Fracture Treatment

By admin On Jan 23, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Fracture Treatment

Fracture Treatment

Derek F. Papp MD

Simon C. Mears MD, PhD

Basics

Description

Fractured or broken bones are a common result of trauma.
Treatment of fractures may be with or without surgery and depends on the location and severity of the fracture.
Nondisplaced:
- 1 or both cortices may be involved, but the fracture has not moved.
- Nondisplaced fractures may be difficult to detect.
Displaced:
- Displacement
- Angulation:
  - A clear way to describe this deformity is to state the direction of the apex of the fracture, such as “fracture apex anterior”
  - Another method is to state the type of deformity, such as “varus angulation”
- Shortening
- Rotation
- Translation

Alert

Open versus closed:
- One of the most important determinations to make when evaluating a patient with a fracture
- Any wound anywhere on a limb with a fracture must be suspect!
  - If one believes that a wound could communicate with the fracture site, the fracture must be considered to be open.
- To decrease bacterial colonization, open
  wounds should be covered with an antiseptic-soaked sterile dressing
  until the patient is in the operating room.
Open fractures: Gustilo Anderson classification (1):
- I: Low energy, laceration <1 cm
- II: Moderate energy, laceration >1 cm and <10 cm
- III: High energy, laceration >10 cm:
  - IIIA: Adequate soft-tissue coverage (muscle flap not necessary)
  - IIIB: Massive soft-tissue destruction, bony exposure (muscle flap necessary)
  - IIIC: Fractures associated with a vascular injury
Fracture sites:
- Diaphysis: May describe by relative anatomic level (i.e., proximal 1/3, middle 1/3, and distal 1/3)
- Metaphysis: Intra-articular (i.e., within a joint, with low tolerance for any incongruence or step-off)
Fracture patterns:
- Transverse: Perpendicular to the bone
- Oblique: Oblique across the bone
- Spiral: Spirals around the bone
- Comminuted: Fragments at fracture site
- Segmental: The same bone is fractured in 2 places, resulting in a “floating segment of bone”
- Impacted
- Avulsion: A tendon or ligament has pulled a section of bone free after trauma.
- Compression

Pediatric Considerations

Greenstick fracture: The cortex and
periosteum on the concave side are intact, whereas the cortex and often
the periosteum on the convex side are fractured.
Buckle (torus fracture): This metaphyseal compression injury is relatively stable and is splinted for comfort.
Growth-plate injuries are defined according to the Salter-Harris classification (3):
- I: Transverse fracture through the physis
- II: Fracture through the physis with a metaphyseal fragment
- III: Fracture through the physis and the epiphysis (intra-articular)
- IV: Fracture through the epiphysis, physis, and metaphysis (intra-articular)
- V: Crush injury of the physis
- VI: Injury to the perichondral ring (not part of the original classification)

General Prevention

Avoidance of trauma
Osteoporosis prevention

Pathophysiology

Force applied to a bone may result in fracture.
Bones that are weaker from osteoporosis require less force to fracture.

Diagnosis

Signs and Symptoms

History

Most often traumatic, whether secondary to a motor vehicle crash, fall, or direct blow to the affected area
Fractures in the elderly may occur with minimal trauma.

Alert

When the mechanism reported seems mild in
comparison to the injury (e.g., humerus fracture while throwing a ball
or femur fracture while stepping off a curb), one must consider a
pathologic fracture (through a tumor or metabolic process) in the
differential diagnosis.
Suspect child abuse when fractures and bruises of different ages are seen, or when the story is not consistent with the injury.
- In decreasing order of incidence, fractures of the humerus, tibia, and femur are most commonly seen in child abuse (4).

Physical Exam

Look for gross deformity, swelling, and pain to
palpation and, with movement of the affected area, bruising, warmth,
and possibly fracture blisters.

Tests

Imaging

Plain radiographs in 2 planes are mandatory and should include the joint above and below the injury.
CT is better than radiography at
identifying fractures of the spine and showing the joint involvement in
intra-articular fractures.
MRI or bone scans may be used to detect nondisplaced fractures.

Treatment

General Measures

Begin ice, elevation, and immobilization as soon as the patient is in the emergency department (5).
Reduce displaced fractures under sedation or anesthesia.
- Immobilization protects soft tissue and allows the bone to heal.
- The goal of immobilization is to maintain the alignment of the reduction of the fracture until it heals.

P.147

For early treatment with closed therapy,
splinting is preferred to casting because of a lower risk of
compartment syndrome and soft-tissue injury.
Regardless of whether the final treatment
is nonoperative or operative, definitive fracture management depends on
basic principles:
- Adequate fracture reduction (restored as close to the anatomic position as possible)
- Fracture stabilization
Cast:
- Used for many nondisplaced or simple fractures
- Univalved or bivalved models reduce the risk of compartment syndrome.
- Must be molded with 3-point fixation to maintain fracture reduction
Functional bracing has been successful in the treatment of humerus and tibial fractures (6).

