What is the treatment for a long bone injury?

Treatment for Long Bone Injury

For traumatic long bone fractures in hemodynamically stable patients without severe visceral injuries, perform early definitive osteosynthesis within 24 hours to reduce systemic complications including ARDS and fat embolism syndrome. 1, 2

Initial Assessment and Stabilization

First Aid Management (Pre-Hospital)

• Immobilize the injured extremity in the position found without attempting to straighten or realign the fracture 1
• Apply splinting to reduce pain, prevent further injury, and facilitate transport 1
• Activate emergency services immediately if the extremity appears blue, purple, or pale, indicating vascular compromise 1
• Cover any open wounds with a clean dressing to reduce contamination risk 1
• Apply cold therapy (ice and water mixture in a damp cloth) for 20-30 minutes, 3-4 times daily to reduce acute pain and swelling 1

Emergency Department Evaluation

• Obtain CT angiography for suspected vascular injury (96.2% sensitivity, 99.2% specificity) 1
• Assess for severe associated injuries: brain, thorax, abdomen, pelvis, or spinal cord trauma 1
• Evaluate hemodynamic stability, respiratory function, and coagulation status 1

Definitive Surgical Management

Timing of Surgery: The Critical Decision

For stable patients (no severe visceral injury, circulatory shock, or respiratory failure):

• Perform early definitive osteosynthesis within 24 hours for femoral and tibial shaft fractures 1, 2, 3
• Early stabilization significantly reduces incidence of ARDS and fat embolism syndrome compared to delayed surgery beyond 24 hours 2, 3

For unstable patients (with severe visceral injuries, circulatory shock, or respiratory failure):

• Perform temporary stabilization with external fixation or skeletal traction initially 1, 2
• Delay definitive osteosynthesis until clinical stabilization is achieved to avoid the surgical "second hit" phenomenon 1, 2
• Management of intracranial hypertension takes precedence over fracture fixation 2

Surgical Technique

For diaphyseal fractures:

• Intramedullary nailing is the preferred operative approach for metadiaphyseal and diaphyseal fractures 1, 4
• Provides mechanical stability, faster mobilization, and better pain control 4

For proximal femur fractures:

• Use standard total joint arthroplasty for pathologic fractures of the femoral head, neck, and intertrochanteric fractures 1

Intraoperative measures to reduce fat embolism risk:

• Thoroughly wash and dry the femoral canal before instrumentation 3
• Use pressurized lavage to clean endosteal bone of fat and marrow 3
• Maintain systolic blood pressure within 20% of pre-induction values 2, 3
• Increase inspired oxygen concentration during critical moments 3
• Ensure adequate hydration before and during anesthesia 3

Post-Operative Management

• Administer supplemental oxygen for at least 24 hours postoperatively 2, 3
• For pathologic fractures from metastatic disease, perform radiotherapy 2-4 weeks following surgery (30 Gy in 10 fractions or 20 Gy in 5 fractions) 1
• Monitor for development of ARDS and fat embolism syndrome 2

Critical Pitfalls to Avoid

Do NOT administer corticosteroids for prevention or treatment of fat embolism syndrome - they increase mortality in traumatic brain injury and infection risk without proven benefit 2

Do NOT rush to definitive surgery in unstable patients with ongoing cerebral injury or hemodynamic compromise, as the surgical "second hit" can worsen outcomes and trigger multiple organ failure 1, 2

Do NOT delay surgery beyond 24 hours in stable patients - this increases risk of respiratory complications, ARDS, and fat embolism syndrome 1, 2, 3

Expected Outcomes

Operative intervention for long bone fractures provides good functional results in approximately 80-85% of patients with effective pain control in the majority 1, 4