General Principles of Fracture Care Quick Fin

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INTRODUCTION Section 2 of 10
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As the burden of musculoskeletal disease is at the forefront of healthcare worldwide,

the World Health Organization (WHO) has declared 2000-2010 the Bone and Joint
Decade. According to the WHO, 1.25 million people die per year worldwide as a
result of injuries arising from motor vehicle accidents (see Image 1). The death rate
of teenagers and young adults in the United States is 50% higher than that in
countries such as Japan, Sweden, and the United Kingdom. Trauma associated with
motor vehicle collisions is caused by excessive speed, reckless behavior, homicide,
burns, and alcohol and drug abuse.

More than 40% of deaths due to traumatic injuries are preventable. Trauma affects
young individuals who can contribute to society and thus costs society more than
$230 million per day in terms of death, disability, and loss of productivity (Trunkey,
1984).

Problem: A fracture is defined as a disruption in the integrity of a living bone

involving injury to bone marrow, periosteum, and adjacent soft tissues. Many types of
fractures exist such as pathological, stress, and greenstick fractures. When a fracture
occurs, it is described radiographically and clinically in terms of the following factors.

 Anatomy: The fracture is described in 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?
 Displacement: Is the distal fracture fragment displaced compared to the
proximal fragment? To what degree or percent is it displaced?
 Angulation: The angular deformity is defined in degrees in terms of the distal
fragment in relation to the proximal fragment.
 Rotation: Rotational deformity is described both clinically and radiographically.
 Shortening: Has the fracture caused shortening of the bone involved? To what
extent has shortening occurred?
 Fragmentation: The Muller AO Comprehensive Classification of Fractures
provides a standardized description of fracture patterns making
communication more precise and understandable.
o A multifragmentary fracture is one that has several breaks in the bone,
creating more than 2 fragments.
o Wedge fractures are either spiral (low energy) or bending (high energy)
and allow the proximal and distal fracture fragments to contact each
other.
o 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.
o Simple fractures are spiral, oblique, or transverse.
o Management of multifragmentary fractures may be more complicated
than that for simple fractures.
 Soft tissue involvement: Is the fracture open or closed? Is associated
neurological and or vascular injury present? Is there muscle damage or
compartment syndrome evident? In 1990, Gustilo et al described a
classification of open fractures involving 3 types with subtypes.
o Type I: The wound is shorter than 1 cm. It is clean and generally is
 caused by a fracture fragment piercing the skin (ie, inside-out injury).
This is a low-energy injury.
o Type II: The wound is longer than 1 cm. It is not contaminated and
without major soft tissue damage or defect. This is also a low-energy
injury.
o Type III: The wound is longer than 1 cm, with significant soft tissue
disruption. The mechanism often involves high-energy trauma resulting
in a severely unstable fracture with varying degrees of fragmentation.
Type III fractures are also subdivided.
 IIIA: The wound has sufficient soft tissue to cover the bone
without the need for local or distant flap coverage.
 IIIB: Disruption of the soft tissue is extensive, such that local or
distant flap coverage is necessary to cover the bone. The wound
may be contaminated, and serial irrigation and debridement
procedures are necessary to ensure a clean surgical wound.
 IIIC: Any open fracture associated with an arterial injury, which
requires repair is considered type IIIC. Involvement of vascular
surgeons is generally required (see Images 10-11).
 Single-limb versus many traumatic injuries: This is critical to note because
presence of additional injuries influences overall patient management
dramatically especially if associated with non-orthopedic injuries to the head,
chest, and abdomen.

Frequency: In the United States, 5.6 million fractures occur per year; this number
corresponds to an incidence of 2% (Canale, 1998). Johansen (1997) reported a
fracture incidence of 21.1 cases per 1000 population (2.1%) per year in the United
Kingdom.

Etiology: Fractures occur when force applied exceed the strength of the involved
bone. Both intrinsic and extrinsic factors are important with respect to fractures.
Extrinsic factors include the rate at which the bone is loaded and the duration,
direction, and magnitude of the forces acting on the bone. Intrinsic factors include
energy-absorbing capacity, modulus of elasticity, fatigue, strength, and bone density
(Evans, 1961).

