Bone Fracture Treatment
The position and severity of the fracture depends on the exact form of treatment that is used, but all fracture treatments are trying to achieve the same thing. All fractures must be –
- Reduced: This involves the realigning of the bones if they are displaced or compound. It may also involve the removing of fragments of bone, the re-piecing together of a comminuted fracture or the use of traction to repair impacted fractures or fractures that need re-aligning over more than one axis.
- Stabilised: The fractured bone must be stabilised so as to keep the bone in a safe position, promoting healthy/normal healing.
- Immobilisation: The fractured area must be immobilised/kept still so as to allow the body’s healing mechanisms to work efficiently.
Reduction is a medical procedure where a bone fracture or dislocation is re-aligned to the normal anatomical position. The procedure is said to be ‘open’ if surgery is required to re-align the bone, or ‘closed’ if the bone can be manipulated without needing surgery. Some fractures, such as those that have not displaced or crushed do not require reduction.
Closed reduction: This type of reduction is more common in cases of dislocation than fractures. The area of the fracture is externally manipulated in order to move the fractured bones back in to place.
Open reduction: This type of reduction is often required for the treatment of more severe fractures, such as those that are displaced, compound or comminuted. The surgical procedures vary depending on the type of fracture. Here are some key points that apply to most open reductions –
Cleaning: This risk of infection is greater with open reductions and surgeons take great care to ensure that the wound is as clean as possible. Any bone debris is removed by suction, with larger bone fragments being placed in saline before being re-inserted during the fracture repair, as is demonstrated in this video of the open reduction of a comminuted calcaneal fracture -
Traction: Some fractures need re-aligning or separating along the vertical axis (eg impacted fracture or any fracture where the two ends of the bone have passed each other in the vertical axis). Traction can be achieved through the pulling apart of the bones using pins and wire that are inserted into the bone and then put under a pulling force, as shown in the image below. Traction may also be achieved through the pulling of the limb externally, although this method is not used for prolonged periods of time due to the bruising and damage it causes to the skin. It may be necessary for the fracture to undergo traction for a few days before the fracture can be further repaired.
Re-aligning: The re-aligning of the fracture is achieved through the use of bone clamps and temporary wiring. The bone is re-aligned and held in place by these temporary measures before more long term forms of stabilisation can be introduced. The use of K-wires to hold parts of a fractured bone together can be seen in the calcaneal fracture video above. The use of bone clamps to temporarily re-align a fracture can be seen in the Fibula Fracture video below –
Some forms of fracture do not require extra stabilisation, and can be immobilised in a plaster cast straight away, other more serious fractures require some form of surgical stabilisation. The form of stabilisation used depends on the type of fraction and its position in the body. The video below gives a brief overview of some of the main types of fracture stabilisation/fixation discussed below –
K-Wires/Pins: Kirschner wires are sharp, smooth, sterilised pins that are used to hold pieces of broken bone together. The pins can be used by themselves, often to hold together comminuted fractures, or as part of another form of bone fixation. The calcaneal fracture video above shows the pins being used to temporarily hold a fracture together, before it is joined together with a more permanent structure, whilst the picture below shows the pins being used alone. The video below shows surgeons stabilising a calcaneal fracture by inserting K-wires, guided by in-surgery radiography. Depending on the area and type of fracture the pins may be removed once the fracture is healed or left indefinitely.
Plates: Plates are often used to provide stability and structure to many different types of fracture. Holes are drilled in to sites of healthy bone around the fractured area, after it has been reduced and brought in to alignment. A plate is then placed over the fracture and, using the pre-drilled holes, is screwed in to place. Plating is a very useful method of stabilisation as plates can be designed for almost any shape of bone (as is shown in the two images below), making it a very versatile stabilising option. Once a plate has been fitted it is left indefinitely.
Intramedullary Rods: Long metal rods can be inserted into the long bones of the body (most often the femur) in order to aid repair. The strong metal rods are often used in fractures of long bones that are weight bearing, such as the femur. A long drill bit is used to drill a hole through the length of the bone (through the fractured area), before the metal rod is inserted and hammered in to the cavity. The rod is then fixed in place at either end, using pins that are designed to prevent rotation of the fractured area around the rod. The video below shows the surgical process and the image shows an example of successful intramedullary rod insertion surgery.
External Fixation: This type of fracture repair is used when internal fixation (plating or pining) is not possible due to other medical reasons, as a temporary measure or when traction is needed to help fix the fracture. Metal rods are inserted through the skin and into the bone (after reduction of the fracture), either side of the fractured area. The external metal rods are then held together with a rod or curved piece of metal, which provides the fixation with structure and stability.
External fixation is also used to exert traction forces on a fracture that needs to be lengthened or re-aligned vertically. The external rods are attached to cylindrical structure, called the Ilizarov apparatus, which sits around the fractured limb. The length of the apparatus can be gradually varied so as to pull apart the fracture. The apparatus may be used prior to another form of fracture treatment. The images below show the apparatus.
In order for the fracture to heal, it must be kept in line and in close proximity to itself. This is achieved through the immobilisation of the fracture using a plaster cast or splint. The immobilisation of the fracture can be split into Primary and Secondary immobilisation.
Primary Immobilisation: This form of immobilisation is usually used for minor fractures. It involves placing the fractured limb into a removable/temporary cast which provides a splinted support. The support allows for a small range of movement and takes into account any swelling of the limb that may occur.
Secondary Immobilisation: This form of immobilisation provides structured support throughout the healing process. It is often in the form of a plaster cast, but can be in the form of external fixation. A secondary cast is often applied after primary immobilisation has been used to ensure that the bone is properly aligned before completely immobilising it.
Fig.1 - Courtesy of JustinKSU, Wikipedia
Fig.2 - Courtesy of Michael L. Richardson MD, University of Washington
Fig.3 - Courtesy of Fremry, Wikipedia
Fig.4 - Courtesy of Wjlean, Wikipedia
Fig.5 - Courtesy of Kolossos, Wikipedia
Fig.6 - Courtesy of Grook da Oger, Wikipedia
Fig.7 - Courtesy of Ashish j29, Wikipedia
Fig.8 - Courtesy of Viapastrengo, Wikipedia
Fig.9 - Courtesy of Viapastrengo, Wikipedia
Fig.10 - Courtesy of PhysioRoom
Fig.11 - Courtesy of Wikipedia