You are in: eMedicine Specialties > Orthopedic Surgery > TRAUMA General Principles of Fracture CareArticle Last Updated: Jul 19, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Richard Buckley, MD, FRCSC, Associate Professor of Orthopaedic Traumatology, University of Calgary; Consulting Staff, Department of Surgery, Division of Orthopaedics, Foothills Hospital Richard Buckley is a member of the following medical societies: Canadian Orthopaedic Association and Orthopaedic Trauma Association Coauthor(s): Carlo D A Panaro, MD, Staff Physician, Department of Orthopedic Surgery, University of Alberta Editors: James F Kellam, MD, Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: fracture management, open fracture, closed fracture, broken bone, traumatic bone injury, open reduction and internal fixation, ORIF, external fixation, ankle fracture, femur fracture INTRODUCTIONSection 2 of 10
  With the burden of musculoskeletal disease at the forefront of health care worldwide, the World Health Organization (WHO) declared 2000-2010 the Bone and Joint Decade.1, 2 Trauma causes more than 140,000 deaths per year in the ProblemA fracture is defined as a disruption in the integrity of a living bone, involving injury to the bone marrow, periosteum, and adjacent soft tissues. Many types of fractures exist, such as pathologic, stress, and greenstick fractures. When a fracture occurs, it is described radiographically and clinically in terms of the following factors:
The soft-tissue injury component of trauma has become increasingly important with respect to fracture treatment outcomes. The Gustilo classification has been shown to have only moderate intraobserver and interobserver reliability in terms of fracture classification.5 The Tscherne6 and Hanover fracture scales are classification systems that allow for a greater evaluation of the soft-tissue injury relative to wound size, area of skin loss, and underlying soft-tissue damage.7 FrequencyFracture incidence is multifactorial and often complicated by such factors as patients' age, sex, comorbidities, lifestyle, and occupation. In the EtiologyFractures occur when the force applied to a bone exceeds the strength of the involved bone. Both intrinsic and extrinsic factors are important with respect to fractures.10 Extrinsic factors include the rate at which the bone’s mechanical load is imposed and the duration, direction, and magnitude of the forces acting on the bone. Intrinsic factors include the involved bone’s energy-absorbing capacity, modulus of elasticity, fatigue, strength, and density. Bones can fracture as a result of direct or indirect trauma. Direct trauma consists of direct force applied to the bone; direct mechanisms include tapping fractures (eg, bumper injury), penetrating fractures (eg, gunshot wound), and crush fractures. Indirect trauma involves forces acting at a distance from the fracture site such as tension (traction), compressive, and rotational forces. PathophysiologyThe 5 phases of fracture healing are the following11:
Actual fracture injuries to the bone include insult to the bone marrow, periosteum, and local soft tissues. The most important stage in fracture healing is the inflammatory phase and subsequent hematoma formation. It is during this stage that the cellular signaling mechanisms work via chemotaxis and an inflammatory mechanism to attract the cells necessary to initiate the healing response. Within 7 days, the body forms granulation tissue between the fracture fragments. Various biochemical signaling substances are involved in the formation of the granulation tissue stage, which lasts roughly 2 weeks. During callus formation, cell proliferation and differentiation begin to produce osteoblasts and chondroblasts in the granulation tissue. The osteoblasts and chondroblasts, respectively, synthesize the extracellular organic matrices of woven bone and cartilage, and then the newly formed bone is mineralized. This stage requires 4-16 weeks. During the fourth stage, the meshlike callus of woven bone is replaced by lamellar bone, which is organized parallel to the axis of the bone. The final stage involves remodeling of the bone at the site of the healing fracture by various cellular types such as osteoclasts. The final 2 stages require 1-4 years. Patient factors that influence fracture healing include age,12 comorbidities,13 medication use,14 social factors,15 and nutrition16 (see Table). Other factors that affect fracture healing include the type of fracture,17 degree of trauma,18 systemic and local disease, and infection.19 Patients who have poor prognostic factors in terms of fracture healing are at increased risk for complications of fracture healing such as nonunion (a fracture with no possible chance of healing), malunion (healing of bone in an unacceptable position in any plane), osteomyelitis, and chronic pain. Table: Patient factors that influence fracture healing.