Bones can fracture as a result of direct trauma 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), and crush
fractures. Indirect trauma involves forces acting at a distance from the fracture site.
Indirect mechanisms include tension (traction), compressive, and rotational forces.

Pathophysiology:

Five phases of fracture healing are the following (Frost, 1989):

1. Fracture and inflammatory phase

 2. Granulation tissue formation
3. Callus formation
4. Lamellar bone deposition
5. Remodeling

Injury involves the actual fracture to the bone, including insult to bone marrow,
periosteum, and local soft tissues. Various biochemical signaling substances are
involved in the formation of the granulation tissue stage, lasting roughly 2 weeks.
Within 7 days, the body forms granulation tissue between the fracture fragments. 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 via chemotaxis and an inflammatory mechanism to attract the cells necessary
to initiate the healing response.

During callus formation, cell proliferation and differentiation begin to produce

osteoblasts and chondroblasts in the granulation tissue. The osteoblasts and
chondroblasts synthesize the extracellular organic matrices of woven bone and
cartilage respectively, and then the newly formed bone is mineralized. This stage
requires 4-16 weeks.

During the fourth stage, the meshlike callus of woven bone is replaced by lamellar
bone, which is organized parallel to the axis of the bone. The final stage involves
remodeling of the bone at the site of the healing fracture by various cellular types
such as osteoclasts. The final 2 stages require 1-4 years.

Patient factors influencing fracture healing include age, degree of trauma, patient
comorbidities, medication use, social factors, type of fracture, systemic and local
disease, infection, and nutrition (see the Table). Patients who have poor prognostic
factors in terms of fracture healing are at increased risk for complications of fracture
healing such as nonunion, malunion, osteomyelitis, and chronic pain.

Patient factors influencing fracture healing

Factors Ideal Problematic

Age (Farmer, 1984) Youth Advanced age (>40 y)
Trauma (Schemling,
Single limb Multiple traumatic injuries
1995)
Comorbidities Multiple medical comorbidities
None
(Loder, 1988) (eg, diabetes)
Nonsteroidal anti-
Medications
None inflammatory drugs (NSAIDs),
(Giannoudis, 2000)
corticosteroids
Social factors
Nonsmoking Smoking
(Kwiatkowski, 1996)
 Local factors (Mollitt,
No infection Local infection
2002)
Type (Rockwood, Closed fracture, Open fracture with poor blood
1996) neurovascularly intact supply
Nutrition
(Hernandez-Avila, Well nourished Poor nutrition
1991)

Clinical:

Single-limb injury

A thorough history should be elicited of the mechanism of injury and any

accompanying or associated events surrounding the injury. Obtaining a history of any
previous injury or fracture is mandatory. A complete personal, social, and work history
should also be obtained, along with any medications that the patient takes. Also ask
about smoking history and history of allergies. Certainly, a history of osteoporosis or
diseases that may cause osteoporosis or osteopenia should be elicited.

The physical examination must include a thorough inspection of the integument (with
documentation). If the fracture is open, a clinical photograph may be taken for
documentation purposes. Distal neurologic and vascular status must be assessed
and documented. Palpate the whole limb, including the joint above and below the
injury, for areas of pain, effusions, and crepitus. Often, accompanying or associated
injuries may be present (eg, injuries to the spine with a jumping mechanism of injury).
Assessment of range of motion (ROM) may not be possible, but this should be
documented. Assessments for ligamentous injury and tendon rupture and other
noteworthy tests surrounding a special examination of the joints should be
completed.

Multiple traumatic injuries

Initial assessment of a patient with polytrauma follows the advanced trauma life
support (ATLS) protocols (American College of Surgeons, 1997). The assessment
initially includes the identification and treatment of life-threatening injuries. The first
step is evaluation of the individual's airway, breathing, and circulation. Endotracheal
intubation and rapid administration of intravenous fluids may be immediately
necessary. Spinal precautions must be maintained until injury to the whole spine can
be excluded clinically and radiographically (with radiographs or CT scans). Once the
patient is hemodynamically stable, the secondary survey—including evaluation of the
cervical, thoracic, and lumbar spine; pelvis; and extremities— is performed.

