What is the management and treatment for an acute comminuted and minimally displaced fracture?

Management of Acute Comminuted and Minimally Displaced Fractures

Acute comminuted and minimally displaced fractures require appropriate treatment based on fracture location, with surgical intervention recommended for most comminuted fractures to optimize outcomes related to morbidity, mortality, and quality of life. 1

Understanding the Terminology

An acute comminuted and minimally displaced fracture refers to:

• Acute: A recent fracture injury
• Comminuted: The bone has broken into multiple fragments (three or more pieces)
• Minimally displaced: The bone fragments remain nearly in their normal anatomical position (typically <5mm displacement and/or <15 degrees angulation)

Treatment Approach Based on Location

Non-Surgical Management

Non-surgical management may be appropriate for certain minimally displaced comminuted fractures:

• Proximal humerus fractures: Early mobilization with a short period of immobilization (3 weeks) can be sufficient for minimally displaced fractures 2
• Forefoot fractures: Offloading shoes may be used for stable, minimally displaced fractures with 4-6 weeks of non-weight bearing or partial weight bearing 1

Surgical Management

Surgical intervention is strongly recommended for most comminuted fractures, particularly:

• Hip fractures:

  • Intracapsular fractures: Internal fixation with multiple screws or sliding hip screw for undisplaced fractures; hemiarthroplasty or total hip arthroplasty for displaced fractures 3
  • Extracapsular fractures: Sliding hip screw for intertrochanteric fractures or proximal femoral intramedullary nail for subtrochanteric fractures 3
  • Cemented femoral stems are recommended over uncemented (strong recommendation) 1

• Other fracture sites:

  • Minimally invasive plate osteosynthesis (MIPO) may be beneficial for comminuted fractures of the distal radius to minimize soft tissue damage 4

Postoperative Care

1. Weight-bearing status:

   • Immediate, full weight-bearing to tolerance after hip fracture surgery (limited strength option) 3, 1

2. Blood management:

   • Blood transfusion recommended for symptomatic anemia 3
   • Transfusion threshold no higher than 8 g/dL in postoperative, asymptomatic hip fracture patients 3

3. VTE prophylaxis:

   • Strong recommendation for VTE prophylaxis in hip fracture patients 3
   • Sequential compression devices during hospitalization followed by pharmacological prophylaxis for 4 weeks postoperatively 3, 1

4. Pain management:

   • Multimodal analgesia including peripheral nerve blocks 1

5. Follow-up imaging:

   • Regular radiographs at 2,6, and 12 weeks for surgically treated fractures 1

Special Considerations

1. Elderly patients with osteoporosis:

   • Referral to bone health clinic for osteoporosis evaluation and treatment is recommended 3, 1
   • In elderly patients with advanced bone loss where anatomical reduction is difficult, arthroplasty should be considered 5

2. Diagnostic challenges:

   • MRI without contrast is the gold standard for diagnosing occult fractures (nearly 100% sensitivity) 1
   • CT scans are useful for assessing fracture extent and preoperative planning 1

Potential Complications

• Avascular necrosis (particularly in displaced intracapsular hip fractures) 3
• Nonunion or malunion 1
• Joint stiffness if rehabilitation is delayed 5
• Blood loss (can exceed one liter in extracapsular hip fractures) 3

Rehabilitation

Early rehabilitation is crucial to prevent joint stiffness and optimize functional outcomes. For minimally displaced fractures treated conservatively, early mobilization after a short period of immobilization has shown good results 2.

The decision between conservative and surgical treatment should consider that surgical stabilization eliminates the need for prolonged immobilization, enables immediate rehabilitation, reduces the risk of joint stiffness, and shortens recovery time 5.