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

Dr. Sechrest: Now let’s talk a little bit about the case when we do operations. Is there anything inherently different in terms of the postoperative course or the healing of a fracture once it’s been operated on versus one that’s been treated nonoperatively?

Dr. Clough: Well, that’s quite a technical question. There’s a body of science that suggests that the actual healing process of the renewal of the structure of the bone is different. That when you have living bone butting up against, the two fragments are re-applied themselves and held rigidly, instead of having the healing process go through the blood clot transformation, to callus transformation, to bone, that you have actual living systems of bone grow from one to another. I forget what they’re called, coring tunnels or something like that, but people have done some scientific experiments in which they’ve shown the actual process of healing in the totally unnatural situation of rigid internal fixation is different.

Dr. Sechrest: So you’re saying that you bypass that episode where the blood clot has to form, it has to go through the process of scar formation, and then convert itself into bone. It’s more bone healing to bone like we would think skin healing to skin.

Dr. Clough: Yes. That has a speed element and a strength element in that you’re essentially healing cortex to cortex so that you don’t have to go through a remodeling process. The whole thing happens a lot more quickly and that’s why I think internal fixation, in many situations, causes a more rapid return of normality.

Dr. Sechrest: You know, the other piece to that, I think, that we should probably bring out is the fact that there has been almost a steady march, at least in my career in the last 30 years, in faster, faster, faster movement after any sort of operation. I think the sports medicine people first taught us this, and then everyone has adopted this whether it’s the trauma surgeon treating fractures or the total joint surgeon, it’s not uncommon these days to operate on a fracture and have that person in physical therapy the next day beginning movement, beginning to get normal movement back as long as ever how you fix that bone is strong enough to withstand that. So it seems to me that our trend towards getting people moving faster.

Dr. Clough: I think you’re right and I think we believe that immobility is the enemy, and there are two aspects to that. The first is it’s actually dangerous. If you have a fracture you have a higher potential for complications that are based on immobility and one of them would be a blood clot, another might be a pressure ulcer and chest infections because you’re laying in bed and not doing anything. So there’s an actual risk to your health through immobility. Then there’s a risk to a poorer outcome from the treatment of the injury if it doesn’t – the sooner they move, the better, because this process of scar formation which I talked about in the fracture is also occurring in the soft tissue. They’re laying down scar everywhere there’s a soft tissue injury, everywhere where it has bled you’ll get scar formation. If, while the blood clot is very weak, you move things, then that scar will be thin, attenuated, it’s not going to really bind things down. But if you wait and keep everything immobile until the scar has become scar then you’re going to have to stretch the scar and that’s painful, it’s difficult, and it doesn’t always succeed. So getting the patient up may seem like real cruelty, and this is one of the things that patients need to understand, the reasons that people ask you to do uncomfortable, unpleasant things right after an operation isn’t sadism, it’s because early mobilization after a fracture is both life-saving in some situations and improves the prognosis of the fracture.

Dr. Sechrest: I think we should probably turn to some things that orthopaedists and patients don’t always like to discuss and that is really what could go wrong with treatment of a fracture. Whether it’s treated nonoperatively or operatively, what are the things that you as an orthopaedic surgeon and would advise patients to think about in terms of long-term complications of fractures?

Dr. Clough: I think very important that complications are discussed because it’s the key to so much of our management. Although many of the complications that we’re talking about are rare, we adapt the whole of the rest of our treatment to make them as rare as they can be so that, let’s say, we’re talking about the complication of venous thromboembolism in which blood clots form in the legs and then travel up to the heart or go through the heart up to the lungs and cause problems with the lungs. This is a very serious problem. It’s potentiated by an injury because the mechanism for blood to clot is turned on by the existence of an injury and sometimes that means that blood clots inside the veins and when it does there’s a risk that it will move from the veins in the leg up to the lung. That problem is called thromboembolism and a lot of our management is based on minimizing the risk. So getting patients up, moving them around when they’re still quite sore quite soon after surgery, getting them to sit rather than lie, getting them to roll around and move around, that’s all directed at reducing the incidence of venous thromboembolism. So are things like putting on stockings, so are things like using certain medications to thin the blood. I think that a full discussion of complications actually helps people to understand why all these weird things are happening to them.

Dr. Sechrest: So let’s go through some of the complications that you worry about. You mentioned deep venous thrombosis, venous thromboembolism, pulmonary embolism, where the blood clot actually leaves the limb and goes into the lung. We’ve covered a little bit about infection and the risk of infection which is always there. Let’s talk a little bit about complications that are specifically about the healing of the fracture, things such as: What if the fracture doesn’t heal appropriately? What if it goes on not to heal?