ClinicalSingle-limb injury The physical examination must include a thorough inspection of the integument (with documentation). If the fracture is open, a clinical photograph may be taken for documentation purposes. Distal neurologic and vascular status must be assessed and documented. Palpate the entire limb—including the joints above and below the injury—for areas of pain, effusions, and crepitus. Often, accompanying or associated injuries may be present (eg, injuries to the spine with a jumping mechanism of injury). Assessment of range of motion (ROM) may not be possible, but this should be documented. Assessments for ligamentous injury and tendon rupture, as well as other noteworthy tests that surround a special examination of the joints, should be completed and documented. Multiple traumatic injuries The initial assessment of a patient with polytrauma follows the advanced trauma life support (ATLS) protocols20 and includes the identification and treatment of life-threatening injuries. The first step is evaluation of the individual's airway, breathing, and circulation. Immediate endotracheal intubation and rapid administration of intravenous fluids may be necessary. Spinal precautions must be maintained until injury to the complete spine can be excluded clinically and radiographically (with radiographs or computed tomography [CT] scans). Once the patient is hemodynamically stable, the secondary survey, a complete systems-based physical examination, is performed. Initial management of fractures The initial management of fractures consists of realignment of the broken limb segment and then immobilizing the fractured extremity in a splint. The distal neurologic and vascular status must be clinically assessed and documented before and after realignment and splinting. If a patient sustains an open fracture, achieving hemostasis as rapidly as possible at the injury site is essential; this can be achieved by placing a sterile pressure dressing over the injury site (see Open Fractures). Splinting is critical in providing symptomatic relief for the patient, as well as in preventing potential neurologic and vascular injury and further injury to the local soft tissues. Patients should receive adequate analgesics in the form of acetaminophen or opiates, if necessary. Management of open fracturesThe treatment goals for open fractures are to prevent infection, to allow the fracture to heal, and to restore function in the injured limb. Once the initial assessment, evaluation, and management of any life-threatening injury are completed, the open fracture is treated. Hemostasis should be obtained, followed by antibiotic administration and tetanus vaccination. Cefazolin or clindamycin is adequate for type I and type II fracture injuries. If the wound is severely contaminated (type III), an aminoglycoside (eg, gentamicin or tobramycin) should be added to complement treatment. If the injury is a "barnyard injury" or water-type injury, penicillin should also be added to provide prophylaxis against Clostridium perfringens. Tetanus prophylaxis and immunization should be administered to patients who have not been previously immunized. The prophylactic use of quinolones should not be used because of the rapid development of resistant staphylococci and because quinolones are important drugs in the treatment of implant-related infections.21 Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory. For type II and type III injuries, serial I&Ds are recommended every 24-48 hours after the initial debridement until a clean surgical wound is ensured. The wound is closed when it is clean and antibiotics are generally continued until 2 days after the final I&D. Management of the open fracture depends on the site of injury and type of open fracture. The wound is subsequently stabilized either temporarily or definitively. If soft-tissue coverage over the injury is inadequate, soft-tissue transfers or free flaps are performed when the wound is clean and the fracture is definitively treated. INDICATIONSSection 3 of 10
Fracture management can be divided into nonoperative and operative techniques. The nonoperative technique consists of a closed reduction if required, followed by a period of immobilization with casting or splinting. Closed reduction is needed if the fracture is significantly displaced or angulated. If the fracture cannot be reduced, surgical intervention may be required. Indications for surgical intervention include the following:
CONTRAINDICATIONSSection 4 of 10
Contraindications to surgical reconstruction are as follows:
WORKUPSection 5 of 10
Lab Studies
Imaging Studies
TREATMENTSection 6 of 10
