Orthopedic notes surgery
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Orthopedic Surgery: Fractures & Fixation
Medical Student Notes
1. Epidemiology & Importance
Musculoskeletal (MSK) injuries account for nearly 20% of all emergency department and primary care visits annually. About 46% of trauma patients have an orthopedic injury. In the US alone, MSK-related annual costs (treatment + lost wages) are estimated at $980 billion. Elderly patients are disproportionately affected, with MSK complaints accounting for 31.4% of their ED encounters.
- Sabiston Textbook of Surgery, p. 759
2. Fracture Biomechanics
A fracture occurs when the applied load exceeds the bone's load-bearing capacity. Key loading patterns:
| Loading Type | Fracture Pattern |
|---|---|
| Axial / Compression | Impaction or burst fracture |
| Bending | Transverse fracture (tension side) + butterfly/wedge fragment (compression side) |
| Torsion | Spiral fracture |
| Crush / High-energy | Comminuted, multifragmentary |
Cortical bone = dense, outer surface of long bones, primary load-bearing.
Cancellous (trabecular) bone = porous, found in metaphysis; less strong, more elastic.
Energy of injury: KE = ½ mv² - hence velocity matters more than mass in high-energy trauma. This explains why young patients with strong bones need high-energy mechanisms, while elderly patients with osteoporotic bone fracture from low-energy falls.
- Sabiston Textbook of Surgery, pp. 759-760
3. Fracture Terminology
Mastering descriptors enables clear communication between providers:
| Descriptor | Examples |
|---|---|
| Location | Diaphysis, metaphysis, epiphysis, intra-articular |
| Pattern | Transverse, oblique, spiral, comminuted, segmental |
| Displacement | Undisplaced, displaced (shift), angulated, shortened, rotated |
| Soft tissue | Closed vs. open (compound) |
| Timing | Acute, subacute (callus visible), chronic (nonunion ≥6 months) |
Key rule: Intra-articular fractures = anatomical reduction required to restore normal joint mechanics and prevent degenerative arthritis.
Eponymous fractures (still commonly used):
- Colles' fracture - distal radius, dorsal displacement, "dinner fork" deformity
- Pott's fracture - bimalleolar ankle
- Monteggia - ulna fracture + proximal radio-ulnar dislocation
- Galeazzi - radial shaft fracture + distal radio-ulnar dislocation
- Rockwood and Green's Fractures in Adults, p. 140; Sabiston Textbook of Surgery, p. 760
4. Pediatric Fractures - Special Considerations
Children's bones differ from adults - less dense, greater plasticity, thicker periosteum, open physes (growth plates):
- Plastic deformity - bone bends without cortical disruption
- Greenstick fracture - cortex fails on one side only (tension side fractures, compression side bends)
- Buckle (torus) fracture - metaphyseal compression failure; stable, seen in distal radius
- Physeal (Salter-Harris) fractures - involve the growth plate; must be recognized because injury to the physis can arrest growth
Salter-Harris Classification:
| Type | Pattern | Mnemonic |
|---|---|---|
| I | Through physis only | Straight across |
| II | Through physis + metaphysis | Above (metaphysis) |
| III | Through physis + epiphysis | Lower (epiphysis) |
| IV | Through all three (metaphysis + physis + epiphysis) | Through all |
| V | Crush injury of physis | Rammed / crushed |
Types I-II generally have a good prognosis. Types III-V carry higher risk of growth disturbance.
- Sabiston Textbook of Surgery, p. 760
5. Fracture Healing
The cornerstone of understanding why and how we fixate fractures.
Two Modes of Healing
Primary (Direct) Bone Healing
- Requires cortical apposition and absolute stability (no interfragmentary movement)
- No callus forms; osteoclast cutting cones cross the fracture line, followed by osteoblasts laying lamellar bone
- Achieved by rigid compression fixation (e.g., lag screws + plate)
- Analogous to a sutured wound healing by primary intention
Secondary (Indirect) Bone Healing
- Requires relative stability with some controlled interfragmentary movement (strain)
- Sequence: fracture hematoma → fibrous tissue → soft callus → hard callus → remodeling
- Most common form of bone healing in clinical practice
- Analogous to a scab forming and maturing
Perren's Strain Theory
The local strain (% deformation) at the fracture site determines which tissue forms:
-
100% strain → fibrous connective tissue only
- < 10% strain → soft callus (fibrocartilage)
- < 2% strain → hard callus, then mineralization
- ~0% strain (absolute rigidity) → direct bone healing
Too much movement = no healing. Too little (with compression) = direct healing. Moderate = callus/indirect healing.
