General fracture care

My fracture expertise spans the entire spectrum of extremity injuries, from minor nondisplaced fractures, to major open comminuted and contaminated lower extremity joint injuries. I successfully treat fracture nonunions as well.

The following is a discussion of the basics of fractures, intended for laypersons.

What's in a name?

"Fracture" is a Latin derived word that means exactly the same thing as the English word "break".

Obviously not all fractures are the same. Generally speaking, the higher the energy of the original impact that caused the fracture, the more problematic the fracture.

  1. A fracture may be comminuted: this means that the bone has broken in multiple pieces.
  2. A fracture may be open: this means that one or more of the bone ends came out, through the skin, and saw the light of day (or perhaps the moon). This represents an infection risk. A compound fracture is the same as an open fracture, these two words are synonyms.
  3. A shaft fracture involves the middle of the bone, the tube part of it, away from the joints.
  4. An intraarticular fracture involves the joint in one or the other end of a bone.

There is such a thing as an open intraarticular comminuted fracture. The implication of this diagnosis is that the fracture has shattered a joint surface, and in addition bone fragments have come into contact with the environment. Such a fracture is at increased risk of getting infected. In addition, if the infection is avoided, there is still a high risk of posttraumatic arthritis from the fragmentation of the joint. Even in the best case scenario there will likely be stiffness and pain.

What is the role of the orthopedic surgeon?

Healing is a complicated biological process, not fully understood in detail by the medical science. Suffice to say that a broken bone usually heals as a consequence of the normal biological processes of the body. The body's healing response starts with the bleeding that occurs from the broken bone ends. That pool of blood starts a process that results in formation of first soft, and then hard callus. If everything goes well, preliminary healing takes about 6-8 weeks. Remodelling and continued strengthening of a fracture then takes months and years.

It is important for me to say that as an orthopedic surgeon, I do not make bones heal. I reduce and stabilize fractures. Healing is what mother nature does. Of course, sometimes there are things that get in the way of mother nature, and it is my job to recognize those situations and try and do something about it, to allow the healing process to progress in the best way possible.

Reduction

The first part of my job is to reduce the fracture, in other words to place broken bone ends in their proper position relative to each other. The reduction of a fracture may be "open" or "closed". The reduction is "open" when the surgeon cuts through the layers and exposes the fractured bone ends, manipulates them with instruments or fingers, and thus achieves proper alignment of the fractured bone.

The reduction is "closed" when the broken bone is manipulated without cutting and exposing the fractured bone ends.

Fixation

The second part of my job is to stabilize the fracture, hold the broken ends of the bone in place somehow until the biological healing is complete. This is referred to as "fixation." Fixation can be external, for instance with a cast, or with an external fixator apparatus. Fixation can be internal, and this implies using an orthopedic, usually metallic, implant that is buried under the skin.

It follows that for fractures that are not displaced, reduction is not necessary. Most of the time, surgical stabilization is not necessary either, because nondisplaced fractures are inherently rather stable compared to displaced fractures. Nondisplaced fractures around the proximal femur are an exception, due to the high forces and high stakes nature of the proximal femur. Even nondisplaced femoral neck fractures are best stabilized with hardware (However, I have successfully treated a nondisplaced femoral neck stress fracture without surgery).

To illustrate some of the points above, the procedure known as ORIF (open reduction internal fixation) implies that surgery is done, skin and deeper layers are cut, broken bone ends are exposed and reduced, and then the break is held together by a buried orthopedic implant.

As another example, a femur shaft fracture is often treated by "rodding." This procedure is often accomplished by "closed reduction" by means of an operative traction table, followed by implanting a titanium alloy rod in the middle of the bone: the only surgical opening being the opening for placing the rod inside the femur. The description of the procedure therefore would be "closed reduction internal fixation," but it certainly is more commonly known as "intramedullary nailing".

Who needs surgery?

The decision to proceed with fracture surgery quite often is not a simple one. One has to weigh pros and cons of each treatment method, for each patient. Often the right thing to do is not immediately clear. For instance, for an identical distal radius fracture, internal fixation with plate and screws may offer much faster recovery and a slightly better radiographic outcome, whereas nonsurgical treatment will require an extra 6 weeks in a cast, may result in less correct shape of the bone, but avoids the risks of surgery. Which is the correct treatment??

Often it is difficult to say.

What can go wrong with fracture surgery?

Many things, a few examples will be given below.

Early loss of fixation

Despite a surgeon's best efforts, sometimes the stabilization of a fracture is not effective. Rods, pins, screws, etc., may fail. The bone may be too weak for the implants to stay fixed securely. Or a patient may fall again, twist, impact, etc. Sometimes as a surgeon one expects a higher failure rate with a certain treatment method, but alternative treatments may be more invasive.

Nonunion

In general, a fracture that moves too much may not heal. However, a fracture that is stabilized surgically too stiffly but with a gap between bones may also not heal.

Certain bones are just predisposed to not heal. Often this has something to do with the blood supply. Scaphoid fractures for instance may not heal because their biology is such that the blood supply to the proximal scaphoid is tenuous. Femoral neck fractures also may not heal, because the blood supply to the fractured head is disrupted from the injury. Bone without blood supply dies, and dead bone does not heal.

When a bone does not heal biologically, it is a matter of time before the orthopedic implant will fail and break or pull out, resulting in delayed loss of fixation.

Malunion

Malunion means a "bad union," literally. That is to say, the bone heals but the shape is not "right," the bone heals with deformity. It is important to say that the diagnosis of malunion is not black-and-white. What may be a malunion to one doctor, may be a perfectly good union to another. The typical case is that of the very common distal radius fractures, where a lot of "malunions" are well tolerated by the patients, and the patients go on and live happy lives even though xrays may not look pretty. Also, a deformed bone may function well and sometimes it represents only a cosmetic problem.

Nerve damage, numbness, tingling, etc.

Any time skin is cut during surgery, tiny skin nerves are also cut. Some numbness around he incision is to be expected. But even before the surgeon brings the knife, the sharp broken bone ends stab the surrounding tissues from inside out, including muscles, tendons, and nerves. Quite often the deformity of the injury may stretch or crush a nerve as well.

Infection

There used to be a time when the word "surgery" meant "amputation," and the only virtue of a surgeon was speed. Aseptic technique and antibiotics have changed that, and as surgeons we can now perform sophisticated operations that would have been impossible in the past. Infection however remains a risk and there is no sure way to avoid it.

The risk of infection is increased if there is an open wound, if there is diabetes, obesity, immune deficiency, etc. Also, the worse the soft tissue injury that is associated with the fracture, the higher the infection risk. The importance of the injuries to the soft tissues cannot be overemphasized: when a bone breaks, it isn't just the bone that suffers, on the contrary: quite often the main problem is the soft tissue injury, not the bony fracture.

Swelling

It is important to realize that after a bone breaks, its broken ends bleed. Not only that, but the blood vessels in the flesh around the broken bone are torn and they bleed as well. Sometimes the bleeding can't stop because the sharp broken bone ends keep stabbing the flesh around them with every little move. All that bleeding eventually turns into a clot, and all that clot with time becomes scar tissue, new extra bone, etc. New blood circulation patterns are established, and the broken bone and the area around it are never quite the same. That is why some swelling, in the end, is to be expected after a lot of fractures.