incredibly valuable for us to be able to reach out to our colleagues with that type of expertise."

Also of great value is Yale Medicine’s international reputation for groundbreaking work and innovations in treating orthopaedic trauma, including complex fracture. Dr. Casemyr says, “We have people actively involved in research that is changing how major orthopaedic trauma is treated around the world.”