Medical therapyThe general aim of early fracture management is to control hemorrhage, provide pain relief, prevent ischemia-reperfusion injury, and remove potential sources of contamination (foreign body and nonviable tissues). Once these are accomplished, the fracture should be reduced and the reduction should be maintained, which will optimize the conditions for fracture union and minimize potential complications. Nonoperative (closed) therapy consists of casting and traction (skin and skeletal traction). Casting Closed reduction should be performed initially for any fracture that is displaced, shortened, or angulated. This is achieved by applying traction to the long axis of the injured limb and then reversing the mechanism of injury/fracture, followed by subsequent immobilization through casting or splinting. Splints and casts can be made from fiberglass or plaster of Paris. Barriers to accomplishing reduction include soft-tissue interposition and hematoma formation that create tension in the soft tissues. Closed reduction is contraindicated under the following conditions17:
Traction For hundreds of years, traction has been used for the management of fractures and dislocations that are not able to be treated by casting. With the advancement of orthopedic implant technology and operative techniques, traction is now rarely used for definitive fracture/dislocation management. Two types of traction exist: skin traction and skeletal traction. In skin traction, traction tapes are attached to the skin of the limb segment that is below the fracture. When applying skin traction, or Buck traction, usually 10% of the patient's body weight (up to a maximum of 10 lb) is recommended.22 At weights greater than 10 lb, superficial skin layers are disrupted and irritated. Because most of the forces created by skin traction are lost and dissipated in the soft-tissue structures, skin traction is rarely used as definitive therapy in adults; rather, it is commonly used as a temporary measure until definitive therapy is achieved. In skeletal traction, a pin (eg, Steinmann pin) is placed through a bone distal to the fracture. Weights are applied to this pin, and the patient is placed in an apparatus to facilitate traction and nursing care. Skeletal traction is most commonly used in femur fractures: A pin is placed in the distal femur (see Image 4) or proximal tibia 1-2 cm posterior to the tibial tuberosity. Once the pin is placed, a Thomas splint is used to achieve balanced suspension. Surgical therapyIn 1958, the Association for the Study of Internal Fixation (ASIF) created 4 treatment goals for surgical fracture management.7 To date, these goals have not changed and are as follows:
Open reduction and internal fixation (ORIF) The objectives of ORIF include adequately exposing the fracture site and obtaining a reduction of the fracture. Once a reduction is achieved, it must be stabilized and maintained. Kirschner wires Kirschner wires, or K-wires, are commonly used for temporary and definitive treatment of fractures. However, K-wires resist only changes in alignment; They do not resist rotation, and they have poor resistance to torque and bending forces. K-wires are commonly used as adjunctive fixation for screws or plates and screws that involve fractures around joints. When K-wires are used as the sole form of fixation, casting or splinting is used in conjunction. The wires can be placed percutaneously or through a mini-open mechanism. Per Canale, K-wire fixation "… is adequate for small fragments in metaphyseal and epiphyseal regions, especially in fractures of the distal foot, wrist, and hand, such as Colles fractures, and in displaced metacarpal and phalangeal fractures after closed reduction."8 K-wires are also commonly used as adjunctive therapy for many fractures, including patellar fractures, proximal humerus fractures, olecranon fractures, and calcaneus fractures. Plates and screws Plates and screws are commonly used in the management of articular fractures. This use demands an anatomic reduction of the fracture fragments and allows for early ROM of the injured extremity. Plates provide strength and stability to neutralize the forces on the injured limb for functional postoperative aftercare (see Images 5-6). Plate designs vary, depending on the anatomic region and size of the bone the plate is used for. All plates should be applied with minimal stripping of the soft tissue. Five main plate designs exist7:
