General Principles of Fracture Care

Fractures can heal by two different mechanisms, depending on their position and stability. Primary or direct healing is possible when an anatomic reduction with compression is achieved.[5] With primary healing, the modeling occurs internally, and no callus is formed. Secondary or indirect healing occurs with relative stability when an anatomic reduction is not achieved or compression is not possible.[5] This type of healing involves the formation of a bony callus and then subsequent external remodeling to bridge the gap.

The four phases of indirect fracture healing are as follows[5] :

• Fracture and inflammatory phase
• Granulation tissue/soft callus formation
• Hard callus formation, including woven bone creation ^[6]
• Remodeling, including lamellar bone creation

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 soft callus, which lasts approximately 2 weeks.

During hard 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 hard lamellar bone, which is organized parallel to the axis of the bone. This final stage involves remodeling of the bone at the site of the healing fracture by various cellular types such as osteoclasts. Remodeling can take months to years, depending on patient and fracture factors.[5]

Patient factors that influence fracture healing include age,[7] comorbidities,[8] medication use,[9] social factors,[10] and nutrition[11] (see Table 1 below). Other factors that affect fracture healing include fracture type,[12] degree of trauma,[13] systemic and local disease, and infection.[14]

Table 1. Patient Factors That Influence Fracture Healing (Open Table in a new window)

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.

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.[16] 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),[17] and crush fractures. Indirect trauma involves forces acting at a distance from the fracture site such as tension (traction), compressive, and rotational forces.

Trauma causes more than 200,000 deaths per year in the United States[18] and is the leading cause of death for those aged 1-44 years.[19] Each year, more than 55 million Americans undergo medical treatment for an injury, and the estimated total cost of all injuries exceeds $1 trillion.[20]

The WHO estimated that injuries account for 12% of all disability-adjusted life years (DALYs) lost, which includes a significant number of fractures.[21] In low- and middle-income countries, falls and traffic injuries are the top causes of disease burden, higher than communicable diseases such as tuberculosis and HIV disease.

The proportion of burden from injury, as opposed to communicable or degenerative disease, is highest in middle-income regions such as China and South America, where it nears 20%.[21] A household survey in Sierra Leone found that 12% of respondents had experienced a traumatic injury within the preceding year, with falls being the most common cause (40%) and the extremities being the most common site of injury.[22]

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.[23]

Almost 6000 fractures were treated in an orthopedic trauma unit in Edinburgh, Scotland, in 1 year.[24] 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 orthopedic trauma surgeons, see Busse et al.[25] For frequency of hip fractures, see Gjertsen et al,[26] Parker,[27] and Holt et al.[28]

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. If the injury involved a fall, the circumstances surrounding the fall should be explored. If a syncopal or presyncopal prodrome occurred, further medical workup is required.

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) history, occupational history, and documentation of dominant handedness if the injury involves an upper extremity.

The physical examination must include a thorough inspection of the overlying soft tissues (with documentation). If the fracture is open, a clinical photograph may be taken for documentation purposes and to avoid multiple clinicians having to take down dressings to observe the wound. Distal neurologic and vascular status must be assessed and documented for all fractures.

It is necessary to classify the soft tissues overlying the fracture and to grade any open wounds according to the well-known Gustilo-Anderson system. Compartment syndromes in areas of the body prone to this malady (erg, the forearm and lower leg) must be ruled out by careful examination and documentation and serial assessment.

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 be impossible because of pain, 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

Initial assessment of a patient with polytrauma follows the Advanced Trauma Life Support (ATLS) protocols[29] and includes the identification and treatment of life-threatening injuries.[30] The first step is evaluation of the individual's airway, breathing, and circulation (the ABCs). Immediate endotracheal intubation and rapid administration of intravenous fluids may be necessary. Full spinal precautions must be maintained until injury to the complete spine can be excluded clinically and through diagnostic imaging (with radiography or computed tomography [CT]).

Pelvic instability must be addressed urgently; continued venous bleeding from the pelvis can be life-threatening. Closed reduction (after examination for open wounds) of open-book pelvic injuries with application of a sheet or binder is imperative to save lives. If the pelvic injury has a vertical component as well as an open-book component, a traction pin should be placed in the distal femur and the hemipelvis reduced by femoral traction and then splinted with a sheet or binder. These life-saving maneuvers are now part of the early resuscitation of a trauma patient.

