Treatment Options for Different Types of Fractures
The optimal treatment for fractures depends on the fracture type, location, and patient factors, with surgical intervention indicated for displaced fractures (>2-3mm displacement) and conservative management appropriate for stable, non-displaced fractures. 1
Classification and General Approach
Fractures can be broadly categorized by location:
Hip/Proximal Femur Fractures
- Intracapsular (50%): Subcapital, transcervical, basicervical
- Extracapsular (50%): Intertrochanteric, subtrochanteric 2
Vertebral Compression Fractures
- Osteoporotic
- Pathologic (malignancy-related)
- Traumatic 2
Other Common Fractures
- Femoral condyle fractures
- Foot fractures
- Olecranon fractures
- Axis (C2) fractures
Hip Fracture Management
Intracapsular Fractures
- Undisplaced fractures: Internal fixation with multiple screws or sliding hip screw 2
- Displaced fractures:
- Younger, active patients: Total hip replacement
- Frail elderly patients: Hemiarthroplasty (shorter operative time, lower dislocation risk) 2
- Cemented vs. uncemented: Cemented arthroplasty improves hip function and reduces postoperative pain 2
Extracapsular Fractures
- Intertrochanteric fractures: Sliding hip screw fixation
- Subtrochanteric fractures: Proximal femoral intramedullary nail 2
Vertebral Compression Fractures
Osteoporotic Compression Fractures
- Initial approach: Medical management for first 3 months
- Pain management
- Activity modification
- Bracing
- For persistent symptoms with spinal deformity or pulmonary dysfunction: Percutaneous vertebral augmentation (VA) 2
Pathologic (Malignant) Fractures
- Asymptomatic: Radiation oncology consultation or medical management
- Severe/worsening pain: Multidisciplinary approach with interventional radiology, surgery, and radiation oncology
- Options include percutaneous thermal ablation or vertebral augmentation
- With neurologic effects: Surgical consultation and radiation oncology consultation 2
Femoral Condyle Fractures
Displaced fractures (>2-3mm): Surgical intervention
- Lateral condyle: Headless compression screws
- Medial condyle: Lag screws with buttress plating
- Osteochondral fractures: Arthroscopic-assisted reduction and fixation 1
Non-displaced fractures: Conservative management
- Limited weight-bearing with crutches/walker for 4-6 weeks
- Pain management
- Progressive mobilization 1
Foot Fractures
- Toe fractures: Hard-soled shoe for 2-6 weeks (special attention to great toe)
- Metatarsal shaft fractures: Boot or hard-soled shoe for 3-6 weeks
- Proximal fifth metatarsal fractures: Management based on fracture zone due to variable blood supply
- Lisfranc fractures: Often require surgical intervention due to joint instability
- Tarsal bone fractures: Short leg cast or boot for 4-6 weeks when nonsurgical treatment is indicated 3
Post-Treatment Care
Rehabilitation
- Early postfracture physical training and muscle strengthening
- Long-term balance training and multidimensional fall prevention 2
- Progressive weight-bearing as tolerated with return to full activities typically at 3-4 months 1
Fracture Prevention
- Calcium intake of 1000-1200 mg/day
- Vitamin D supplementation (800 IU/day)
- Smoking cessation and limitation of alcohol intake 2, 1
- Pharmacological treatment for osteoporosis when appropriate:
- First-line: Alendronate, risedronate (oral bisphosphonates)
- For intolerance/non-compliance: Zoledronic acid (IV) or denosumab (subcutaneous)
- For severe osteoporosis: Teriparatide 2
Special Considerations
Atypical Femoral Fractures
- Associated with prolonged (3-5 years) antiresorptive medication use
- Incomplete fractures without visible line: Nonoperative with protected weight-bearing
- Complete fractures or incomplete with visible line: Intramedullary nailing
- All patients: Withdraw bisphosphonates, optimize vitamin D and calcium 4
Axis (C2) Fractures
- Type II odontoid fractures have highest nonunion rate (28.4%)
- Surgical fusion recommended for:
- Fracture instability despite external immobilization
- Transverse ligament disruption
- Type II odontoid fractures with ≥6mm displacement
- Severe hangman's fractures
- Otherwise, nonoperative management with external immobilization 5
Common Complications
- Pain associated with hardware
- Infection
- Pseudarthrosis/nonunion
- Post-traumatic arthritis
- Arthrofibrosis
- Extensor mechanism insufficiency 1
- Deep vein thrombosis (37% prevalence in hip fracture patients) 1
By understanding the specific characteristics of different fracture types and following evidence-based treatment algorithms, optimal outcomes can be achieved while minimizing complications and promoting return to function.