Adult Fractures (Part 3 of 5) - Myles Clough, MD

Dr. Sechrest: Well, let’s move on and talk a little bit about imaging of fractures and, I think, most people assume that a fracture is diagnosed by an x-ray, and I think for the most part that’s true. But give us a summary, if you would, about the different radiologic techniques that we use to make diagnosis of fractures, and what role they play – things like MRI scan, things like CAT scan, things like plain x-ray – when do you use one versus the other and what are the benefits of each of those?

Dr. Clough: I think that the plain x-ray is the used most often and, in fact, in the majority of cases that’s all you need. The plain x-ray tells you, first of all, that there is a fracture, and in probably 9 out of 10 to 8 out of 10 cases, it tells you the type of fracture it is, the anatomy of the fracture, how many pieces there are, how good the alignment is. So when it comes to taking an x-ray, we as orthopaedic surgeons have to be sure that the original x-ray is adequate and that means that it shows the whole of the area of injury. Often that means that you have to look at the joint above the fracture and the joint below the fracture. You need an x-ray from the front alignment and from the side alignment – we call those AP, anteroposterior, or lateral, and you’ll use people AP as though everybody knows what it means, but it isn’t really clear. It means an x-ray from front going through the back. So those x-rays will tell you the nature of the fracture, how it’s likely to behave, and how it should be treated 8-9 out of 10 times. Where you need more sophisticated radiology is where the x-ray shows that there’s a fracture but the details of the anatomy of the fracture may not be clear. One good example would be a fracture around the knee where the existence of the fracture can be seen on an ordinary x-ray but there may be so many pieces and there may be fairly subtle areas of damage to the joint surface which don’t show well on x-ray because a lot of pieces are superimposed on one another, and there a CAT scan gives you a 3D image of exactly what’s happened and you can see the anatomy of the fracture, you can with more sophisticated CT scans you can kind of rotate the thing and look at it from different angles, build up a model of the broken bone, not a normal bone, you can build up a model of the exact fracture that we’re dealing with and the surgeon can then say, “Well, there’s that piece at the back which I’ve got to move up this way, and there’s that piece over there which is pushed down and so if I do this, and I put the fixation here, I’m going to be able to plan my operation and get the best possible result.” So that’s where a CT scan has a role. An MRI scan, I’d almost would like to put that question back to you because I don’t use and MRI scan very much in the diagnosis of fractures.

Dr. Sechrest: Well, I think, as you said, I think a couple things. One is, people need to realize that an x-ray of a fracture or any bone, what we’re doing as orthopaedists is really taking a 2D picture and in our minds we’re translating it to a 3D structure. So we’re interpreting that knee as a 3D structure in our minds if we’re looking at 2 x-rays for example. The CAT scan has actually allowed us to expand that and have a computer do that translation for us so we’re not making it up as we go along. We’re actually seeing and being able to rotate and seeing those pieces, so that’s clearly a benefit in some of those complex fractures. Now if you’ve got a fracture straight through the femur, for example, and you see it on x-ray I don’t think a CAT scan is going to give you a much better understanding of that.

Dr. Clough: It’s going to add expense and time.

Dr. Sechrest: Right. So obviously your mind is as good a CAT scanner as the computer is. I think the MRI scan basically is for soft tissue and it does bone very poorly so the only reason I could see using an MRI scanner was if you’re concerned about the soft tissue injury and, as you said, sometimes the soft tissue injury is much more severe and much more of a problem than the fracture. So, for example, if we’re worried about nerves being damaged, muscles being torn, tendons being torn, something that is soft tissue we can’t see that with a CAT scanner or the x-ray, so if we’re worried about that we may have to get an MRI scan. But we’re not using the MRI scanner to look at the bony anatomy.

Dr. Clough: I think another area where an MRI scanner is often used is in spinal injuries where the spinal cord shows up well on a MRI scan and even shows a little bit in differences if it has been damaged so that gives you a lot of information if there’s potentially been a spinal cord injury.

Dr. Sechrest: And again, that’s soft tissue versus bone.

Dr. Clough: Right.

Dr. Sechrest: Because that same patient is probably going to get a CAT scan to look at the bone injury and really define that before anyone considers how to fix the fracture.

Dr. Clough: Yes.

Dr. Sechrest: The MRI scanner is being used to see the disc and the spinal cord and the nerves and what’s going on with them.

Dr. Clough: Right.

