Sports Medicine and Orthopaedics

----- Compassionate Care, Education & Excellence Phone: 401-383-7753 Fax: 401-383-8982 ----------------------- 400 Massasoit Ave. Suite 200 East Providence, Rhode Island 02914 -------------------

by Jack Goldstein, MD

 

Fracture Treatment

Fractures of bone may be minor, or a serious threat to life and limb.  Severity depends on fracture location, complexity, joint involvement, and the presence of  a wound at the fracture site. Simple fractures may be treated with as little as a rigid  shoe,
while complex fractures often require surgical fixation. This depends on patient  age, general health, fracture pattern, site and stability, and functional status of the  patient. Often the decisions involved in fracture treatment are best made with the help of  both patient and family. They are influenced by patient age, mobility, and functional  status as well as functional requirements.  Fractures or breaks of bone are one and  the same. Displacement is generally a large determinant for the need to reduce the  fracture (replace the bone fragments in proper alignment). If the fracture enters a joint  surface, or disturbs the competence of weight-bearing bones, this will likely enter into  the decision process between surgical fixation and cast treatment.  In children, a  fracture which involves the growth plate may disturb or halt the growth of a long bone or  disturb joint function in later life. This is often an important determinant in initial  treatment and follow-up care.

Emergency Care

In general, immediate treatment of fractures requires immobilization  whether or not surgical treatment is required. The severity of trauma, displacement, and  instability will dictate the need for surgical or cast treatment. If the fracture is  simple, or if severe swelling is expected, then splint immobilization is most appropriate.  In general, immediate casting is dangerous and unnecessary.  If this is needed, hospital  admission is indicated for observation for swelling. The risk of swelling and resultant  compartment syndrome, which may permanently damage muscles and nerves especially in the  forearm and lower leg, are significant especially with fractures here. When splint  immobilization is only needed, a week of elevation and ice treatment will help the  swelling to reduce and thereby minimize the risk of cast placement thereafter.

Cast Treatment

Cast treatment of fractures is common when  operative fixation is not needed. Casts usually hold the joint above and below the  fractured part so that the cast effectively supports and aids the healing process. Casts  may be made of Plaster of Paris or fiberglass. Fiberglass is water resistant while plaster  will melt if wetted. The padding between the skin and the cast provides comfort, but if  this becomes wet, it dries slowly and encourages skin overgrowth with fungal organisms  causing itching and skin breakdown. Gortex liner is expensive, but allows a fiberglass  cast to be immersed daily in water. This minimizes skin irritation and itching, and even  allows swimming in fresh water. Casts need to be protected in order to provide  support until the limb is healed enough to allow removal. In the case of a walking cast, a  cast shoe should be worn at all times. All casts should be kept clean and dry, and  scratching inside with instruments should be avoided.

Fracture Reduction

Closed reduction of fractures means manipulation of the fracture fragments to  realign them without surgically opening the site. This may be accomplished with local  block analgesia or general anesthesia depending on the fracture site and severity. Open reduction and internal fixation of fractures (operative treatment of fractures) requires surgical exploration and generally fixation with pins,  plates, screws, or intramedullary (within the bone) device. The aim of internal fixation  is to provide stability, improve joint motion near the fracture, and allow early  weight-bearing in the lower limb, or rapid functional use in the upper extremity. In many  instances, the decision between closed and open reduction of fractures depends on multiple  factors. These include patient age and agility, fracture site and extension into a joint,  and weight bearing on the affected part.  Cast immobilization of the fracture is  often used. This holds the fracture fragments aligned without implanted hardware. This  also lowers the risk of infection and provides easy access to the open wound.  These fractures are in general more prone to delayed healing and infection.

Open Fractures

Open fractures are those with a laceration which enters the fracture site. These are more  severe than closed fractures. These need to be cleansed in the Operating Room rapidly, and  stabilized to lower the risk of infection. Hospitalization and intravenous antibiotic  treatment is required. In this circumstance external fixation of the  affected fracture is often indicated or other internal fixation.  This  is dependent on open fracture severity and grade of contamination as well as  the bone involved.

Functional Recovery

In general, fracture healing is encouraged by use of the extremity. This helps nearby  joints maintain motion, and aids normal limb function, maintains bone mass, and general  well being. Effective fracture care combines patient desires and needs with fracture  location and anatomy and socioeconomic factors. The aim of any well designed fracture care  is to allow the earliest possible use of the fractured part without complicating healing.  In addition, every effort should be made to minimize pain and restore as normal function  as possible.

Complications

Complications of fracture care include non-union (failure to heal), malunion (healing  in improper alignment), arthritis (if the fracture involves a joint), or infection (after  open fracture or following open reduction). Complications are minimized by proper  management. Initially, fractures which do not require closed or open reduction, should be  splinted, elevated and iced to allow swelling to reduce. After one week, swelling is  generally minimal, and definitive cast treatment may be performed. Even when surgical  fixation is the best long term option, a week of rest is helpful in reducing swelling and  minimizing surgical complications. Surgical treatment is thus best instituted within the  first 24 hours or after one week when swelling is at a minimum.

 

Compliments of Sports Medicine and Orthopaedics, East Providence, Rhode Island