Reduction is usually desirable in displaced or angulated fractures, but is not always required (e.g. most clavicular fractures heal uneventfully with a satisfactory outcome despite some displacement). The fracture can be reduced by closed methods (e.g. manipulation or traction) or by direct surgical exposure – open reduction. Once the fracture is reduced, the surgeon then has to choose some method of treatment to maintain the reduction until union occurs. Non-operative or operative methods can be chosen. Each method has advantages and disadvantages, and several options can be considered in most situations. The decision is influenced by location and morphology of the fracture, the presence of associated injuries and the experience of the surgeon.

Fracture union is dependent mainly on the blood supply of the bone at the site of the injury. This is related to the intrinsic quality of the bone blood supply in a given location and the energy of the injury. In general, cancellous bone has a better blood supply than cortical bone and heals more rapidly and reliably. The nature of the injury also has a major influence. Higher-energy injuries do more damage to the blood supply and are, therefore, associated with more prolonged healing times.

Non-operative treatment

Fractures can be treated non-operatively by a variety of methods. The advantages of non-operative methods include the following:

• Non-invasive – no surgery required

• Cheap – no modern theatre facility and implants needed.

The disadvantages include:

• Reduction is not always precise.

• Stability is often inadequate for major injuries.

• Mal-union rates are higher in adults.

• More outpatient visits and radiographs are required to monitor treatment.

Relative indications for non-operative treatment

• Low-energy undisplaced injuries

• Fractures in cancellous bone

• Phalangeal/metacarpal/metatarsal fractures

• Fractures that do not require anatomical reduction (e.g. clavicle, many humeral fractures)

• Some children’s fractures.

Types of non-operative treatment

1. Bed rest: some fractures can be treated with rest and analgesia alone, e.g. isolated pubic ramus fractures.

2. Cast treatment: reduction and cast application is suitable for many common injuries in adults and children, particularly distal radial fractures.

3. Splints: there is a variety of modern splints available that can be introduced at the outset or during the course of treatment to assist in immobilizing the fracture.

4. Traction: this method of treatment confines the patient to bed, sometimes for long periods, and is seldom used now in adults.

Operative treatment methods

External fixation

External fixation devices are attached to bone by pins or wires and consist of an external frame (Fig. 9.2). Devices vary in design from simple uni-axial frames to complex circular frames for more difficult problems. The main advantages are minimally invasive surgery and versatility of application. Disadvantages are problems with pin-track infection, poor patient acceptance and a higher rate of mal-union. These devices are particularly suitable for use in situations where application of internal fixation would be difficult or risky. Examples include distal metaphyseal fractures, bone where there has been previous osteomyelitis, multiple fractures, or extensive skin damage and swelling following high-energy trauma. External fixation may be used temporarily in these situations until internal fixation is deemed safe.

FIGURE 9.2 External fixator applied to proximal tibial shaft fracture. Note extensive skin swelling and soft-tissue contusions that would have been associated with a high risk of soft-tissue complications if internal fixation had been chosen

Indications for external fixation

• Closed fractures with extensive soft-tissue trauma

• Some open fractures

• Juxta-articular fractures where nailing and plating are technically difficult

• Temporary stabilization of long-bone fractures in multiple trauma

• Leg lengthening after post-traumatic shortening

• Correction of complex post-traumatic angular/rotational deformity.

Internal fixation

Internal fixation devices fall into two main categories: intramedullary devices and plates. Other variations are used, such as screws or wiring techniques. Intramedullary nails are widely used in the treatment of lower-limb long-bone fractures in adults. They can be inserted with minimally invasive surgery and are excellent for restoring normal length, alignment and rotation. They are biomechanically very strong and are ideal for lower-limb diaphyseal fractures, where union times may be prolonged (Fig. 9.3). They are associated with a reliably high rate of union and very low rates of mal-union. Other complications, such as infection, are also very low. They cannot be applied so easily to the bones in the upper limb. The narrow medullary canals in forearm bones make nailing difficult to apply in the radius and ulna. The humerus can be more readily nailed, but the entry points at the elbow and shoulder are associated with complications. In children, flexible intramedullary nails can be used to stabilize long-bone fractures and the radius and ulna. Nails should not cross an open physis in a child.

FIGURE 9.3 Complex segmental tibial shaft fracture fixed with interlocking intramedullary nail

Plating is most commonly used for metaphyseal fractures, displaced intra-articular fractures and diaphyseal fractures in the upper limb in the adult (Fig. 9.4). The main advantage is that a very precise reduction can be achieved, which is important when anatomical reduction is closely related to functional outcome (e.g. displaced intra-articular fractures). It is a more invasive technique and the complication rate associated with plating of diaphyseal fractures in the lower limb is higher than with intramedullary nailing.

FIGURE 9.4 Plating of isolated fracture of mid-shaft radius forearm fracture

Internal fixation is the treatment of choice for displaced unstable fractures where a poor reduction would compromise healing or functional outcome. It is often used to produce a stable wound environment in higher-energy open fractures and fractures with associated nerve or vascular injury.

Isolated screws are used in epiphyseal injuries (Salter–Harris types III and IV; see Chapter 11) to maintain continuity of the reduced articular surface and to stabilize a slipped upper femoral epiphysis (see Chapter 25). Percutaneous pinning of unstable fractures that have been reduced by manipulation is a useful and widely used technique in children and is effective when combined with the application of a plaster cast. Examples include percutaneous pinning of a supracondylar humeral fracture and a bayoneted distal radial fracture.