Dr. Sechrest: I think we’re on the same page in terms of imaging. I don’t think that in the case of acute fractures, when you’re trying to make a decision about whether to treat it or not, there are many other things that we would use in terms of radiology. As the treatment progresses we may use things like bone scans and that sort of stuff to assess healing. There are a couple of instances that we should say it’s appropriate to get an MRI scan. One example would be a compression fracture of the spine – trying to determine if it’s fresh or not. The one thing MRI scan does do is tell you whether a compression fracture of spine is new or old whereas the CAT scan and the x-ray can’t tell you that. The other thing I find it’s sometimes useful for are fractures in the pelvis such as a femoral neck fracture. Again what you’re looking for is the soft tissue. You’re looking at the swelling inside the bone to tell you if you’ve got a new fracture or not and you can’ sometimes see that with a CAT scanner. You might see a fracture line but the MRI scanner can be much more sensitive sometimes because it shows that swelling inside the bone that we can’t see with anything else.

Dr. Clough: And also disturbance of the blood supply inside the bone can be seen on a femoral neck and that’s a common problem with a femoral neck fracture.

Dr. Sechrest: True, true. Well, once you’ve made the diagnosis and you’ve got the fracture and the soft tissue injury well defined as an orthopaedic surgeon, let’s move on to treatment, and really what I’m interested in doing is discussing the broad range of potential treatments. How a patient is sitting there making the decisions with you when you say this needs to be treated nonoperatively, this needs to be treated operatively, and how you make that decision. Then after we’ve covered that what I would like to do is move on to the different types of treatment that are available.

Dr. Clough: Well, the way that orthopaedic surgeons actually act, even if they don’t think of themselves this way, is disability prevention. So in the back of all of our minds is what’s going to happen to this patient a few years down the road or even throughout the rest of their life, and our aim as orthopaedic surgeons is to make sure that that future is as free from disability as possible. The result is that you can treat many fractures in different ways, and you can get the bone to heal in all of those ways. So let’s say you had a bad fracture of the tibia: shortened, rotated, twisted. You put a cast on that fracture. There’s probably a 50% chance that that fracture will heal. But there is also a very high chance that if you treat it in a cast the fracture will end up angulated, rotated, shortened, distorted, and the patient will live the rest of their life with a leg that is not 100%. Whereas if you treat that fracture operatively the possibility of getting bone looking exactly the way it should is much higher and the function then has a much greater chance of being a 100% for the rest of the patient’s life. So we need to sit down with the patient and say these are the options. There are nonoperative and operative management options, and these are the risks if we take it this way, and these are the risks if we take it that way, and these are the possible outcomes, and these are the complications of the various differences. So it’s a complex decision that needs teamwork and a very important member of the team is the patient and I think it’s becoming more and more important to look at the patient’s overall situation, their past medical history, their expectations, the type of life that they expect to lead, their sports activities, their job, the loads that are going to be put on their limb once it’s healed, and integrate all of those factors in the decision of how the treatment should progress.

Dr. Sechrest: You know, it’s interesting because I think that over the last 30 years of my career in orthopaedics clearly our ability to operate and treat a fracture with a surgical procedure has increased.

Dr. Clough: Yes.

Dr. Sechrest: And the 30 years ago there were fractures that today would immediately be recommended for surgery, that were immediately recommended for treatment nonoperatively.

Dr. Clough: Yes.

Dr. Sechrest: I think that the vast majority of fractures can be treated both operatively and nonoperatively. There are few that most orthopaedic surgeons would say, “if this is me, I want you to operate on this” and there are a few that they would say, “if this is me, do not operate on this fracture and put me in a cast or treat in this fashion”. There’s a huge number of fractures that could go either way.

Dr. Clough: Yes.

Dr. Sechrest: And that’s the number that there are options and this whole process of sitting down and making sure that the patient understands the risks and the benefits of treating it operatively versus nonoperatively are clearly understood. You know, a fracture that heals uneventfully, and you operate on it, and you have no complication is a success. You take that same fracture and if you’re the 1 or 2% of people who end up with an infection in that fracture, that result is a disaster and you would have wished that you had not had an operation.

Dr. Clough: Yes.

Dr. Sechrest: And I think that subtlety in trying to make that decision about when it’s better and when it’s not better is an individual decision. Now I would say that there are clearly fractures that we, as orthopaedists through our experience and through the collective experience of orthopaedics, have come to believe that the results in thousands of cases, statistically, are better when an operation is applied then when it’s not, and we tend to recommend that when that’s the case. But people have to understand that is changing every year and it’s based on our experience and our collective experience in terms of what we think the results of operating on a fracture of that type versus not operating on it.