Buttress plates counteract the compression and shear forces that commonly occur with fractures that involve the metaphysis and epiphysis. These plates are commonly used with interfragmentary screw fixation. The buttress plate is always fixed to the larger main fracture fragment but does not necessarily require fixation through the smaller fragment, because the plate buttresses the small fragment into the larger fragment. To achieve this function requires appropriate plate contouring for adequate fixation and support. Compression plates counteract bending, shear, and torsional forces by providing compression across the fracture site via the eccentrically loaded holes in the plate. Compression plates are commonly used in the long bones, especially the fibula, radius, and ulna, and in nonunion or malunion surgery. Protection plates are used in combination with interfragmentary screw fixation. The interfragmentary compression screws provide compression at the fracture site. This plate function neutralizes bending, shear, and torsional forces on the lag screw fixation, as well as increases the stability of the construct. Protection plates are commonly used for fractures involving the fibula, radius, ulna, and humerus. Bridge plates are useful in the management of multifragmented diaphyseal and metaphyseal fractures. Achieving adequate reduction and stability without disrupting the soft-tissue attachments to the bone fragments may be difficult and requires skill in the use of indirect reduction techniques. A tension band plate technique converts tension forces into compressive forces, thereby providing absolute stability. An example of this technique is when a tension band plate is used for an oblique olecranon fracture. Intramedullary nails The use of intramedullary nails over the past half century has been widely accepted. These nails operate like an internal splint that shares the load with the bone and can be flexible or rigid, locked or unlocked, and reamed or unreamed. Locked intramedullary nails provide relative stability to maintain bone alignment and length and to limit rotation. Ideally, the intramedullary nail allows for compressive forces at the fracture site, which stimulates bone healing. Intramedullary nails are commonly used for femoral and tibial diaphyseal fractures (see Image 7) and, occasionally, humeral diaphyseal fractures. The advantages of intramedullary nails include minimally invasive procedures, early postoperative ambulation, and early External fixation In 1907, European physician Albin Lambotte developed the technique of external fixation for the management of fractures.24 External fixation provides fracture stabilization at a distance from the fracture site—without interfering with the soft-tissue structures that are near the fracture. This technique not only provides stability for the extremity and maintains bone length, alignment, and rotation without requiring casting, but it also allows for inspection of the soft-tissue structures that are vital for fracture healing. Indications for external fixation (temporarily or as definitive care) are as follows:
Soft-tissue injuries and potential open wounds are inflammatory foci that behave much like an endocrine organ by releasing mediators and cytokines both locally and systemically, leading to a systemic inflammatory response. Further surgical insult (ie, femoral nailing for a femur fracture) can aggravate this mediator response, resulting in a further immunologic response, known as the "second hit" phenomenon.25 This, in turn, may exacerbate the patient's clinical status and can lead to further morbidity as well as mortality. Early total care is important; several studies have documented the advantages of early fixation of long-bone fractures, especially femur fractures.25, 26 These advantages include early mobilization with improved pulmonary function, shorter time on a ventilator, reduced morbidity and mortality, and easier nursing care. Early definitive surgical care should only be considered in stable patients who have been adequately resuscitated, whereas those who are unstable should undergo damage-control orthopedics (DCO). This concept refers to an early debridement of surgical wounds, with temporary external fixation of long-bone fractures and dislocations. The pins should be placed outside the zone of injury and should avoid sites of planned future incisions. Damage-control surgery should be considered in patients who are hemodynamically unstable or those with hypothermia, an abnormal base deficit, or blood-clotting abnormalities/pulmonary complications. No single test is available yet to determine which patients are at risk for a major systemic inflammatory response following trauma.7 Preoperative detailsDetecting and adequately addressing all other injuries, including comorbidities and preexisting medical conditions, is essential. If patients have multiple medical problems, consult an internal medicine specialist before performing any operative intervention. Prophylactic antibiotics (cefazolin, 1 g) should be administered. If the patient is allergic to penicillin, clindamycin can be administered. Patients with open fractures should be given appropriate antibiotic prophylaxis (see Management of open fractures). Intraoperative detailsC-arm fluoroscopy is valuable and often necessary in the operating room to provide for and to evaluate the results of internal fixation before the patient leaves the surgical suite. Alternatively, portable radiography can be used if multiple