eMedicine Specialties > Orthopedic Surgery > Trauma

General Principles of Fracture Care: Treatment

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

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.

Closed reduction is contraindicated under the following conditions24 :
  • 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...

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

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Femur fracture managed with skeletal traction and...

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


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 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 f...

Preoperative radiographs showing a type B ankle fracture.

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Preoperative radiographs showing a type B ankle f...

Preoperative radiographs showing a type B ankle fracture.


Ankle fracture radiograph after open reduction an...

Ankle fracture radiograph after open reduction and internal fixation.

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Ankle fracture radiograph after open reduction an...

Ankle fracture radiograph after open reduction and internal fixation.


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 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 reducti...

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

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Midshaft femur fracture managed with open reducti...

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


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 ROM.

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.

    Pelvic fracture managed with external fixation.

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    Pelvic fracture managed with external fixation.

    Pelvic fracture managed with external fixation.


  • Ilizarov fixator.

    Ilizarov fixator.

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    Ilizarov fixator.

    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
The polytrauma patient: Early total care vs damage-control orthopedics

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.39 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.39,40 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.8

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

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

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.

More on General Principles of Fracture Care

Overview: General Principles of Fracture Care
Workup: General Principles of Fracture Care
Treatment: General Principles of Fracture Care
Follow-up: General Principles of Fracture Care
Multimedia: General Principles of Fracture Care
References
Further Reading
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References

  1. Lidgren L. The Bone and Joint Decade 2000 -2010. Bull World Health Organ [online]. Sept 2003;81(9):629. [Full Text].

  2. [No authors listed]. Bone and joint decade: the initiative [guest editorial]. BJDOnline. Available at http://www.boneandjointdecade.org/default.aspx?contId=229. Accessed May 7, 2007.

  3. Corso P, Finkelstein E, Miller T, Fiebelkorn I, Zaloshnja E. Incidence and lifetime costs of injuries in the United States. Inj Prev. Aug 2006;12(4):212-8. [Medline]. [Full Text].

  4. Moran DS, Israeli E, Evans RK, Yanovich R, Constantini N, Shabshin N, et al. Prediction model for stress fracture in young female recruits during basic training. Med Sci Sports Exerc. Nov 2008;40(11 Suppl):S636-44. [Medline].

  5. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am. Feb 1990;72(2):299-304. [Medline].

  6. Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. Aug 1994;76(8):1162-6. [Medline].

  7. Tscherne H, Oestern HJ. [A new classification of soft-tissue damage in open and closed fractures (author's transl)] [German]. Unfallheilkunde. Mar 1982;85(3):111-5. [Medline].

  8. Ruedi TP, Buckley R, Moran C, eds. AO Principles of Fracture Management. 2nd ed. New York, NY: Thieme Medical Publishers, Inc; 2007.

  9. Canale ST. Campbell's Operative Orthopaedics. 10th ed. St Louis, Mo: Mosby-Year Book; 2003.

  10. Court-Brown C, McQueen M, Tornetta P. Trauma. In: Schepsis AA, Busconi BD, Tornetta P, Einhorn TA, eds. Sports Medicine (Orthopedic Surgery Essentials Series). Philadelphia, Pa: Lippincott Williams & Wilkins; 2006.

  11. Busse JW, Morton E, Lacchetti C, Guyatt GH, Bhandari M. Current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons. Acta Orthop. Oct 2008;79(5):689-94. [Medline].

  12. Gjertsen JE, Engesaeter LB, Furnes O, Havelin LI, Steindal K, Vinje T, et al. The Norwegian Hip Fracture Register: experiences after the first 2 years and 15,576 reported operations. Acta Orthop. Oct 2008;79(5):583-93. [Medline].

  13. Parker MJ. Databases for hip fracture audit. Acta Orthop. Oct 2008;79(5):577-9. [Medline].

  14. Holt G, Smith R, Duncan K, Finlayson DF, Gregori A. Early mortality after surgical fixation of hip fractures in the elderly: an analysis of data from the scottish hip fracture audit. J Bone Joint Surg Br. Oct 2008;90(10):1357-63. [Medline].

  15. Evans FG. Relation of the physical properties of bone to fractures. Instr Course Lect. 1961;18:110-21. [Medline].

  16. Pollak AN, Ficke CJ. Extremity war injuries: challenges in definitive reconstruction. J Am Acad Orthop Surg. Nov 2008;16(11):628-34. [Medline].

  17. Frost HM. The biology of fracture healing. An overview for clinicians. Part I. Clin Orthop Relat Res. Nov 1989;248:283-93. [Medline].

  18. Szczêsny G, Interewicz B, Swoboda-Kopec E, Olszewski WL, Górecki A, Wasilewski P. Bacteriology of callus of closed fractures of tibia and femur. J Trauma. Oct 2008;65(4):837-42. [Medline].

  19. Farmer ME, White LR, Brody JA. Race and sex differences in hip fracture incidence. Am J Public Health. Dec 1984;74(12):1374-80. [Medline]. [Full Text].