Once the patient is hemodynamically stable, the secondary survey, a complete systems-based physical examination, is performed. Note that fractures to the pelvis and femur(s) can have substantial hemodynamically altering affects and assessment of these areas should be included in initial resuscitation efforts.

Splinting of limb injuries in emergency department

Reduction and splinting of traumatic injuries (open and closed) in the emergency department (ED) is imperative. Periarticular injuries and dislocations that are not reduced in a timely fashion may cause cartilage necrosis to the affected joints. Splinting reduces pain and deformity and lowers the risk of continued neurovascular injury. Splinting and elevation also enhance nursing care and minimize swelling.

Open wounds and soft-tissue injuries must be covered with sterile moist dressings after being viewed by a clinician. The injured limb is then splinted by going above and below adjacent joints with adequate soft padding, appropriate cast material (whether plaster of Paris or fiberglass), and tensor bandages.

The upper extremity is splinted in a standard position, with the shoulder and humerus beside the chest, the elbow at 90º of flexion, and the forearm and wrist in neutral rotation and neutral flexion and extension. The hand is splinted in the "safe position," with the wrist extended, the metacarpal joints flexed to 90º, and the interphalangeal (IP) joints fully extended. To prevent compartment syndrome, splintage should be half-circumferential and should not fully surround the limb.

The lower extremity also has specific positions for splinting, in that the proximal parts do not lend themselves to casting. To splint an unstable pelvic or femur fracture/dislocation, a distal femoral skeletal traction pin must be placed with 25 lb (~11 kg) of weight off the end of the bed in a pulley system. Knee dislocations and tibial fractures should undergo above-the-knee splinting with half-circumferential dressings and splintage material. Ankle and foot fractures require splintage that includes the whole lower leg up to the knee but does not cross the knee joint.

Postreduction radiographs should be obtained and neurovascular checks performed in the ED to confirm that the reductions are satisfactory and that it is safe to allow the patient to wait for more definitive care in the operating room. Splinting remains part of good care for all limb injuries and is important for preparing an injured patient for the next step in care, whether that involves nonoperative management or operative fixation.

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,[31] 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])/OTA (Orthopaedic Trauma Association) comprehensive classification of fractures[32] provides a standardized description of fracture patterns, making communication regarding such injuries more precise and understandable. The various patterns are described as follows:

• Simple fractures are spiral, oblique, or transverse
• A multifragmentary fracture is one that has several breaks in the bone, creating more than two fragments
• Wedge fractures are either spiral (low-energy) or bending (high-energy) and allow the proximal and distal fracture fragments to remain in 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

Management of multifragmentary fractures may be more complicated than that for simple fractures.

Soft-tissue involvement

Is the fracture open (formerly referred to as "compound") or closed? Is associated neurologic and/or vascular injury present? Is there muscle damage or is compartment syndrome evident? Gustilo et al described a classification of open fractures comprising the following three types[33] :

• 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, minimally contaminated, and without major soft-tissue damage or defect; this is also considered 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 further divided into the following subtypes:

• IIIA - The wound has sufficient healthy soft tissue to cover the bone without the need for local or distant flap coverage
• IIIB - Disruption of the soft tissue is sufficiently extensive that local or distant flap coverage is necessary to cover the bone (see the first image below); the wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound
• IIIC - Any open fracture associated with an arterial or neurologic injury that requires repair is considered type IIIC (see the second image below); involvement of vascular or plastic surgeons is generally required

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.[34] The Tscherne[35] and Hanover fracture scales are classification systems that allow better evaluation of the soft-tissue injury relative to wound size, area of skin loss, and underlying soft-tissue damage.[5] However, the Gustilo classification remains the system most commonly used.

The use of a clear description and classification system is important not only for facilitating communication among clinicians but also for assisting clinicians with the following: decision making, anticipation of potential problems, suggestion of treatment options, prediction of patient and surgical outcomes, and documentation of cases.[5]

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 or if the ankle-brachial index (ABI) is less than 0.9 or grossly different from the contralateral 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

Compartment syndrome, initially reported by von Volkmann in 1872,[36] is a potentially limb- and life-threatening condition. Compartment syndrome 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 compartment syndrome can involve tissue necrosis, functional limb impairment with contracture, and renal failure secondary to rhabdomyolysis, which may lead to death if untreated. Compartment syndrome 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 (abnormal temperature). Pulselessness is a late finding of compartment syndrome.

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.

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 those that are not adequately reduced. Management of posttraumatic arthritis depends on the joint involved and can include arthroscopic debridement, osteotomy, arthroplasty, or arthrodesis.