radiographic images are not anticipated to be necessary. Postoperative detailsPostoperatively, appropriate wound care and suture or staple removal is performed as directed by the physician. Depending on the type of fracture sustained by the patient, he or she may be immobilized in a splint or cast. Postoperatively, patients are examined at follow-up visits, usually within 1-2 weeks after their surgery, and periodically until the fracture has healed and functioning has returned. Weight-bearing status is dependent upon stability of the fracture or osteosynthesis construct. Follow-upConsultation with rehabilitation specialists can be useful in helping inpatients to ambulate with the aid of crutches or a walker and, ultimately, to decrease postoperative morbidity and expedite patients' discharge planning. Rehabilitation services can be invaluable for many individuals in regaining their ROM and strength once the fracture has healed. The need for physiotherapy depends on the nature of the injury and the patient's motivation, educational level, and abilities. Physiotherapists aid in helping patients to recover from joint stiffness and to maintain and restore The timetable for follow-up visits varies, depending on the nature of the injury. All patients must be monitored closely for potential complications (see Complications). At the time of discharge after the initial care of the fracture, the patient should be made aware of all the follow-up requirements specified by the treating physician. COMPLICATIONSSection 7 of 10
Complications of castsComplications of casts include the development of pressure ulcers, thermal burns during plaster hardening, and thrombophlebitis. The AO ASIF group commented that prolonged cast immobilization, or cast disease, can be responsible for creating circulatory disturbances, inflammation, and bone disease that result in osteoporosis, chronic edema, soft-tissue atrophy, and joint stiffness.7 These problems may be avoided by providing functional aftercare. Complications of tractionComplications of traction include the development of pressure ulcers, pulmonary/urinary infections, permanent footdrop contractures (if the foot is positioned in equinus), peroneal nerve palsy, pin tract infection, and thromboembolic events (eg, deep venous thrombosis [DVT], pulmonary embolism). These complications stem from a lack of patient mobility, muscle atrophy, weakness, and stiffness that result from a fracture. Complications of external fixationComplications of external fixation include pin tract infection, pin loosening or breakage, interference with joint motion, neurovascular damage when pins are placed, malalignment caused by poor placement of the fixator, delayed union, and malunion. Complications of fractures and surgical managementComplications of fractures and surgical management include neurologic and/or vascular injury, CS, infection, thromboembolic events, avascular necrosis, and posttraumatic arthritis. Neurologic and vascular injury Neurologic and vascular injuries can occur in any fracture and are more likely in cases with increasing fracture deformity. Peripheral nerve injury is suspected if a patient experiences motor or sensory deficiencies. Management of neurologic injury involves immediate reduction of the fracture and possible nerve exploration, with subsequent follow-up to assess whether or not neurologic function returns. Arterial injury is suspected if the patient’s pulses are diminished or absent in the affected limb. If there is evidence of arterial injury, immediate realignment of the limb is performed, and the pulses and perfusion are checked again. If the pulses do not return, angiography is indicated, with concomitant involvement of vascular surgeons. Arterial injuries are especially prevalent in cases of knee dislocations, proximal tibial fractures, and supracondylar humerus fractures. Compartment syndrome CS, initially reported by von Volkmann in 1872,27 is a potentially limb- and life-threatening condition. CS occurs when tissue pressure exceeds perfusion pressure in a closed anatomic space. This condition can occur in any compartment, such as the hand, forearm, upper arm, abdomen, buttock, thigh, and leg, but it most commonly occurs in the anterior compartment of the leg. The natural history of CS involves tissue necrosis, functional limb impairment, and renal failure secondary to rhabdomyolysis, which may lead to death if untreated. CS can occur after traumatic injury to an extremity, after ischemia (eg, after hemorrhage or thromboembolic event), and, in rare cases, with exercise. Clinically, patients experience pain that is out of proportion to the degree of injury and pain with passive stretching of the involved muscles, as well as pallor, paresthesia, and poikilothermia. Pulselessness, however, is a late finding of CS. Compartment pressures can be objectively