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Orthopedic strategies in the management of the adult head-injured patient.

The purpose of this paper is to outline a systematic approach to the care of adult patients with traumatic head injury. The orthopedic management of these individuals is divided in three phases. In the acute period after the initial trauma, musculoskeletal injuries should be diagnosed and treated. Delayed diagnoses of fractures and peripheral nerve injuries are common. Fracture care often differs from the care given to patients without head injuries because open reduction and internal fixation are more frequently indicated. The results of fracture treatment are compromised by spasticity and heterotopic ossification. The second phase is the subacute period during which neurologic recovery is occurring. This period may last up to 18 months. While neurologic recovery is proceeding, heterotopic ossification and spasticity with its resulting deformities are treated. Drugs, casting, and phenol blocks of peripheral nerves and motor points are used in the control of spasticity. Drugs and aggressive range-of-motion exercises aid in maintenance of joint motion when heterotopic ossification is present. When neurologic recovery has stabilized, the third phase begins. At this time, residual limb deformities may be surgically corrected and heterotopic bone may be excised.