In terms of long bone fractures in a patient with polytrauma, evidence exists in the
literature that once the patient is stable medically, early stabilization of such fractures
is helpful for the patient's management. Specifically, femur fractures that are treated
with early stabilization decrease the risk of fat embolism and time spent in the
intensive care unit (ICU) (Bone, 1989; Phillips, 1990). The treatment of patients with
polytrauma requires a team approach, with orthopedic surgeons involved in their
care.

Initial management of fractures

Initial management of fractures consists of realignment of the broken limb segment

and then immobilizing the fractured extremity in a splint. The distal neurologic and
vascular status must be clinically assessed and documented before and after
realignment and splinting. If a patient sustains an open fracture, achieving
hemostasis as rapidly as possible at the injury site is essential; this can be achieved
by placing a sterile pressure dressing over the injury site (see Open Fractures).

Splinting is critical in providing symptomatic relief for the patient as well as preventing
potential neurologic and vascular injury and further injury to the local soft tissues.
Patients should receive adequate analgesics in the form of acetaminophen or opiates
if necessary.

INDICATIONS Section 3 of 10
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Fracture management can be divided into nonoperative and surgical methods. The
nonoperative technique consists of a closed reduction if required, followed by a
period of immobilization with casting or splinting. Closed reduction is needed if the
fracture is significant displaced or angulated.

If the fracture cannot be reduced, surgical intervention may be required. Indications

for surgical intervention include the following:

 Failed nonoperative (closed) management

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

RELEVANT ANATOMY AND Section 4 of 10

CONTRAINDICATIONS
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Contraindications: Contraindications to surgical reconstruction (open reduction and

internal fixation [ORIF]) are as follows:

 Active infection (local or systemic) or osteomyelitis

 Osteoporotic bone that is too weak to sustain internal or external fixation
 Soft tissues overlying the fracture or surgical approach that are poor in quality
due to burns, surgical scars, or infection (In such scenarios, soft tissue
coverage is recommended.)
 Medical conditions that contraindicate surgery or anesthesia (eg, recent
myocardial infarction)

 Cases in which amputation would better serve the limb and the patient

WORKUP Section 5 of 10
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Lab Studies:

 Preoperative laboratory studies performed depend on the age of the patient, the extent of the
injuries, and other conditions that add to the patient's morbidity.

 Patients with trauma also require an ATLS workup (American College of Surgeons, 1997).

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

o CBC determination

o Urinalysis

o Coagulation studies, including measurement of the activated partial thromboplastin tim

(aPTT) and international normalized ratio (INR)

o Cross-matching and typing of the patient's blood

Imaging Studies:
 Depending on the patient's medical status, chest radiography may be indicated.

o The rule of 2s has been developed for obtaining radiographs.

 Two views: Obtain anteroposterior (AP) and lateral views of the injured limb (2 v
90° orthogonal to each other); depending on the area involved, specific radiogra
may be required (see Joint-specific radiographs).
 Two joints: When an injury occurs to an injured extremity, obtaining radiographs
joint above and the joint below the injury is recommended to rule out a potential
associated fracture or dislocation involving a corresponding joint (see Image 3).
 Two limbs: Obtaining radiographs of both the injured and noninjured limbs is
recommended to aid in analysis of the osseous anatomy and ultimately to aid in
diagnosis, especially in children with epiphyseal-plate injuries.
 Two times: Obtaining 1 prereduction image and 1 postreduction or postfixation i
is recommended to assess the adequacy of the reduction. (See Joint-specific
radiographs for specific radiographs for various joints.)

o Radiographs should be described in terms of the rule of A's as follows:

 Anatomy (eg, proximal tibia)
 Articular (eg, extra-articular)
 Alignment (eg, first plane)
 Angulation (eg, second plane)
 Apex (eg, apex pointing medially)
 Apposition (eg, 75% or 0% [bayonet])

o Joint-specific radiographs other than AP, lateral, or oblique images

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

 CT scanning is not indicated for routine evaluation of common fractures. However, depending
bones involved and the degree of fragmentation, CT can be invaluable in preoperative plannin
 complicated fractures.

o CT scans provide information about the architecture of fracture lines along with informa
about intra-articular fractures.

o For procedures requiring ORIF, CT scans help to demonstrate the position and displac
of the fracture fragments.

o CT scanning is particularly useful to evaluate severely fragmented fractures and those

involving the epiphyseal segment.

o CT scanning is indicated in assessing the spinal column for injury.