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 Advanced Trauma Life Support (ATLS) workup.[29]

Tests that can be performed preoperatively but are not mandatory are as follows:

• Complete blood count (CBC)
• 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

Radiography

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

Radiographs of the limbs are obtained in accordance with the so-called rule of twos, as follows:

• Two views - Obtain anteroposterior (AP) and lateral views of the injured limb (these views are 90° orthogonal to each other); depending on the area involved, specific radiographs may be required (see below)
• 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 the image below)
• 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 for helping determine limb length and rotation in children with epiphyseal-plate injuries or in patients with severely comminuted fractures
• Two times - The authors recommend obtaining prereduction images and postreduction or postfixation images to assess the adequacy of the fracture reduction

The radiographs obtained should be described in terms of the so-called rule of six As, as follows:

• 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])

Joint-specific radiographs other than AP, lateral, or oblique images include, but are not limited to, the following:

• 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
• Comminuted elbow - traction views (the surgeon will likely need to provide the traction)
• Scaphoid – Posteroanterior (PA) in ulnar deviation
• Pelvis – Inlet and outlet
• Acetabulum – Iliac oblique, obturator oblique (Judet views)
• Femoral neck – AP view with 15° internal rotation ^[37]
• Knee joint – Notch view and/or Merchant view
• Ankle joint – Mortise view
• Calcaneus – Broden views
• Talus – Canale view

Computed tomography and magnetic resonance imaging

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

Magnetic resonance imaging (MRI) is indicated in assessing the spinal column for injury.[38]

Depending on the patient's medical status, baseline electrocardiography (ECG) may be indicated preoperatively.

Fracture management can be divided into nonoperative and operative techniques. The nonoperative approach 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.[39] Pediatric fractures are generally much more tolerant of nonoperative management, owing to their significant remodeling potential.[40]

If closed reduction is inadequate, 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) ^[41]
• 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, any type II or type III open fracture
• Fractures in individuals who would poorly tolerate prolonged immobilization required for nonoperative management (eg, elderly patients with proximal femur fractures ^[42] )
• 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 for 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, excessive swelling, previous surgical scars, or active infection
• Medical conditions that contraindicate surgery or anesthesia (eg, recent myocardial infarction)
• Cases in which amputation, rather than attempted fracture fixation, would better serve the limb and the patient

Nondisplaced fractures all require a period of healing that may or may not involve cast care. In this time of aggressive operative treatment, only simple nondisplaced fractures of long bones or joints may be treated with nonoperative cast care; the rest are treated with emergency operative care so as to allow early motion and thereby prevent stiffness of adjacent joints.

The most important factors in fracture healing are blood supply and soft-tissue health, and initial management of an injured limb should have the goal of maintaining or improving these.[23]

The initial management of fractures consists of realignment of the broken limb segment (if grossly deformed) 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.

Open fractures

The treatment goals for open fractures are as follows:

• To prevent infection
• To allow the fracture to heal
• To restore function in the injured limb

Once the initial assessment, evaluation, and management of any life-threatening injury are completed, the open fracture is treated. Hemostasis should be obtained if there is significant ongoing bleeding, though bone bleeding is best reduced by anatomic reduction. Gross contaminants can be removed if possible and the soft-tissue wound can be covered by a sterile dressing moistened with normal saline. Harsher adjuncts, such as iodine solutions, are not recommended, because of their cytotoxic effects.[43] Tetanus immunization should be provided if the patient does not have current immunity.

Bhandari’s Evidence-Based Orthopedics[43] provides an excellent overview of current best evidence for open fracture management. Time to antibiotic administration has been shown to be the most important factor in reduction of infection risk in open fractures; therefore, antibiotics should be given immediately.

For type I and type II fracture injuries, a first-generation cephalosporin (eg, cefazolin) is adequate. If the wound is severely contaminated (type III), an aminoglycoside (eg, gentamicin, tobramycin) is commonly added to complement treatment. If the injury is a "barnyard injury" (contaminated with soil) or water-type injury, penicillin may also be added to provide prophylaxis against Clostridium perfringens and other anaerobes.

Rodriguez et al reported on the use of an evidence-based antibiotic protocol based on open fracture grade, in which patients with grade I or II fractures received cefazolin (clindamycin in the case of allergy) and those with grade III fractures received ceftriaxone (clindamycin and aztreonam in the case of allergy) for 48 hours; aminoglycosides, vancomycin, and penicillin were excluded from the protocol.[44] Implementation of this protocol for open fracture antibiotic prophylaxis led to significantly reduced use of aminoglycoside and glycopeptide antibiotics without increasing rates of in skin and soft-tissue infection.

