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.
CASTS
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.
REDUCTION OF FRACTURES
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 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.
|
|