Dr. Clough: There’s a spectrum of delay in healing and failure to heal, and sometimes it’s difficult to tell where you are with that. We normally expect a bone to heal, to show some signs of healing in 6 weeks. But if we don’t see it until 3 months that’s not usually cause for concern. Beyond 3 months we begin to think that the process is delayed and if it goes on beyond 9 months, some people say 6 but certainly beyond 9 months, if there are no signs of healing in the fracture then you’d say that the bone has actually failed to heal and that is a process called nonunion. Nonunion is not common, but it is made more common by movement of the fracture site. So if the fracture is not stable and there is a certain amount of movement there, then failure to heal can occur and that’s one of the reasons we do internal fixation is to stop the movement. If a nonunion has occurred then there are surgical methods to heal that bone. Usually repeat surgery, improving both the biology and mechanics of the situation by making it still again and perhaps adding material that makes bone heal more quickly.

Dr. Sechrest: Let’s talk about when a bone heals inappropriately, a malunion, is a term that we commonly use when a fracture has healed in the wrong alignment, for example.

Dr. Clough: Well, malunion means that instead of the bone being straight it’s either bent or twisted or perhaps rotated. It’s still healed, but it’s not in the exact shape, and I think that is commoner again with nonoperative treatment but it does sometimes occur when the reduction is difficult or when perhaps the fracture or fixation fails. Once it’s occurred and you’ve got a healed bone that’s in the wrong shape, you have an elaborate decision making process of trying to work out whether that’s going to affect function in a big way or whether it’s going to perhaps be a cosmetic problem only, or whether it’s really not going to be a problem. So if you have a finger fracture and the tip of your finger is slightly out of alignment that’s extremely unlikely to give you a serious functional problem. If, on the other hand, you have a leg fracture and the leg is rotated in the wrong way and your foot is pointing east when you want to go north, that’s a problem, and you may well have to have another operation to rotate the bone, bring everything back into alignment, and fix it again so that it’s functioning the best way possible.

Dr. Sechrest: So again, what the take-home message here is that if a fracture does not heal appropriately, the question as to whether or not anything needs to be done is really what problems is it causing. If it’s not causing any problems –

Dr. Clough: Better to leave it alone. Because any operation carries with it risks, and so if there’s no functional disability, then don’t take the risk.

Dr. Sechrest: Now there are certain things that come from the soft tissue that we need to discuss, and fractures tend to have complications that the bone goes ahead and heals but we’ve got a problem with the soft tissue. Things like lack of blood supply or damage to the soft tissue to the point to where the bone heals fine but the muscles aren’t working around, so what, I mean the limb is not functioning.

Dr. Clough: The most dangerous problem there is called compartment syndrome, and compartment syndrome is a problem of increased pressure inside the muscle compartments of the limb, and it occurs in the arm and the leg most commonly but it also can occur in the hand and the foot and the thigh. What happens is that the muscles are bound by an envelope of tissue that doesn’t stretch so that if the muscles swell, because they bleed, they can’t expand, and so if they can’t expand but they’re swollen, then the pressure goes up. If the pressure goes up high enough to stop the blood circulation, then the muscle dies, and guess what if the muscle dies, it swells. There’s a positive reinforcement, a self-reinforcing process of cell death, swelling, more cell death, and if that process is allowed to continue without treatment then a lot of muscle will die. After it has died it will shrink and shorten and you end up with severe contractures and difficulty, not just because the muscle isn’t there to do the pulling, the difficulty occurs because the muscle has tightened and the fingers deform, the hand deforms, or the foot deforms, a really terrible problem. It’s preventable if we get to it really early. We’re not always able to do that, but if we can get there before any cell death occurs then by opening up the muscle compartment, by doing a big operation with a big scar and relieving the pressure, the muscle resupplies itself with blood and all the bad things don’t happen.

Dr. Sechrest: I think the other thing that we need to alert patients to is that sometimes that can occur because of casts or because of dressings themselves. That can also cause pressure on the outside and create a compartment syndrome.