Biological Requirements for Healing
- Intact blood supply from periosteum, surrounding soft tissues, and nutrient artery
- Diabetes, peripheral vascular disease, open fractures with soft-tissue stripping, and infection all impair healing
Outcomes Terminology
| Term | Definition |
|---|---|
| Union | Clinical: minimal pain, withstands physiological load. Radiological: callus bridges fracture site |
| Malunion | Healed but in unacceptable position (angulation, rotation, shortening) |
| Delayed union | Healing slower than expected for bone and mechanism |
| Nonunion | Healing has ceased; typically ≥6 months, no progressive healing on serial X-rays |
- Bailey & Love's Short Practice of Surgery, pp. 445-446; Rockwood and Green's Fractures in Adults
6. Open Fractures
Definition: Any fracture where the fracture hematoma communicates with a breach in the epithelial lining - not just skin. Includes fractures communicating with vagina, rectum, or oral mucosa.
Gustilo-Anderson Classification (1984)
| Grade | Description |
|---|---|
| I | Low-energy; wound < 1 cm, clean |
| II | Wound > 1 cm, no extensive soft-tissue damage, flaps, or avulsion |
| III | High-energy, extensive soft-tissue damage, high contamination, multifragmentary |
| IIIA | Adequate soft-tissue cover after debridement and stabilization |
| IIIB | Inadequate cover - requires flap reconstruction |
| IIIC | Associated arterial injury requiring repair |
Grade IIIC carries the highest risk of amputation. IIIB typically needs plastic surgery (rotational or free flap). All open fractures need:
- IV antibiotics (within 1-3 hours; 1st gen cephalosporin ± gentamicin ± metronidazole for grade III)
- Tetanus prophylaxis
- Urgent debridement and washout
- Skeletal stabilization
- Bailey & Love's Short Practice of Surgery, p. 442; Rockwood and Green's Fractures in Adults
7. Fracture Management Principles
The classic framework (Apley's system):
- Reduce - restore anatomy
- Hold - maintain reduction until healed
- Heal - support the biological process
- Rehabilitate - restore function
Reduction Methods
- Closed reduction - manipulation under anesthesia; used for most stable fractures
- Open reduction - surgical exposure; needed when closed reduction fails or for articular fractures requiring anatomical restoration
8. Methods of Fixation
Summary Table of Stabilization Methods
| Method | Stability | Indications | Pros | Cons |
|---|---|---|---|---|
| Splint/Cast | Low (indirect bone control) | Stable closed fractures; temporary stabilization | Non-invasive; accommodates swelling | Not length-stable; indirect control |
| Traction splint | Low | Temporary for femoral shaft fractures | Controls pain and bleeding; maintains length | Pressure ulcers at ischial tuberosity/ankle |
| Skeletal traction | Low-moderate | Temporary for femur/pelvis | Maintains length | No patient mobilization |
| External fixation | Moderate-high | Damage control; open fractures; temporary bridge; ring fixators for definitive care of complex injuries | Direct bone control; adjustable | Pin-site infections; bulky |
| CRPP (closed reduction + percutaneous pins) | Moderate | Small bones; pediatric; distal radius | Minimally invasive; pins removed after healing | Indirect reduction; pin-site infection risk |
| Intramedullary (IM) nail | High | Long bone diaphyseal fractures (femur, tibia, humerus) | Load-sharing; minimally invasive; early mobilization | Canal preparation needed; rotational control limited in some designs |
| Plate and screw (ORIF) | High | Articular fractures; metaphyseal fractures; forearm | Anatomical reduction; rigid or bridging options | More soft-tissue dissection; infection risk |
- Sabiston Textbook of Surgery, pp. 762-763; Rockwood and Green's Fractures in Adults
Fixation Strategy Principles (Rockwood & Green)
"Fracture fixation is a race between bone healing and construct failure."
- Absolute stability (compression fixation) → suppresses callus, promotes direct healing. Used for articular fractures. Lag screw technique + neutralization plate.
- Relative stability (bridge/locked fixation) → allows interfragmentary movement, promotes callus/indirect healing. Used for diaphyseal fractures. Bridge plating, IM nailing, external fixation.
- The paradox of internal fixation: rigid fixation restores function, but some flexibility is needed to stimulate natural healing
Locking plates = screws lock into the plate, acting as a fixed-angle construct. Particularly useful in osteoporotic bone and periarticular fractures where conventional screws would strip.
