eMedicine Specialties > Orthopedic Surgery > Trauma

General Principles of Fracture Care

Richard Buckley, MD, FRCS(C), Head of Orthopedic Trauma Surgery, Clinical Associate Professor, Department of Surgery, Division of Orthopedics, University of Calgary
Carlo D A Panaro, MD, Resident, Department of Orthopedic Surgery, University of Alberta

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).

Gustilo type IIIB open fracture.

Angiographic evidence of vascular injury after traumatic injury (Gustilo type IIIC open fracture).

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.

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

Workup

Laboratory Studies

• The preoperative laboratory studies that are performed depend on the patient’s age, the extent of the injuries, and other conditions that add to the patient's morbidity.
• Patients with trauma require an ATLS workup.²⁸
• Tests that can be performed preoperatively but are not mandatory are as follows: 
  • Complete blood cell count
  • Electrolyte, creatinine, and glucose levels
  • Urinalysis
  • Coagulation studies, including measurement of the activated partial thromboplastin time (aPTT) and international normalized ratio (INR)
  • Cross-matching and typing of the patient's blood
  • Alcohol and toxicology screening

Imaging Studies

Depending on the patient's medical status, chest radiography may be indicated.

• The rule of 2s has been developed for obtaining radiographs. 
  • Two views: Obtain anteroposterior (AP) and lateral views of the injured limb (2 views 90° orthogonal to each other); depending on the area involved, specific radiographs may be required (see Joint-specific radiographs) . 
  • Two joints: When an injury occurs to an extremity, the authors recommend obtaining radiographs of the joints above and below the injury to rule out any potential associated fracture or dislocation in a corresponding joint (see Image 3).
  • 
    

    

    Midshaft femoral fracture with associated ipsilateral hip dislocation. This radiograph illustrates the rule of 2s principle.

    
    
  • Two limbs: The authors recommend obtaining radiographs of both the injured and noninjured limbs to aid in analysis of the osseous anatomy and, ultimately, to aid in the diagnosis. This is especially important to help determine limb length and rotation in children with epiphyseal-plate injuries or in patients with severely comminuted fractures. 
  • Two times: The authors recommend obtaining 1 prereduction image and 1 postreduction or postfixation image to assess the adequacy of the fracture reduction. (See Joint-specific radiographs for specific radiographs for various joints.) 

Radiographs should be described in terms of the rule of the 6 A’s:

• Anatomy (eg, proximal tibia)
• Articular (eg, intra- vs extra-articular)
• Alignment (eg, first plane)
• Angulation (eg, second plane)
• Apex (in terms of the distal fracture fragment)
• Apposition (eg, 75% or 0% [bayonet]) 

• Cervical spine – Odontoid view
• Spine instability – Flexion and extension
• Shoulder – Axillary
• Clavicle – AP in 30° cephalic tilt
• Scapula – Y view
• Glenohumeral joint – Axillary (Because of pain from the fracture, the surgeon ordering these views may need to supervise the imaging examination.)
• Acromioclavicular joint – No stress views required
• Radial head – 45° Lateral
• Scaphoid – Posteroanterior (PA) in ulnar deviation
• Pelvis – Inlet and outlet
• Acetabulum – Iliac oblique, obturator oblique
• Femoral neck – AP view with 15° internal rotation³³
• Knee joint – Notch view and/or Merchant view
• Ankle joint – Mortise view
• Calcaneus – Broden views
• Talus – Canale view

CT scanning is not indicated for the routine evaluation of common fractures. However, depending on the bones involved and the degree of comminution, CT scanning can be invaluable in the preoperative planning for complicated fractures. This planning is paramount in periarticular fractures in which intra-articular involvement is suspected. CT scanning is also an important adjunct for assessing fracture reduction and fixation.

Magnetic resonance imaging (MRI) is indicated in assessing the spinal column for injury.³⁴

Depending on the patient's medical status, electrocardiography may be indicated.

Treatment

Medical Therapy

The 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.

The goal in managing fractures is to ensure that the involved limb segment, when healed, has returned to its maximal possible function. This is accomplished by obtaining and subsequently maintaining a reduction of the fracture with an immobilization technique that allows the fracture to heal and, at the same time, provides the patient with functional aftercare. Either nonoperative or surgical means may be used.

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.

• Undisplaced fractures
• If displacement exists but is not relevant (eg, humeral shaft fracture)
• If reduction is impossible (severely comminuted fracture)
• If the reduction, when achieved, cannot be maintained
• If the fracture has been produced by traction forces (eg, displaced patellar fracture)

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 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.³⁵ 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.

Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.

Surgical Therapy

In 1958, the Association for the Study of Internal Fixation (ASIF) created 4 treatment goals for surgical fracture management.⁸ To date, these goals have not changed and are as follows:

1. Anatomic reduction of the fracture fragments: For the diaphysis, anatomic alignment ensuring that length, angulation, and rotation are corrected is required, whereas intra-articular fractures demand an anatomic reduction of all fragments.
2. Stable internal fixation to fulfill biomechanical demands
3. Preservation of blood supply to the injured area of the extremity
4. Active, pain-free mobilization of adjacent muscles and joints to prevent the development of fracture disease

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. As stated by 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."⁹ 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).

Preoperative radiographs showing a type B ankle fracture.

Ankle fracture radiograph after open reduction and internal fixation.

Five main plate designs exist⁸ :

• Buttress (antiglide) plates
• Compression plates
• Protection plates
• Tension band plate
• Bridge plates

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.

