eMedicine Specialties > Orthopedic Surgery > Trauma

General Principles of Fracture Care

Author: Richard Buckley, MD, FRCS(C), Head of Orthopedic Trauma Surgery, Clinical Associate Professor, Department of Surgery, Division of Orthopedics, University of Calgary
Coauthor(s): Carlo D A Panaro, MD, Resident, Department of Orthopedic Surgery, University of Alberta
Contributor Information and Disclosures

Updated: Mar 5, 2009

Introduction

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 United States, is the leading cause of death for those aged 1-34 years, and causes more years of lost productivity before age 65 years than coronary artery disease, cancer, and stroke combined.³ Each year, more than 50 million Americans undergo medical treatment for an injury.³ The estimated lifetime cost of these injuries is over $400 billion.

Problem

A 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,⁴ and greenstick fractures. When a fracture occurs, it is described radiographically and clinically in terms of the following factors:

• Anatomy: The fracture is described with relation to the bones involved and the location within the bone (diaphysis, metaphysis, physis, epiphysis).
• Articular surface involvement: Does the fracture have intra-articular involvement? Is there intra-articular displacement or gapping?
• Displacement: Is the distal fracture fragment displaced compared with the proximal fragment? To what degree or percentage is the fracture displaced?
• Angulation: The angular deformity is defined in degrees in terms of the distal fragment in relation to the proximal fragment or with respect to the proximal apex of the distal fragment.
• Rotation: Rotational deformity is described both clinically and radiographically.
• Shortening: Has the fracture caused shortening of the involved bone? To what extent has shortening occurred?
• Fragmentation: The Muller AO (Arbeitsgemeinschaft für Osteosynthesefragen [Association for Osteosynthesis]) Comprehensive Classification of Fractures provides a standardized description of fracture patterns, making communication regarding such injuries more precise and understandable.
  • A multifragmentary fracture is one that has several breaks in the bone, creating more than 2 fragments.
  • Wedge fractures are either spiral (low energy) or bending (high energy) and allow the proximal and distal fracture fragments to contact each other.
  • The complex multifragmentary fracture is a segmental fracture or one in which there is no contact between the proximal and distal fragments without the bone shortening.
  • Simple fractures are spiral, oblique, or transverse.
  • Management of multifragmentary fractures may be more complicated than that for simple fractures. 
• Soft-tissue involvement: Is the fracture open or closed? Is associated neurologic and/or vascular injury present? Is there muscle damage or is compartment syndrome (CS) evident? Gustilo et al described a classification of open fractures comprising 3 types⁵ :
  • Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (ie, inside-out injury). This is a low-energy injury.
  • Type II: The wound is longer than 1 cm, not contaminated, and without major soft-tissue damage or defect. This is also a low-energy injury.
  • Type III: The wound is longer than 1 cm, with significant soft-tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation. Type III fractures are also subdivided into the following:
    • IIIA: The wound has sufficient soft tissue to cover the bone without the need for local or distant flap coverage.
    • IIIB: Disruption of the soft tissue is extensive, such that local or distant flap coverage is necessary to cover the bone. The wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound (see Image 1 ).
    • IIIC: Any open fracture associated with an arterial injury that requires repair is considered type IIIC. Involvement of vascular surgeons is generally required (see Image 2).

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.⁶ The Tscherne⁷ 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.⁸

The use of a classification system is important as it facilitates communication among clinicians, as well as assists clinicians in the following: decision making, anticipating potential problems, suggesting treatment options, predicting patient and surgical outcomes, and documenting cases.⁸

Frequency

Fracture incidence is multifactorial and often complicated by such factors as the patient's age, sex, comorbidities, lifestyle, and occupation. In the United States, 5.6 million fractures occur each year, corresponding to a 2% incidence.⁹  Almost 6000 fractures were treated in an orthopedic trauma unit in Edinburgh, Scotland, in one year.¹⁰ The overall fracture incidence in the Scottish case series was 1.13% in men and 1.16% in women. Interestingly, there was a bimodal distribution of fractures in males, with a high incidence in young men and a second rise in men starting at the age of 60 years. In women, there was a unimodal distribution of fractures, with a rise around the time of menopause. For a study of tibial shaft fractures among Canadian orthopedia trauma surgeons, see Busse et al¹¹ . For frequency of hip fractures, see Gjertsen et al; Parker; and Holt et al.^12,13,14

Etiology

Fractures 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.¹⁵ 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),¹⁶ and crush fractures. Indirect trauma involves forces acting at a distance from the fracture site such as tension (traction), compressive, and rotational forces.

Pathophysiology

The 5 phases of fracture healing are the following¹⁷ :

1. Fracture and inflammatory phase
2. Granulation tissue formation
3. Callus formation¹⁸
4. Lamellar bone deposition
5. Remodeling

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 through 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 approximately 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,¹⁹ comorbidities,²⁰ medication use,²¹ social factors,²² and nutrition²³ (see Table). Other factors that affect fracture healing include the type of fracture,²⁴ degree of trauma,²⁵ systemic and local disease, and infection.²⁶

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.

Open table in new window

Presentation

Single-limb injury

A thorough history should be elicited for the mechanism of injury and for any accompanying or associated events surrounding the injury; obtaining a history of any previous injury or fracture is mandatory. A complete past medical and surgical history should also be obtained, including medications and allergies, as well as a social (smoking and illicit drug use) and occupational history.

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) protocols²⁸ and includes the identification and treatment of life-threatening injuries.²⁹ 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.

Indications

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.³¹

If the fracture cannot be reduced, surgical intervention may be required. Indications for surgical intervention include the following:

• Failed nonoperative (closed) management
• Unstable fractures that cannot be adequately maintained in a reduced position
• Displaced intra-articular fractures (>2 mm)
• Patients with fractures that are known to heal poorly following nonoperative management (eg, femoral neck fractures)³²
• Large avulsion fractures that disrupt the muscle-tendon or ligamentous function of an affected joint (eg, patella fracture)
• Impending pathologic fractures
• Multiple traumatic injuries with fractures involving the pelvis, femur, or vertebrae
• Unstable open fractures or complicated open fractures
• Fractures in individuals who are poor candidates for nonoperative management that requires prolonged immobilization (eg, elderly patients with proximal femur fractures)
• Fractures in growth areas in skeletally immature individuals that have increased risk for growth arrest (eg, Salter-Harris types III-V)
• Nonunions or malunions that have failed to respond to nonoperative treatment

Contraindications

Contraindications to surgical reconstruction are as follows:

• Active infection (local or systemic) or osteomyelitis
• Soft tissues that compromise the overlying fracture or the surgical approach because of poor soft-tissue quality due to soft-tissue injury or burns, previous surgical scars, or active infection
• Medical conditions that contraindicate surgery or anesthesia (eg, recent myocardial infarction)
• Cases in which amputation would better serve the limb and the patient

• Search for CME/CE on This Topic »