  20. Loder RT. The influence of diabetes mellitus on the healing of closed fractures. Clin Orthop. Jul 1988;(232):210-6. [Medline].

  21. Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg Br. Jul 2000;82(5):655-8. [Medline]. [Full Text].

  22. Kwiatkowski TC, Hanley EN Jr, Ramp WK. Cigarette smoking and its orthopedic consequences. Am J Orthop. Sep 1996;25(9):590-7. [Medline].

  23. Hernandez-Avila M, Colditz GA, Stampfer MJ, et al. Caffeine, moderate alcohol intake, and risk of fractures of the hip and forearm in middle-aged women. Am J Clin Nutr. Jul 1991;54(1):157-63. [Medline].

  24. Bucholz RW, Heckman JD, Court-Brown C, et al, eds. Rockwood & Green's Fractures in Adults. 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005.

  25. Schmeling GJ, Schwab JP. Polytrauma care. The effect of head injuries and timing of skeletal fixation. Clin Orthop Relat Res. Sep 1995;318:106-16. [Medline].

  26. Mollitt DL. Infection control: avoiding the inevitable. Surg Clin North Am. Apr 2002;82(2):365-78. [Medline].

  27. Steele B, Serota A, Helfet DL, Peterson M, Lyman S, Lane JM. Vitamin D Deficiency: A Common Occurrence in Both High-and Low-energy Fractures. HSS J. Sep 2008;4(2):143-8. [Medline].

  28. American College of Surgeons. Advanced Trauma Life Support for Doctors (ATLS): Student Course Manual. 7th ed. Chicago, Ill: American College of Surgeons; 2004.

  29. Wang AM, Yin X, Sun HZ, DU QY, Wang ZM. Damage control orthopaedics in 53 cases of severe polytrauma who have mainly sustained orthopaedic trauma. Chin J Traumatol. Oct 2008;11(5):283-7. [Medline].

  30. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. Oct 14 2004;351(16):1645-54. [Medline].

  31. McManus JG, Morton MJ, Crystal CS, McArthur TJ, Helphenstine JS, Masneri DA, et al. Use of ultrasound to assess acute fracture reduction in emergency care settings. Am J Disaster Med. Jul-Aug 2008;3(4):241-7. [Medline].

  32. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. Oct 2008;90(10):2254-66. [Medline].

  33. Bryant LR, Song WS, Banks KP, Bui-Mansfield LT, Bradley YC. Comparison of planar scintigraphy alone and with SPECT for the initial evaluation of femoral neck stress fracture. AJR Am J Roentgenol. Oct 2008;191(4):1010-5. [Medline].

  34. Yang HL, Wang GL, Niu GQ, Liu JY, Hiltner E, Meng B, et al. Using MRI to determine painful vertebrae to be treated by kyphoplasty in multiple-level vertebral compression fractures: a prospective study. J Int Med Res. Sep-Oct 2008;36(5):1056-63. [Medline].

  35. Rang M. Children's Fractures. 2nd ed. Philadelphia, Pa: JB Lippincott; 1983.

  36. O'Toole RV, Andersen RC, Vesnovsky O, Alexander M, Topoleski LD, Nascone JW, et al. Are locking screws advantageous with plate fixation of humeral shaft fractures? A biomechanical analysis of synthetic and cadaveric bone. J Orthop Trauma. Nov-Dec 2008;22(10):709-15. [Medline].

  37. Wagner F, Frigg R, eds. AO Manual of Fracture Management: Internal Fixators. New York, NY: Thieme Medical Publishers, Inc; 2006.

  38. Lambotte A. L'intervention operatoire dans les fractures recentes et anciennes. In: Relter LF, ed. Fractures. Brussels, Belgium: Henri Lamertin; 1907.

  39. Roberts CS, Pape HC, Jones AL, et al. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005;54:447-62. [Medline].

  40. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. Mar 1989;71(3):336-40. [Medline].

  41. von Volkmann R. Verletzungen und krannkheiten der bewwgungsorgane. In: Pitha FJ, Billroth T, eds. Handbuch der Allegemeinen und Speziellen Chirurgie. Vol 2. Stuttgart, Germany: Verlag von Ferdinand Enke; 1872:234-920.

  42. [No authors listed]. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) Trial. Lancet. Apr 15 2000;355(9212):1295-302. [Medline].

  43. Madsen JL. Bone SPECT/CT detection of a sequestrum in chronic-infected nonunion of the tibia. Clin Nucl Med. Oct 2008;33(10):700-1. [Medline].

  44. Tu YK, Chen AC, Chou YC, Ueng SW, Ma CH, Yen CY. Treatment for scaphoid fracture and nonunion--the application of 3.0 mm cannulated screws and pedicle vascularised bone grafts. Injury. Oct 2008;39 Suppl 4:96-106. [Medline].

  45. Krettek C, Schandelmaier P, Miclau T, Tscherne H. Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury. 1997;28 (suppl 1):A20-30. [Medline].

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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.

 
 
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