Orthopaedic Surgery - Fracture Treatment

Basics

Fractures are common injuries caused by trauma or, less commonly, by pathologic weakening of bone.

Management may be operative or nonoperative and depends on the location, displacement, stability, soft-tissue injury, patient age, bone quality, and functional requirements.

Nondisplaced Fractures

A nondisplaced fracture may involve one or both cortices, but the fragments remain essentially in their normal anatomic relationship.

These fractures can be difficult to identify on initial imaging, particularly when the fracture line is subtle.

Persistent unexplained pain after trauma should therefore raise suspicion for an occult nondisplaced fracture.

Displaced Fractures

Displacement can be described according to several features, including angulation, translation, rotation, and shortening.

Precise description is important for communication and treatment planning.

Angulation

One method of describing angular deformity is to state the direction of the fracture apex, such as “apex anterior.”

Another method is to describe the resulting alignment, such as varus or valgus angulation.

Translation

Translation refers to sideways displacement of one main fracture fragment relative to the other.

Rotation

Rotational deformity occurs when one fragment is twisted relative to the other.

Rotational malalignment may be clinically important even when plain radiographs appear relatively well aligned.

Shortening

Shortening results from fracture overlap or loss of bone length.

The amount that can be accepted varies greatly according to the bone involved, patient age, and functional demands.

Open Versus Closed Fracture

Determining whether a fracture is open or closed is one of the most important early decisions in fracture management.

Any wound anywhere near a limb containing a fracture must be treated with suspicion.

If there is a possibility that the wound communicates with the fracture or fracture hematoma, the injury should be considered an open fracture until proven otherwise.

Initial Management of an Open Fracture

Open fractures require prompt intravenous antibiotics, tetanus assessment, sterile wound coverage, fracture stabilization, and urgent surgical evaluation.

The wound should be covered with a sterile dressing after gross contamination is addressed, and repeated unnecessary manipulation should be avoided before operative debridement.

Gustilo-Anderson Classification

The Gustilo-Anderson system classifies open fractures according to wound size, injury energy, contamination, soft-tissue destruction, and vascular involvement.

Definitive grading is best assigned after operative debridement.

Type I

Type I injuries are low-energy open fractures with a relatively clean wound typically less than 1 cm in length and minimal soft-tissue damage.

Type II

Type II injuries have a wound generally greater than 1 cm but less than 10 cm, with moderate soft-tissue injury but without extensive stripping or loss of coverage.

Type III

Type III injuries are high-energy open fractures with severe soft-tissue damage, contamination, or complex injury.

Historically, a wound greater than 10 cm has been included in this category, although wound size alone does not determine severity.

Type IIIA

Type IIIA fractures have substantial soft-tissue injury but retain enough tissue for adequate coverage of the bone without requiring a major flap.

Type IIIB

Type IIIB injuries involve extensive soft-tissue destruction, periosteal stripping, exposed bone, and inadequate local coverage, often requiring flap reconstruction.

Type IIIC

Type IIIC fractures are associated with a vascular injury requiring repair, regardless of wound size.

Fracture Location

Diaphyseal Fractures

Diaphyseal fractures involve the shaft of a long bone and are commonly described according to level, such as proximal third, middle third, or distal third.

Metaphyseal Fractures

Metaphyseal fractures occur near the ends of long bones.

Some extend into the adjacent joint surface.

Intra-Articular Fractures

Intra-articular fractures disrupt the joint surface.

These injuries tolerate relatively little residual incongruity because persistent step-off or malalignment can contribute to joint stiffness and post-traumatic osteoarthritis.

Fracture Patterns

Transverse Fracture

A transverse fracture line runs approximately perpendicular to the long axis of the bone.

Oblique Fracture

An oblique fracture crosses the bone at an angle.

Spiral Fracture

A spiral fracture wraps around the bone and typically results from a rotational mechanism.

Comminuted Fracture

A comminuted fracture consists of three or more fragments at the fracture site.

Increasing comminution usually reflects greater injury energy or poor bone quality.

Segmental Fracture

A segmental fracture occurs when the same bone is broken at two separate levels, creating an isolated or “floating” intermediate segment.

Impacted Fracture

In an impacted fracture, one fragment is driven into another.

Avulsion Fracture

An avulsion fracture occurs when a tendon or ligament pulls off a fragment of bone from its attachment site.

Compression Fracture

Compression fractures occur when bone is crushed under axial load.

They are particularly common in osteoporotic vertebral bodies.

Pediatric Considerations

Children sustain several fracture patterns that are uncommon in adults because pediatric bone is more flexible and the periosteum is thicker.

Greenstick Fracture

In a greenstick fracture, the cortex and periosteum on the concave side remain intact, while the cortex on the convex side fails.

This produces an incomplete fracture with angular deformity.

Buckle or Torus Fracture

A buckle fracture is a stable metaphyseal compression injury characterized by cortical buckling rather than complete disruption.

It is often treated with removable splinting primarily for comfort and protection.

Physeal Injuries

Growth-plate fractures are commonly described using the Salter-Harris classification.

Salter-Harris Type I

Type I extends transversely through the physis alone.

