X-ray showing the proximal portion of a fractured tibia with an intramedullary nail.
Proximal femur nail with locking and stabilisation screws for treatment of femur fractures of left thigh.
Treatment of bone fractures are broadly classified as surgical or conservative, the latter basically referring to any non-surgical procedure, such as pain management, immobilization or other non-surgical stabilization. A similar classification is open versus closed treatment, in which open treatment refers to any treatment in which the fracture site is surgically opened, regardless of whether the fracture itself isanopen or closed fracture.
While you are pain-free under general or local anesthesia, a surgical cut is made over the fractured bone. The bone is placed in the proper position. Screws, pins, or plates are attached to or placed in the bone temporarily or permanently. Long bones may be fixed with nails placed in the bone cavity.
Any disrupted blood vessels are tied off or burned (cauterized). If a lot of bone has been lost due to the fracture (especially if there is a gap between the broken bone ends), the surgeon may decide to do a bone graft. Bone grafting may be performed using the patient’s own bone, usually taken from the hip. Or, bone taken from a donor can be used.
If bone grafting is not necessary, the fracture can be repaired by the following methods:
- One or more screws may be inserted across the break to hold it.
- A steel plate held by screws may be drilled into the bone.
- A long, thick metal pin (sometimes called a rod or nail) with holes in it may be driven down the shaft of the bone from one end. Screws are then passed through the bone and through a hole in the pin.
In some cases, blood vessels and nerves are repaired with microsurgery. The opening in the skin is then closed. If the broken bone has pierced the skin, the bone ends need to be washed with sterile fluid in the operating room to prevent infection. The washing process may need to be repeated if the wound is dirty or becomes infected.
Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done only if conservative treatment has failed, is very likely to fail, or likely to result in a poor functional outcome. With some fractures such as hip fractures (usually caused by osteoporosis), surgery is offered routinely because non-operative treatment results in prolonged immobilisation, which commonly results in complications including chest infections, pressure sores, deconditioning, deep vein thrombosis (DVT) and pulmonary embolism, which are more dangerous than surgery. When a joint surface is damaged by a fracture, surgery is also commonly recommended to make an accurate anatomical reduction and restore the smoothness of the joint.
Infection is especially dangerous in bones, due to the recrudescent nature of bone infections. Bone tissue is predominantly extracellular matrix, rather than living cells, and the few blood vessels needed to support this low metabolism are only able to bring a limited number of immune cellsto an injury to fight infection. For this reason, open fractures and osteotomies call for very careful antiseptic procedures and prophylacticantibiotics.
Occasionally bone grafting is used to treat a fracture.
Sometimes bones are reinforced with metal. These implants must be designed and installed with care. Stress shielding occurs when plates or screws carry too large of a portion of the bone’s load, causing atrophy. This problem is reduced, but not eliminated, by the use of low-modulusmaterials, including titanium and its alloys. The heat generated by the friction of installing hardware can easily accumulate and damage bone tissue, reducing the strength of the connections. If dissimilar metals are installed in contact with one another (i.e., a titanium plate with cobalt-chromium alloy or stainless steel screws), galvanic corrosion will result. The metal ions produced can damage the bone locally and may cause systemic effects as well.
Electrical bone growth stimulation or osteostimulation has been attempted to speed or improve bone healing. Results however do not support its effectiveness.