Broken bones are one of the most common orthopedic injuries. Fractures require treatment which may be as simple as rest, or as invasive as surgery. There are many factors that must be considered to determine the most appropriate treatment of a broken bone including:
- Location of the broken bone
- Alignment of the fracture
- Patient's expectations
Some of the most frequently used fracture treatments are described here.
The most common type of fracture management is with immobilization. There are different types of immobilization including splint, braces, casts, slings, and others.
Cast immobilization is the most common method where a material (typically plaster or fiberglass) is wrapped around an injured extremity and allowed to harden. Casts come in an endless number of shapes and sizes and require proper cast care.
Fractures treated with immobilization must be adequately aligned to allow for healing with good results. If the alignment of the fracture is not sufficient, further treatment will be needed.
Reducing (Reseting) the Broken Bone
A procedure called a fracture reduction, or reducing a fracture, is an intervention to better align the broken bones. A fracture reduction can either be done as a closed reduction (nonsurgical) or an open reduction (surgery).
A typical closed reduction is performed either by providing local anesthetic to the broken bone, or a general anesthesia, followed by a specific maneuver to attempt to realign the broken bone. After a closed reduction a splint or cast would be applied to hold the bones in the improved alignment.
Traction is an older form of fracture management that is used much less commonly today. However, there are certain situations where traction can be a very useful treatment option.
Traction involves gentle pulling of the extremity to align the bones. Often a metal pin is place in the bone on the far side of the fracture, this is called skeletal traction. Ropes and weights are attached to the pin to gently pull the bone fragments into alignment.
Skin traction is a similar concept, but instead of a pin being inserted into the bone, the traction is just by pulling externally on the extremity. Skin traction cannot pull with as much force as skeletal traction, so if traction is being used for more than a short time, usually skeletal traction is favored.
Pins are often used to stabilize smaller bones (hands and wrist, for example) when a closed reduction can be used to improve alignment, but a cast is insufficient to hold the bones in place.
Pins are typically placed through the skin in a procedure called a closed reduction with percutaneous pinning (CRPP). The pins are placed in an operating room, but can typically be removed in your doctors office and there is little discomfort in most pin removal procedures. If there is discomfort, the removal can be performed in the operating room.
External fixation also uses pins that enter the skin, but are held together outside the body with a frame to maintain alignment. External fixation is an excellent option with severe trauma as they can be applied quickly, they can be adjusted as needed, and they allow access to the skin and soft-tissue wounds. External fixation is often used with open fractures.
External fixation can also be helpful when there is significant swelling that could make surgery too risky. By temporarily immobilizing the fracture, the swelling can improve, and internal fixation can be considered at a later time.
Open Reduction with Internal Fixation
Open reduction means to surgically open the site of the fracture, align the bone fragments, and then hold them in place. The most common type of internal fixation are metal plates and screws, although there are many devices that can be used to stabilize different types of fractures.
Open reduction with internal fixation (ORIF) is the preferred treatment for a number of different types of fractures:
- Fractures that tend to displace with immobilization
- Fractures that are poorly lined up
- Fractures around joints that have significant joint damage
Determining when a fracture should have surgery is a complex decision that must take into account many variables including the type, location, and severity of the fractures, as well as the expectations of the patient. In some situations, metal implants may have to be removed at a later date.
Intramedullary (IM) rodding is a surgical procedure to stabilize a broken bone by inserting a metal rod in the hollow medullary canal of the bone. This part of the bone (where the bone marrow is) can be used to hold the rod and allow for early movement and weight bearing.
IM rodding is often the preferred treatment for fractures of the lower extremity long bones that are not close to the joints (bone ends). In these cases, patients can resume walking much sooner than with other types of fracture treatment.