Dr. Clough: So I think that we could make a balance sheet between operative and nonoperative treatment and look at the benefits of both sides and perhaps some of the downside as well. So, for most fractures, you can treat them nonoperatively, and that means either putting a cast on or putting them in traction. The way that traction works is not always obvious to patients. If you have something that’s sagging, like a broken bone, if you pull on it, it goes straight, and that’s essentially why traction is used. By putting the pull on the bone it keeps everything aligned properly, and the same applies to casts. Here without doing an operation, you can keep the bone in alignment and protect it and make sure it doesn’t move out of alignment, and even with some casts you can adjust the position. You can bend the cast a little bit to change it and adjust the reduction over time if you find that it’s not going in the right way. So the benefits of nonoperative treatment: 1) There’s no operation. That leaves the blood supply, sometimes a very critical part of the problem, the blood supply is not altered. There are some downsides though. The fractures often are not perfectly reduced so they’re not usually completely in normal alignment. The casts themselves can be a problem. They can be a little bit tight and that can interfere with the circulation to critical structures. But I think the worst problem with casts, even if everything else is good, is that a cast keeps everything still for too long, and during the period that the cast is on the limb. You can’t move the joint. You often can’t move the muscles and everything gets weak for certain and stiff for very likely, and that makes the rehabilitation a lot longer and it makes, sometimes, you don’t get a full return of function of the injured area.

Dr. Sechrest: You know, and I think that’s the major reason why we as surgeons have moved more and more and more towards operative intervention, and a lot of it is because the risk of operations have gone down. Our implants are better, our destruction of soft tissue with minimally invasive techniques such as intramedullary rods and things that are put in through small incisions, we don’t have to damage all that blood supply now to get a firm fixation. I think that we have moved towards trying to get patients moving faster while still holding the fracture and allowing it to heal. I mean that seems to be the biggest advance over the last 30 years.

Dr. Clough: I agree with you. When I was taught, I was taught that doing an operation on a fracture converted it from a closed fracture to an open fracture, and the people who taught me, it sounded as though they really believed that it was an open fracture with exactly the same sort of risk of developing an infection as if it was a contaminated fracture that came in off the road and we now know that that’s not true. The risk of developing an infection after an operation on a closed fracture is not a great deal higher than the risk of having an operation in totally clean uninjured situations. So it’s around about 1 in 50 to a little bit more than 1 in 50, at most, in good quality North American hospitals. If we look at the balance sheet for operative versus nonoperative treatment of fractures, I think in the hands of a skilled surgeon, an operation on a fracture aligns the bone exactly. You’ve got at the end of the operation an object that looks pretty much the way nature intended. The joint surface are restored accurately and, more than that, the bone is rigidly fixed. By that I mean that it moves as one. There’s only a very minor amount of movement between the fracture fragments, and that’s of huge importance to the patient because it stops all the pain that comes from the fracture; and the second part of the importance is that then you can use the leg as a leg again and move the muscles, move the joints, and prevent stiffness. So the two big plus advantages of an operation are that it restores the alignment anatomically and it allows early movement and faster rehabilitation. I think there’s a third slightly less certain benefit is that I think the healing takes less time. I mean we get on to the downside of open treatment. I think there is an increased risk of infection over completely closed treatment. I’ve seen one patient my entire life who developed an infection in a fracture without either being a compound open fracture or without an operation and this patient, some bacteria went round the bloodstream, ended up in the fracture site, and developed and it was a huge surprise. We don’t see that very often. But we do see operations that have got infected, round about as I say, 1 in 50 or less. So that’s a big downside. I think the expense is, in some parts of the world, another big downside and the cost of implants are quite large and a significant problem in many parts of the world. I also think that we don’t always do the operation exactly right. So sometimes the surgery makes the problem worse and that’s always a very terrible situation for both the patient and doctor and we’ve all, it’s happened to every one of us, that we’ve done our best and it hasn’t turned out well.

Dr. Sechrest: I think that people have to understand that infection is not the only risk to an operation. There’s the anesthesia potential complication, and there’s the risk and benefit of do I do more soft tissue damage or not? You alluded to the fact that a lot of fractures can be made beautiful on x-ray. The problem is, for example, the tibia fracture where you go in and you open that tibia up, you strip all the soft tissue, now you’ve got 3 inches of bone on either end that does not have a blood supply and how do you expect that bone to heal? So you’ve got to really ask yourself, “Am I, with an operation, by making that bone look better, am I really creating an environment where that bone can optimally heal?” I think we’ve learned more about how to do that.

Dr. Clough: We definitely have, and most of the most widely accepted treatments for fractures now include that element of “I must preserve the blood supply at all costs or minimize the damage to the blood supply” and when we therefore approach the bone distantly, if you want to put a rod into a femur fracture, nowadays you don’t come anywhere near the fracture. You make a little small hole up by the hip and you pass your rod down inside the bone, minimizing the damage to the blood supply to the area of the fracture, and yet, at the same time, you achieve all the aims of operative treatment namely rigid internal fixation and fast rehabilitation.