Prophylactic use of quinolones is not appropriate, both because of the rapid development of resistant staphylococci and because quinolones are important drugs in the treatment of implant-related infections.[45]

There is little evidence available to guide the decision of appropriate duration to continue antibiotic administration, but general practice in North America is to provide 24 hours of coverage after definitive wound closure.

The traditional teaching of open fracture management was that urgent irrigation and debridement (I&D) of the wound in the operating room (OR) is mandatory within 6 hours and that open fractures are considered orthopedic emergencies. More recent data, such as the findings from the Lower Extremity Assessment Program (LEAP), suggested that surgical I&D within 24 hours of injury is sufficient.[43] For type II and type III injuries, serial I&Ds are recommended every 24-48 hours after the initial debridement until a clean surgical wound is ensured and no necrotic tissue persists.

Debridement must be carried out by the most senior clinician available because experience has been proved to enhance infection prevention. All dead and devitalized tissue is removed, including all skin, bone, muscle, tendon, body fat, vessels, and nerves that are not viable and without blood supply. The best way of determining with assurance that a type of tissue is alive is to see if it bleeds.

A tumor-type resection is performed to ensure that all dead tissue is removed. Thorough irrigation is then carried out. If the wound is not too dirty, a single debridement may be satisfactory, but if there is any doubt as to the efficacy of the debridement, a second or third debridement should be planned. At this time, any tissues that were at all questionable with regard to survival will have declared themselves and either will be salvageable or will be best treated with excision.[46]

There is some controversy with regard to the most appropriate type of irrigation fluid, the optimal volume, and the preferred degree of pressure. Antisepsis must be balanced against the cytotoxic effect on the native tissues. Bhandari et al advocated the use of simple normal saline for irrigation via a low-pressure delivery system.[43] A widely accepted approach is to use a minimum of 3 L of irrigation for a type I fracture, 6 L for a type II fracture, and 9 L for a type III fracture.

The wound is closed when it is clean, ideally within 3-7 days of the initial injury; the risk of infection and flap failure rise precipitously when closure of type III fractures occurs more than 7 days after injury.[43] Plastic surgery colleagues may need to be involved in the wound closure.

Management of the open fracture depends on the site of injury and type of open fracture. The wound is subsequently stabilized either temporarily or definitively. If soft-tissue coverage over the injury is inadequate between debridements, wet-to-dry dressings or negative-pressure wound therapy (eg, vacuum-assisted closure [VAC] dressings) may be used. If the fracture reduction cannot be maintained between debridements, an external fixator may be used, with the pin sites well outside the zone of injury.[5]

Guidelines for wound care (eg, those from the British Orthopaedic Association[47] ) have helped make soft tissue a priority in the management of these injuries.

Early fracture management is generally aimed at controlling hemorrhage, providing pain relief, preventing ischemia-reperfusion injury, and removing potential sources of contamination (foreign body and nonviable tissues). Once these tasks 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 ultimate goal of fracture management 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 employed.

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, reversing the mechanism of injury/fracture, and finally immobilizing the limb through casting or splinting. Splints and casts can be made from fiberglass or plaster of Paris. Barriers to accomplishing reduction include soft-tissue interposition at the fracture site and hematoma formation that create tension in the soft tissues.

Closed reduction is contraindicated in the following circumstances[12] :

• If there is no displacement
• If displacement exists but is not relevant to functional outcome (eg, humeral shaft fracture where the shoulder and elbow motion can compensate for residual angulation)
• 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 cannot be treated by means of 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.

Skin traction

In skin traction, traction tapes are attached to the skin of the limb segment that is below the fracture or a foam boot is securely fitted to the patient's foot. In the application of skin traction, or Buck traction, usually 10% of the patient's body weight (up to a maximum of 10 lb [~4.5 kg]) is recommended.[40] 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.

Skeletal traction

In skeletal traction, a pin (eg, a 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 the image below) 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.