 MRI is indicated in assessing the spinal column for injury.

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

TREATMENT Section 6 of 10
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Medical therapy: 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 subseq
maintaining a reduction of the fracture with a technique of immobilization, which allows the fracture t
and, at the same time, provide the patient with functional aftercare. Either nonoperative or surgical m
may be used.

Nonoperative therapy consists of casting and traction, which includes skin traction and skeletal tracti

Casting

Closed reduction should be performed initially for any fracture that is displaced, shortened, or angula
Closed reduction is achieved by applying traction to the long axis of the injured limb and then revers
mechanism of injury/fracture followed by immobilization through casting or splinting. Splints and cast
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 conditions (Rockwood, 1996):

 If significant displacement is unappreciable

 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 tha
not able to be treated by casting. With the advancement of orthopedic technology and techniques, tr
is rarely used today. Two types of traction exist: skin traction and skeletal traction.

In skin traction, traction tapes are attached to the skin of the limb segment below the fracture. When
applying skin traction, or Buck traction, usually 10% of the patient's body weight (up to 10 lbs) is
recommended. At weights greater than 10 lbs, superficial skin layers are disrupted and irritated. Bec
most of the forces created by skin traction are lost and dissipated in the soft tissue structures, skin tr
is rarely used as definitive therapy in adults; rather, it is commonly used temporarily until definitive th
is achieved. For example, skin traction is used preoperatively in individuals who have sustained a fe
neck fracture. The traction is maintained until the patient is taken to the operating room for ORIF or
hemiarthroplasty.

In skeletal traction, a pin (eg, Steinmann pin) is placed through a bone distal to the fracture. Weights
applied to this pin, and the patient is placed in an apparatus to facilitate traction and nursing care. Sk
traction is most commonly used in femur fractures: A pin is placed in the distal femur (see Image 4) o
proximal tibia 1-2 cm posterior to the tibial tuberosity. Once the pin is placed, a Thomas splint is used
achieve balanced suspension.

Surgical therapy: In 1958, the Association for the Study of Internal Fixation (ASIF) created 4 treatm
goals in terms of surgical fracture management (Muller, 1990). They have not changed today and ar
follows:

1. Anatomic reduction of the fracture fragments: For the diaphysis, anatomical alignment assurin
length, angulation, and rotation are corrected is required, whereas intra-articular fractures dem
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 fra
disease

Open reduction and internal fixation

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 have poor resista
torque and bending forces. They are commonly used as adjunctive fixation for screws or plates and
especially involving fractures around joints.

When K-wires are used as the sole form of fixation, casting or splinting is used in conjunction. They
placed percutaneously or through a mini-open mechanism. K-wire fixation “is adequate for small frag
in metaphyseal and epiphyseal regions, especially in fractures of the distal foot, wrist, and hand, suc
Colles fractures, and in displaced metacarpal and phalangeal fractures after closed reduction” (Cana
1998). K-wires are commonly used as adjunctive therapy for many fractures such as patellar fracture
proximal humerus fractures, olecranon fractures, and calcaneus fractures.

Plates and screws

Plate designs vary depending on the anatomic region and size of the bone the plate is used on, and
designs exist: buttress plates, compression plates, neutralizing plates, and bridge plates (Muller, 199
plates should be applied with minimal stripping of the soft tissue.

Buttress plates counteract compression and shear forces that commonly occur with fractures involvin
metaphysis and epiphysis and are commonly used with interfragmentary screw fixation. The plate is
fixed to the larger main fracture fragment but does not necessarily require fixation through the small
fragment, as the plate buttresses the small fragment into the larger fragment. This function requires
appropriate plate contouring to provide adequate fixation and support. They are commonly used aro
joints to support intra-articular fractures.

Compression plates counteract bending, shear, and torsion forces by providing compression across
fracture site through the use of the eccentrically loaded holes in the plate. They are commonly used
bones, especially the fibula, radius, and ulna, and in nonunion or malunion surgery.

