Treatment

How are fractures treated?

The treatment of each individual fracture is different. In this section we concentrate on the general principles of fracture treatment.

First Aid

A person suspected of having a broken bone needs to be transported quickly to receive medical attention. You should undertake general measures to reduce shock, keeping the victim warm and at rest. Wounds should be dressed. If possible the limb should be splinted to reduce pain and prevent further injury. Applying a sling and then wrapping a bandage around the body to keep the arm into the chest can splint arm and shoulder injuries. When only one leg is injured bandaging it to the other leg may splint it. Spinal injuries need special precautions because of the risk of damaging the nerves of the spinal cord. If possible it is best not to move injury victims until professional rescue help arrives. If they have to be moved for safety, do it carefully and be reassured by the thought that the movement of the bone fragments at the time of injury was much greater than any movement likely to be caused by carefully shifting the victim out of harm’s way.

Closed (Nonsurgical) Treatment of Fractures

Most fractures are treated this way. The doctor determines that the bones are in satisfactory position (nondisplaced) and the fracture pattern is stable. The limb is splinted, often with a cast and rested until the bones heal. Sometimes the bone position is not acceptable but the fracture pattern is stable. In this situation the fracture can be manipulated back into a good position under anesthesia. Once it the fracture is reduced it can be splinted like a nondisplaced fracture.

During the healing process it may be necessary to repeat x-rays of the fractured area to make sure that the bones are staying in a good position and that healing is advancing. It is important to return for follow-up when asked to so the doctor can make sure the healing process is going according to plan.

Moving the fingers or toes when a limb is in a cast is important to prevent stiffness and help the circulation, but it is usually unwise to put weight on a broken bone in a cast until some healing has taken place.

Surgery

Surgery for the treatment of fractures has two goals:

• align the fracture fragments as best possible
• hold the fragments in alignment until they heal

Open reduction means moving the bone fragments back into the correct position. Opening up the skin and exposing the fracture fragments makes this easier but we risk introducing infection and affecting the blood supply of the broken pieces. The second goal, fixation, means holding the fragments in position using casts, pins, screws, plates or rods. Internal fixation implies that the fixation devices (pin, screws, plates and rods) are inserted into the body and left in at least until the bone is healed. External fixation means that the pins pass through the skin into the bone and are held by an external frame. Doctors prefer to avoid surgery but will undertake it without hesitation if the end result without surgery is going to be worse.

Surgery may be required when there is partial nerve injury. Making the fracture stable reduces the risk that the neurological injury might get worse. This is especially important in spinal injuries as the spinal cord nerves do not repair or re-grow.

Surgery is usually preferred in hip fractures. The prolonged bed rest needed to heal a hip fracture leads to a high rate of life-threatening medical complications such as pneumonia and pulmonary embolism. This means that nonoperative treatment of hip fractures in the elderly is actually more dangerous than surgery. Performing surgery to fix the fracture allows the patient to get out of bed and begin to move around as soon as possible. This is life saving in many cases.


Surgery is usually always required in open fractures. The wounds must be cleansed of all contamination and this requires exposure of the fracture fragments. Open fractures heal better with less chance of infection if they are held motionless. It is common to use some form of fixation to hold the reduction.

Surgery is usually always required when there is also injury to the arteries of the limb. Without repair or grafting of a ruptured artery the limb would die. Fracture fixation is necessary to protect the repair of the blood vessel.


Surgery is usually preferred in displaced intraarticular fractures. Accurately restoring the joint surface to smoothness is often not possible without surgery. Leaving a joint irregular makes painful wearing out of the joint almost inevitable.


Surgery may be required when a fracture cannot be reduced closed. Surgery is needed when it is impossible to obtain an acceptable reduction by closed means. In some cases, if a fracture later displaces in a cast, surgery may be undertaken to restore the alignment of the bone or to prevent further displacement.


Surgery may also be suggested for unstable fractures. Fractures that are very likely to displace into an unacceptable position may be treated with surgical fixation to convert them to a stable configuration.


Surgery may be preferable in some cases because it leads to faster recovery. Surgical fixation of some fractures may allow the patient to recover range of movement and strength of the injured limb before the bone is fully healed. Surgical fixation may make a significant difference to the length of disability, the length of time in a hospital, or even to the degree of permanent disability. For example, the treatment of a fractured femur (thigh bone) in both adults and children has changed because surgically fixing the fracture reduces time in the hospital, shortens the time to walking, and reduces the potential complications of stiffness in the knee.

Soft tissue injury

We have stressed that broken bones are always accompanied by injuries to the soft tissue especially muscle. These injuries heal by scar formation filling in the gaps between the torn muscle ends. The risk is that the scar tissue will also bind everything else together and prevent normal movement of the muscles, tendons and local joints. Stiffness after injury is a common problem. The treatment is early movement which prevents muscles sticking to each other and to bone.

Bone Healing

All connective tissues heal in a similar fashion. This process begins with a blood clot and ends with hard bone. In that initial blood clot are the stem cells that will begin to form the new bone tissue that will eventually heal the fracture. During the process, there is a gradual replacement of the injured and dead tissue by new living tissue. The connective tissue that forms will go through a set of stages before it becomes bone tissue able withstand the large forces it must.

Basically there are 4 stages:

Stage 1 - Inflammation: The damage to the bone and muscle, as well as the bleeding sets off an inflammatory reaction. The bleeding from the injury stops when the blood coagulates forming a blood clot. The early blood clot stimulates the growth of small capillary blood vessels from the surrounding normal tissue into the damaged area. As the blood supply increases the area swells and hurts. The vessels bring with them cells that lay down collagen fibers. This stage lasts from zero to seven days. The tissue formed is weak and can be disrupted if the fracture fragments move too much.

Stage 2 - Soft Callus: The tissue that was originally blood clot and dead tissue is replaced by scar tissue, collagen fibers laid down in a random fashion with a rich blood supply and nerve supply. Cartilage tissue may develop in soft callus. This cartilage is a rubbery tissue that is strong enough to keep the bone fragments together as long as it isn't stressed too much. This stage begins at seven days and lasts until six weeks following the fracture.

Stage 3 - Hard Callus: Some of the cells in the soft callus begin to change (differentiate) into bone forming cells. These cells begin to produce bone mineral. This bone mineral forms in the scar tissue and makes it stiff. The result is a materials called "woven bone". This early bone material begins to bridge across from one fragment to another. Woven bone is 80% as strong as normal bone. This stage begins at six weeks after the fracture and extends to 12 weeks after the fracture.

Stage 4 - Consolidation: The woven bone is gradually remodeled into compact bone. As a result, the bone recovers almost all of its pre-injury strength. The medullary cavity is reformed. Bone remodeling continues to occur. Our skeleton responds continuously to how much we demand of it. For example, weight bearing will stimulate the body to change the strength of the fractured bone. It does this both by increasing the strength of the bone material and slowly changing the shape of the bone. This process will continue up to 18 months.

It is important to understand from this that bone healing is basically a growth process and cannot be hurried. Even in the bone is well fixed and doesn’t hurt, it is not healed and isn’t strong enough for normal use until stage 3 at the earliest.

Failure to heal

A fracture fails to heal when there is interference with one of the stages noted above. If there is too much movement between the fracture fragments soft callus breaks down and never transforms into hard callus. Too much stress in stage 3 may cause a breakdown of the weaker woven bone.

Smoking is known to hinder healing probably because it constricts the blood supply. Inflammation is a necessary part of the healing process. Some medications such as anti-inflammatory medications are suspected of interfering with fracture healing. You may want to discuss the medications you are taking with your health care provider.