Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Fracture Treatment

Basics
Description
  • Fractured or broken bones are a common result of trauma.
  • Treatment of fractures may be with or without surgery and depends on the location and severity of the fracture.
  • Nondisplaced:
    • 1 or both cortices may be involved, but the fracture has not moved.
    • Nondisplaced fractures may be difficult to detect.
  • Displaced:
    • Displacement
    • Angulation:
      • A clear way to describe this deformity is to state the direction of the apex of the fracture, such as fracture apex anterior
      • Another method is to state the type of deformity, such as varus angulation
    • Shortening
    • Rotation
    • Translation
Alert
  • Open versus closed:
    • One of the most important determinations to make when evaluating a patient with a fracture
    • Any wound anywhere on a limb with a fracture must be suspect!
      • If one believes that a wound could communicate with the fracture site, the fracture must be considered to be open.
    • To decrease bacterial colonization, open wounds should be covered with an antiseptic-soaked sterile dressing until the patient is in the operating room.
  • Open fractures: Gustilo Anderson classification:
    • I: Low energy, laceration <1 cm
    • II: Moderate energy, laceration >1 cm and <10 cm
    • III: High energy, laceration >10 cm:
      • IIIA: Adequate soft-tissue coverage (muscle flap not necessary)
      • IIIB: Massive soft-tissue destruction, bony exposure (muscle flap necessary)
      • IIIC: Fractures associated with a vascular injury
  • Fracture sites:
    • Diaphysis: May describe by relative anatomic level (i.e., proximal 1/3, middle 1/3, and distal 1/3)
    • Metaphysis: Intra-articular (i.e., within a joint, with low tolerance for any incongruence or step-off)
  • Fracture patterns:
    • Transverse: Perpendicular to the bone
    • Oblique: Oblique across the bone
    • Spiral: Spirals around the bone
    • Comminuted: Fragments at fracture site
    • Segmental: The same bone is fractured in 2 places, resulting in a floating segment of bone
    • Impacted
    • Avulsion: A tendon or ligament has pulled a section of bone free after trauma.
    • Compression
Pediatric Considerations
  • Greenstick fracture: The cortex and periosteum on the concave side are intact, whereas the cortex and often the periosteum on the convex side are fractured.
  • Buckle (torus fracture): This metaphyseal compression injury is relatively stable and is splinted for comfort.
  • Growth-plate injuries are defined according to the Salter-Harris classification:
    • I: Transverse fracture through the physis
    • II: Fracture through the physis with a metaphyseal fragment
    • III: Fracture through the physis and the epiphysis (intra-articular)
    • IV: Fracture through the epiphysis, physis, and metaphysis (intra-articular)
    • V: Crush injury of the physis
    • VI: Injury to the perichondral ring (not part of the original classification)
General Prevention
  • Avoidance of trauma
  • Osteoporosis prevention
Pathophysiology
  • Force applied to a bone may result in fracture.
  • Bones that are weaker from osteoporosis require less force to fracture.
Diagnosis
Signs and Symptoms
History
  • Most often traumatic, whether secondary to a motor vehicle crash, fall, or direct blow to the affected area
  • Fractures in the elderly may occur with minimal trauma.
Alert
  • When the mechanism reported seems mild in comparison to the injury (e.g., humerus fracture while throwing a ball or femur fracture while stepping off a curb), one must consider a pathologic fracture (through a tumor or metabolic process) in the differential diagnosis.
  • Suspect child abuse when fractures and bruises of different ages are seen, or when the story is not consistent with the injury.
    • In decreasing order of incidence, fractures of the humerus, tibia, and femur are most commonly seen in child abuse.
Physical Exam
Look for gross deformity, swelling, and pain to palpation and, with movement of the affected area, bruising, warmth, and possibly fracture blisters.
 