Neutralization plates are used in combination with interfragmentary screw fixation. The interfragmen
compression screws provide compression at the fracture site. This plate function neutralizes torsiona
bending, and shear forces on the lag screw fixation and increases the stability of the construct.
Neutralization plates are commonly used for fractures involving the fibula, radius and ulna, and hume

Bridge plates are useful in the management of multifragmented diaphyseal and metaphyseal fracture
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.

Plates and screws are commonly used in the management of articular fractures. This use demands
anatomic reduction of the fracture fragments. This allows for early ROM and the use of muscles and
in the injured extremity. Plates provide strength and stability to neutralize the forces on the injured lim
functional postoperative aftercare (see Images 7-8).

Intramedullary nailing

The use of intramedullary nails over the past half century has been widely accepted. Intramedullary
operate like an internal splint that shares the load with the bone. Intramedullary nails can be flexible
locked or unlocked, and the intramedullary canal can be reamed or unreamed.

Locked intramedullary nails provide sufficient stability to maintain alignment and length, and limit rota
Ideally, the intramedullary nail allows for compressive forces at the fracture site, which stimulates bo
healing. Intramedullary nails are commonly used for femoral shaft fractures (see Image 9); tibial sha
fractures; and, occasionally, humeral shaft fractures. Advantages of intramedullary nails include mini
invasive procedures, early postoperative ambulation, and early ROM.

External fixation

In 1907 in Europe, Alvin Lambotte developed external fixation for management of fractures. External
fixation provides stabilization of a fracture at a distance from the fracture site without interfering with
tissue structures that are near the fracture. This provides stability for the extremity and maintains len
alignment, and rotation without requiring casting. It also allows for inspection of the soft tissue structu
vital for fracture healing. Indications for external fixation (temporarily or as definitive care) are as follo

 Open fractures that have significant soft tissue disruption (eg, type II or III open fractures)
 Soft tissue injury (eg, burns)
 Acetabular fractures
 Pelvic fractures (see Image 5)
 Severely comminuted and unstable fractures
 Fractures that are associated with bony deficits
 Limb-lengthening procedures (see Image 6)
 Fractures associated with infection or nonunion

Management of open fractures

The goals of treatment of open fractures are to prevent infection, to allow the fracture to heal, and to
function in the injured limb. Once initial assessment, evaluation, and management of any life-threate
injury are completed, the open fracture is managed. Hemostasis should be obtained, followed by ant
administration.

Cefazolin is adequate for type I and type II injuries. If the wound is severely contaminated (type III), a
aminoglycoside can be added (eg, gentamycin or tobramycin). If the injury is a “barnyard injury” and
Clostridium perfringens prophylaxis is required, penicillin is added. Tetanus prophylaxis and immuniz
should be administered to patients who have not been previously immunized.

Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory. For type II
type III injuries, serial I&D is recommended every 24-48 hours after the initial debridement until a cle
surgical wound is assured. The wound is closed when it is clean. Antibiotics are generally given for 2
after final I&D. Management of the fracture depends on the site of injury and type of open fracture;
however, the fracture is stabilized with external or internal fixation. If soft tissue coverage is inadequa
tissue transfers or free flaps are performed when the wound is clean and the fracture reduced and
stabilized definitively.

Preoperative details: Detecting and adequately addressing all other injuries, along with other
comorbidities and preexisting medical conditions, is essential. If patients have multiple medical probl
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 prophyla
(see Management of open fractures).

Intraoperative details: C-arm fluoroscopy is valuable and often necessary in the operating room to
for and evaluate the results of internal fixation prior to the patient leaving the operating room. Alterna
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 are
performed as directed by the physician. Depending on the type of fracture sustained, patients may b
immobilized in a splint or cast. Postoperatively, patients are examined at follow-up visits usually with
weeks of their surgery and periodically until the fracture has healed and function has returned. Weig
bearing status is dependent upon fracture or osteosynthesis construct stability. With lower-extremity
fractures, weight bearing is usually restricted, but early ROM is encouraged.