Salter-Harris Type II

Type II passes through the physis and exits through the metaphysis, creating a metaphyseal fragment.

Salter-Harris Type III

Type III extends through the physis and epiphysis into the joint.

It is therefore an intra-articular fracture.

Salter-Harris Type IV

Type IV passes through the metaphysis, physis, and epiphysis, crossing the articular surface.

Precise reduction is important because both the joint and growth plate are involved.

Salter-Harris Type V

Type V is a crush injury of the physis.

It can be difficult to recognize initially and carries a significant risk of growth disturbance.

Perichondral Ring Injury

Injury to the peripheral physeal ring has sometimes been referred to as a Type VI injury, although this was not part of the original Salter-Harris classification.

Prevention

General fracture prevention includes trauma avoidance, fall prevention, appropriate safety equipment, and prevention or treatment of osteoporosis.

Pathophysiology

A fracture occurs when an applied force exceeds the mechanical strength of bone.

Healthy bone generally requires greater force to fracture than bone weakened by osteoporosis, tumor, infection, or metabolic disease.

Diagnosis

History

Most fractures follow trauma such as a motor vehicle collision, fall, sports injury, or direct blow.

Older patients may sustain fractures after relatively minor trauma because of osteoporosis.

Suspected Pathologic Fracture

When the reported mechanism seems too minor to explain the injury, an underlying pathologic process should be considered.

Examples include a humeral fracture while performing a trivial household activity or a femoral fracture after a minimal step or twist.

Possible causes include metastatic disease, primary bone tumor, osteoporosis, metabolic bone disease, or other structural abnormalities.

Nonaccidental Injury

Child abuse should be considered when fractures or bruises of different ages are present, the mechanism is inconsistent with the child’s developmental abilities, or the reported history does not adequately explain the injury.

Any concern should trigger a formal multidisciplinary safeguarding evaluation.

Physical Examination

The involved area should be inspected for deformity, swelling, bruising, warmth, skin wounds, fracture blisters, and focal tenderness.

Movement of the injured region may cause substantial pain and should be performed cautiously.

Neurovascular Examination

Motor function, sensation, pulses, capillary refill, and distal perfusion should be documented before and after reduction or splinting.

Soft-Tissue Examination

Any wound near the fracture must be examined carefully because even a small wound may communicate with the fracture.

Imaging

Plain Radiographs

Plain radiographs in at least two orthogonal planes are the basic imaging study for most fractures.

The images should generally include the joint above and below the fracture when practical, especially for long-bone injuries.

CT

CT is superior to plain radiography for defining many complex fractures, particularly those involving the spine, pelvis, hindfoot, and articular surfaces.

It is especially useful when operative planning requires detailed assessment of joint involvement and fragment morphology.

MRI

MRI can detect radiographically occult fractures and associated soft-tissue injury.

It is especially useful for stress fractures, occult hip fractures, and injuries involving ligaments or cartilage.

Bone Scintigraphy

Bone scintigraphy can identify occult or multifocal fractures when other imaging is unavailable or nondiagnostic, although MRI is now preferred for many indications.

Initial Treatment

Ice and Elevation

Ice and elevation may help limit pain and swelling in appropriate extremity injuries.

Immobilization

Early immobilization reduces pain, limits further soft-tissue injury, and helps maintain alignment.

Reduction

Displaced fractures should be reduced when necessary under appropriate analgesia, sedation, regional anesthesia, or general anesthesia.

Principles of Definitive Fracture Treatment

Regardless of whether management is operative or nonoperative, two fundamental goals apply:

Restoration of acceptable alignment and provision of sufficient stability to permit healing and function.

Splinting

During the acute swollen phase, a splint is often preferred over a circumferential cast.

Splints accommodate swelling and therefore reduce the risk of excessive pressure, skin injury, and compartment syndrome.

Casting

Casts are commonly used for stable or nondisplaced fractures and for fractures that remain acceptably aligned after closed reduction.

Cast Valving

A cast may be univalved or bivalved when significant swelling is anticipated.

This reduces circumferential pressure.

Three-Point Mold

A well-applied cast uses three-point molding to resist the deforming forces acting across the fracture and maintain reduction.

Functional Bracing

Functional braces permit controlled motion while maintaining fracture alignment.

They have been used successfully for selected humeral shaft and tibial shaft fractures.

Activity

Weight-bearing and joint-motion recommendations depend on fracture location, stability, fixation, and healing.

Operative fixation often permits earlier motion and, in some cases, earlier weight bearing than prolonged cast treatment.

Nursing Care

Careful monitoring is required for complications such as compartment syndrome, cast pressure, skin breakdown, swelling, neurovascular compromise, and uncontrolled pain.

Medication

Open Fracture Antibiotics

Open fractures require prompt intravenous antibiotic prophylaxis, ideally as soon as possible after injury.

Antibiotic selection depends on the Gustilo grade, contamination, local resistance patterns, and institutional protocol.

First-generation cephalosporins such as cefazolin are commonly used for gram-positive coverage in lower-grade injuries.

Broader gram-negative coverage is generally added for selected severe Type III injuries rather than simply for all Type II fractures.

