High Velocity Injuries to the Appendicular Skeleton

Aside from their association with concurrent damages to vital organ systems, high-velocity injuries to the appendicular skeleton can represent a major challenge to the surgeon. Regardless of the insulting event, they are associated with various levels of damage to surrounding tissues including skin, muscles, tendons and neurovascular bundles. The potential for functional recovery depends on both the severity of these initial injuries and their management as well as on the successful treatment of the osseous lesions. While the attending medical team has no impact on the original injury, they play a major role in optimizing outcomes by preserving tissue viability and fostering healing capability. This includes prehospital care practice and initial patient management at admission. Once vital systems are stable, the fracture(s) is (are) most commonly treated surgically to enable uncomplicated healing. Methods of fixation are highly variable depending on the affected segment and fracture configuration. However, fixation techniques should share a common goal: minimizing iatrogenic tissue damage. It is now well known that disturbance of tissue viability during surgical maneuvers directly affects healing and potentiates development of postoperative complications. While early recommendations for fracture repair through open reduction and internal fixation (ORIF) included principles of delicate tissue handling and preservation of blood supply, it focused on the restoration of bony columns with rigid fixation and interfragmentary compression. Understanding the impact of tissue violation by the surgeon lead to a paradigm shift, emphasizing preservation of tissue viability, and optimize construct biomechanics rather than focusing on the mechanical properties of the repair. This approach is known as Minimally Invasive Osteosynthesis (MIO) and is progressively supplanting traditional orthopedic techniques. It is probably fair to state that minimizing tissue damage is beneficial in all cases of appendicular skeleton fractures. The most obvious benefit would be felt in cases where a high amount of tissue damage was sustained during the initial injury. For that reason, it is crucial to take every action possible to protect viable tissues and prioritize biology over all other aspects of fracture repair until healing capability is assured, particularly in casespresenting with high energy trauma. This concept is not new as it was first put forward in the Hippocratic Oath and re-introduced in modern medicine at the beginning of the 19th century: Primum Non Nocere. It is critical to adhere to these principles in cases where trauma severely jeopardized functional integrity from the moment care can be provided to the resolution of the injury.  [...]