Activity

Depends on method of treatment, but operative management often leads to earlier return to motion and weightbearing.

Nursing

Awareness of complications such as compartment syndrome and cast problems is important.

Medication

First Line

Patients with open fractures should be treated with intravenous antibiotics to prevent deep infection (7).
- Gram-positive coverage (often cefazolin, 1 g in adults and 25 mg/kg in children) and tetanus prophylaxis
- For Gustilo type II fractures, an aminoglycoside also should be given for Gram-negative coverage
- For patients with fractures that occurred
  in a farm environment, with vascular compromise or with extensive
  soft-tissue crush, 4–5 million units of aqueous penicillin G every 4–6
  hours should be given (1st-generation cephalosporin plus an
  aminoglycoside plus penicillin).
Patients may require pain medicines, depending on the severity of the fracture.

Surgery

The decision to proceed to operative management depends on several issues, including:
- The severity of the fracture
- The need to return to activity more quickly
- The need to avoid stiffness that comes with casting
Intra-articular fracture with
displacement requires reduction and fixation to avoid posttraumatic
arthritis and to allow for joint motion (8).
- Diaphyseal fractures may require fixation to allow for early mobilization or to correct deformity.
Types of surgical fixation:
- Plates and screws:
  - Used for intra-articular fractures after reduction
- Intramedullary nails:
  - Used for long-bone diaphyseal fractures
  - Allows for early weightbearing
- External fixation:
  - This approach is used in situations of
    tenuous blood supply, marked soft-tissue injury, and gross
    contamination, and for comminuted distal radius fractures.
  - Polytrauma patients with multiple
    fractures may be treated with damage-control orthopaedics: Temporary
    external fixators are applied and, later, when the patient is
    stabilized, staged definitive fixation is performed (9).

Follow-up

Disposition

Issues for Referral

When a question of child abuse arises, a social worker and pediatrician should be involved.

Prognosis

Intra-articular injuries and injuries with substantial
soft-tissue damage have poorer prognoses than do injuries to the
diaphysis.

Complications

Delayed union: Healing has not occurred in 3–4 months
Nonunion: Healing has not occurred in 6 months
Malunion: Healing with malalignment
Osteonecrosis (AVN):
- This condition occurs secondary to the disruption of the blood supply to the bone.
- Most commonly seen with fractures of the
  femoral neck and head, femoral condyles, proximal scaphoid, proximal
  humerus, and talar neck.
Osteomyelitis
Compartment syndrome
Pulmonary disorders:
- Adult respiratory distress syndrome
- Fat emboli syndrome
- DVT/PE
Reflex sympathetic dystrophy
Posttraumatic arthritis

Geriatric Considerations

It is important to consider carefully operative versus
nonoperative management in the elderly, given their higher rates of
comorbidities such as diabetes, coronary artery disease, and vascular
disease.

Patient Monitoring

A patient with a fracture should be followed carefully with serial radiographs to ensure fracture stability and healing.

References

1. Gustilo
RB, Anderson JT. Prevention of infection in the treatment of one
thousand and twenty-five open fractures of long bones: retrospective
and prospective analysis. J Bone Joint Surg 1976;58A:453–458.

2. Rodriguez-Merchan EC. Pediatric skeletal trauma: a review and historical perspective. Clin Orthop Relat Res 2005;432:8–13.

3. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963;45A: 587–622.

4. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10–20.

5. Lee C, Porter KM. Prehospital management of lower limb fractures. Emerg Med J 2005;22: 660–663.

6. Sarmiento A, Latta L. The evolution of functional bracing of fractures. J Bone Joint Surg 2006;88B: 141–148.

7. Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg 2003;11:212–219.

8. Dirschl DR, Marsh JL, Buckwalter JA, et al. Articular fractures. J Am Acad Orthop Surg 2004;12:416–423.

9. Pape
HC, Giannoudis P, Krettek C. The timing of fracture treatment in
polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg 2002;183:622–629.

Additional Reading

Cole PA, Bhandari M. What’s new in orthopaedic trauma. J Bone Joint Surg 2004;86A:2782–2795.

Miscellaneous

Codes

ICD9-CM

829.0 Fracture

FAQ

Q: Which fractures require surgery?

A:
No definitive rule exists. However, in general, open fractures require
surgery for débridement of foreign material; intra-articular fractures
require surgery to correct displacement, avoid arthritis, and allow for
early joint motion; displaced fractures may require surgery to correct
deformity; and patients with multiple injuries may require surgery for
early mobilization.