Farm or Grossly Contaminated Injuries

Fractures contaminated with soil, farm material, fecal material, or other high-risk substances may require additional anaerobic coverage according to local trauma and infectious-disease protocols.

Tetanus Prophylaxis

Tetanus immunization status should be assessed in all open wounds, with booster vaccination or immune globulin provided when indicated.

Analgesia

Pain control should be tailored to injury severity.

Options include acetaminophen, NSAIDs when appropriate, regional anesthesia, and opioids for severe pain.

Surgery

The decision for operative treatment depends on fracture severity, instability, soft-tissue condition, patient factors, need for early mobilization, and ability to obtain or maintain acceptable alignment nonoperatively.

Intra-Articular Fractures

Displaced intra-articular fractures often require anatomic or near-anatomic reduction and stable fixation to restore the joint surface and allow early motion.

Failure to restore congruity increases the risk of stiffness and post-traumatic arthritis.

Diaphyseal Fractures

Shaft fractures may require fixation to restore length, rotation, and alignment and to permit earlier mobilization.

Plates and Screws

Plate-and-screw constructs are frequently used for intra-articular, metaphyseal, periarticular, and selected diaphyseal fractures.

They allow direct or indirect restoration of alignment and stable fixation.

Intramedullary Nails

Intramedullary nails are commonly used for long-bone diaphyseal fractures, particularly of the femur and tibia.

They function as load-sharing implants and often permit relatively early weight bearing.

External Fixation

External fixation is useful when there is severe soft-tissue injury, gross contamination, vascular compromise, marked swelling, or a need for temporary damage-control stabilization.

It may also be used definitively in selected injuries.

Damage-Control Orthopaedics

Severely injured polytrauma patients may not tolerate lengthy definitive fracture surgery immediately.

In these cases, temporary external fixation can provide rapid skeletal stabilization while minimizing the additional physiologic stress sometimes described as a “second hit.”

Definitive fixation is performed later after resuscitation and physiologic stabilization.

Referral and Safeguarding

When nonaccidental injury is suspected in a child, a pediatrician, child-protection team, and social worker or equivalent safeguarding professional should be involved promptly.

Prognosis

Prognosis depends on fracture location, displacement, soft-tissue injury, vascular status, infection, and patient factors.

In general, intra-articular fractures and fractures with major soft-tissue damage have a worse prognosis than uncomplicated shaft fractures.

Complications

Delayed Union

Delayed union refers to fracture healing that is progressing more slowly than expected.

Older definitions often used approximately 3–4 months, but the diagnosis should be interpreted according to the bone, fracture pattern, and biologic environment.

Nonunion

Nonunion is failure of a fracture to unite despite sufficient time and biologic opportunity.

Traditionally, absence of healing by about 6 months has been used in some settings, although modern definitions depend on clinical and radiographic progression rather than time alone.

Malunion

Malunion occurs when the fracture heals in an unacceptable position, producing deformity such as angulation, rotation, shortening, or translation.

Osteonecrosis

Osteonecrosis, or avascular necrosis, results from disruption of the blood supply to bone.

It is particularly associated with fractures involving the femoral head and neck, talar neck, proximal scaphoid, proximal humerus, and selected periarticular regions.

Osteomyelitis

Bone infection is a major complication, particularly after open fractures, severe contamination, or infected fixation.

Compartment Syndrome

Acute compartment syndrome occurs when pressure within a closed fascial compartment compromises tissue perfusion.

It is a surgical emergency.

Disproportionate pain, pain with passive stretch, tense swelling, neurologic changes, and progressive symptoms require immediate attention.

Pulmonary Complications

Major fractures, especially long-bone and pelvic injuries, may be associated with serious pulmonary complications.

Acute Respiratory Distress Syndrome

Severe trauma and systemic inflammation may contribute to acute respiratory distress syndrome.

Fat Embolism Syndrome

Fat embolism syndrome may follow long-bone or pelvic fractures and can produce respiratory, neurologic, and hematologic abnormalities.

Venous Thromboembolism

Deep venous thrombosis and pulmonary embolism are important risks, particularly in patients with lower-extremity fractures, major trauma, or prolonged immobility.

Complex Regional Pain Syndrome

The condition historically called reflex sympathetic dystrophy is now generally termed complex regional pain syndrome.

It may cause persistent pain, swelling, stiffness, and autonomic changes after fracture or surgery.

Post-Traumatic Arthritis

Fractures involving joint surfaces may eventually lead to degenerative arthritis, particularly when residual incongruity, cartilage injury, or instability remains.

Geriatric Considerations

Treatment decisions in older adults require careful balancing of operative risk against the consequences of immobility and deformity.

Common comorbidities include diabetes, coronary artery disease, peripheral vascular disease, osteoporosis, and frailty.

Early mobilization is often particularly important in this population.

Patient Monitoring

Patients with fractures should be followed clinically and radiographically until healing is established.

Serial assessment should evaluate alignment, stability, callus formation, pain, function, neurovascular status, implant position when applicable, and evidence of complications such as infection, nonunion, malunion, or post-traumatic arthritis.