Fracture management

Fracture management stages include (4 R’s):

1. Resuscitate
2. Reduce (if displaced) – may be done by open reduction, closed manipulation or traction
3. Retain (to maintain position while healing occurs) – by internal fixation, external fixation or conservative methods
4. Rehabilitate

REsuscitate

• Advanced trauma life support in life-threatening wounds (see ATLS)
• Look for other injuries (don’t get distracted by one obvious injury!) – does the cervical spine need to be immobilised?

REduce

(if displaced)

• Open reduction – when anatomical (perfect) reduction is required (e.g. for intra-articular fractures) or associated neurovascular damage
• Closed manipulation (may be done in emergency department or require general anaesthesia) – for extra-articular fractures where adequate and acceptable reduction can be achieved
• Traction (to aid reduction, analgesia and in patients who are unsuitable for anaesthesia)

REtain

(to maintain reduced position while callus forms in ~ 6 weeks)

• External fixation – required for: contaminated open wounds, severe open fractures, severe associated soft tissue injury
• Internal fixation– required for: comminuted or displaced fractures, intra-articular fractures, bones not able to be reduced by other methods, associated joint incongruity
  • Intramedullary
    • Intramedullary nail – for long bone fractures (femur/tibia/humerus)
    • K-wires (stainless steel pins which can be inserted percutaneously to hold bone fragments together; can be used as temporary fixation for ~4 weeks) – for fracture fragments or for intramedullary fixation of small bones  
  • Extramedullary
    • Plates and screws – to bridge comminuted fractures, compress simple fractures around joints, support areas of thin cortex or secure tension side of fracture
• Conservative immobilisation – can be used for most fractures without above properties, and also to stabilise fractures temporarily in case of delay before reduction/fixation
  • Splints and casts
    • Splint (non-circumferential immobiliser), e.g. plaster backslab, fibreglass backslab, aluminium/wire/heat-mouldable plastic splints 
    • Cast (circumferential immobiliser), e.g. fibreglass cast, full plaster cast 
  • Brace (supportive device that allows continued function)
  • Sustained traction:
    • Collar and cuff arm sling
    • Skin traction (adhesive strappings around parts of limb distil and proximal to fracture, and weight traction applied to each in opposite directions)
    • Traction splint 
    • Skeletal traction (pins passed through bone to provide point of traction)

NB: femur and tibia/fibula shaft fractures can be managed conservatively but are usually managed with intramedullary nailing to reduce time non-weight-bearing.

REhabilitate

• Physiotherapy to regain function
• Consider weight-bearing status of affected lower limb
  • Non-weight-bearing (leg must not touch floor) – for ~6 weeks in conservatively managed unstable fractures and after fixation with plates 

Other aspects to management

• For swelling, RIE: Rest, Ice, Elevation
• Smoking cessation – delays bone healing 
• Analgesia (but avoid NSAIDs – they interfere with bone healing)
• Antibiotic prophylaxis for open fractures 
• VTE prophylaxis
• Treat the cause of the fracture if necessary, e.g. osteoporosis, fall etc.

Other points

• Timings
  • Callus forms in 6 weeks – temporary fixations (e.g. traction, cast, external fixations, K-wires) removed at this stage
  • Full fracture healing in 12 weeks
  • Generally, lower limb bones take twice as long to fully heal as upper limb bones, and young children’s bones heal twice as fast as adult’s bones
• Repeat X-rays are performed post-operatively or after cast application 
• Fractures with a fragment at risk of avascular necrosis due to retrograde blood supply:
  • Head of femur 
  • Waist of scaphoid
  • Neck of talus

Specific management of common fractures

Clavicle	Broad arm sling or polysling
Proximal humerus	Collar and cuff sling (applies traction)
Mid-humerus	Collar and cuff sling + U-slab cast, or functional brace
Distal humerus	Above elbow backslab/cast
Colles’ fracture	Closed manipulation under haematoma block then Colles’ backslab/cast (below elbow backslab/cast with wrist flexed and ulnar deviated) applied
Scaphoid	Futuro splint ± thumb extension, or thumb spica splint/cast if definite fracture
Neck of femur (intracapsular)	Displaced >60 years → total hip replacement/hemiarthroplasty Undisplaced/displaced <60 years → cannulated screws
Neck of femur (extracapsular)	Intertrochanteric → dynamic hip screw/gamma nail Subtrochanteric → intramedullary nail
Femur/tibia shaft	Intramedullary nail
Lateral malleolus (Weber A)	Below knee backslab/cast or aircast boot or stirrup brace (full weight-bearing)
Bimalleolar, trimalleolar or lateral malleolar fractures that disrupt the syndesmosis (i.e. Weber C and some Weber B)	Surgical fixation

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