Tests
Imaging
  • Plain radiographs in 2 planes are mandatory and should include the joint above and below the injury.
  • CT is better than radiography at identifying fractures of the spine and showing the joint involvement in intra-articular fractures.
  • MRI or bone scans may be used to detect nondisplaced fractures.
Treatment
General Measures
  • Begin ice, elevation, and immobilization as soon as the patient is in the emergency department.
  • Reduce displaced fractures under sedation or anesthesia.
    • Immobilization protects soft tissue and allows the bone to heal.
    • The goal of immobilization is to maintain the alignment of the reduction of the fracture until it heals.
  • For early treatment with closed therapy, splinting is preferred to casting because of a lower risk of compartment syndrome and soft-tissue injury.
  • Regardless of whether the final treatment is nonoperative or operative, definitive fracture management depends on basic principles:
    • Adequate fracture reduction (restored as close to the anatomic position as possible)
    • Fracture stabilization
  • Cast:
    • Used for many nondisplaced or simple fractures
    • Univalved or bivalved models reduce the risk of compartment syndrome.
    • Must be molded with 3-point fixation to maintain fracture reduction
  • Functional bracing has been successful in the treatment of humerus and tibial fractures.
Activity
Depends on method of treatment, but operative management often leads to earlier return to motion and weightbearing.
 
Nursing
Awareness of complications such as compartment syndrome and cast problems is important.
 
Medication
First Line
  • Patients with open fractures should be treated with intravenous antibiotics to prevent deep infection.
    • Gram-positive coverage (often cefazolin, 1 g in adults and 25 mg/kg in children) and tetanus prophylaxis
    • For Gustilo type II fractures, an aminoglycoside also should be given for Gram-negative coverage
    • For patients with fractures that occurred in a farm environment, with vascular compromise or with extensive soft-tissue crush, 4-5 million units of aqueous penicillin G every 4-6 hours should be given (1st-generation cephalosporin plus an aminoglycoside plus penicillin).
  • Patients may require pain medicines, depending on the severity of the fracture.
Surgery
  • The decision to proceed to operative management depends on several issues, including:
    • The severity of the fracture
    • The need to return to activity more quickly
    • The need to avoid stiffness that comes with casting
  • Intra-articular fracture with displacement requires reduction and fixation to avoid posttraumatic arthritis and to allow for joint motion.
    • Diaphyseal fractures may require fixation to allow for early mobilization or to correct deformity.
  • Types of surgical fixation:
    • Plates and screws:
      • Used for intra-articular fractures after reduction
    • Intramedullary nails:
      • Used for long-bone diaphyseal fractures
      • Allows for early weightbearing
    • External fixation:
      • This approach is used in situations of tenuous blood supply, marked soft-tissue injury, and gross contamination, and for comminuted distal radius fractures.
      • Polytrauma patients with multiple fractures may be treated with damage-control orthopaedics: Temporary external fixators are applied and, later, when the patient is stabilized, staged definitive fixation is performed.
Follow-up
Disposition
Issues for Referral
When a question of child abuse arises, a social worker and pediatrician should be involved.
 
Prognosis
Intra-articular injuries and injuries with substantial soft-tissue damage have poorer prognoses than do injuries to the diaphysis.
 
Complications
  • Delayed union: Healing has not occurred in 3-4 months
  • Nonunion: Healing has not occurred in 6 months
  • Malunion: Healing with malalignment
  • Osteonecrosis (AVN):
    • This condition occurs secondary to the disruption of the blood supply to the bone.
    • Most commonly seen with fractures of the femoral neck and head, femoral condyles, proximal scaphoid, proximal humerus, and talar neck.
  • Osteomyelitis
  • Compartment syndrome
  • Pulmonary disorders:
    • Adult respiratory distress syndrome
    • Fat emboli syndrome
    • DVT/PE
  • Reflex sympathetic dystrophy
  • Posttraumatic arthritis
Geriatric Considerations
It is important to consider carefully operative versus nonoperative management in the elderly, given their higher rates of comorbidities such as diabetes, coronary artery disease, and vascular disease.
 
Patient Monitoring
A patient with a fracture should be followed carefully with serial radiographs to ensure fracture stability and healing.
 
Miscellaneous
Codes
ICD9-CM
829.0 Fracture
 
FAQ
Q: Which fractures require surgery?
A: No definitive rule exists. However, in general, open fractures require surgery for debridement of foreign material; intra-articular fractures require surgery to correct displacement, avoid arthritis, and allow for early joint motion; displaced fractures may require surgery to correct deformity; and patients with multiple injuries may require surgery for early mobilization.

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