What are the principles of fracture management?

Principles of Fracture Management

The fundamental goal of fracture management is to achieve stable fracture fixation that enables rapid bone healing while restoring early mobility and full function of the injured extremity, with treatment decisions based on fracture stability requirements, soft tissue condition, and patient factors. 1

Core Treatment Principles

Primary Objectives

• Achieve adequate fracture stability to allow bone consolidation, as fracture stability is crucial for both healing and infection eradication 2, 3
• Restore anatomical alignment when necessary for function
• Preserve or restore blood supply to bone and soft tissues
• Enable early mobilization and rehabilitation 1

Treatment Decision Algorithm

Step 1: Assess Fracture Characteristics

• Fracture pattern (simple vs. multifragmentary)
• Location (metaphyseal, diaphyseal, articular)
• Displacement and stability
• Open vs. closed injury 2

Step 2: Evaluate Soft Tissue Status

• Skin integrity and viability
• Muscle and periosteal damage
• Presence of infection or contamination 2

Step 3: Select Treatment Method

Treatment Modalities

Conservative (Non-Operative) Management

• Indicated for: Stable fractures, minimally displaced fractures, or when surgery poses excessive risk 2, 1
• Methods include:
  • Closed reduction to restore alignment 1
  • Splinting for acute injuries with anticipated swelling (noncircumferential, accommodates edema) 4
  • Casting for definitive immobilization once swelling subsides (circumferential, superior immobilization) 4
  • Traction for specific fracture patterns 1

Critical caveat: Limit immobilization duration to prevent complications including joint stiffness, muscle atrophy, chronic pain, and complex regional pain syndrome 4

Operative Management

Internal Fixation Principles:

The advantage of implants for stabilization outweighs their increased susceptibility to infection, as experimentally contaminated fractures without internal fixation are more prone to infection than those with fixation. 2, 3

Device Selection:

• Intramedullary nails/rods: Provide relative stability, promote secondary (callus) healing 3, 1
• Plates and screws: Can provide absolute stability (compression plating) or relative stability (bridge plating) depending on technique 1, 5
• External fixators: Useful for severe soft tissue injury, infection, or damage control situations 1
• Wires, pins, screws: Adjunctive or primary fixation for specific fractures 1, 6

Modern Fixation Concepts:

• Locked plating systems (LCP, LISS) allow fixation without plate-to-bone compression, preserving periosteal blood supply 5
• Bridge plating technique for multifragmentary fractures reduces soft tissue stripping and vascular damage 5
• Minimally invasive percutaneous osteosynthesis (MIPO) when appropriate 5

Special Considerations for Open Fractures

Immediate Management:

• Perform thorough debridement with removal of all dead tissue 2
• Obtain deep tissue biopsies for microbiology and histopathology 2
• Consider wash-out and windowed cast application 2
• Achieve osseous stabilization (implant retention, exchange, or external fixation) 2
• Provide dead space management 2
• Deliver antimicrobial therapy (local and systemic) 2
• Ensure sufficient vital soft tissue coverage 2

Fracture-Related Infection Management

Timing-Based Algorithm for Implant Decisions:

• Within 3 weeks of fixation: Debridement, antibiotics, and implant retention (DAIR) achieves 90%+ success rates 2
• 3-6 weeks post-fixation: DAIR success rates approximately 70% 2
• Beyond 10 weeks: DAIR success decreases to 51-67%; consider implant exchange 2

Preconditions for implant retention:

• Stable osteosynthetic construct 2
• Viable soft tissue envelope 2
• Ability to perform adequate debridement 2
• Appropriate timing from initial fixation 2

Critical pitfall: Biofilm maturation over time means antibiotics alone cannot eradicate infection regardless of duration once biofilm is established 2

Pediatric-Specific Principles

• Accept more initial deformity than in adults due to high remodeling potential 2
• Maximize use of removable casts and splints 2
• Most upper limb fractures can be managed conservatively 2
• Corrective procedures remain highly successful options if residual deformity occurs 2
• Minimize postoperative imaging (2018 systematic review showed only 0.22% absolute benefit in identifying complications) 2

Hip Fracture Management (Elderly Patients)

Time-Critical Targets:

• Admission within 4 hours of emergency department arrival 2
• Surgery within 24 hours of fitness determination 2
• Maximum delay of 48 hours from admission unless clear reversible medical conditions exist 2

Essential Infrastructure:

• Multidisciplinary hip fracture management group 2
• Fast-track admission pathways 2
• Protected daily trauma lists (including weekends) 2
• Consultant-delivered service (not trainees) 2
• Orthogeriatric co-management for frail elderly patients 2

Immediate priorities: Pain control, fluid resuscitation, warming, pressure care 2

Rehabilitation Principles

• Early mobilization is essential to prevent complications 2, 1
• Begin range-of-motion exercises within first postoperative days for upper extremity fractures 2
• Exercise programs and fall prevention reduce subsequent fracture risk 2
• Patient education regarding disease burden, risk factors, and treatment duration 2

Common Pitfalls to Avoid

• Excessive immobilization duration leading to stiffness and chronic pain 4
• Inadequate fracture stability risking nonunion and infection 2, 3
• Insufficient debridement in open or infected fractures 2
• Delayed surgery in hip fractures increasing morbidity and mortality 2
• Overly aggressive physical therapy before adequate healing, risking fixation failure 2
• Using intramedullary nailing for infected nonunions (higher failure rates than plate osteosynthesis) 7