Dr. Clough: The combination is usually is that there is some bleeding and swelling inside the compartment in the first place, and there’s a tight cast on top of it, and it makes everything worse. So the real important message is that when people, nurses or doctors, are coming up to you and saying, “I want you to move your fingers and I’m going to feel around here.” It’s, again, it’s not because they haven’t anything better to do. They’re there looking for the first signs of a compartment syndrome amongst other problems, and the same applies to a nerve injury. If your fracture has caused an injury to the nerve that will very likely require additional surgery to repair the nerve at a later date or repair the artery. The artery needs to be repaired right away. The nerve often can be repaired at a more distant time. So officious nurses or medical students or anybody else coming around and asking you to do these weird things, they’ve got a job to do and that job is to protect you against these very bad complications.

Dr. Sechrest: One of the things that I would also like to bring out and that is sometimes a complication of a specific type of nerve injury, and that’s called a complex regional pain syndrome, it used to be called colsalgia or reflex sympathetic dystrophy. Today I think the term is complex regional pain syndrome and I think that one of the more common causes of this condition is after a fracture especially in the upper extremity, sometimes in the lower extremity. Explain what that is.

Dr. Clough: They occur, these events occur after a number of insults, but you’re right, that fracture is one of the commonest. There’s a system which is mediated by the sympathetic nerve supply that improves the blood supply to an injured area so that makes sense. When you’ve got an injury you need to up the transport system that will bring new material in there to build new scar tissue, for instance, or new bone, and take away dead material and fluid. So increasing the blood supply acutely after injury is a good idea, but so is decreasing the blood supply later on when the work is done, and this seems to be what doesn’t happen. So that the blood supply increases as a result of the injury but for reasons that we really don’t understand, it doesn’t decrease again. So you get an increased red, hot, swollen area that is very painful, often the nerves are super-sensitive and give you a burning type of feeling and it goes on way longer than expected and it’s very difficult to treat. Once this problem has been established the treatment is to improve the movement of the muscles and basically use the muscles to pump away the surplus blood supply, and that can be very painful and because in itself a symptom of the pain syndrome, the treatment increases the pain and many patients find that very, very difficult to deal with.

Dr. Sechrest: I think that one of the things that patients need to understand about this condition is that there’s just really no good idea amongst orthopaedic surgeons about what we can do to stop this. It seems to come on out of the blue.

Dr. Clough: Yes.

Dr. Sechrest: Everything may just be going beautifully and all of the sudden the CRPS appears and we can’t really connect it to any sort of surgical insult. We can’t connect it to any sort of anesthesia or cast or anything like that. It’s really an enigma. It is very difficult to treat.

Dr. Clough: It is an enigma and it’s difficult to treat because the treatment hurts and actually makes the symptoms worse. Probably the commonest thing I ever say to patients is there’s a difference between hurt and harm, and many things that happen to you when you’re recovering from an operation or from a fracture hurt you, but they don’t necessarily harm you.

Dr. Sechrest: Well, I think this has been an incredibly comprehensive discussion about understanding fractures from a patient’s perspective. Is there anything that we have not discussed today that you think patients should understand about fractures and if they’re faced with either seeking treatment for a fracture that they’ve incurred, or they’re going through this process anything that you think they should know?

Dr. Clough: Not really. I think, as you say, we’ve been quite comprehensive. I think there’s only one other perhaps placement of emphasis and that is trust. You know, a lot of things happen quite quickly after you’ve had a fracture, and some of them are quite mysterious. I think it’s very important to understand that the person who has imposed those events on you has thought about them a long time, has a lot of experience in the problem, and is doing his best or her best. You can’t guarantee 100% success. All you can really guarantee, I think, in modern medicine, is that the person who is working on your behalf is actually, has got a system that has worked for them and is the result of a lot of thought, a lot of education, and a lot of experience.

Dr. Sechrest: I think that’s an important point. I do think that sometimes we think that most operations, most treatment programs that require us to have surgery or to have some significant treatment, like for a fracture, it’s a very controlled environment. The orthopaedic surgeon is presented with a new puzzle every time.

Dr. Clough: It’s totally new.

Dr. Sechrest: And that is you present with a fracture. It may be a similar fracture to the one that came in last week, but essentially that fracture is in a new person, you, with different medical comorbidities, different expectations, and it’s starting all over again every time.

Dr. Clough: I think that makes a big difference to the issue of what information is appropriate to give to patients, because we, as orthopaedic surgeons ahead of time, can give information that’s general. That’s by the generality of the fracture and that’s not what patients want. They want to know the information that appropriate to their individual fracture, and even if you can classify that fracture down to some nine lines of description, it’s still in a unique person and that person’s uniqueness makes the type of information that they need and deserve to get very different.

Dr. Sechrest: Well, thank you very much. Thanks for adding to that body of knowledge.

Dr. Clough: Thank you.