Follow-up care: The timetable for follow-up visits varies depending on the nature of the injury. All pa
must be monitored closely for potential complications (see Complications). At the time of discharge a
initial care of the fracture, the patient should be made aware of all of the follow-up requirements spec
by the treating physician.

Consultation with rehabilitation specialists can be useful in helping inpatients to ambulate with the ai
crutches or a walker and, ultimately, to decrease postoperative morbidity and expedite their discharg
planning.

Consultation with rehabilitation specialists is not essential for some outpatients to regain function. Ho
rehabilitation services can be invaluable for many individuals in regaining their ROM and strength on
fracture has healed.

The need for physiotherapy depends on the nature of the injury and the motivation, education level,
abilities of the patient. Physiotherapists aid in helping patients to recover from joint stiffness and to m
and restore ROM. They provide appropriate guidance with respect to exercises and activities that aid
healing process.

COMPLICATIONS Section 7 of 10
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Complications of casts

Complications of casts include the development of pressure ulcers, thermal burns during plaster har
and thrombophlebitis. The AO ASIF group commented on prolonged cast immobilization, or cast dise
as being responsible for circulatory disturbances, inflammation, and bone disease resulting in osteop
chronic edema, soft tissue atrophy, and joint stiffness (Muller, 1990). These problems may be avoide
providing functional aftercare.
Complications of traction

Complications of traction include development of pressure ulcers, permanent foot-drop contractures

foot is positioned in equinus), peroneal nerve palsy, pin tract infection, and thromboembolic events (e
deep vein thrombosis, pulmonary embolism). These complications stem from a lack of mobility, musc
atrophy, weakness, and stiffness resulting from a fracture.

Complications of external fixation

Complications of external fixation include pin tract infection, pin loosening or breakage, interference
joint motion, neurovascular damage when placing pins, malalignment caused by poor placement of t
fixator, delayed union, and malunion.

Complications of fractures and surgical management

Complications of fractures and surgical management include neurologic and vascular injury, compar
syndrome, infection, thromboembolic events, avascular necrosis, and posttraumatic arthritis.

Neurologic and vascular injury

Neurologic and vascular injury can occur in any fracture and is more likely with increasing fracture
deformity. Peripheral nerve injury can be suspected if a patient experiences motor or sensory deficie
Management of neurologic injury involves immediate reduction of the fracture and subsequent follow
assess if neurologic function returns.

Arterial injury is suspected if pulses are diminished or absent in the affected limb. If arterial injury is
suspected, immediate realignment of the limb is performed, and the pulse and perfusion are checked
pulse does not return, angiography is indicated, with concomitant involvement of vascular surgeons.
problem is especially prevalent in knee dislocations, proximal tibial fractures, and supracondylar hum
fractures.

Compartment syndrome

Compartment syndrome (CS), initially reported by von Volkmann in 1872, is a potentially limb-threate
condition. CS occurs when tissue pressure exceeds perfusion pressure in a closed anatomic space.
occur in any compartment, such as the hand, forearm, upper arm, abdomen, buttock, thigh, and leg.
commonly occurs in the anterior compartment of the leg.

The natural history of CS involves tissue necrosis; functional limb impairment; and renal failure seco
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 ex
Clinically, patients experience pain out of proportion to the degree of injury, pain with passive stretch
involved muscles, pallor, paresthesia, and poikilothermia. Pulselessness is a late finding of CS.

Compartment pressures can be objectively measured. Intracompartmental pressures greater than 30

Hg or diastolic blood pressure minus intracompartmental pressure greater than 30 mm Hg are indica
to intervene surgically. Definitive therapy consists of surgical fasciotomy of the affected compartmen

Infection

Complications of surgical intervention include local infection in the form of cellulitis or osteomyelitis a
systemic infection in the form of sepsis. Early recognition of a local infection may prevent the develo
of sepsis and, thus, decrease morbidity. The most common pathogen is Staphylococcus aureus. Oth
pathogens include group A streptococci, coagulase-negative staphylococci, and enterococci. Approp
antibiotics should be administered if an infection is suspected, and serial C-reactive protein and eryth
sedimentation rate (ESR) measurements should be obtained. If infection cannot be eradicated with
antibiotics, I&D of the surgical wound may be necessary, with removal of the hardware, but only if it i
performing its role.