measured. Intracompartmental pressures greater than 30 mm Hg or a diastolic blood pressure minus intracompartmental pressure that is greater than 30 mm Hg is an indication for surgical intervention. Definitive therapy consists of surgical fasciotomy of the affected compartments. Infection Complications of surgical intervention include local infection in the form of cellulitis or osteomyelitis and systemic infection in the form of sepsis. Early recognition of a local infection may prevent the development of sepsis and, thus, decrease patient morbidity. The most common pathogen is Staphylococcus aureus. Other pathogens include group A streptococci, coagulase-negative staphylococci, and enterococci. Appropriate antibiotics should be administered if an infection is suspected. Serial C-reactive protein and erythrocyte sedimentation rate measurements should be obtained and may be used to assess treatment response to antibiotics. If infection cannot be eradicated with antibiotics, I&D of the surgical wound may be necessary, with removal of orthopedic hardware, but only if the hardware is not performing its role. Thromboembolic events Thromboembolic events may occur after orthopedic trauma with prolonged patient immobilization. Patients with significant fractures who are immobile for 10 days or longer have a 67% incidence of thrombosis.8 Prophylaxis is effective in decreasing the incidence of DVT in the immobilized extremity,28 but it has not been shown to be effective in decreasing the incidence of fatal pulmonary embolism. In addition, prophylactic anticoagulation carries with it its own set of serious and life-threatening complications, such as bleeding. Before using DVT prophylaxis, the risks and benefits of such therapy must be thoroughly explained to the patient. Avascular necrosis Avascular necrosis (AVN) is caused by disruption of the blood supply to a region of bone. Revascularization of the avascular bone can lead to nonunion, bone collapse, or degenerative changes. AVN is most commonly associated with fractures of the femoral head and neck, scaphoid, talar neck and body, and proximal humerus. Posttraumatic arthritis Posttraumatic arthritis is common in intra-articular fractures, particularly in intra-articular fractures that are not adequately reduced. Management of posttraumatic arthritis depends on the joint involved and can include arthroscopic debridement, osteotomy, arthroplasty, or arthrodesis. Complications of bone healing Delayed union is defined as a fracture that has not healed after a reasonable time period (the time in which it was expected to heal) has passed. Nonunion is defined as a fracture with no possible chance of healing, no matter how long the initial treatment is carried out. Risk factors for nonunion are summarized in the Table. Management consists of treatment of the cause of the nonunion and can include eradication of infection, stabilization of the fracture, removal of interfering soft tissues, bone grafting, and medical/nutritional modifications of comorbidities. Malunion is defined as healing of bone in an unacceptable position in any plane, which leads to a disability for the patient, cosmesis, or the potential for the development of posttraumatic arthritis. Treatment involves surgical correction of the anatomic abnormality. FUTURE AND CONTROVERSIESSection 8 of 10
Two subjects that will be prominent in upcoming years are the use of minimally invasive fracture-fixation techniques and the use of biologic agents to aid in fracture healing. Minimally invasive orthopedic techniques, from arthroscopic surgery to the use of intramedullary nails, have dramatically decreased the morbidity rate associated with orthopedic surgical intervention. Krettek et al were prominent in developing the concept of minimally invasive percutaneous plate osteosynthesis (MIPPO) with indirect reduction.29 This technique involves the use of anatomically preshaped plates and instrumentation to safely and effectively insert the plate percutaneously or through limited incisions. Various plates, clamps, and other devices aid in the reduction of the affected bones. A number of organic and synthetic materials have been used to promote fracture healing. These include hydroxyapatite, tricalcium phosphate, and calcium sulfate. Other biologic agents that have been recognized as stimulators of fracture healing include peptide-signaling molecules (eg, bone morphogenic protein, β-transforming growth factor, gene family fibroblast growth factor, and platelet-derived growth factor) and immunomodulatory cytokines (interleukins 1 and 6). These biologic agents are not commonly used, but with further research, they may become important in fracture healing. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
General Principles of Fracture Care excerpt Article Last Updated: Jul 19, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
