What is the treatment for a complete fracture diagnosis?

Treatment of Complete Fractures

Complete fractures require immediate multidisciplinary management with surgery within 48 hours, appropriate pain control, and comprehensive preoperative assessment to minimize morbidity and mortality. 1

Immediate Management

Emergency Assessment and Stabilization

• Activate emergency response immediately if the fractured extremity appears blue, purple, or pale, as this indicates compromised perfusion and represents a limb-threatening emergency 1
• Control severe bleeding first if present—apply direct pressure and follow hemorrhage control protocols before addressing the fracture itself 1
• Provide adequate pain relief as soon as possible before diagnostic investigations begin 1
• Splint the fractured extremity to reduce pain, prevent further injury, and facilitate transport, though splinting in the first aid setting lacks strong evidence for benefit 1
• Cover any open wounds with clean dressing to reduce contamination and infection risk 1

Critical Preoperative Preparation

• Surgery should occur within 24-48 hours of admission to significantly reduce short-term and mid-term mortality rates and decrease complications from immobility (pneumonia, pressure ulcers, prolonged hospital stay) 1
• Perform comprehensive medical assessment including chest X-ray, ECG, complete blood count, clotting studies, renal function, and cognitive baseline 1
• Optimize fluid management and correct electrolyte disturbances, anemia, and exacerbations of chronic conditions 1
• Consider nerve blocks for hip fractures, as meta-analyses demonstrate significant acute pain reduction 1

Surgical Treatment by Fracture Location

Hip Fractures (Femoral Neck)

• Non-displaced stable fractures: Treat with percutaneous cannulated screw fixation 1
• Displaced fractures in healthy, active elderly patients: Total hip arthroplasty is preferred, allowing immediate full weight-bearing and superior long-term function 1
• Displaced fractures in frail patients: Hemiarthroplasty may be preferred due to shorter operative time and lower dislocation risk, though functional outcomes are less optimal 1

Hip Fractures (Trochanteric)

• Stable intertrochanteric fractures: Use sliding hip screw 1
• Unstable intertrochanteric, subtrochanteric, or reverse oblique fractures: Treat with antegrade cephalomedullary nail, supported by strong evidence 1

Wrist Fractures (Distal Radius)

• Can be managed with cast immobilization, locking plates, Kirschner wires, or external fixation 1
• Recent RCTs have not identified clear superiority of one method in elderly populations 1

Proximal Humerus Fractures

• Most can be treated non-operatively with good functional outcomes 1
• Displaced three-part and four-part fractures remain controversial—open reduction with locking plates has considerable complications 1
• Reverse shoulder arthroplasty may provide satisfactory function in geriatric patients with pre-existing rotator cuff dysfunction 1

Postoperative Management

Orthogeriatric Co-Management

• Implement orthogeriatric co-management immediately, especially in elderly patients with hip fractures, to improve functional outcomes, reduce hospital stay, and decrease mortality 1, 2
• The joint care model between geriatrician and orthopedic surgeon on dedicated orthogeriatric wards demonstrates shortest time to surgery, shortest inpatient stay, and lowest mortality rates 1

Early Mobilization and Rehabilitation

• Avoid prolonged bed rest, as it accelerates bone loss, muscle weakness, and increases thrombosis and pressure ulcer risk 2
• Begin range-of-motion exercises within the first postoperative days 2
• Provide comprehensive geriatric assessment including evaluation for malnutrition, delirium, dementia, and medical comorbidities 1

Secondary Fracture Prevention

Risk Assessment

• Every patient aged 50 years and over with a recent fracture requires systematic evaluation for subsequent fracture risk 1
• Implement Fracture Liaison Service (FLS) model with dedicated coordinator—this is the most effective organizational structure, achieving up to 90% treatment adherence compared to 26% in usual care 1
• Perform DXA of spine and hip, spine imaging for vertebral fractures, falls risk evaluation, and assessment for secondary osteoporosis 1

Pharmacological Prevention

• Provide calcium 1000-1200 mg/day and vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20% 1, 2
• First-line treatment: Alendronate or risedronate (oral bisphosphonates) for patients with GFR ≥30 mL/min—these reduce vertebral, non-vertebral, and hip fractures 1, 2
• Alternative agents: For patients with GFR <30 mL/min, oral intolerance, dementia, or non-compliance, use zoledronic acid (IV) or denosumab (subcutaneous 60 mg every 6 months) 1, 2
• For very severe osteoporosis, consider anabolic agents such as teriparatide 1
• Prescribe anti-osteoporosis drugs for 3-5 years initially, longer in patients who remain high-risk 1

Non-Pharmacological Prevention

• Implement smoking cessation and limit alcohol intake to improve bone mineral density and reduce fall risk 1, 2
• Initiate weight-bearing exercise programs to improve BMD, muscle strength, and reduce falls 2
• Address environmental hazards and review medications that increase fall risk 2

Critical Pitfalls to Avoid

• Never delay surgery beyond 48 hours unless acute medical optimization is absolutely necessary—prolonged immobility increases mortality and complications 1
• Do not use NSAIDs for pain control in patients with chronic kidney disease and cardiovascular disease; use acetaminophen as first-line 2
• Avoid high-pulse dosages of vitamin D, as these are associated with increased fall risk 1
• Do not treat the fracture in isolation—infection is the most common complication in open fractures, and nonunion in infected fractures is the most common reason for postoperative failure 1
• Never discharge elderly fracture patients without establishing secondary prevention—the treatment gap remains high without systematic FLS programs 1