Thromboembolic events

Thromboembolic events may occur after orthopedic trauma with prolonged immobilization. Patients w
significant fractures who were immobile for 10 or more days have a 67% incidence of thrombosis (C
1998). Prophylaxis is effective in decreasing the incidence of deep vein thrombosis in the immobilize
extremity, but it has not been shown to be effective in decreasing the incidence of fatal pulmonary
embolism. Prophylactic anticoagulation carries with it its own set of serious and life threatening
complications, such as bleeding. Prior to using prophylaxis, the risks and benefits must be explained
patient.

Avascular necrosis

Avascular necrosis (AVN) is caused by the disruption of blood supply to a region of bone. Revascula
of the avascular bone can lead to nonunion, bone collapse, or degenerative changes. It is most com
associated with fractures of the femoral head and neck, scaphoid, talar neck and body, and proxima
humerus.

Posttraumatic arthritis

Posttraumatic arthritis is common in intra-articular fractures and particularly common in intra-articula

fractures that are not adequately reduced. Management of posttraumatic arthritis depends on the joi
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 3 consecutive 6 week visits after the
the fracture was normally expected to heal.

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 consis
treatment of the cause of the nonunion and can include eradication of infection, stabilizing the fractu
removal of interfering soft tissues, and bone grafting.

Malunion is defined as healing of bone in an unacceptable position in any plane, which leads to a dis
for the patient or the potential for the development of posttraumatic arthritis. Treatment involves corre
the anatomical abnormality surgically.

FUTURE AND CONTROVERSIES Section 8 of 10

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Future And Controversies Pictures
Bibliography

Two subjects that will be prominent in upcoming years are the use of minimally invasive fracture-fixa
techniques and the use of biologic agents to aid in fracture healing.

Minimally invasive orthopedic techniques, from arthroscopic surgery to the use of intramedullary nail
dramatically decreased the morbidity rate associated with orthopedic surgical intervention. Krettek e
(1997) have been prominent in developing the concept of minimally invasive plate osteosynthesis wi
indirect reduction. This technique involves the use of anatomically preshaped plates and instrumenta
safely and effectively insert the plate percutaneously or through limited incisions. Various plates, clam
and other devices aid in this technique.

Secondly, 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. Cadave
cortical bone grafting is commonly used to provide diaphyseal structural support and to aid in filling l
diaphyseal deficits.

A number of organic and synthetic materials have been to promote fracture healing. These include
hydroxyapatite, tricalcium phosphite, and calcium sulfate. Other biologic agents that have been reco
as stimulators of fracture healing include peptide-signaling molecules (eg, bone morphogenic protein
transforming growth factor, gene family fibroblast growth factor, and platelet-derived growth factor) a
immunomodulatory cytokines (interleukins 1 and 6). These biologic agents are not commonly used,
further research, they may become important in fracture healing.

PICTURES Section 9 of 10
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Future And Controversies Pictures
Bibliography

Caption: Picture 1. General principles of fracture care. Every year, 1.25 million
people die worldwide from injuries due to motor vehicle accidents.

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Caption: Picture 2. General principles of fracture care. Acute respiratory distress
syndrome (ARDS).

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Caption: Picture 3. General principles of fracture care. Midshaft femoral fracture
with associated ipsilateral hip dislocation. This radiograph illustrates the rule of 2s
principle.

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Caption: Picture 4. General principles of fracture care. Skeletal traction with a
Steinmann pin in the distal femur for management of a femur fracture.

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Caption: Picture 5. General principles of fracture care. Pelvic fracture managed with
external fixation.

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Caption: Picture 6. General principles of fracture care. Ilizarov fixator.

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Caption: Picture 7. General principles of fracture care. Preoperative radiographs
show a type B ankle fracture.

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Caption: Picture 8. General principles of fracture care. Image obtained after open
reduction and internal fixation of an ankle fracture.

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Caption: Picture 9. General principles of fracture care. Midshaft femur fracture
managed with open reduction and internal fixation performed by using an
intramedullary nail.

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Caption: Picture 10. General principles of fracture care. Gustilo type IIIB open
fracture.

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