The four AO (Arbeitsgemeinschaft für Osteosynthesefragen [Association for Osteosynthesis]) principles, in their basic form, have governed the society’s approach to fracture management for decades.[5] They are as follows:

• Anatomic reduction of the fracture fragments - For the diaphysis, anatomic alignment ensuring that length, angulation, and rotation are corrected as required; intra-articular fractures demand anatomic reduction of all fragments
• Stable fixation, absolute or relative, to fulfill biomechanical demands
• Preservation of blood supply to the injured area of the extremity and respect for the soft tissues
• Early range of motion (ROM) and rehabilitation

Preparation for operative intervention

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 and/or anesthesiologist before performing any operative intervention.

Prophylactic antibiotics (cefazolin, 1-2 g) should be administered prior to incision. If the patient is allergic to penicillin, clindamycin can be administered. Patients with open fractures should be given appropriate antibiotic prophylaxis (see Elements of Initial Fracture Management). There is no evidence to support continuing prophylactic antibiotics beyond 24 hours postoperatively.[43]

Open reduction and internal fixation

The objectives of open reduction and internal fixation (ORIF) include the following:

• Adequately exposing the fracture site
• Minimizing soft-tissue stripping
• Obtaining a reduction of the fracture
• Stabilizing and maintaining the reduction that has been achieved

Kirschner wires

Kirschner wires (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, they are supplemented by casting or splinting. The wires can be placed percutaneously or through a miniopen mechanism. K-wire fixation has been used for small fragments in metaphyseal and epiphyseal regions, especially in fractures of the distal foot, wrist, and hand (eg, Colles fractures) and in displaced metacarpal and phalangeal fractures after closed reduction.[23] 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 the images below).

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.

Plates may be divided into five types on the basis of their main functions, as follows[5] :

• Buttress (antiglide) plates
• Compression plates
• Neutralization plates
• Tension-band plate
• Bridge plates

Locking plates or fixed-angle devices are also helpful.

Buttress plates encourage compression and counteract the 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. These plates are commonly used in the long bones, especially the fibula, radius, and ulna, and in nonunion or malunion surgery.

Neutralization plates are used in combination with interfragmentary lag-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. Neutralization 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. Care should be taken to obtain correction of rotation, length, and alignment with bridge plating.

A tension-band plate technique converts tension forces into compressive forces, thereby providing absolute stability. An example of this technique is the use of a tension-band plate for fixation of a transverse olecranon fracture.

A locking plate acts like an internal fixator.[48] There is no need to anatomically contour the plate onto the bone; consequently, bone necrosis is reduced, and a minimally invasive technique is possible. 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 poor-quality bone (ie, 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.[49] Locking plates can only hold a reduction that has already been obtained.

Intramedullary nails

The use of intramedullary nails in fracture management has been widely accepted. These nails operate like an internal splint that shares the load with the bone and can be flexible or rigid, locked or unlocked, and reamed or unreamed.

Locked intramedullary nails provide relative stability to maintain bone alignment and length and to limit rotation. Ideally, intramedullary nailing allows for compressive forces at the fracture site, which stimulates bone healing. Intramedullary nails are commonly used for femoral and tibial diaphyseal fractures (see the image below) and, occasionally, humeral diaphyseal fractures. The advantages of intramedullary nails include minimally invasive procedures, early postoperative ambulation, and early ROM.

Imaging for evaluation of results

C-arm fluoroscopy is valuable and often necessary in the OR 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. All staff within the operating suite should be protected from radiation, either with aprons or with lead shields, while fluoroscopy is in use.[50]

External fixation

In 1907, the Belgian physician Albin Lambotte developed the technique of external fixation for the management of fractures.[51] 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 also allows inspection of the soft-tissue structures that are vital for fracture healing, as well as subsequent wound care.

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 the first image below)
• Severely comminuted and unstable fractures
• Fractures that are associated with bony deficits
• Limb-lengthening procedures (see the second image below)
• Fractures associated with infection or nonunion

Polytrauma: 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.[52] 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.[52, 53, 54] 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 be considered only in stable patients who have been adequately resuscitated, whereas those who are unstable should undergo damage-control orthopedics (DCO). The DCO concept refers to early debridement of surgical wounds with minimally invasive temporary fixation of long-bone fractures and dislocations. External fixator pins should be placed outside the zone of injury and should avoid sites of planned future incisions.

DCO 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; however, concern should be high in patients with Injury Severity Scale (ISS) scores higher than 40, those with ISS scores higher than 20 who have thoracoabdominal injuries, and those who have moderate-to-severe head injuries, among others.[5, 43]

Moderate-quality evidence exists that DCO results in shorter operating times and less blood loss than early total care.[43] Although studies have not yet shown that DCO results in a decrease in mortality in a broad population of trauma patients, it may be that the benefit is primarily in a subset of severely injured patients.[43] Even if an initial DCO approach is followed, definitive management should be performed within 7 days from injury, once the patient is stabilized, to minimize the risk of infectious complications.