A locking plate acts like an internal fixator.³⁶ There is no need to anatomically contour the plate onto the bone, thus reducing bone necrosis and allowing for a minimally invasive technique. Locking screws directly anchor and lock onto the plate, thereby providing angular and axial stability. These screws are incapable of toggling, sliding, or becoming dislodged, thus reducing the possibility of a secondary loss of reduction, as well as eliminating the possibility of intraoperative overtightening of the screws. The locking plate is indicated for osteoporotic fractures, for short and metaphyseal segment fractures, and for bridging comminuted areas. These plates are also appropriate for metaphyseal areas where subsidence may occur or prostheses are involved.³⁷

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.

Midshaft femur fracture managed with open reduction and internal fixation performed with use of an intramedullary nail.

External fixation

In 1907, European physician Albin Lambotte developed the technique of external fixation for the management of fractures.³⁸ 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:

• Open fractures that have significant soft-tissue disruption (eg, type II or III open fractures)
• Soft-tissue injury (eg, burns)
• Pelvic fractures (see Image 8)
• 
  

  

  Pelvic fracture managed with external fixation.

  
  
• 
  

  

  Ilizarov fixator.

  
  
• Severely comminuted and unstable fractures
• Fractures that are associated with bony deficits
• Limb-lengthening procedures (see Image 9)
• Fractures associated with infection or nonunion

Preoperative Details

Detecting 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 Details

C-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 Details

Postoperatively, 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-up

Consultation 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 ROM. These therapists can provide appropriate guidance with respect to exercises and activities that aid in the patient's healing process.

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.

Complications

Complications of casts

Complications 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.⁸ These problems may be avoided by providing functional aftercare.

Complications of traction

Complications 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 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 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 1872,⁴¹ 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.⁹ Prophylaxis is effective in decreasing the incidence of DVT in the immobilized extremity,⁴² 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,⁴³ stabilization of the fracture, removal of interfering soft tissues, bone grafting,⁴⁴ 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 Controversies

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.⁴⁵ 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.

Certain advantages of MIPPO may include faster bone healing, reduced infection rate, decreased need for bone grafting, less postoperative pain, faster rehabilitation, and more aesthetic results. Some disadvantages may include difficulty with indirect reduction, increased C-arm exposure, malunion, pseudoarthrosis through diastases, and delayed union with flexible fixation in simple fractures.³⁷

The use of biologic agents that aid in fracture healing will be commonly used in fracture management. Currently, autologous and cadaveric bone grafts are used in fracture management. Autologous cancellous bone grafts are used to fill defects and to provide stimulus for growth. Cadaveric cortical bone grafting is commonly used to provide diaphyseal structural support and to aid in filling large diaphyseal deficits.

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.

Multimedia

Media file 1: Gustilo type IIIB open fracture.

Media file 2: Angiographic evidence of vascular injury after traumatic injury (Gustilo type IIIC open fracture).

Media file 3: Midshaft femoral fracture with associated ipsilateral hip dislocation. This radiograph illustrates the rule of 2s principle.

Media file 4: Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.

Media file 5: Preoperative radiographs showing a type B ankle fracture.

Media file 6: Ankle fracture radiograph after open reduction and internal fixation.

Media file 7: Midshaft femur fracture managed with open reduction and internal fixation performed with use of an intramedullary nail.

Media file 8: Pelvic fracture managed with external fixation.

Media file 9: Ilizarov fixator.

Media file 10: Every year, 1.25 million people worldwide die from injuries due to motor vehicle accidents.

Media file 11: Radiograph in patient with acute respiratory distress syndrome.

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Keywords

fracture care, fracture management, open fracture, closed fracture, broken bone, traumatic bone injury, open reduction and internal fixation, ORIF, external fixation , ankle fracture, femur fracture, elbow fracture, hip fracture, cervical spine fracture, tibia and fibula fracture, vertebral fracture, knee fracture, humerus fracture, wrist fracture, pelvic fracture, foot fracture, forearm fracture

Contributor Information and Disclosures

Author

Richard Buckley, MD, FRCS(C), Head of Orthopedic Trauma Surgery, Clinical Associate Professor, Department of Surgery, Division of Orthopedics, University of Calgary
Richard Buckley, MD, FRCS(C) is a member of the following medical societies: Canadian Orthopaedic Association and Orthopaedic Trauma Association
Disclosure: Nothing to disclose.

Coauthor(s)

Carlo D A Panaro, MD, Resident, Department of Orthopedic Surgery, University of Alberta
Carlo D A Panaro, MD is a member of the following medical societies: Alberta Medical Association, Canadian Medical Association, and Canadian Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

James F Kellam, MD, Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center
James F Kellam, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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
Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS, Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center
Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

Clinical guidelines

Evaluating infants and young children with multiple fractures. American Academy of Pediatrics - Medical Specialty Society. 2006 Sep. 5 pages. NGC:005253

Evidence-based care guideline for femoral shaft fractures. Cincinnati Children's Hospital Medical Center - Hospital/Medical Center. 2002 Dec 9 (revised 2006 Jul 21; reviewed 2006 Dec). 19 pages. NGC:005206

Rib fractures. American College of Radiology - Medical Specialty Society. 1995 (revised 2005). 5 pages. NGC:004640

Stress/insufficiency fracture, including sacrum, excluding other vertebrae. American College of Radiology - Medical Specialty Society. 1995 (revised 2005). 7 pages. NGC:004785

Clinical trials

Clinical Study of the U-Plate Fracture Repair System to Treat Rib Fractures

Re-Evaluation of GAmma3 Intramedullary Nails in Hip Fracture (REGAIN)

Management of Displaced Supracondylar Fractures of the Humerus Using Lateral vs. Crossed K-Wires

Allomatrix Injectable Putty in Distal Radius Fractures

Comparison of Balloon Kyphoplasty and Vertebroplasty in Subacute Osteoporotic Vertebral Fractures

Percutaneous Autologous Bone-Marrow Grafting for Open Tibial Shaft Fracture

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