- Rockwood and Green's Fractures in Adults, p. 76
9. Specific Fixation by Fracture Type
| Fracture | Preferred Fixation |
|---|---|
| Femoral shaft | Antegrade IM nail (gold standard) |
| Tibial shaft | IM nail; plate if very distal |
| Humeral shaft | Conservative (functional bracing) or IM nail/plate |
| Distal radius | Volar locking plate (ORIF) or cast if reducible and stable |
| Hip (intertrochanteric) | Dynamic hip screw (DHS) or cephalomedullary nail (e.g., Gamma nail) |
| Femoral neck | Cannulated screws (young patient) or hemiarthroplasty/THA (elderly displaced) |
| Ankle (bi/trimalleolar) | ORIF with plate and screws |
| Distal tibia (pilon) | Staged: initial external fixation → definitive ORIF when soft tissues permit |
10. Acute Compartment Syndrome
A time-critical complication of fractures (and soft tissue injuries). Must not be missed.
Pathophysiology: Pressure rises within a closed fascial compartment → reduced perfusion pressure → ischemia of muscles and nerves.
Most common location: Anterior compartment of the leg (after tibial fractures).
Diagnosis - The 6 P's
- Pain (especially with passive stretch of muscles in the compartment - most sensitive early sign)
- Pressure (tense, woody compartment on palpation)
- Paresthesia (sensory loss in distribution of nerves in the compartment)
- Paralysis (late sign)
- Pallor (late)
- Pulselessness (very late; palpable pulses do NOT rule out compartment syndrome)
Compartment pressure measurement: Delta pressure (diastolic BP - compartment pressure) < 30 mmHg = indication for fasciotomy.
Treatment
Urgent fasciotomy - decompress all compartments of the affected region.
- Leg: 4-compartment fasciotomy via 2 incisions (anterolateral + posteromedial)
- Thigh: anterolateral + medial (medial compartment rarely needed)
- Forearm: volar + dorsal releases
The wound is left open, covered with a wound dressing, and closed or skin-grafted at 48-72 hours.
- Bailey & Love's Short Practice of Surgery, p. 1034; Tintinalli's Emergency Medicine
11. Complications of Fractures
Early (Hours to Days)
| Complication | Notes |
|---|---|
| Hemorrhage | Femur shaft ~1-2 L; pelvis can lose 3-4 L |
| Neurovascular injury | Check distal pulses and sensation before and after reduction |
| Compartment syndrome | See above - surgical emergency |
| Open fracture infection | Grade IIIB/C especially; early antibiotics + debridement |
| Fat embolism syndrome | 12-72 hours post-fracture; triad of hypoxia, confusion, petechiae (especially long bone/pelvic fractures) |
Late (Weeks to Months)
| Complication | Notes |
|---|---|
| Malunion | Healed in poor position; may require osteotomy |
| Nonunion | Atrophic (avascular) vs. hypertrophic (too much motion); treated with fixation ± bone graft |
| Avascular necrosis (AVN) | Disrupted blood supply; femoral head, scaphoid, talus, humeral head at highest risk |
| Post-traumatic arthritis | After intra-articular fractures |
| Reflex sympathetic dystrophy (CRPS) | Chronic pain syndrome after fracture/injury |
| DVT / PE | Particularly lower limb and pelvic fractures |
12. High-Yield Nerve Injuries with Common Fractures
| Fracture | Nerve at Risk | Deficit |
|---|---|---|
| Humeral shaft | Radial nerve | Wrist drop (finger/wrist extension loss) |
| Supracondylar humerus (pediatric) | Anterior interosseous nerve (AIN) | Loss of pinch (FPL + FDP of index) |
| Posterior hip dislocation | Sciatic nerve | Foot drop, sensory loss posterior thigh/leg |
| Knee dislocation | Peroneal nerve (CPN) | Foot drop, sensory loss dorsum of foot |
| Clavicle fracture | Brachial plexus | Variable |
| Fibula neck fracture | Common peroneal nerve | Foot drop |
13. Quick Revision: Key Numbers
| Fact | Value |
|---|---|
| Compartment syndrome pressure threshold | ΔP < 30 mmHg (or absolute > 30 mmHg) |
| Nonunion defined as | ≥ 6 months, no progressive healing |
| Gustilo I wound size | < 1 cm |
| Fat embolism onset | 12-72 hours post-fracture |
| Blood loss - femur shaft | ~1-2 L |
| Blood loss - pelvis | Up to 3-4 L |
Sources
- Rockwood and Green's Fractures in Adults, 10th ed. 2025
- Bailey and Love's Short Practice of Surgery, 28th ed.
- Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice
- Campbell's Operative Orthopaedics, 15th ed. 2026
- Tintinalli's Emergency Medicine, A Comprehensive Study
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