Minimally invasive percutaneous plate osteosynthesis

Krettek et al were prominent in developing the concept of minimally invasive percutaneous plate osteosynthesis (MIPPO) with indirect reduction.[55] 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.[49]

Biologic aids for fracture healing

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 [BMP], transforming growth factor [TGF] beta, gene family fibroblast growth factor [FGF], and platelet-derived growth factor [PDGF]) and immunomodulatory cytokines (interleukin [IL]-1 and IL-6). Some of these biologic agents have been gaining in popularity. BMP, for example, is now commonly used in spine surgery to facilitate interbody fusion.

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. In all surgical cases, postoperative splinting is important for preventing issues with skin-wound healing and contractures.

Each joint is splinted in the safest position for that joint. Any joint that has undergone a periarticular surgical approach for reconstruction should be splinted in the neutral position (eg, ankle or wrist). A long bones with nails inserted (eg, tibia, femur, or humerus) need not be splinted but can be moved in an early fashion. Large joints (eg, shoulder, hip and knee) that have been approached in a periarticular fashion usually are not splinted or are splinted for a short period to allow optimal wound healing (no more than 10 days).

Postoperatively, patients are examined at follow-up visits, usually within 1-2 weeks after their surgical procedure, and periodically thereafter until the fracture has healed and functioning has returned. Careful surgical postoperative protocols exist for all long-bone and joint injuries.[46] Weightbearing status depends on the stability of the fracture or osteosynthesis construct.[46]

Any patient who has sustained an intra-articular injury may develop arthritis and joint pain postoperatively. Careful patient education is imperative to ensure that the patient is aware of this potential problem, so that steps can be taken to achieve the best possible outcome.

Complications of casts

Complications of casts include the development of pressure injuries, thermal burns during plaster hardening, and thrombophlebitis. The AO 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.[5]

These problems may be avoided by providing functional aftercare. Children in prolonged cast immobilization need to be especially watched and educated on cast care; they have been known to stick items between their cast and skin in an attempt to scratch and alleviate pruritus. Broken skin can lead to festering infection, and “lost” items inside the cast can lead to pressure injuries.[40]

Complications of traction

Complications of traction include the development of pressure injuries, pulmonary/urinary infections, permanent foot-drop contractures (if the foot is positioned in equinus), peroneal nerve palsy, pin-tract infection, and thromboembolic events (eg, deep venous thrombosis [DVT], pulmonary embolism [PE]). 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 surgical intervention

Infection

Complications of surgical intervention include local infection in the form of cellulitis or, in more serious cases, 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. A 2-week course of first-generation cephalosporins, such as cephalexin, is generally sufficient for superficial surgical-site infections (SSIs).

Serial C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) measurements should be obtained and may be used to assess treatment response to antibiotics, though these will naturally be elevated in the immediate postoperative period.

If infection cannot be eradicated with antibiotics, I&D of the surgical wound may be necessary. If the facture has healed, any hardware at the site of infection should be removed.

Unhealed, infected fractures are a complex problem and each instance must be approached uniquely.

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.[23]

Prophylaxis is effective in decreasing the incidence of DVT in the immobilized extremity,[56] but it has not been shown to be effective in decreasing the incidence of fatal PE. In addition, prophylactic anticoagulation carries with it its own set of serious and life-threatening complications, such as bleeding.

Not all orthopedic patients have the same risk of DVT. One study suggested that the risk of DVT in those with orthopedic trauma distal to the knee is not elevated, and the risk in upper-extremity trauma is intuitively minimal.[43] Before using DVT prophylaxis, the risks and benefits of such therapy must be thoroughly explained to the patient.

Low-molecular-weight-heparin (LMWH) injectables such as enoxaparin have been shown to have the best efficacy–versus–adverse effect profile.[43]

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 Table 1 (see Pathophysiology). Management consists of treatment of the cause of the nonunion and can include eradication of infection,[57] stabilization of the fracture, removal of interfering soft tissues, bone grafting,[58] 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.

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 helping them regain their ROM and strength once the fracture has healed (eg, older patients who have sustained hip fractures[59] ).

The need for physiotherapy depends on the nature of the injury and the patient's motivation, educational level, and abilities. Physiotherapists can help 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.